Blue Horizon Pk, Inc.

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard 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 provide copies of their individualized plan of care (a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) for two of seven sampled patients (Patient 1 and 5). This deficient practice resulted in Patients 1 and 5 not being informed about services, goals, care schedules, medical instructions, and safety measures. Findings: a. A review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a start of care date of 5/8/2026 and a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) of 7/7/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), essential hypertension (high blood pressure), asthma (a long-term lung disease that causes inflammation, swelling, and narrowing of the airways), myalgia (muscle aches and pains) and radiculopathy of lumbar region (pinched nerve-occurs when a nerve root in the spine is compressed, inflamed, or injured). Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. During a concurrent record review and interview on 9/2/2026 at 3:30pm, Patient 1’s Home Health Folder (a folder given to patients from the HHA that includes important information about the about the agency and the services they are providing) was reviewed with Administrator/Director of Nursing (ADM/DPCS) and did not have a copy of Patient 1’s Plan of Care. The ADM/DPCS stated that she did not give Patient 1 a copy of the Plan of Care because she did not know she was supposed to. ADM/DPCS stated that they should be given a copy incase a different nurse came to visit the patient, they would have a copy to look at, also so the patient and family know the care they are supposed to be receiving. A review of the HHA’s policy titled “Care Planning Process”, dated November 2022, indicated that a written plan of care will be initiated within five (5) says of start of care. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A.Visit schedule, including the day of the week, frequency of visits by personnel and personnel acting on behalf of the organization. B. Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization C. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. D. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs. A review of Patient ’s 5’s undated Patient Profile indicated that the HHA admitted Patient 5, a 67-year-old male, on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026to 10/8/2026. Patient 5 was to receive skilled nursing home visit once a week for 9 weeks, and certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The document also indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and observation at Patient 5’s home on 9/2/2026 at 3:30 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the HHA sends him a copy of the patients Home Health Certification and Plan of Care for his review but there wasn’t one in the Patient 5’s home. During an interview on 9/3/2026 at 12:43 am with ADM/DPCS, ADM/DPCS stated the HHA provides its visiting staff with a copy of each patient’s Home Health Certification and Plan of Care, but the HHA does not provide a copy to patients. ADM/DCPS stated that the Home Health Certification and Plan of Care included information such as goals for care of each patient, as well as who and how often nurses or CHHA’s should be visiting. ADM/DPCS stated she was unaware the Home Health Certification and Plan of Care should be provided to each patient. Findings: a. During a review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a start of care date of 5/8/2026 and a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) of 7/7/2026 to 9/4/2026. Patient 1’s POC indicated that Patient 1 had diagnoses of type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), essential hypertension (high blood pressure), asthma (a long-term lung disease that causes inflammation, swelling, and narrowing of the airways), myalgia (muscle aches and pains) and radiculopathy of lumbar region (pinched nerve-occurs when a nerve root in the spine is compressed, inflamed, or injured). Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. During a concurrent interview and record review on 9/2/2026 at 3:30 pm with Administrator/Director of Nursing (ADM/DPCS), Patient 1’s Home Health Folder (a folder given to patients by the HHA that includes important information about the agency and the services being provided) was reviewed. The ADM/DPCS stated Patient 1’s folder did not include a copy of Patient 1’s Plan of Care (POC). The ADM/DPCS stated that she (ADM/DPCS) did not give Patient 1 a copy of the Plan of Care because she (ADM/DPCS) was not aware that she (ADM/DPCS) was required to do so. The ADM/DPCS further stated that the HHA should provide a copy of the POC to Patient 1 so the patient and family know the care they are supposed to be receiving. b. During a review of Patient 5’s Patient Profile, undated, the document indicated that the HHA admitted Patient 5 on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026 to 10/8/2026. The POC indicated that Patient 5 was to receive skilled nursing home visit once a week for 9 weeks, and certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The POC indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent observation and interview on 9/2/2026 at 3:30 pm, at Patient 5’s resident with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the HHA sends him a copy of the patients Home Health Certification and Plan of Care for his review but there wasn’t one in the Patient 5’s home. During an interview on 9/3/2026 at 12:43 am with ADM/DPCS, ADM/DPCS stated the HHA provides its visiting staff with a copy of each patient’s Home Health Certification and Plan of Care, but the HHA does not provide a copy to patients. ADM/DCPS stated that the Home Health Certification and Plan of Care included information such as goals for care of each patient, as well as who and how often nurses or CHHA’s should be visiting. ADM/DPCS stated she was unaware the Home Health Certification and Plan of Care should be provided to each patient. A review of the HHA’s policy titled “Care Planning Process”, dated November 2022, indicated that a written plan of care will be initiated within five (5) says of start of care. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including the day of the week, frequency of visits by personnel and personnel acting on behalf of the organization. B. Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization C. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. D. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on 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 develop and implement a plan of care (a structured, individualized document that outlines the medical and supportive services a patient needs) for the certified home health aide providing care for one of seven sampled patients (Patient 5). This failure had the potential to place patient 5 safety at risk, creating a situation where the CHHA could have provided services that were not appropriate or safe for the patient. A review of Patient ’s 5’s undated Patient Profile indicated that the HHA admitted Patient 5, a 67-year-old male, on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026to 10/8/2026. Patient 5 was to receive skilled nursing home visit once a week for 9 weeks, and certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The document also indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). A Review of Patient 5’s Home Health Certification and Plan of Care dated 6/23/2026, indicated a certification period from 6/11/2026 to 8/9/2026. Patient 5 was to receive certified home health aide (CHHA) visits once a week for 9 weeks to assist with ADL’s. During a concurrent interview and record review on 9/3/2026 at 12:25 pm of Patient 5’s electronic medical records for the dates 6/11/2026 to 9/3/2026 with Administrator/Director of Patient Care Services (ADM/DPCS), ADM/DPCS stated the HHA did not have documentation of a Certified Home Health Aide Plan of Care for Patient 5’s CHHA. ADM/DCPS stated that Patient 5 had been receiving HHA care once a week for the period of 6/11/2026 to 9/3/2026. ADM/DCPS stated the HHA does document the plan of the care for each CHHA, but that it was the responsibility of the primary nurse to verbally endorse the care plan to each CHHA they are working with. ADM/DPCS stated that the purpose of a plan of care for each CHHA is a guide for them to know what care measures can be safely provided for each patient. A review of the HHA’s policy titled “Home Health Aide Plan of Care”, dated November 2022, indicated, “Each patient receiving home health aide services will have an individualized plan developed by an appropriate professional and utilized to direct the care performed by the assigned aide.” The policy indicated that for each patient receiving home health aide services, the care plan developed for the home health aide will include: 1. Type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self administered. 2. Frequency of visits (use of PRN or per patient choice are not acceptable) 3. Diagnosis/prognosis, if relevant to care 4. Functional limitations 5. Patient’s mental status 6. Activities permitted 7. Nutritional requirements 8. Specific procedure to be performed, including amount, frequency, and duration 9. Safety measures, including use of specific equipment 10. Instructions for completion of documentation 11. Reporting changes in patient’s condition and needs”

“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 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 maintain an updated medication profile (med profile-a complete, up-to-date record of all the prescription drugs, over-the-counter medicines, vitamins, and herbal supplements a person takes) for one out of seven sampled patients (Patient 1). Patient 1 was taking a medication that was not listed on her medication profile. This failure had the potential to place Patient 1 at risk for medication errors and adverse drug reactions (a harmful, unintended reaction to medication). Findings: A review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a start of care date of 5/8/2026 and a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) of 7/7/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), essential hypertension (high blood pressure), asthma (a long-term lung disease that causes inflammation, swelling, and narrowing of the airways), myalgia (muscle aches and pains) and radiculopathy of lumbar region (pinched nerve-occurs when a nerve root in the spine is compressed, inflamed, or injured). Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. On 9/2/2026, at 1:21pm, a medication reconciliation (the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Administrator/ Director of Nursing (ADM/DPCS) at Patient 1’s home. Patient 1 was taking the following medication, but it was not listed on their medication profile. Diclofenac (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild-to-moderate pain, joint inflammation, and stiffness) 1% topical gel.During an interview on 9/2/2026, at 3:17pm, Patient 1 stated that the medication diclofenac was prescribed by her doctor and that she had been taking it for the past few months. During an interview on 9/2/2026, at 3:20pm, the ADM/DPCS confirmed that the medication was not listed on med profile. The ADM/DPCS stated that she must have missed adding it to the med profile. The ADM/DPCS stated that the med profile needs to be kept updated for patient safety, so that the HHA can monitor the medications that the patient is taking for any adverse side effects. A review of the Agency’s policy titled “Medication Reconciliation” (undated), indicated that patients receiving medication administered by the home health will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and /or discontinued medications.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. 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 therapeutics service to a patient at home) failed to provide copies of Medication Profile (an organized, up-to-date record of all the medicines a person takes) to two of seven sampled patients (Patients 1 and 5). This failure had the potential to place Patients 1 and 5’s at risk for harm by potentially misunderstanding medication instructions and increasing the risk of medication omissions, duplications, dosing errors or adverse drug events. A review of Patient ’s 5’s undated Patient Profile indicated that the HHA admitted Patient 5, a 67-year-old male, on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026to 10/8/2026. Patient 5 was to receive skilled nursing home visit once a week for 9 weeks, and certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The document also indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and observation at Patient 5’s home on 9/2/2026 at 3:30 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the HHA sends him a copy of the patients medication profile for his review but there wasn’t one in the Patient 5’s home. During an interview on 9/3/2026 at 12:43 am with ADM/DPCS, ADM/DPCS stated the HHA provides its visiting staff with a copy of each patient’s medication profile, but the HHA does not provide a copy to patients. ADM/DCPS stated that the medication profile was a list of current medication each patient was taking, including names and doses of medications. ADM/DPCS stated she was unaware the medication should be provided to each patient. Findings: a. A review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a start of care date of 5/8/2026 and a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) of 7/7/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), essential hypertension (high blood pressure), asthma (a long-term lung disease that causes inflammation, swelling, and narrowing of the airways), myalgia (muscle aches and pains) and radiculopathy of lumbar region (pinched nerve-occurs when a nerve root in the spine is compressed, inflamed, or injured). Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. During a concurrent record review and interview on 9/2/2026 at 3:30pm, Patient 1’s Home Health Folder (a folder given to patients from the HHA that includes important information about the about the agency and the services they are providing) was reviewed with Administrator/Director of Nursing (ADM/DPCS) and did not have a copy of Patient 1’s medication profile. Patient 1’s caregiver stated that they never received a copy of Patient 1’s medication list from the HHA. The ADM/DPCS confirmed that she did not give Patient 1 a copy of her medication profile but stated that she should have so that the patient and her family are aware of the medications she is supposed to be taking. A review of the Agency’s policy titled “Medication Reconciliation” (undated), indicated that the drug regimen review will be completed by the registered nurse and a copy of the medication profile will be left at the patient’s home.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on 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 complete and document a supervisory assessment of the certified home health aide for one of seven sampled patients (Patient 5). This failure placed patient 5’s safety at risk by creating a situation where Patient 5 could be exposed to care provided by a CHHA who may deliver unsafe or improper services. A review of Patient ’s 5’s undated Patient Profile indicated that the HHA admitted Patient 5, a 67-year-old male, on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026 to 10/8/2026. Patient 5 was to receive certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The document also indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). A Review of Patient 5’s Home Health Certification and Plan of Care dated 6/23/2026, indicated a certification period from 6/11/2026 to 8/9/2026. Patient 5 was to receive certified home health aide (CHHA) visits once a week for 9 weeks to assist with ADL’s. During a concurrent interview and record review on 9/3/2026 at 12:02 pm of Patient 5’s electronic medical records for the dates 6/11/2026 to 9/3/2026 with the Administrator/Director of Patient Care Services (ADM/DPCS), ADM/DPCS stated the HHA did not have documentation of supervisory visits performed on Patient 5’s Certified Home Health Aide (CHHA). ADM/DCPS stated that Patient 5 had been receiving HHA care once a week for the period of 6/11/2026 to 9/3/2026. ADM/DCPS stated CHHA supervisory visits were to oversee the CHHA to ensure quality and safety of the CHHA’s work. ADM/DPCS stated the HHA performs CHHA supervisory visits twice monthly however the only time a nurse providing a supervisory visit should document the supervisory visit was when there was an issue or problem found during the visit. A review of the HHA’s policy titled “Supervisory Visits”, dated November 2022, indicated, “Ongoing supervision will be documented within the plan of care, home health aide assignment sheet, and clinical notes.” The policy also indicated, “The frequency of supervisory visits for home health aides will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days if the patient is receiving skilled services.””

“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- an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure that three of seven sampled patients (Patients 1, 3 and 5) had complete and accurate clinical records. Patient 1’s nursing note dated 8/21/2026 had inaccurate information documented.Patient 1 was missing the following nursing notes: 7/8, 7/13, 7/23, 8/1, 8/5, 8/10, 8/26.Patient 1 did not have their diagnoses listed on their Patient Profile (face sheet -a document of a patient’s personal information such as diagnoses, date of birth, and address).Patient 3 did not have a primary and secondary diagnosis on their Patient Profile. Patient 5 was missing the following nursing notes: 8/4/26, 8/18/2026, 8/25/2026.Patient 5’s nursing note dated 7/15/2026 had inaccurate information documented.Theses deficient practices had the potential to place Patients 1, 3 and 5 at risk for receiving inadequate patient care which could lead to decline in their health or hospitalization. A review of Patient ’s 5’s undated Patient Profile indicated that the HHA admitted Patient 5, a 67-year-old male, on 6/11/2026. A Review of Patient 5’s Home Health Certification and Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) dated 8/18/2026, indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/10/2026to 10/8/2026. Patient 5 was to receive skilled nursing home visit once a week for 9 weeks, and certified home health aide (CHHA) visits once a week for 8 weeks to assist with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The document also indicated Patient 5 had diagnosis of bilateral inguinal hernia (a condition where fatty tissue or a part of the intestine protrudes through weak spots in the lower abdominal wall on both the left and right sides of the groin), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 9/3/2026 at 12:50 pm of Patient 5’s skilled nursing notes for the dates 6/11/2026 to 9/3/2026 with Administrator/Director of Patient Care Services (ADM/DPCS), the last documentation of weekly nursing care given to Patient 5 was missing for the dates 8/4/26, 8/18/2026, 8/25/2026. ADM/DCPS stated the nurses had not yet submitted their weekly visit documentation. During a concurrent interview and record review on 9/3/2026 at 3:15 pm of Patient 5’s skilled nursing notes for the date 7/15/2026 with Administrator/Director of Patient Care Services (ADM/DPCS), the skilled nursing note indicated, “teaching done for hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body),” and, “treatment will involve managing the symptoms of quality of life.” ADM/DPCS stated that Patient 5 did not have hemiplegia and that the charting was incorrect and inaccurate. During an interview on 9/3/2026 at 3:18 pm with ADM/DPCS, ADM/DPCS stated that the right (correct) documentation was necessary to provide good care, enhance communication between the home health agency staff and to direct the plan of care for each patient. During an interview on 9/3/2026 at 3:23 pm with DPCS/ADM, DPCS ADM stated that documentation on care given to patients should be submitted to the HHA within 7 days. DPCS/ADM stated the reason timely submission or notes was important was so that the agency is aware of the patient’s health status for the overall care and safety for the patients. During a review of Patient 3’s clinical record titled Patient Profile, undated, indicated Patient 3 had a start of care date of 6/05/2026 with primary diagnosis of type 2 diabetes mellitus (a disease where too much sugar is in the blood which can lead to serious health problems), and secondary diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and epilepsy (a chronic brain disorder defined by a lasting tendency to have recurring, unprovoked seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)). During a concurrent interview and record review on 9/3/2026 at 3:00 p.m. with Administrator /Director of Patient Care Services (ADM/DPCS), patient 3’s clinical record titled “Patient Profile”, undated, was reviewed. The ADM/DPCS confirmed the “Patient Profile” was missing both primary and secondary diagnosis. The ADM/DPCS emphasized that including a diagnosis on the face sheet helps clinical staff understand the patient’s medical needs. The ADM/DPCS also stressed that accurate information in clinical records ensures patient safety and promotes healing. The ADM/DPCS stated there is no staff appointed to review clinical medical records. During a review of the facility’s Policy & Procedure (P&P) titled, “Clinical/Service Data Collection”, dated November 2022, indicated, A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum, Pertinent medical history. During a review of the facility’s Policy & Procedure (P&P) titled, “Clinical Record Review”, dated November 2022, indicated, clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered is reliable, timely, valid, and accurate. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor, Performance Improvement Coordinator, Clinical Director, or designees for: A. The completeness of clinical records. B. The accuracy of clinical records. Findings: a. A review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a start of care date of 5/8/2026 and a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) of 7/6/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), essential hypertension (high blood pressure), asthma (a long-term lung disease that causes inflammation, swelling, and narrowing of the airways), myalgia (muscle aches and pains) and radiculopathy of lumbar region (pinched nerve-occurs when a nerve root in the spine is compressed, inflamed, or injured). Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. A review of Patient ‘1’s Nursing Progress Note, dated 8/21/26, signed by Licensed Vocational Nurse 1 (LVN 1), indicated “Additional SN Notes” that stated the following… “Teaching done regarding Parkinson’s disease. It is a chronic progressive disorder of the nervous system (CNS). An estimated 1% of the USA population older than age 50 and 2% older than age 60 have this disorder… Problems secondary to bradykinesia can be alleviated by simple measures as: when walking consciously think about stepping over imaginary or real lines on floor.” During an interview on 9/2/2026, at 3:10pm, Patient 1’s Caregiver (CG) stated that Patient 1 does not have a diagnosis of Parkinson’s Disease (a progressing brain disorder that damages nerve cells leading to shaking stiffness and slow movement). During an interview on 9/3/2026, at 3:15pm, the Administrator/Director of Patient Care Service (ADM/DPCS) confirmed that Patient 1 did not have Parkinson’s Disease and the information written in the nursing note dated 8/21/2026 was incorrect and inappropriate for Patient 1, and if LVN was teaching Patient 1 about Parkinson’s Disease it would have been very confusing for the patient. During an interview on 9/3/2026, at 3:18 pm, ADM/DPCS stated that no one has been reviewing nursing notes for accuracy. ADM/DPCS stated that it is important to have the right documentation to benefit the patient and provide good patient care. A review of the HHA’s policy titled” Clinical Record Review”, dated November 2022, indicated that each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor, Performance Improvement Coordinator, Clinical Director, or designees for: A. The timeliness of entries into the clinical record, including following procedures for late entries B. Meets payor requirements for medical necessity, homebound status, qualifying service and face-to-face visit C. The completeness of clinical records D. The accuracy of clinical records E. The appropriateness of services rendered (e.g. reasonable and necessary services, appropriate level of care and services rendered, medical condition justifies the number of visits provided, etc.) b. A review of Patient 1’s POC indicated a start-of-care date of 5/8/2026 and a certification period of 7/6/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus, essential hypertension, asthma, myalgia, and radiculopathy of lumbar region. Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. During a concurrent record review and interview on 9/3/2026, at 3:23pm, Patient 1’s electronic medical record was reviewed with the ADM/DPCS and Patient 1 did not have skilled nurse visit notes documented for the following dates: 7/8/2026, 7/13/2026, 7/23/2026, 8/1/2026, 8/5/2026, 8/10/2026, 8/26/2026. ADM/DPCS that there should be SN visit notes for every home visit to be on track and updated on patient’s condition, to know if their condition is improving or not. A review of the HHA’s policy titled “Content of Clinical Record”, dated November 2022, indicated that staff notes will be submitted within 7 days of clinical visit date with patient. c. A review of Patient 1’s POC indicated a start-of-care date of 5/8/2026 and a certification period of 7/6/2026 to 9/4/2026. Patient 1’s POC indicated that they had diagnoses of type 2 diabetes mellitus, essential hypertension, asthma, myalgia, and radiculopathy of lumbar region. Patient 1 was to receive skilled nursing (SN) visits once a week for nine weeks. A review of Patient 1’s Patient Profile (face sheet) did not have any of Patient 1’s diagnoses listed under the section titled “Admitting Diagnosis.” During an interview on 9/3/2026, at 3:29pm, the ADM/DPCS stated that the patient diagnoses are supposed to be listed on the face sheet, because it gives the caregiver a visualization of what the patients’ health needs are and what care they will need to provide based on the diagnoses. A review of the HHA’s policy titled “Content of the Clinical Record” dated November 2022, indicated that the clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs. The following information will be available in the clinical record for patients receiving skilled care: 1. Primary and secondary diagnoses and prognosis, admission diagnosis or pertinent health information. 2. Notation of the conditions and diagnoses which are relevant to the plan of treatment, plan of care, or plan for personal care services.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); 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 therapeutics service to a patient at home) failed to document Patient Profile (face sheet -a document of a patient’s personal information such as diagnoses, date of birth, and address) for one of seven sampled patients (Patient 1). This failure had the potential to result in HHA sending staff to an incorrect location, which could delay or interrupt needed care or services for Patient 1. Findings: On 9/2/2026, at 2:50pm, Surveyor went to address listed on Patient 1’s face sheet for a home visit with Administrator/Director of Patient care Services (ADM/DPCS), and it was the incorrect address. During an interview, on 9/3/2026, at 2:50pm, ADM/DPCS stated that the address on the face sheet was the Patient’s old address and it was never updated on the face sheet. ADM/DPCS stated that there should be the correct address because if a different nurse or physical therapist visit the patient, they would go to the wrong address and there would be a delay in the patients care. ADM/DPCS stated that she does not have staff to monitor the accuracy of patient records. A review of the HHA’s policy titled “Content of the Clinical Record” dated November 2022, indicated that the clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs. 1. The following information will be available in the clinical record for patients receiving skilled care: A. Patient’s name, clinical record number, sex, current address, phone number, date of birth, and his/her legally authorized representative A review of the HHA’s policy titled” Clinical Record Review”, dated November 2022, indicated that each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor, Performance Improvement Coordinator, Clinical Director, or designees for: The accuracy of clinical records”