Happy Visit Home Health

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Patient Rights as follows: The HHA failed to ensure one of eight patients (Patient 2) received written notice about their rights and responsibilities as a home health patient in their preferred language. This failure resulted in Patient 2 signing consent forms without full knowledge and understanding of the rights and responsibilities as a home health patient. (Refer to G412). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Patient Rights to ensure patient rights are not violated to all patients certified to receive the home health benefits.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Comprehensive Assessment of Patients as follows: 1. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five days of admission for five of eight sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8). This failure had the potential to result in delayed patient care, decline in functional, physical health and lack of communication between the interdisciplinary team. (Refer to G520) 2. The HHA failed to ensure Licensed Vocational Nurse (LVN) 1 assessed one of eight sampled patients (Patient 6) for pain during the home visit conducted on 7/22/2026. This failure resulted in the absence of required pain assessment data and created the potential for unrecognized discomfort, unmanaged pain, increased physiological distress, delays in appropriate clinical interventions. (Refer to G530) 3. The HHA failed to ensure medications administered to patients were reflected on the HHA’s “Patient Medication Profile,” resulting in incomplete and inaccurate medication information for two of eight sampled patients (Patient 1 and Patient 6). This failure had the potential to result in medication duplication, drug-to-drug interactions, and adverse drug events due to missing or accurate documentation needed to ensure safe medication management. (Refer to G536) 4. The HHA failed to ensure the recertification comprehensive assessment (a required evaluation completed during the final 5 days of a 60-day certification period to establish ongoing patient eligibility) was completed within the last five days of a 60-day certification period for five of eight sampled patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7). This failure had the potential to result in ineligible patients being recertified for home health care and a lack of communication between the interdisciplinary team. (Refer to G546) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Comprehensive Assessment of Patients to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Care Planning, Coordination, and Quality of Care as follows: 1. The HHA failed to ensure four of eight sampled patients (Patient 1, Patient 2, Patient 5 and Patient 8) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1 and Patient 8 receiving home health services without an individualized, written plan of care and Patient 2 and Patient 5 not receiving ordered weekly skilled nursing visits that could lead to serious harm and hospitalization of the patients. (Refer to G572) 2. The HHA failed to ensure the individualized POC included patient-specific interventions and education for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. (Refer to G574) 3. The HHA failed to ensure physician orders were recorded in the POC for two of eight sampled patients (Patient 1 and Patient 8). This failure had the potential to affect patient safety and impair continuity and coordination of care for Patient 1 and Patient 8. (Refer to G576) 4. The HHA failed to ensure that services were provided only as ordered by a physician or allowed partitioner for two of eight sampled patients (Patient 6 and Patient 7). The missing physician orders resulted in physical therapy services being documented without evidence of authorization. This failure placed both patients at risk of receiving services without verified medical necessity, and without assurance that the services aligned with their clinical needs and individualized Plan of Care. (Refer to G580) 5. The HHA failed to ensure the physician reviewed the POC for four of eight sampled patients (Patient 1, Patient 6, Patient 7 and Patient 8). This failure had the potential to result in delayed care and lack of coordination between the interdisciplinary team (IDT, coordinated group of medical, clinical, and support professionals who work together to create, manage, and evaluate a unified care plan for a patient). (Refer to G588) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Care Planning, Coordination, and Quality of Care to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Skilled Professional Services as follows: The HHA failed to ensure one of eight sampled patients (Patient 2) received a physical therapist (PT, a licensed healthcare professional who helps patients manage pain, improve movement, and recover from injuries) initial evaluation and order as indicated in the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) within 48 hours of referral. This failure resulted in Patient 2 not receiving physical therapy services in a timely manner, which increased the risk of injury and pain that could lead to hospitalization. (Refer to G710) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Skilled Professional Services to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Compliance with All Federal, State, and Local Laws as follows. Findings: 1. The HHA failed to maintain a current and valid California Department of Public Health license as required by state law. This failure resulted in the HHA providing home health services to 131 patients without legal authorization and placing patients at risk for disruption of services and regulatory oversight. (Refer to G860) 2. The HHA failed to obtain a current Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver while performing point-of-care blood glucose testing (finger sticks). This failure resulted in the HHA conducting laboratory testing without the required federal certification, creating potential for inaccurate blood glucose results and inappropriate clinical decision-making for patients whose treatment depends on these values. (Refer to G862) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutory (written law) mandated compliance with Federal regulation for Compliance with All Federal, State, and Local Laws to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure Condition of Participation (COP, conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Organization and Administration of Services was met as follows: A. The HHA’s Administrator failed to organize and administer the agency’s day to day operations to ensure effective oversight of personnel, maintenance of administrative functions, continuity of clinical supervision, and adherence to regulatory requirements. These failures resulted in medication errors, skipped patient care visits, lack of authentication by medical providers for medical documentation, and risk of harm to patient care. (Refer to G948) B. The HHA failed to ensure the Director of Patient Care Services (DPCS) provided oversight of patient care coordination and plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) management, for seven of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, and Patient 8) by failing to: 1.Ensure medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency). was completed at each visit for Patient 1, Patient 3, and Patient 6. This failure resulted in increased risk for medication error and adverse effects from new medications. 2.Ensure to follow the plan of care (POC) for Patient 2 and Patient 5, to receive the ordered weekly skilled nursing visits. This failure resulted in Patient 2, and Patient 5, did not receive a weekly skilled visit per POC. 3.Ensure initial assessments (a prompt evaluation conducted by a registered nurse or qualified clinician within 48 hours of a patient’s referral or return home), were completed within five days of admission for five of eight sampled patients Patient 1’s start of care (SOC) was on 4/29/2026, Patient 2’s SOC was on 5/9/2026, Patient 6’s SOC was on 3/31/2026, Patient 7’s SOC was on 5/2/2026, and Patient 8’s SOC was on 7/17/2026. This failure resulted in patients at risk for delayed care and not receiving home health services. 4. Ensure recertification assessments were completed within the last five days of each 60-day certification period for five of eight sampled patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7). This failure had an increase for Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7 not receiving care and services needed to meet their care goa; needs. 5. Develop individualized plans of care for Patient 1, Patient 3, Patient 5, and Patient 8 that addressed their specific diagnoses and included patient specific measurable outcomes and goals, and which were established, periodically reviewed, and signed by a physician. This failure resulted in increased risk for delayed care, treatments, and hospitalization. (Refer to G958) The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (rules or law) mandated compliance with the Federal (government) regulations for Organization and Administration of Services to ensure the highest practicable functional capacity, including optimal care and services to meet patients’ care goals.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA - an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Clinical Records as follows: 1. The HHA failed to ensure the initial comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) and recertification comprehensive assessments (a required evaluation completed during the final 5 days of a 60-day certification period to establish ongoing patient eligibility) were documented in the clinical record for seven of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, and Patient 8). This failure resulted in patients not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. (Refer to G1012) 2. The HHA failed to ensure that the plan of care (POC, a document where a doctor certifies that a patient needs home health services, outlining the specific skilled care [nursing, therapy], medical equipment, frequency of visits, and goals) included patient-specific interventions, medications, treatments, services, and education for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. (Refer to G1014) 3. The HHA failed to ensure the POC included patient-specific goals and the patient’s progress toward achieving them for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. (Refer to G1016) 4. The HHA failed to ensure that required clinical record entries – including Outcome and Assessment Information Set (OASIS) assessments and Nursing Progress Notes - were authenticated (formally signed, dated, and timed) by the responsible healthcare staff for five of eight sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8). This failure compromised the reliability and accuracy of patient information used by the interdisciplinary team for ongoing assessment, care planning, and coordination of services. (Refer to G1024) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Clinical Records to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure four of eight sampled patients (Patient 1, Patient 2, Patient 5 and Patient 8) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identified patient-specific measurable outcomes and goals, and identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1 and Patient 8 receiving home health services without an individualized, written plan of care and Patient 2 and Patient 5 not receiving ordered weekly skilled nursing visits that could lead to serious harm and hospitalization of the patients. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit on 7/22/2026 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed sitting on a bed, awake, alert, oriented to person, place, and time. During an observation, LVN 2 performed a head-to-toe assessment, checked vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and assessed pain level for Patient 1. LVN 2 also provided education regarding physical therapy and pain medication to Patient 1. During a concurrent interview and record review on 7/22/2026 at 11:04 a.m., with LVN 2, Patient 1’s POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. LVN 2 stated she (LVN 2) performed a full body assessment, checked vital signs, assessed the pain level, and provided education for Patient 1, but was unable to confirm all the care and services that she just provided were written in the POC. LVN 2 stated Patient 1’s POC was not complete. LVN 2 stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review on 7/27/2026 at 1:30 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 1. The DPCS Designee stated the POC was missing sections for patient goals, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated Patient 1 was being visited and treated without a proper plan of care. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. b. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s SOC date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period starting from 5/9/2026 to 7/7/2026, the POC indicated for Patient 2 to receive skilled nurse visits once a week for nine weeks for “assessment and observation on all body systems, assess/monitor vital signs and teaching/instruction regarding disease care management.” During an interview on 7/22/2026 at 8:23 a.m., with Patient 2’s Caregiver (PCG 1), PCG 1 stated there was a large gap in skilled nurse visits from 5/12/2026 to 5/23/2026. PCG 1 stated she (PCG 1) contacted the agency from 5/16/20126 to 5/20/2026 several times to find out when the visiting nurse would make a visit, but no definitive answer was provided. During a concurrent interview and record review on 7/24/2026 at 3:33 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Notes” for May 2026 were reviewed. The Nursing Progress Notes indicated Patient 2 was visited on 5/9/2026, 5/12/2026, and 5/23/2026. The DPCS stated a skilled nurse visit should have been made within seven days from 5/12/2026. The DPCS stated a gap in skilled nurse visits from 5/12/2026 and 5/23/2026 is considered a missed visit. The DPCS stated visits should be conducted once every seven days because it is the agreed upon frequency of treatment between the patient and interdisciplinary team. The DPCS stated there was no communication note from the agency addressing why there was a missed visit. The DPCS stated the DPCS and DPCS Designee should have provided more oversight to ensure missed visits did not occur. The DPCS stated missed visits could result in patient needs being missed and patient assessments not being made, which could lead to patient harm and hospitalization. c. During a record review of Patient 5’s medical record form titled “Patient Demographics” undated, indicated a start of care date of 1/23/2026 with a primary diagnosis of encounter for fitting and adjustment of urinary device. During a record review of Patient 5’s medical record form titled “Order/Telephone Order” dated 5/21/2026, indicated Patient 5 was to have Skilled Nurse (SN) visits once a week for eight weeks, starting the week of 5/24/2026. The form also indicated the Director of Patient Care Services Designee (DPCSD) was listed as Patient 5’s ordering physician. During a record review on 7/27/2026 at 2:09 p.m., of Patient 5’s electronic medical record (EMR), Patient 5’s EMR indicated the last SN visit was documented on 7/9/2026. During a concurrent interview and record review on 7/27/2026 at 2:15 p.m., with the DPCSD of Patient 5’s EMR, the DPCSD stated that according to Patient 5’s EMR, Patient 5 was to have SN visits once a week. The DPCSD stated that she (DPCSD) did not know Patient 5 was last seen on 7/9/2026. The DPCSD stated that she (DPCSD) was Patient 5’s ordering physician and that she (DPCDS) wrote Patient 5’s physician order dated 5/21/2026, which ordered to have Patient 5’s visited every week, but did not sign it. The DPCSD stated that no one from the HHA contacted her (DPCSD) to inform her (DPCSD) that Patient 5 had not been seen since 7/9/2026. The DPCSD stated that she (DPCSD) did not know Patient 5’s current admission status. d. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 8’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 8. The DPCS Designee stated the POC was missing sections for patient goals, medications, functional limitations, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. The DPCS Designee stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCS Designee stated the DPCS and DPCS Designee did not provide sufficient oversight to ensure the POC was completed. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” undated, the P&P indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician (or other authorized licensed independent practitioner). A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.””

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency failed to furnish services in compliance with Federal, State, and Local Laws as follows: 1. The HHA failed to maintain a current and valid California Department of Public Health license as required by state law. This failure resulted in the HHA providing home health services to 131 patients without legal authorization and placing patients at risk for disruption of services and regulatory oversight. 2. The HHA failed to obtain a current Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver while performing point-of-care blood glucose testing (finger sticks). This failure resulted in the HHA conducting laboratory testing without the required federal certification, creating potential for inaccurate blood glucose results and inappropriate clinical decision-making for patients whose treatment depends on these values. During an observation on 7/21/2026 at 11:05 am., at the HHA offices located at 3440 Wilshire Blvd, Suite 1208, Los Angeles, 90010, the facility’s posted State of California Department of Public Health license displayed an expiration date of 3/25/2024. During a concurrent interview and record review on 7/23/2026 at 10:50 a.m., with ADM, license renewal application, undated, and copy of check dated 4/1/2026 were reviewed. The license renewal application indicated an Administrator name different from ADM. ADM stated he submitted a Change of Ownership (CHOW) application to National Government Services (NGS –health care contractor that processes medical claims, manages data, and provides IT infrastructure for government agencies) on 7/1/2026, and ‘doesn’t know what the holdup is.’ During a concurrent interview and record review on 7/23/2026 at 11 a.m., with ADM, CHOW application, dated 7/1/2026 was reviewed. The CHOW application indicated NGS returned the CHOW submission because 31 of the required 51 pages were missing. ADM stated he was “working on it now” and waited to submit the CHOW because “it takes a lot of money to start a business.” During a record review of ELMS (Electronic Licensing Management System – a database used by California Department of Public Health to track facility licenses, enforcement actions, and federal provider certifications from the Centers for Medicare & Medicaid Services), dated 7/27/2026, indicated the facility’s license expired on 3/25/2026. No current or active license was listed in the system. Operating without a current state license prevents verification that the HHA meets required regulatory standards for patient safety, administrative oversight, and legal eligibility to provide home health services. Without an active license, the agency cannot demonstrate compliance with state law or regulatory safeguards, placing patients at risk for disruptions in care and potentially invalidating reimbursement or service authorization processes.”

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) failed to obtain a current Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver while performing point-of-care blood glucose testing (finger sticks) for one of 8 patients (Patient 8). This deficient practice resulted in the HHA conducting laboratory testing without the required federal certification, creating potential for inaccurate blood glucose results and inappropriate clinical decision-making for patients whose treatment depends on these values. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During an interview on 7/20/2026 at 11:56 a.m., with DPCSD, stated The Agency “does not have a CLIA waiver, we are in the process of applying for it .” During a concurrent interview and record review on 7/21/2026 at 12:31 p.m., with OM, the CLIA application dated 6/18/2026 was reviewed. The application indicated the HHA had submitted payment but had not been issued a CLIA Certificate of Waiver. The OM stated “I thought sending the money was the same as having a CLIA. If not, we should not perform finger sticks because we may be at risk for inaccurate test results.” During an observation on 7/22/2026 at 1:35 p.m., at Facility 1 in Patient 6’s room, LVN 1 did not perform blood glucose monitoring. During an interview on 7/22/2026 at 1:58 p.m., with MT 2, Mt 2 stated “Patient 6’s blood sugar is not checked because they do not have a doctor’s order.” During a concurrent interview and record review on 7/22/2026 at 2:20 p.m., with LVN 1 at Facility 1, Patient 6’s Plan of Care (POC - written, step-by-step guide that lists a patient’s health problems, medical goals, and specific treatments) for certification period 5/30/2026 – 7/28/2026, dated 6/1/2026 was reviewed. The POC indicated “Skilled nurse to perform blood sugar monitoring via finger stick using glucometer machine.” LVN 1 stated, LVN 1 “usually checks Patient 6’s blood sugar levels weekly” and documents results as RBS (Random Blood Sugar - measures the amount of glucose in your blood at any time of day, regardless of when you last ate) in the nursing notes. LVN 1 further stated the glucometer was not available during the 7/22/2026 visit, but LVN 1 had performed blood glucose monitoring via finger stick on prior visits. During a concurrent interview and record review on 7/22/2026 at 2:20 p.m., with LVN 1 at Facility 1, Patient 6’s nursing notes (a formal, documented record of a patient’s current health status, the care provided by the nurse, and the patient’s response to treatment), dated 6/4/2026, 6/10/2026, 6/16/2026, 6/23/2026, 6/30/2026, 7/7/2026, and 7/14/2026 were reviewed. All seven nursing notes indicated RBS were obtained during the home visits. LVN 1 stated LVN 1 performed finger sticks and documented RBS during each of these home visits. During an interview with Director of Patient Care Services (DPCS – clinical manager responsible for managing nursing services, coordinating interdisciplinary care teams, and adhering to state and federal health care regulations) on 7/23/2026 at 2:20 p.m., the DPCS stated “If we don’t have a CLIA waiver, we should not perform blood sugar tests on patients. Doing so without a CLIA waiver puts the patient at risk for an unskilled nurse, unmonitored equipment giving false readings, dangerous dosing mistakes and potential for infections.” By performing point‑of‑care blood glucose testing without a CLIA Certificate of Waiver, the HHA lacked federal authorization to conduct laboratory testing. Without required certification, there is no assurance that testing procedures, equipment, and quality controls meet regulatory standards, placing patients at risk for inaccurate blood glucose results and inappropriate clinical interventions.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Director of Patient Care Services (DPCS) provided oversight of patient care coordination and plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) management, for seven of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, and Patient 8) by failing to: 1.Ensure medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency). was completed at each visit for Patient 1, Patient 3, and Patient 6. This failure resulted in increased risk for medication error and adverse effects from new medications. 2.Ensure to follow the plan of care (POC) for Patient 2 and Patient 5, to receive the ordered weekly skilled nursing visits. This failure resulted in Patient 2, and Patient 5, did not receive a weekly skilled visit per POC. 3.Ensure initial assessments (a prompt evaluation conducted by a registered nurse or qualified clinician within 48 hours of a patient’s referral or return home), were completed within five days of admission for five of eight sampled patients Patient 1’s start of care (SOC) was on 4/29/2026, Patient 2’s SOC was on 5/9/2026, Patient 6’s SOC was on 3/31/2026, Patient 7’s SOC was on 5/2/2026, and Patient 8’s SOC was on 7/17/2026. This failure resulted in patients at risk for delayed care and not receiving home health services. 4. Ensure recertification assessments were completed within the last five days of each 60-day certification period for five of eight sampled patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7). This failure had an increase for Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7 not receiving care and services needed to meet their care goa; needs. 5. Develop individualized plans of care for Patient 1, Patient 3, Patient 5, and Patient 8 that addressed their specific diagnoses and included patient specific measurable outcomes and goals, and which were established, periodically reviewed, and signed by a physician. This failure resulted in increased risk for delayed care, treatments, and hospitalization. On 7/28/2026, at 12:38 p.m., the California Department of Public Health called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Administrator (ADM) related to the agency’s failure to ensure the Director of Patient Care Services (DPCS) provided oversight of patient care coordination and POC management for eight of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, and Patient 8) compromising patients’ safety. On 7/28/2026, at 4:25 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 7/28/2026, at 4:30 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM with the IJ not removed. Findings: 1a. During a review of Patient 1’s medical record titled, “Patient Demographics,” (describe a patient’s most basic information), the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy (medical condition that affects the brain and causes seizures[sudden burst of electrical activity in the brain]), unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control), and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 4/29/2026 to 6/27/2026, the POC indicated Patient 1 was admitted for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a joint home visit, observation, and interview, on 7/22/2026 at 10:50 a.m., with Licensed Vocational Nurse 2 (LVN) 2, the following medications were observed and available at Patient 1’s residence and were not listed in Patient 1’s medication profile or POC provided by the HHA. Folic acid (a vitamin used to prevent and treat folate deficiency) 1 milligram (mg, a unit of measurement) tablet, one tablet daily.Ketorolac 0.5% ophthalmic solution (a prescription eye drop used to treat pain, burning, stinging, and swelling after cataract surgery), one drop into the left eye three times a day.Prednisolone acetate 1% eye drops (a prescription steroid medicine used to treat eye swelling, redness, and pain caused by surgery), one drop into the right eye four times a day. During an interview on 7/22/2026 at 10:52 a.m. with Medication Technician (MT, provide or assist with basic care or support under the direction of onsite licensed nursing staff) 1, MT 1 stated Patient 1 has been taking the folic acid tablets since 6/16/2026. MT 1 stated Patient 1 has been taking both the ketorolac and prednisolone acetate eye drops since 5/28/2026. During a joint home visit observation, on 7/22/2026 at 10:55 a.m., with LVN 2, the following medications were not available in Patient 1’s residence but were listed in Patient 1’s medication profile and POC, provided by the HHA: Tamsulosin (a medication used to treat an enlarged prostate, improve urine flow, and help pass kidney stones) 0.4 mg capsule, one capsule daily.Quetiapine (a medication used to treat schizophrenia (a serious and chronic brain disorder that makes it hard for a person to tell what is real and what is not), bipolar disorder (a mental health condition that causes extreme mood swings), and major depressive disorder (serious mood disorder characterized by persistent sadness, loss of interest in activities, and a lack of energy), 200 mg. tablet, two tablets daily. During an interview on 7/22/2026, at 10:56 a.m., with MT 1, MT 1 stated Patient 1 has not taken the tamsulosin capsules since 11/29/2025. MT 1 stated Patient 1’s order for quetiapine two tablets daily was changed to one tablet daily on 6/17/2026. During an interview on 7/22/2026, at 11:04 a.m., with LVN 2, LVN 2 stated medication reconciliation should have been completed during every visit by the visiting nurse. LVN 2 stated the folic acid tablets, ketorolac solution, and prednisolone eye drops should have been included in the Patient 1’s medication profile because Patient 1 was taking them daily. LVN 2 stated the tamsulosin capsules should have been removed from Patient 1’s medication profile because Patient 1 has not taken them for months. LVN 2 stated the quetiapine tablet orders should have been updated in Patient 1’s medication profile to reflect the correct dosage. LVN 2 stated she (LVN 2) would contact the agency office to ensure Patient 1’s medication profile was current and accurate. During an interview on 7/24/2026, at 3:19 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation should be done regularly at every skilled nurse visit to ensure the medication profile is kept current and accurate. The DPCS stated not completing medication reconciliation at every visit could result in medication errors and possible hospitalization for Patient 1. During an interview on 7/27/2026 at 12:15 p.m., with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated patient’s medications were to be reconciliated during every skilled nurse (SN) visit for safety. The DPCSD stated that medication reconciliations prevent dual therapy and identification of medications contraindication. The DPCS stated that when a patient has medication changes, the visiting SN reports the findings to the Office Manager (OM), the Director of Patient Care Services (DPCS) or the DPCSD. The DPCSD stated that the person who receives the SN’s call must update the patient’s medication profile. The DPCSD stated the HHA hold Care Conference meetings at the HHA once or twice a week to discuss patients changes, including medication changes. During an interview on 7/27/2026 at 1:32 p.m. with the DPCS Designee, the DPCS Designee stated the visiting nurse should have reported medication profile discrepancies to either the DPCS or DPCS Designee. The DPCS Designee stated the DPCS and DPCS Designee should have provided sufficient oversight to ensure Patient 1’s medication profile was up to date. 1b. During a review or Patient 3’s medical record form titled “Patient Demographics” undated, indicated Patient 3 start of date care date was 4/27/2026 with a primary diagnosis of type II diabetes (high blood sugar) with diabetic polyneuropathy (malfunctioning body nerves casing numbness, tingling, and muscle weakness). 1b. During a review of Patient 3’s medical record titled “Patient Medication Profile” undated, indicated Patient 3 was currently prescribed aspirin (pain medication), cetirizine (antihistamine, commonly treat allergy symptoms, like runny nose, sneezing and itchy eyes.), Diclofenac (topical corticosteroids, medications applied directly to the skin to reduce redness, swelling, and itching), docusate sodium (stool softener), multivitamins (supplement), pantoprazole (stomach anti acid medication), and polyethylene glycol (laxative, stool softeners or fiber supplements). During a joint home visit, observation, and interview, on 7/22/2026, at 11:45 a.m., with LVN3 at Patient 3’s residence, Patient 3’s medications were reconciliated by LVN 3. LVN 3 stated Patient 3’s home health medication profile had not been updated to reflect her (LVN3) 6/29/2026 findings. LVN 3 stated she (LVN3) called the HHA and spoke with the Office Manager (OM) on 6/29/2026, to report the changes to Patient 3’s medications. LVN 3 stated Patient 3 was no longer taking aspirin, cetirizine, Diclofenac, docusate sodium, multivitamins, pantoprazole, and polyethylene glycol, since 6/29/2026. During a concurrent interview and record review, on 7/27/2026, at 12:15 p.m., with the DPCSD of Patient 3’s medical record, the DPCSD stated she (DPCSD) did not know Patient 3’s current medications. The DPCSD stated Patient 3’s medications have to be reconciliated at every skilled nurse (SN) visit. The DPCSD stated there was a communication oversight with Patient 3’s medication updates. The DPCSD stated that she (DPCSD) did not know how Patient 3’s medication changes were not discussed during the HHA’s Care Conference meetings. The DPCSD stated that Patient 3’s medication profile was not updated due to communication oversight. 1c. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, the Patient Profile indicated Patient 6’s start of care date was 3/31/2026 with diagnoses of chronic obstructive pulmonary disease (COPD, a long-term lung condition making it hard to breathe with episodes of sudden worsening), with (acute) exacerbation, essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a joint home visit, observation, on 7/22/2026 at 1:30 p.m., with LVN 1, the following medications were observed and were available at Patient 6’s resident, but not listed in Patient 6’s Medication Profile, Episode Period: 5/30/2026 to 7/28/2026 or Patient 6’s POC dated 6/1/2026: Acetaminophen (medication used to lower fever and treat mild to moderate pain) 325 milligrams (mg, unit of weight) tablet, take two tablets by mouth every 6 hours as needed for mild pain/temperature.Senna 8.6 mg., tablet, take two tablets by mouth every day as needed for no BM (bowel movement – passing waste from the body) up to 48 hours. During a concurrent interview and record review on 7/22/2026, at 1:30 p.m., with LVN 1, Facility 2’s Medication Administration Record, dated Jul 2026 was reviewed. The MAR indicated Patient 6 received one dose of Acetaminophen on 7/1/2026, 7/9/2026, 7/11/2026, 7/19/2026, and two doses on 7/4/2026. LVN 1 stated, “I should have checked Patient 6’s Physician’s Orders and MAR at facility 2 during medication reconciliation to confirm the medications administered to Patient 6. LVN1 stated Patient 6 could be receiving duplicate or double doses of medications or experience medication interactions that could cause Patient 6 to be overmedicated.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” undated, the P&P indicated, “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” 2a. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s SOC date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s Home Health Certification and Plan of Care (POC), for the certification period starting from 5/9/2026 to 7/7/2026, the POC indicated for Patient 2 to receive skilled nurse visits once a week for nine weeks for “assessment and observation on all body systems, assess/monitor vital signs and teaching/instruction regarding disease care management.” During an interview on 7/22/2026 at 8:23 a.m., with Patient 2’s Caregiver (PCG 1), PCG 1 stated there was a large gap in skilled nurse visits from 5/12/2026 to 5/23/2026. PCG 1 stated she (PCG 1) contacted the agency from 5/16/20126 to 5/20/2026 several times to find out when the visiting nurse would make a visit, but no definitive answer was provided. During a concurrent interview and record review on 7/24/2026 at 3:33 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Notes” for May 2026 were reviewed. The Nursing Progress Notes indicated Patient 2 was visited on 5/9/2026, 5/12/2026, and 5/23/2026. The DPCS stated a skilled nurse visit should have been made within seven days from 5/12/2026. The DPCS stated a gap in skilled nurse visits from 5/12/2026 and 5/23/2026 is considered a missed visit. The DPCS stated visits should be conducted once every seven days because it is the agreed upon frequency of treatment between the patient and interdisciplinary team. The DPCS stated there was no communication note from the agency addressing why there was a missed visit. The DPCS stated the DPCS and DPCS Designee should have provided more oversight to ensure missed visits did not occur. The DPCS stated missed visits could result in patient needs being missed and patient assessments not being made, which could lead to patient harm and hospitalization. 2b. During a record review of Patient 5’s medical record form titled “Patient Demographics” undated, the Patient Demographics indicated Patient 5’s start of care date of 1/23/2026, with a primary diagnosis of encounter for fitting and adjustment of urinary device. During a review of Patient 5’s medical record titled “Order/Telephone Order” dated 5/21/2026, indicated Patient 5 was to have Skilled Nurse (SN) visits once a week for eight weeks, starting the week of 5/24/2026. The Order/Telephone Order indicated (DPCSD) was listed as Patient 5’s ordering physician. During a record review on 7/27/2026 at 2:09 p.m., of Patient 5’s electronic medical record (EMR, an electronic health record is the systematized collection of patient and population electronically stored health information in a digital format), Patient 5’s EMR indicated the last SN visit was documented on 7/9/2026. During a concurrent interview and record review on 7/27/2026 at 2:15 p.m., with the DPCSD of Patient 5’s EMR, the DPCSD stated that according to Patient 5’s EMR, Patient 5 was to have SN visits once a week. The DPCSD stated that she (DPCSD) did not know Patient 5 was last seen on 7/9/2026. The DPCSD stated that she (DPCSD) was Patient 5’s ordering physician and that she (DPCDS) wrote Patient 5’s physician order dated 5/21/2026, which ordered to have Patient 5’s visited every week, but did not sign it. The DPCSD stated that no one from the HHA contacted her (DPCSD) to inform her (DPCSD) that Patient 5 had not been seen since 7/9/2026. The DPCSD stated that she (DPCSD) did not know Patient 5’s current admission status. 3a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 4/27/2026, the Order/Telephone Order indicated Patient 1 was referred for admission to the HHA on 4/27/2026 and the Registered Nurse (RN) was to “perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m. with the DPCS, Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a concurrent interview and record review on 7/27/2026, at 1:21 p.m., with the DPCSD, Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCSD stated the Nursing Progress Note was not complete. The DPCSD stated Patient 1 did not have an initial assessment documented, either in the electronic record or paper chart. The DPCSD stated it was important to document an initial assessment because it establishes a baseline for the patient and forms a basis for home care needs. The DPCSD stated initial assessments are important to establish possible risk factors or safety concerns for the patient. The DPCSD stated ensuring that initial assessments are documented is a shared responsibility between the DPCS and DPCS Designee. The DPCSD stated there should be better communication between the visiting RN, DPCS, and DPCSD. 3b. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s SOC date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s medical record titled, “Order/Telephone Order,” dated 4/22/2026, the Order/Telephone Order indicated Patient 2 was referred for admission to the HHA on 4/22/2026 and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a concurrent interview and record review on 7/24/2026 at 3:30 p.m., with the DPCS, Patient 2’s “Nursing Progress Note,” dated 5/9/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. 3c. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated Patient 6’s SOC date was 3/31/2026 with diagnoses include chronic obstructive pulmonary disease (COPD, long-term lung condition making it hard to breathe with episodes of sudden worsening) with (acute) exacerbation, essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 3/31/2026, the Order/Telephone Order indicated Patient 3 was referred for admission to the HHA on 3/31/2026 for “comprehensive skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems … as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, and response to teaching.” During a concurrent interview and record review on 7/24/2026, at 3:09 p.m., with the DPCS, Patient 6’s “Nursing Progress Note,” dated 3/31/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. 3d. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated Patient 7’s start of care date was 5/2/2026 with diagnoses include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a concurrent interview and record review, on 7/24/2026, at 3:09 p.m., with the DPCS, Patient 7’s “Nursing Progress Note,” dated 6/26/2026 were reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. 3e. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s medical record titled, “Order/Telephone Order,” dated 7/13/2026, the Order/Telephone Order indicated Patient 8 was referred for admission to the HHA on 7/13/2026, and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care. RN to report initial assessment findings to MD and verify orders.” During a concurrent interview and record review on 7/24/2026, at 3:38 p.m., with the DPCS, Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. During a concurrent interview and record review on 7/27/2026, at 1:45 p.m., with the DPCS Designee, Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS Designee stated the Nursing Progress Note was not complete. The DPCS Designee stated Patient 8 did not have an initial assessment documented, either in the electronic record or paper chart. During a review of the facility’s policy and procedure titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The initial assessment visit must be performed either within 48 hours of the referral, on the start date ordered by the physician.” 4a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus and bilateral primary osteoarthritis of knee. During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 6/23/2026, the Order/Telephone Order indicated Patient 1 was recertified for home health care at the HHA for the period starting on 6/28/2026 to 8/26/2026 for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the DPCS, Patient 1’s “Nursing Progress Note,” dated 6/23/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the Registered Nurse (RN) who initiated the recertification visit should have completed the recertification assessment documentation. The DPCS stated recertification assessments should be completed within the last five days of each 60-day certification period. During a concurrent interview and record review on 7/27/2026 at 1:34 p.m. with the DPCS Designee, Patient 1’s “Nursing Progress Note,” dated 6/23/2026, was reviewed. The DPCS Designee stated Patient 1 did not have a recertification assessment documented, either in the electronic record or paper chart. The DPCS Designee stated recertification assessments (in general) are completed by the assigned RN. The DPCS Designee stated the recertification assessments are important to document because it outlines the trajectory of the patient and recertifies that the patient still needs home health care. The DPCS Designee stated ensuring recertification assessments are documented is a shared responsibility between the DPCS and DPCS Designee. The DPCS Designee stated there should have been better communication between the visiting RN, DPCS, and DPCS Designee. 4b. During a record review or Patient 3’s medical record form titled “Patient Demographics” undated, indicated Patient 3’s SOC date was 4/27/2026 with a primary diagnosis of type II diabetes with diabetic polyneuropathy. During a record review or Patient 3’s medical record form titled “Recertification (follow-up) Assessment” undated, indicated Patient 3’s body systems were assessed. During a concurrent interview and record review on 7/27/2026 at 11:35 a.m., with the DPCSD of Patient 3’s medical record (in general), the DPCDS stated that Patient 3’s medical record (in general) did not contain an admission order to justify his (Patient 3) admission. The DPCSD stated that Patient 3’s recertification assessment dated 6/24/2026, was incomplete because it did not have Patient 3’s head to toe assessment documented. The DPCSD stated that Patient 3’s recertification assessment needed to be complete to justify his (Patient 3) admission. The DPCSD stated a head-to-toe assessment is required to ensure the patient is getting the right medical treatment. 4c. During a review of Patient 5’s medical record form titled “Patient Demographics” undated, indicated Patient 5’s SOC date was 1/23/2026 with a primary diagnosis of encounter for fitting and adjustment of urinary device. During a review of Patient 5’s medical record form titled “Order/Telephone Order” dated 5/21/2026, indicated Patient 5 was to be recertify for home health services from 5/23/2026 to 7/21/2026. During a review of Patient 5’s medical record form titled “Recertification (follow-up) Assessment” with a lock date of 5/23/2026, did not indicate Patient 5’s strengths/limitations, refused cares, risk factors/hospital admission/emergency room, care preferences/patient personal goals, patient/caregiver education, skilled interventions/instructions, medication status, care coordination, analysis of findings, and home bound reason. During a concurrent interview and record review on 7/27/2026 at 2:05 p.m., with the DPCSD of Patient 5’s medical record, the DPCSD stated that she (DPCSD) was Patient 5’s primary physician. The DPCSD stated that according to Patient 5’s medical record, she (DPCSD) did not know if Patient 5 was discharged or recertified because Patient 5 did not have a current recertification nursing assessment or an admission/discharge order. The DPCSD stated Patient 5’s recertification assessment dated 5/21/2026 was missing elements needed for his (Patient 5) trajectory of care, safety, and to document his (Patient 5) plan of care. The DPCSD stated that she (DPCSD) did not know who documented Patient 5’s rectification assessment dated 5/21/2026 because it does not specify a nurse’s name and it was not signed. 4d. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated Patient 6’s a SOC date was 3/31/2026 with diagnoses included COPD with (acute) exacerbation, essential hypertension, and type 2 diabetes. During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 5/28/2026, the Order/Telephone Order indicated Patient 6 was recertified for home health care at the HHA for the period starting on 5/30/2026 to 7/28/2026 for “skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems … as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention a, and response to teaching.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the DPCS, Patient 6’s “Nursing Progress Note,” dated 5/28/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated Patient 6’s start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments (in general) should be documented within 48 hours of physician referral to HHA. 4e. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated Patient 7’s start of care date was 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure, mixed hyperlipidemia, and unspecified asthma. During a review of Patient 7’s medical record titled, “Order/Telephone Order,” dated 6/26/2026, the Order/Telephone Order indicated Patient 7 was recertified for home health care at the HHA for the period starting on 7/1/2026 – 8/29/2026 and the SN (SN – skilled nurse) was to perform comprehensive skilled nursing services for observation and assessment of vital signs and all body systems…and nutritional status as well as pain level/control, fall/safety measures, physical mobility, knowledge of disease process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention a, and response to teaching. Report significant changes in condition to MD/case manager” During a concurrent interview and record review on 7/24/2026, at 3:09 p.m., with the DPCS, Patient 7’s “Nursing Progress Note,” dated 6/26/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a review of the facility’s policy and procedure titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: the last five (5) days of every 60-day episode beginning with the start of care date (recertification). 5a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus and bilateral primary osteoarthritis of knee. During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit on 7/22/2026, at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed sitting on a bed, awake, alert, oriented to person, place, and time. During an observation, LVN 2 performed a head-to-toe assessment, checked vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and assessed pain level for Patient 1. LVN 2 provided education regarding physical therapy and pain medication to Patient 1. During a concurrent interview and record review on 7/22/2026, at 11:04 a.m., with LVN 2, Patient 1’s POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. LVN 2 stated she (LVN 2) performed a full body assessment, checked vital signs, assessed the pain level, and provided education for Patient 1, but was unable to confirm all the care and services that she just provided were written in the POC. LVN 2 stated Patient 1’s POC was not complete. LVN 2 stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review on 7/27/2026, at 1:30 p.m., with the DPCS Designee, Patient 1’s Home Health Certification and POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 1. The DPCS Designee stated the POC was missing sections for patient goals, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated Patient 1 was being visited and treated without a proper plan of care. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. 5b. During a review or Patient 3’s medical record form titled “Patient Demographics” undated, indicated Patient 3’s SOC was 4/27/2026, with a primary diagnosis of type II diabetes with diabetic polyneuropathy. During a record review or Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/26/2026 to 8/24/2026, did not indicate medical equipment needed, nutritional requirements, orders for discipline and treatments, goals, rehabilitation potential, discharge plans, referral plan, the author of the form, skilled nurse responsibilities, and parameters that were required to be reported to the physician. During a joint home visit and an interview on 7/22/2026, at 11:45 a.m., with LVN3 to Patient 3’s residence. LVN 3 was unable to show Patient 3’s current plan of care. LVN 3 stated the HHA did not provide her (LVN 3) of Patient 3’s current plan of care. During a concurrent interview and record review on 7/27/2026, at 11:35 a.m., with the DPCSD of Patient 3’s medical record (in general), the DPCSD stated Patient 3’s was on his (Patient 3) 2nd certification period from 6/26/2026 to 8/24/2026. The DPCSD stated that Patient 3’s plan of care dated from 6/26/2026 to 8/24/2026 was not done and that the information on it was auto populated from his (Patient 3) recertification period. 5c. During a review of Patient 5’s medical record form titled “Patient Demographics” undated, indicated Patient 5’s SOC date was 1/23/2026 with a primary diagnosis of encounter for fitting and adjustment of urinary device. The form indicated that the DPCSD was Patient 5’s primary physician. During a concurrent interview and record review on 7/27/2026, at 2:05 p.m., with the DPCSD of Patient 5’s medical record, the DPCSD stated that she (DPCDS) was Patient 5’s primary physician. The DPCSD stated that according to Patient 5’s medical record, she (DPCSD) did not know if Patient 5 was discharged or recertified. The DPCSD stated Patient 5’s current plan of care was dated from 5/23/2026 to 7/21/2026, and was not signed by the primary physician, which was her (DPCSD). The DPCSD stated that Patient 5 did not have a current plan of care in his (Patient 5) medical record. 5d. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026, at 1:45 p.m., with the DPCSD, Patient 8’s Home Health Certification and POC for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The DPCSD stated there was no written plan of care developed for Patient 8. The DPCSD stated the POC was missing sections for patient goals, medications, functional limitations, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCSD stated not having a complete POC could result in increased risk of hospitalization. The DPCSD stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCSD stated the DPCS and DPCSD did not provide sufficient oversight to ensure the POC was completed. During an interview on 7/27/2026, at 11:35 a.m., with the DPCSD, the DPCSD stated that patients plan of care directs the care team on the appropriate care, goals, skilled needs, possible therapies, and frequencies for the patient. The DPCSD stated that patients need their plan of care because the plan specifies each patient’s goals to prevent negative outcomes. The DPCSD stated that when a patient does not have a plan of care the possible outcomes are delayed reporting, missed care treatments, and hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) failed to ensure clinical record entries including Outcome and Assessment Information Set (OASIS) assessments and Nursing Progress Notes were completed and authenticated (formally signed, dated, and timed) by the responsible healthcare staff for five of eight sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8). This failure had the potential to compromise the reliability and accuracy of patient information used by the interdisciplinary team for ongoing assessment, care planning, and coordination of services. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 4/29/2026 to 6/27/2026, the POC indicated Patient 1 was admitted for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 1’s Nursing Progress Notes dated 7/3/2026, 7/10/2026, and 7/17/2026 were reviewed. The DPCS stated the Nursing Progress Notes were not electronically signed by the nurse who completed the visit. The DPCS stated the DPCS and DPCS Designee were responsible for ensuring the Nursing Progress Notes were electronically signed and completed. The DPCS stated a clinical record is invalid if it is not electronically signed by the appropriate clinical staff member. During a concurrent interview and record review on 7/24/2026 at 3:10 p.m., with the DPCS, Patient 1’s Initial Outcome and Assessment Information Set (OASIS, a comprehensive assessment for home health patients under CMS that determines Medicare eligibility) dated 4/29/2026 and Recertification OASIS dated 6/22/2026 were reviewed. The DPCS stated both the Initial and Recertification OASIS were not electronically signed. The DPCS stated both OASIS assessments should have been signed by the nurse who completed them to ensure they are valid documents. The DPCS stated a clinical record is invalid if it is not electronically signed by the appropriate clinical staff member. b. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s start of care (SOC) date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period starting from 5/9/2026 to 7/7/2026, the POC indicated for Patient 2 to receive skilled nurse visits once a week for nine weeks for “assessment and observation on all body systems, assess/monitor vital signs and teaching/instruction regarding disease care management.” During a concurrent interview and record review on 7/24/2026 at 3:35 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s Nursing Progress Note dated 7/3/2026 was reviewed. The DPCS stated the Nursing Progress Note was not electronically signed by the nurse who completed the visit. The DPCS stated the DPCS and DPCS Designee were responsible for ensuring the Nursing Progress Notes were electronically signed and completed. The DPCS stated a clinical record is invalid if it is not electronically signed by the appropriate clinical staff member. During a concurrent interview and record review on 7/24/2026 at 3:10 p.m., with the DPCS, Patient 1’s Initial Outcome and Assessment Information Set (OASIS, a comprehensive assessment for home health patients under CMS that determines Medicare eligibility) dated 5/9/2026 was reviewed. The DPCS stated the Initial OASIS was not electronically signed. The DPCS stated the Initial OASIS assessment should have been signed by the nurse who completed them to ensure they are valid documents. The DPCS stated a clinical record is invalid if it is not electronically signed by the appropriate clinical staff member. c. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a concurrent interview and record review on 7/22/2026 at 12:30 p.m. with LVN 1, Patient 6’s ‘Nursing Progress Notes’ dated 6/4/2026, 6/10/2026, 6/16/2026, 6/23/2026, 6/30/2026, 7/7/2026, and 7/14/2026 were reviewed. Each “Nursing Progress Note” lacked the required nurse signature, date, and time. LVN 1 stated “I signed them, but it does not state “electronically signed. Without my signature, the notes cannot be validated.” During a concurrent interview and record review on 7/23/2026 at 12:13 p.m., with Director of Patient Care Services (DPCS – clinical manager responsible for managing nursing services, coordinating interdisciplinary care teams, and adhering to state and federal health care regulations) and Office Manager (OM – staff member of directs day-to-day business operations and oversees adherence to federal regulations), two OASIS assessments for Patient 6 lock dated 4/3/2026 and 5/30/2026, were reviewed. Both OASIS indicated no evidence of the required nursing signature, date, and time. The OM stated the OASIS were submitted to CMS unsigned but acknowledged they should have been signed and dated to indicate clinicians performed assessments and the data matches the patient’s medical record. OM stated there is no specific policy or procedure (P&P - formal document outlining an organization’s rules, consisting of high-level guiding principles and step-by-step instructions) regarding OASIS. During a concurrent interview and record review on 7/23/2026 at 2:30 p.m., with DPCS, Patient 6’s Nursing progress notes for 6/4/2026, 6/10/2026, 6/16/2026, 6/23/2026, 6/30/2026, 7/7/2026, and 7/14/2026 were reviewed. Each “Nursing Progress Notes” indicated no evidence of the required nurse electronic signature, date, and time. The DPCS stated, nurses are required to sign their Nursing Progress Notes for each visit before they submit them. If the Nursing Progress Notes are not signed, they are not valid. d. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a concurrent interview and record review on 7/23/2026 at 12:13 p.m. with DPCS OM, two OASIS assessments for Patient 7 locked dated 5/5/2026 and Patient 7 Assessment dated 6/26/2026 were reviewed. Both OASIS’ indicated no evidence of the required nursing signature, date, and time. The OM stated the OASIS’ were submitted to CMS unsigned, but acknowledged they should have been signed and dated to indicate clinicians performed assessments and the data matches the patient’s medical record. OM stated there is no specific P&P regarding OASIS. During a concurrent interview and record review on 7/23/2026 at 2:30 p.m. with DPCS, Patient 7’s Nursing Progress Notes for 7/3/2026 and 7/10/2026 were reviewed. Each “Nursing Progress Notes” indicated no evidence of the required nurse electronic signature, date, and time. The DPCS stated, nurses are required to sign their Nursing Progress Notes for each visit before they submit them. If the Nursing Progress Notes are not signed, they are not valid. e. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/24/2026 at 3:38 p.m. with the DPCS, Patient 8’s Initial Outcome and Assessment Information Set (OASIS, a comprehensive assessment for home health patients under CMS that determines Medicare eligibility) dated 7/17/2026 was reviewed. The DPCS stated the Initial OASIS was not electronically signed. The DPCS stated the Initial OASIS assessment should have been signed by the nurse who completed them to ensure they are valid documents. The DPCS stated a clinical record is invalid if it is not electronically signed by the appropriate clinical staff member. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated that documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday and clinical notes, dictated or written, will be incorporated into the patient’s health record at least every seven working days.” Failure to authenticate clinical record entries, including OASIS assessments and Nursing Progress Notes, may result in inaccurate patient records, undermine the reliability of clinical documentation, and compromise patient safety and regulatory compliance.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure one of eight patients (Patient 2) received written notice about their rights and responsibilities as a home health patient in their preferred language of communication. This failure resulted in Patient 2 signing consent forms without full knowledge and understanding of her rights and responsibilities as a patient of the home health agency. Findings: During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s start of care (SOC) date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period starting from 5/9/2026 to 7/7/2026, the POC indicated for Patient 2 to receive skilled nurse visits once a week for nine weeks for “assessment and observation on all body systems, assess/monitor vital signs and teaching/instruction regarding disease care management.” During an interview on 7/22/2026 at 8:23 a.m., with Patient Caregiver (PCG) 1, PCG 1 stated Patient 2’s primary language was Spanish. PCG 1 stated Patient 2 was first visited by a skilled nurse from the HHA whose primary language was English on 5/9/2026. PCG 1 stated she contacted the HHA several times to provide Patient 2 a Spanish speaking nurse, but the HHA informed them they could not provide them with any. During an interview on 7/24/2026 at 8:02 a.m., with Patient 2 stated her primary language was Spanish. Patient 2 stated she had difficulty understanding all the skilled nurses from the HHA because they only spoke English and did not use a translator. Patient 2 stated she signed consent forms for the HHA in English because she was not provided Spanish consent forms. Patient 2 stated she felt confused while signing the consent forms because the nurse that completed her SOC visit could not explain what she was signing in Spanish. Patient 2 stated she felt “bad and sad,” because she could not communicate efficiently with anyone from the HHA. During a concurrent interview and record review on 7/24/2026 at 3:35 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Consent/Certification,” dated 5/9/2026 was reviewed. The Consent/Certification indicated it was written in English and signed by Patient 2. The DPCS stated the HHA should have provided a Spanish consent form for Patient 2 to sign because her (Patient 2) primary language is Spanish and Patient 2 should understand what they are consenting to. The DPCS stated it is part of a patient’s rights to receive written information in a language and manner that is understandable to them. The DPCS stated the visiting nurses from the HHA should have used a translator to communicate with Patient 2 during each visit to ensure thorough communication between the HHA and patient. During a review of the facility’s policy and procedure (P&P) titled, “Bill of Rights,” undated, the P&P indicated the Patient Bill of Rights statement defines the right of the patient to have communication needs met. The organization shall provide verbal notice of the patient’s rights and responsibilities in the patient’s primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second visit from a skilled professional (RN, PT, SLP, OT).”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the initial comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five calendar days after the start of care for five of eight sampled patients (Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8). This failure had the potential to result in delayed patient care, decline in functional, physical health and lack of communication between the interdisciplinary team for Patient 1, Patient 2, Patient 6, Patient 7, and Patient 8. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 4/27/2026, the Order/Telephone Order indicated Patient 1 was referred for admission to the HHA on 4/27/2026 and the Registered Nurse (RN) was to “perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a concurrent interview and record review on 7/27/2026 at 1:21 p.m., with the DPCS Designee, Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS Designee stated Patient 1 did not have an initial assessment documented, either in the electronic record or paper chart. The DPCS Designee stated it was important to document an initial assessment because it establishes a baseline for the patient and forms a basis for home care needs. The DPCS Designee stated initial assessments are important to establish possible risk factors or safety concerns for the patient. The DPCS Designee stated ensuring that initial assessments are documented is a shared responsibility between the DPCS and DPCS Designee. The DPCS Designee stated there should have been better communication between the visiting RN, DPCS, and DPCS Designee. b. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s SOC date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s medical record titled, “Order/Telephone Order,” dated 4/22/2026, the Order/Telephone Order indicated Patient 2 was referred for admission to the HHA on 4/22/2026 and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a concurrent interview and record review on 7/24/2026 at 3:30 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Note,” dated 5/9/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. c. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 3/31/2026, the Order/Telephone Order indicated Patient 6 was referred for admission to the HHA on 3/31/2026 for “comprehensive skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, and response to teaching.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 6’s “Nursing Progress Note,” dated 3/31/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. d. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 7’s “Nursing Progress Note,” dated 6/26/2026 were reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. e. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s medical record titled, “Order/Telephone Order,” dated 7/13/2026, the Order/Telephone Order indicated Patient 8 was referred for admission to the HHA on 7/13/2026 and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care. RN to report initial assessment findings to MD and verify orders.” During a concurrent interview and record review on 7/24/2026 at 3:38 p.m., with the Director of Patient Care Services (DPCS), Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the DPCS Designee, Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS Designee stated Patient 8 did not have an initial assessment documented, either in the electronic record or paper chart. During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The initial assessment visit must be performed either within 48 hours of the referral, on the start date ordered by the physician.””

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on observation, interview, and record review, the HHA (Home Health Agency – an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) failed to ensure Licensed Vocational Nurse (LVN) 1 assessed Patient 6 for pain during the home visit conducted on 7/22/2026. This failure resulted in the absence of required pain assessment data and created the potential for unrecognized discomfort, unmanaged pain, increased physiological distress, and delays in appropriate clinical interventions. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During an observation on 7/22/2026 at 1 pm., at Patient 6’s room at facility 1, LVN 1 did not perform a pain assessment during the visit. During a concurrent interview and record review on 7/22/2026 at 2:10 p.m., with LVN 1, Patient 6’s ‘Home Health Certification and Plan of Care’ (POC), dated certification period 5/30/2026-7/28/2026 was reviewed. The POC indicated, “Skilled nurse to perform pain assessment every visit including location, frequency, quality, intensity, aggravating and relieving factors.” LVN stated, “I forgot to assess Patient 6 for pain. I usually do and should have today.” LVN 1 further stated not giving patients pain medications can cause patients physical distress and slow their healing, and “I do not know the policy for pain or what to do unless the patient has pain score of more than a 6.” During a review of the facility’s policy and procedure titled, ‘Pain Management Education, Policy No. 2-031,’ not dated, indicated, “Clinicians will identify patients with pain or who are at risk for pain during initial and ongoing patient assessments.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) failed to ensure that medications administered to patients were reflected on the HHA’s “Patient Medication Profile,” for two of eight sampled patients (Patient 1 and Patient 6). This failure has the potential risk for medication duplication, drug-to-drug interactions, and adverse drug events due to missing or accurate documentation needed to ensure safe medication management. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 4/29/2026 to 6/27/2026, the POC indicated Patient 1 was admitted for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a joint home visit on 7/22/2026 at 10:50 a.m., with Licensed Vocational Nurse (LVN) 2, the following medications were available at Patient 1’s residence but not listed in Patient 1’s medication profile or POC provided by the HHA: - Folic acid (a vitamin used to prevent and treat folate deficiency) 1 milligram (mg, a unit of measurement) tablet, one tablet daily - Ketorolac 0.5% ophthalmic solution (a prescription eye drop used to treat pain, burning, stinging, and swelling after cataract surgery), one drop into the left eye three times a day - Prednisolone acetate 1% eye drops (a prescription steroid medicine used to treat eye swelling, redness, and pain caused by surgery), one drop into the right eye four times a day During an interview on 7/22/2026 at 10:52 a.m., with Medication Technician (MT) 1, MT 1 stated Patient 1 has been taking the folic acid tablets since 6/16/2026. MT 1 stated Patient 1 has been taking both the ketorolac and prednisolone acetate eye drops since 5/28/2026. During a joint home visit on 7/22/2026 at 10:55 a.m., with LVN 2, the following medications were not available in Patient 1’s residence but were listed in Patient 1’s medication profile and POC provided by the HHA: - Tamsulosin (a medication used to treat an enlarged prostate, improve urine flow, and help pass kidney stones) 0.4 mg capsule, one capsule daily - Quetiapine (a medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 200 mg tablet, two tablets daily During an interview on 7/22/2026 at 10:56 a.m., with MT 1, MT 1 stated Patient 1 has not taken the tamsulosin capsules since 11/29/2025. MT 1 stated Patient 1’s order for quetiapine two tablets daily was changed to one tablet daily on 6/17/2026. During an interview on 7/22/2026 at 11:04 a.m. with LVN 2, LVN 2 stated medication reconciliation should have been completed during every visit by the visiting nurse. LVN 2 stated the folic acid tablets, ketorolac solution, and prednisolone eye drops should have been included in the Patient 1’s medication profile because Patient 1 was taking them daily. LVN 2 stated the tamsulosin capsules should have been removed from Patient 1’s medication profile because Patient 1 has not taken them for months. LVN 2 stated the quetiapine tablet orders should have been updated in Patient 1’s medication profile to reflect the correct dosage. LVN 2 stated she (LVN 2) would contact the agency office to ensure Patient 1’s medication profile was current and accurate. During an interview on 7/24/2026 at 3:19 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation should be done regularly at every skilled nurse visit to ensure the medication profile is kept current and accurate. The DPCS stated not completing medication reconciliation at every visit could result in medication errors and possible hospitalization for Patient 1. During an interview on 7/27/2026 at 1:32 p.m. with the DPCS Designee, the DPCS Designee stated the visiting nurse should have reported medication profile discrepancies to either the DPCS or DPCS Designee. The DPCS Designee stated the DPCS and DPCS Designee should have provided sufficient oversight to ensure Patient 1’s medication profile was up to date. b. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a concurrent interview and record review on 7/22/2026 at 2 pm., with LVN 1, Patient 6’s Facility 1 “Physician’s Orders” and “MAR” (Medical Administration Record - official legal report used in healthcare to track patient drugs, timing, and dosages), dated 7/22/2026, and HHA’s “Patient Medication Profile”, undated were reviewed. The Facility 1 “Physician’s Orders” and “MAR” listed the following medications that were not documented on the HHA “Patient Medication Profile”: Acetaminophen (medication used to lower fever and treat mild to moderate pain) 325 mg tablet, take 2 tablets by mouth every 6 hours as needed for mild pain/temp more than 00.0 F NOT TO EXCEED 3GM (gram – unit of measurement)/24 HRS Senna 8.6 MG (milligram – unit of measurement) tablet, take 2 tablets by mouth every day as needed for no BM (bowel movement – passing waste from the body) up to 48 hours.Review of Facility 1 MAR indicated Patient 6 Acetaminophen on 7/1/2026, 7/4/2026 (two doses), 7/9/2026, 7/11/2026, and 7/19/2026 LVN 1 stated, “I should have checked Patient 6’s Facility 1 “Physician’s Orders” and “MAR” during medication reconciliation to confirm the medications administered matched HHA “Patient Medication Profile. If that is not done, Patient 6 could be receiving duplicate doses of medications or experience medication interactions.” During a concurrent interview and record review on 7/24/2026 at 3:09 pm., with Director of Patient Care Services (DPCS – clinical manager responsible for patient care services), Patient 6 Facility 1’s “Physician’s Orders” and “MAR”, and HHA’s “Patient Medication Profile”, undated were reviewed. The same discrepancies were observed - medications administered at Facility 1 were not reflected on the HHA’s medication profile. The DPCS stated, “Patient 6’s medication reconciliation was not performed correctly. This is a medication error, and the patient could be hospitalized or die.” During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Medication Profile,” undated, the P&P indicated, “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.””

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the recertification comprehensive assessment (a required evaluation completed during the final 5 days of a 60-day certification period to establish ongoing patient eligibility) was completed within the last five days of a 60-day certification period for five of eight sampled patients (Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7). This failure had the potential to result in ineligible patients being recertified for home health care and a lack of communication between the interdisciplinary team for Patient 1, Patient 3, Patient 5, Patient 6, and Patient 7. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 6/23/2026, the Order/Telephone Order indicated Patient 1 was recertified for home health care at the HHA for the period starting on 6/28/2026 to 8/26/2026 for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 1’s “Nursing Progress Note,” dated 6/23/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the Registered Nurse (RN) who initiated the recertification visit should have completed the recertification assessment documentation. The DPCS stated recertification assessments should be completed within the last five days of each 60-day certification period. During a concurrent interview and record review on 7/27/2026 at 1:34 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Nursing Progress Note,” dated 6/23/2026, was reviewed. The DPCS Designee stated Patient 1 did not have a recertification assessment documented, either in the electronic record or paper chart. The DPCS Designee stated recertification assessments are completed by the assigned RN. The DPCS Designee stated the recertification assessments are important to document because it outlines the trajectory of the patient and recertifies that the patient still needs home health care. The DPCS Designee stated ensuring recertification assessments are documented is a shared responsibility between the DPCS and DPCS Designee. The DPCS Designee stated there should have been better communication between the visiting RN, DPCS, and DPCS Designee. b. During a record review or Patient 3’s medical record form titled “Patient Demographics” undated, indicated a start of date care of4/27/2026 with a primary diagnosis of type II diabetes (high blood sugar) with diabetic polyneuropathy (malfunctioning body nerves casing numbness, tingling, and muscle weakness). During a record review or Patient 3’s medical record form titled “Recertification (follow-up) Assessment” undated, did indicate Patient 3’s body systems were assessed. During a concurrent interview and record review on 7/27/2026 at 11:35 a.m., with the DPCSD of Patient 3’s medical record, the DPCDS stated that Patient 3’s medical record did not contain an admission order to justify his admission. The DPCSD stated that Patient 3’s recertification assessment dated 6/24/2026, was incomplete because it did not have Patient 3’s head to toe assessment documented. The DPCSD stated that Patient 3’s recertification assessment needed to be complete to justify his (Patient 3) admission. The DPCSD stated that without a head-to-toe assessment is required to ensure the patient is getting the right medical treatment. c. During a record review of Patient 5’s medical record form titled “Patient Demographics” undated, indicated a start of care date of 1/23/2026 with a primary diagnosis of encounter for fitting and adjustment of urinary device. Lastly, the form indicated that the DPCSD was Patient 5’s primary physician. During a record review of Patient 5’s medical record form titled “Order/Telephone Order” dated 5/21/2026, indicated Patient 5 was to be recertify for home health services from 5/23/2026 to 7/21/2026. The form also indicated the DPCSD was Patient 5’s ordering physician. Lastly, the form did not indicate the DPCSD signature. During a record review of Patient 5’s medical record form titled “Recertification (follow-up) Assessment” with a lock date of 5/23/2026, did not indicate Patient 5’s strengths/limitations, refused cares, risk factors/hospital admission/emergency room, care preferences/patient personal goals, patient/caregiver education, skilled interventions/instructions, medication status, care coordination, analysis of findings, and home bound reason. During a concurrent interview and record review on 7/27/2026 at 2:05 p.m., with the DPCSD of Patient 5’s medical record, DPCSD stated that according to Patient 5’s medical record, she did not know if Patient 5 was discharge or recertified because Patient 5 did not have a current recertification nursing assessment or an admission/discharge order. The DPCSD stated that Patient 5’s recertification assessment dated 5/21/2026 was missing elements needed for his (Patient 5) trajectory of care, safety, and to document his (Patient 5) plan of care. The DPCSD stated that she did not know who documented Patient 5’s rectification assessment dated 5/21/2026 because it does not specify a nurse’s name and it was not signed. d. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 5/28/2026, the Order/Telephone Order indicated Patient 6 was recertified for home health care at the HHA for the period starting on 5/30/2026 to 7/28/2026 for “skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems … as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, and response to teaching.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 6’s “Nursing Progress Note,” dated 5/28/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. e. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a review of Patient 7’s medical record titled, “Order/Telephone Order,” dated 6/26/2026, the Order/Telephone Order indicated Patient 7 was recertified for home health care at the HHA for the period starting on 7/1/2026 – 8/29/2026 and the SN (SN – skilled nurse) was to perform comprehensive skilled nursing services for observation and assessment of vital signs and all body systems…and nutritional status as well as pain level/control, fall/safety measures, physical mobility, knowledge of disease process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention a, and response to teaching. Report significant changes in condition to MD/case manager” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m. with the Director of Patient Care Services (DPCS), Patient 7’s “Nursing Progress Note,” dated 6/26/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: the last five (5) days of every 60-day episode beginning with the start of care date (recertification).”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the individualized plan of care (POC, a document where a doctor certifies that a patient needs home health services, outlining the specific skilled care [nursing, therapy], medical equipment, frequency of visits, and goals) included patient-specific interventions and education for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit on 7/22/2026 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed sitting on a bed, awake, alert, oriented to person, place, and time. During an observation, LVN 2 performed a head-to-toe assessment, checked vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and assessed pain level for Patient 1. LVN 2 also provided education regarding physical therapy and pain medication to Patient 1. During a concurrent interview and record review on 7/22/2026 at 11:04 a.m., with LVN 2, Patient 1’s POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. LVN 2 stated she performed a full body assessment, checked vital signs, assessed the pain level, and provided education for Patient 1, but was unable to confirm all the care and services that she just provided were written in the POC. LVN 2 stated Patient 1’s POC was not complete. LVN 2 stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review on 7/27/2026 at 1:30 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 1. The DPCS Designee stated the POC was missing sections for patient goals, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated Patient 1 was being visited and treated without a proper plan of care. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. b. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 8’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 8. The DPCS Designee stated the POC was missing sections for patient goals, medications, functional limitations, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. The DPCS Designee stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCS Designee stated the DPCS and DPCS Designee did not provide sufficient oversight to ensure the POC was completed. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview, observation, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure physician orders were recorded in the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for two of eight sampled patients (Patient 1 and Patient 8). This failure had the potential to affect patient safety and impair continuity and coordination of care that could impact the patients’ quality of care and well being. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identified patient-specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit on 7/22/2026 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed sitting on a bed, awake, alert, oriented to person, place, and time. During an observation, LVN 2 performed a head-to-toe assessment, checked vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and assessed pain level for Patient 1. LVN 2 also provided education regarding physical therapy and pain medication to Patient 1. During a concurrent interview and record review on 7/22/2026 at 11:04 a.m., with LVN 2, Patient 1’s POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. LVN 2 stated she (LVN 2) performed a full body assessment, checked vital signs, assessed the pain level, and provided education for Patient 1, but was unable to confirm all the care and services that she just provided were written in the POC. LVN 2 stated Patient 1’s POC was not complete. LVN 2 stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review on 7/27/2026 at 1:30 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 1. The DPCS Designee stated the POC was missing sections for patient goals, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated Patient 1 was being visited and treated without a POC. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. b. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identified patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 8’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The DPCS Designee stated there was no written plan of care developed for Patient 8. The DPCS Designee stated the POC was missing sections for patient goals, medications, functional limitations, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. The DPCS Designee stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCS Designee stated the DPCS and DPCS Designee did not provide sufficient oversight to ensure the POC was completed. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA – an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) failed to ensure that services were provided only as ordered by a physician or allowed partitioner for two of eight sampled patients (Patient 6 and Patient 7). This failure resulted in physical therapy services being documented without evidence of authorization from the physician that placed the patients at risk of receiving services without verified physical therapy necessity, and assurance that the services aligned with patients’ physical therapy needs. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a concurrent interview and record review on 7/23/2026 at 2:05 pm, with Director of Patient Care Services (DPCS – clinical manager responsible for managing nursing services, coordinating interdisciplinary care teams, and adhering to state and federal health care regulations) and Office Manager (OM – staff member of directs day-to-day business operations and oversees adherence to federal regulations), Patient 6’s ‘Physical Therapy Evaluation and Plan of Care (Includes Route Sheet and MD Order)’, dated 5/31/2026 and 7’s ‘Physical Therapy Assessment’, dated 5/12/2026 were reviewed. The DPCS stated both documents contained no physician signature to authorize physical therapy services. The OM stated the physician must sign an order for physical therapy to validate necessity and ensure patient safety. During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Verification of Physician Orders, Policy No. 2-002,” undated, the P&P indicated “Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients:, “Orders, including verbal orders, are accepted, signed and dated by authorized personnel as defined by the organization’s policy and local, state or federal law and regulation”, “Orders will be signed and dated and indicate the time the order was received,:, and The original of the order form will be delivered to the physician (or other authorized licensed independent practitioner) for signature”, and “A copy of the physician’s (or allowed practitioner’s) orders will be documented in the patient’s clinical record by a registered nurse acting in accordance with state licensure requirement or other practitioner responsible for furnishing or supervising the ordered services.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the physician reviewed the Plan of Care (POC - written, step-by-step roadmap detailing a patient’s health diagnoses, treatment goals, and specific medical interventions) for four of eight sampled patients (Patient 1, Patient 6, Patient 7, and Patient 8). This failure had the potential to result in delayed care and lack of coordination between the interdisciplinary team (IDT, coordinated group of medical, clinical, and support professionals who work together to create, manage, and evaluate a unified care plan for a patient). a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a concurrent interview and record review on 7/24/2026 at 3:09 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s “Home Health Certification and Plan of Care,” (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The POC indicated it was not signed by a physician. The DPCS stated the POC was not signed by a physician, either physically or electronically. The DPCS stated physicians must sign POCs because it will indicate that they agree with and acknowledge the plan of care. b. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a concurrent interview and record review on 7/23/2026 at 1 p.m., with Director of Patient Care Services (DPCS – clinical manager responsible for managing nursing services, coordinating interdisciplinary care teams, and adhering to state and federal health care regulations), Patient 6’s “Home Health Certification & Plan of Care” (POC) dated 3/31/2026 - 5/29/2026 and 5/30/2026 - 7/28/2026 were reviewed. Both “Home Health Certification & Plan of Care” indicated no evidence of a physician’s signature. The DPCS stated, “The POC is not compliant and should have been signed by the physician. This was not caught during the review period. Without the physician’s signature, patient care could be delayed due to no established need for medical care.” c. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a concurrent interview and record review on 7/23/2026 at 1 p.m., with DPCS, Patient 7’s “Home Health Certification & Plan of Care” dated 5/2/2026 - 6/30/2026 and 7/1/2026 - 8/29/2026 were reviewed. Both “Home Health Certification & Plan of Care” indicated no evidence of a physician’s signature. The DPCS stated, “The POC was not compliant and should have been signed by the physician. This was not caught during the review period. Without the physician’s signature, patient care could be delayed due to no established need for medical care.” d. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a concurrent interview and record review on 7/24/2026 at 3:38 p.m., with the DPCS, Patient 8’s “Home Health Certification and Plan of Care,” (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The POC indicated it was not signed by a physician, therefore it was not complete. The DPCS stated the POC was not signed by a physician, either physically or electronically. The DPCS stated physicians must sign POCs because it indicates that they agree with and acknowledge the plan of care. During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Admission Criteria and Process, Policy No. 1-001”, not dated, the P&P indicated “The patient’s physician (or other authorized licensed independent practitioner) must order and approve the provision of any service. A Skilled Service must be ordered.” During a review of the facility’s P&P titled, “Care Planning Process, Policy No. 1-007”, not dated, the P&P indicated “the patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient.””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure one of eight sampled patients (Patient 2) received a physical therapist (PT, a licensed healthcare professional who helps patients manage pain, improve movement, and recover from injuries) initial evaluation and order as indicated in the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) within 48 hours of referral. This failure resulted in Patient 2 not receiving physical therapy services in a timely manner, which increased the risk of injury and pain that could lead to hospitalization. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s start of care (SOC) date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period starting from 5/9/2026 to 7/7/2026, the POC indicated for Patient 2 to receive skilled nurse visits once a week for nine weeks for “assessment and observation on all body systems, assess/monitor vital signs and teaching/instruction regarding disease care management.” The POC also indicated for physical therapy to evaluate and set up plan of treatment. During an interview on 7/22/2026 at 8:23 a.m., with Patient Caregiver (PCG) 1, stated Patient 2 was admitted to the HHA on 5/9/2026. PCG 1 stated they were not seen by a PT until about two weeks after admission. PCG 1 stated they called the HHA several times after admission to find out when physical therapy would begin but the HHA did not provide a clear answer. During a concurrent interview and record review on 7/24/2026 at 3:35 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s electronic clinical record was reviewed. The clinical record indicated Patient 2 was referred to the HHA on 4/22/2026. The clinical record indicated Patient 2 was admitted to the HHA on 5/9/2026 for home health care and “Physical Therapy for functional ability training and safety education.” The clinical record indicated the initial PT evaluation, and PT order was written on 5/20/2026. The DPCS stated Patient 2’s initial evaluation should have been completed within 48 hours from admission to the HHA. The DPCS stated there was a delay of care for Patient 2 because the initial PT evaluation was put in on 5/20/2026. The DPCS stated delaying PT could result in decreased mobility, increased pain and injury, and possible hospitalization. The DPCS stated, both DPCS and DPCS Designee are responsible for ensuring orders for PT are inputted in a timely manner. During a review of the facility’s policy and procedure (P&P) titled, “Internal Referral Process,” undated, the P&P indicated that the clinician assigned to provide additional services will contact the physician (or other authorized licensed independent practitioner) for orders for evaluation and treatment. A 48-hour PT, OT, and ST evaluation requirement applies when the PT, OT, and ST is performing the patient’s initial admission assessment.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation, interview, and record review, the Administrator (ADM - the chief operational and compliance leader who manages the day-to-day business, financial, and regulatory functions of an agency providing in-home patient care to ensure safe patient services, supervise office and field staff, and enforce federal and state healthcare laws), failed to organize and administer the agency’s day‑to‑day operations to ensure effective oversight of personnel, maintenance of administrative functions, continuity of clinical supervision, and adherence to regulatory requirements. These failures resulted in medication errors, skipped patient care visits, lack of authentication by medical providers for medical documentation, and risk of harm to patient care. During an observation on 7/21/2026 at 9:55 a.m., at 1434 Hauser Boulevard, Los Angeles, California, 90019, there was unopened mail addressed to Home Health Agency (HHA – an official organization that provides medical care, skilled nursing, and therapy services directly inside patients’ homes) in the mailbox and no staff present. Repeated knocking at the door went unanswered. A sign indicated the HHA had “moved locations” and provided a new address but no documentation of an approved change of location was available. During an interview on 7/21/2026 at 12:18 p.m., with ADM, stated he did not submit a change of location because he was waiting for the CHOW (Change of Ownership - the official regulatory process used when a Medicare-certified healthcare provider or supplier is bought, leased, or reorganized, transferring the existing provider agreement and billing privileges to a new owner) approval, and that staff were expected to be present at the Hauser location daily from 9 a.m. until 11 a.m. During a concurrent interview and record review on 7/23/2026 at 10:50 a.m., with the ADM, the HHA’s organizational chart, dated 7/1/2026 was reviewed. The organizational chart indicated the ADM was the CEO (Chief Executive Office – highest ranking person in a company or group who leads the business)/CFO (Chief Financial Officer – highest ranking executive in charge of a company’s finances, money tracking and economic planning)/ADM and replaced the previous CEO/ADM, no ADM designee was identified, and the Director of Patient Care Services (DPCS - clinical manager responsible for managing nursing services, coordinating interdisciplinary care teams, and adhering to state and federal health care regulations) reported directly to the ADM, despite the ADM stating, “I am not clinical and do not do anything with patient care.” The ADM further stated the ADM functioned informally as the ADMD until 7/1/2026 after the prior ADM resigned, but there is no documentation assigning these responsibilities. During a concurrent interview and record review on 7/24/2026 at 2:26 p.m., with DPCS, Patient 6’s “Home Health Certification & Plan of Care” dated 3/31/2026-5/29/2026 and 5/30/2026-7/28/2026 and Patient 7’s “Home Health Certification & Plan of Care” dated 5/2/2026-6/30/2026 were reviewed. Each of the three Plans of Care indicated electronic signatures for the DPCS. The DPCS stated the DPCS did not sign the documents and had no access to the computer system until 7/23/2026. No documentation existed for medical leave or delegation of DPCS responsibilities. During a concurrent interview and record review on 7/24/2026 at 2:26 p.m., with DPCS, “DPCS’ employee personnel file was reviewed. The DPCS’s personnel file indicated all documents signed on 1/2/2026. The DPCS stated the application for DPCS was completed and submitted to the HHA in May 2026, and the ADM instructed DPCS not to fill in the date fields. During interview on 7/28/2026 at 11 a.m., with ADM, ADM stated the previous owner verbally agreed to act as ADM, with the current ADM functioning as ADMD, but no written documentation supported this arrangement. The ADM further stated “I am not clinical. The DPCS does not report to me, I have no recollection of attending any of the weekly case conferences regarding patient care, I did not document the DPCS leave or designee periods and was unaware that DPCSD provided care to 42 of the agency’s 131 patients, and “I did not complete my duty as ADM for the HHA. Those are my lapses. I should have been more connected, more communicative with my staff, DPCS, and DPCSD. I’m not as qualified as I thought I was. It is important to be qualified as an ADM because it impacts patients’ lives.” The Administrator’s failure to maintain administrative presence, ensure proper delegation of authority, establish and document clinical supervision, oversee staff functioning, and maintain governing structure and regulatory compliance resulted in a breakdown of organizational and administrative operations and posed a risk to the coordination and delivery of patient care.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the initial comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) and recertification comprehensive assessments (a required evaluation completed during the final 5 days of a 60-day certification period to establish ongoing patient eligibility) were documented in the clinical record for seven of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, and Patient 8). This failure resulted Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, and Patient 8 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 4/27/2026, the Order/Telephone Order indicated Patient 1 was referred for admission to the HHA on 4/27/2026. The Registered Nurse (RN) was to “perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a review of Patient 1’s medical record titled, “Order/Telephone Order,” dated 6/23/2026, the Order/Telephone Order indicated Patient 1 was recertified for home health care at the HHA for the period starting on 6/28/2026 to 8/26/2026 for “skilled assessment of vital signs and all body systems, medication regimen, and home safety evaluation.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a concurrent interview and record review on 7/24/2026 at 3:10 p.m., with the Director of Patient Care Services (DPCS), Patient 1’s “Nursing Progress Note,” dated 6/23/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the Registered Nurse (RN) who initiated the recertification visit should have completed the recertification assessment documentation. The DPCS stated recertification assessments should be completed within the last five days of each 60-day certification period. During a concurrent interview and record review on 7/27/2026 at 1:21 p.m., with the DPCS Designee, Patient 1’s “Nursing Progress Note,” dated 4/29/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS Designee stated Patient 1 did not have an initial assessment documented, either in the electronic record or paper chart. The DPCS Designee stated it was important to document an initial assessment because it establishes a baseline for the patient and forms a basis for home care needs. The DPCS Designee stated initial assessments are important to establish possible risk factors or safety concerns for the patient. The DPCS Designee stated ensuring that initial assessments are documented is a shared responsibility between the DPCS and DPCS Designee. The DPCS Designee stated there should have been better communication between the visiting RN, DPCS, and DPCS Designee. During a concurrent interview and record review on 7/27/2026 at 1:34 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s “Nursing Progress Note,” dated 6/23/2026, was reviewed. The DPCS Designee stated Patient 1 did not have a recertification assessment documented, either in the electronic record or paper chart. The DPCS Designee stated recertification assessments are completed by the assigned RN. The DPCS Designee stated the recertification assessments are important to document because it outlines the trajectory of the patient and recertifies that the patient still needs home health care. The DPCS Designee stated ensuring recertification assessments are documented is a shared responsibility between the DPCS and DPCS Designee. b. During a review of Patient 2’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 2’s SOC date was 5/9/2026, with diagnoses that include type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and complete rotator cuff tear or rupture of unspecified shoulder (injury to a group of muscles and tendons in the shoulder that can cause shoulder pain and the inability to use your arm). During a review of Patient 2’s medical record titled, “Order/Telephone Order,” dated 4/22/2026, the Order/Telephone Order indicated Patient 2 was referred for admission to the HHA on 4/22/2026 and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care.” During a concurrent interview and record review on 7/24/2026 at 3:30 p.m., with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Note,” dated 5/9/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. c. During a record review or Patient 3’s medical record form titled “Patient Demographics” undated, indicated a start of date care of 4/27/2026 with a primary diagnosis of type II diabetes (high blood sugar) with diabetic polyneuropathy (malfunctioning body nerves casing numbness, tingling, and muscle weakness). During a record review or Patient 3’s medical record form titled “Recertification (follow-up) Assessment” undated, did indicate Patient 3’s body systems were assessed. During a concurrent interview and record review on 7/27/2026 at 11:35 a.m., with the DPCSD of Patient 3’s medical record, the DPCDS stated that Patient 3’s medical record did not contain an admission order to justify his (Patient 3) admission. The DPCSD stated that Patient 3’s recertification assessment dated 6/24/2026, was incomplete because it did not have Patient 3’s head to toe assessment documented. The DPCSD stated that Patient 3’s recertification assessment needed to be complete to justify his (Patient 3) admission. The DPCSD stated that without a head-to-toe assessment is required to ensure the patient is getting the right medical treatment. d. During a record review of Patient 5’s medical record form titled “Patient Demographics” undated, indicated a start of care date of 1/23/2026 with a primary diagnosis of encounter for fitting and adjustment of urinary device. Lastly, the form indicated that the DPCSD was Patient 5’s primary physician. During a record review of Patient 5’s medical record form titled “Order/Telephone Order” dated 5/21/2026, indicated Patient 5 was to be recertify for home health services from 5/23/2026 to 7/21/2026. The form also indicated the DPCSD was Patient 5’s ordering physician. Lastly, the form did not indicate the DPCSD signature. During a record review of Patient 5’s medical record form titled “Recertification (follow-up) Assessment” with a lock date of 5/23/2026, did not indicate Patient 5’s strengths/limitations, refused cares, risk factors/hospital admission/emergency room, care preferences/patient personal goals, patient/caregiver education, skilled interventions/instructions, medication status, care coordination, analysis of findings, and home bound reason. During a concurrent interview and record review on 7/27/2026 at 2:05 p.m., with the DPCSD of Patient 5’s medical record, the DPCSD stated that she (DPCDS) was Patient 5’s primary physician. The DPCSD stated that according to Patient 5’s medical record, she (DPCSD) did not know if Patient 5 was discharge or recertified because Patient 5 did not have a current recertification nursing assessment or an admission/discharge order. The DPCSD stated that Patient 5’s recertification assessment dated 5/21/2026 was missing elements needed for his (Patient 5) trajectory of care, safety, and to document his (Patient 5) plan of care. The DPCSD stated that she (DPCSD) did not know who documented Patient 5’s rectification assessment dated 5/21/2026 because it does not specify a nurse’s name and it was not signed. e. During a review of Patient 6’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 3/31/2026 with diagnoses that include chronic obstructive pulmonary disease with (acute) exacerbation (long-term lung condition making it hard to breathe with episodes of sudden worsening), essential hypertension (high blood pressure with no single medical cause), and type 2 diabetes (high blood sugar). During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 3/31/2026, the Order/Telephone Order indicated Patient 6 was referred for admission to the HHA on 3/31/2026 for “comprehensive skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems … as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, and response to teaching.” During a review of Patient 6’s medical record titled, “Order/Telephone Order,” dated 5/28/2026, the Order/Telephone Order indicated Patient 6 was recertified for home health care at the HHA for the period starting on 5/30/2026 to 7/28/2026 for “skilled nursing assessment, and evaluation of vital signs, COVID-19 signs/symptoms and all body systems … as well as pain level/control, nutrition/hydration, fall/safety measures, physical mobility, knowledge process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, and response to teaching.” During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 6’s “Nursing Progress Note,” dated 3/31/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. During a concurrent interview and record review on 7/24/2026 at 3:10 p.m., with the Director of Patient Care Services (DPCS), Patient 6’s “Nursing Progress Note,” dated 5/28/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. f. During a review of Patient 7’s medical record form titled “Patient Profile”, undated, indicated a start of care date of 5/2/2026 with diagnoses that include hypertensive heart disease with heart failure (long-term medical condition where high blood pressure forces the heart to work too hard, causing the main pumping muscle to thicken and eventually weakens the heart so that it cannot pump blood well), mixed hyperlipidemia (medical condition marked by high levels of both LDL (“bad”) cholesterol and triglycerides in the blood), and unspecified asthma (long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways making it difficult to breath). During a review of Patient 7’s medical record titled, “Order/Telephone Order,” dated 5/2/2026, the Order/Telephone Order indicated Patient 7 was referred for admission to the HHA on 5/2/2026 for “comprehensive skilled nursing assessment for observation and assessment of vital signs and all body systems … as well as pain level/control, fall/safety measures, physical mobility, knowledge of disease process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention, response to teaching. Report significant changes in condition to MD/case manager.” During a review of Patient 7’s medical record titled, “Order/Telephone Order,” dated 6/26/2026, the Order/Telephone Order indicated Patient 7 was recertified for home health care at the HHA for the period starting on 7/1/2026 – 8/29/2026 and the SN (SN – skilled nurse) was to perform comprehensive skilled nursing services for observation and assessment of vital signs and all body systems…and nutritional status as well as pain level/control, fall/safety measures, physical mobility, knowledge of disease process and its associated care and treatment, compliance/response/effectiveness and s/sx of complications necessitating medical attention a, and response to teaching. Report significant changes in condition to MD/case manager”. During a concurrent interview and record review on 7/24/2026 at 3:09 p.m., with the Director of Patient Care Services (DPCS), Patient 7’s “Nursing Progress Note,” dated 6/26/2026 were reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the nurse who initiated the start of care (SOC) visit should have completed the initial assessment documentation. The DPCS stated the initial assessments should be documented within 48 hours of physician referral to the HHA. g. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s medical record titled, “Order/Telephone Order,” dated 7/13/2026, the Order/Telephone Order indicated Patient 8 was referred for admission to the HHA on 7/13/2026 and the Registered Nurse (RN) was to perform comprehensive skilled assessment of all body system, vital signs, medication regimen and all other home health care services issues/needs utilizing the OASIS comprehensive assessment/data collection system for the implementation, formulation and establishment of physician order and plan of care. RN to report initial assessment findings to MD and verify orders.” During a concurrent interview and record review on 7/24/2026 at 3:38 p.m., with the Director of Patient Care Services (DPCS), Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS stated the sections for assessing homebound status, vital signs, head to toe assessments, and skilled teaching instructions to patient or caregiver were blank. The DPCS stated the RN who initiated the start of care (SOC) visit should have completed the initial assessment documentation. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the DPCS Designee, Patient 8’s “Nursing Progress Note,” dated 7/17/2026 was reviewed. The DPCS stated the Nursing Progress Note was not complete. The DPCS Designee stated Patient 8 did not have an initial assessment documented, either in the electronic record or paper chart. During a review of the facility’s policy and procedure (P&P - formal rules and action steps an organization uses to run safely and smoothly) titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The initial assessment visit must be performed either within 48 hours of the referral, on the start date ordered by the physician.” During a review of the facility’s policy and procedure titled, “Initial and Comprehensive Assessment,” undated, the P&P indicated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: the last five (5) days of every 60-day episode beginning with the start of care date (recertification). During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated that documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday and clinical notes, dictated or written, will be incorporated into the patient’s health record at least every seven working days.””

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that the plan of care (POC, a document where a doctor certifies that a patient needs home health services, outlining the specific skilled care [nursing, therapy], medical equipment, frequency of visits, and goals) included patient’s specific interventions, medications, treatments, services, and education for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identified the patient’s specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit on 7/22/2026 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, Patient 1 was observed sitting on a bed, awake, alert, oriented to person, place, and time. During an observation, LVN 2 performed a head-to-toe assessment, checked vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and assessed pain level for Patient 1. LVN 2 also provided education regarding physical therapy and pain medication to Patient 1. During a concurrent interview and record review on 7/22/2026 at 11:04 a.m., with LVN 2, Patient 1’s POC for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. LVN 2 stated she performed a full body assessment, checked vital signs, assessed the pain level, and provided education for Patient 1, but was unable to confirm all the care and services that she just provided were written in the POC. LVN 2 stated Patient 1’s POC was not complete. LVN 2 stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review on 7/27/2026 at 1:30 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated the POC was missing sections for patient care goals, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated Patient 1 was being visited and treated without a proper plan of care. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. b. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identified the patient’s specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 8’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. The DPCS Designee stated the POC was missing sections for patient care goals, medications, functional limitations, rehabilitation potentials, physician orders, visit frequency, and homebound status. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. The DPCS Designee stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCS Designee stated the DPCS and DPCS Designee did not provide sufficient oversight to ensure the POC was completed. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated that documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday and clinical notes, dictated or written, will be incorporated into the patient’s health record at least every seven working days.” During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the plan of care (POC, a document where a doctor certifies that a patient needs home health services, outlining the specific skilled care [nursing, therapy], medical equipment, frequency of visits, and goals) included patient-specific goals and the patient’s progress toward achieving them for two of eight sampled patients (Patient 1 and Patient 8). This failure resulted in Patient 1 and Patient 8 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. a. During a review of Patient 1’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 1’s SOC date was 4/29/2026, with diagnoses that include epilepsy, unspecified, not intractable without status epilepticus (recurrent seizure disorder that is not life-threateningly prolonged and is generally responsive to treatment or control) and bilateral primary osteoarthritis of knee (gradual wear and tear of the cartilage in both knees without a specific past injury). During a review of Patient 1’s Home Health Certification and Plan of Care for the certification period starting from 6/28/2026 to 8/26/2026, the POC indicated it was not signed by a physician and there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:30 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 6/28/2026 to 8/26/2026 was reviewed. The DPCS Designee stated there were no written goals included in the plan of care Patient 1. The DPCS Designee stated the POC was missing sections for patient goals and the patient’s progress toward achieving the goals. The DPCS Designee stated Patient 1 was being visited and treated without a proper plan of care. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. b. During a review of Patient 8’s medical record titled, “Patient Demographics,” the Patient Demographics indicated Patient 8’s SOC date was 7/17/2026 with a primary diagnosis of essential hypertension (high blood pressure). During a review of Patient 8’s Home Health Certification and Plan of Care for the certification period starting from 7/17/2026 to 9/14/2026, the POC indicated it was not signed by a physician and there was no plan of care that identified patient’s specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review on 7/27/2026 at 1:45 p.m., with the Director of Patient Care Services Designee (DPCS Designee), Patient 8’s Home Health Certification and Plan of Care (POC) for the certification period starting from 7/17/2026 to 9/14/2026 was reviewed. DPCS Designee stated the POC was missing sections for patient care goals and the patient’s progress toward achieving the goals. The DPCS Designee stated not having a complete POC could result in increased risk of hospitalization. The DPCS Designee stated the visiting RN who completed the start of care (SOC) visit should have completed the POC within five days of the visit. The DPCS Designee stated the DPCS and DPCS Designee did not provide sufficient oversight to ensure the POC was completed. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated that documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday and clinical notes, dictated or written, will be incorporated into the patient’s health record at least every seven working days.” During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” undated, the P&P indicated a written individualized plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The patient-specific clinical plan of care includes all patient care orders including verbal orders, homebound status, measurable outcomes and goals identified by organization and the patient, medications and treatments, patient-specific interventions and education, etc.”