Capital Home Health Care Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on staff interviews, review of agency documentation, and clinical record reviews, it was determined the Condition of Participation: 484.45 EMERGENCY PREPAREDNESS, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. Specifically, the agency failed to develop and maintain an emergency preparedness plan that included strategies for addressing emergency events, assessment of the patient population to identify persons at-risk, the type of services the agency has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Findings include: 1. The emergency preparedness plan (EPP) binder was reviewed on 2/5/26. The binder failed to reveal an updated emergency contact list for staff and patients. The agency provided the survey team with a list of personnel which included former staff members as well as incorrect contact information for current staff. a. The agency failed to maintain a working EPP to establish for the provision of services and care to the agency patients during an emergency. Review of personnel records failed to reveal annual training on EPP was completed for current employees during the previous two years. Review of patient records failed to reveal updated plans of care for several patients thus revealing a gap in emergency preparedness planning for the current home health agency population. Specifically, review of the plan of care for Patient #1 failed to include strategies for addressing tracheotomy care in the emergency assessment. (Cross Reference G572) 2. During an interview on 2/5/26 at 1:50 p.m., the administrator stated the EPP was not up to date. The administrator stated no emergency exercises or table top exercises were completed since 2023. During an additional interview on 2/9/25 at 10:36 a.m., the administrator confirmed the agency did not complete the employee training on EPP. The administrator stated the EPP had not been maintained during the past year or so.”

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on staff interviews, review of agency documentation and clinical record review, it was determined the Condition of Participation 484.45 REPORTING OASIS INFORMATION, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. Specifically, the agency’s routine practice was to have the previous administrator of the agency, transmit Outcome and Assessment Information Set (OASIS) data to the Center for Medicare and Medicare (CMS). However since the departure of the previous administrator, no one at the agency had been transmitting OASIS assessments to CMS for the last year. This led to no OASIS data being available for the unduplicated census of 36 patients. Furthermore it was discovered during documentation and clinical patient review some active patients had not completed OASIS assessments which meant no OASIS data could have been transmitted even had the agency been transmitting OASIS data. The Condition of Participation was found to be out of compliance; Based on interview and record review the agency failed to electronically report all OASIS data collected in accordance with §484.55 - Condition of Participation, Comprehensive Assessment of Patients - each patient must receive and an agency must provide a specific comprehensive assessment as required. Findings include: 1. Review of CMS’s Internet Quality Improvement and Evaluation System (IQIES) revealed the agency failed to submit any OASIS data from 11/2024 to 10/2025. Review of the IQIES reports titled; Agency Patient-Related Characteristics (Case Mix) Report, Potentially Avoidable Event Report, Potentially Avoidable Event Patient Listing Report and OASIS error report obtained on 2/2/26 for the period dated 11/2024 to 10/2025, showed no patient data had been listed for the agency, or more specifically “No Data Returned for Selected Criteria.” During an interview on 2/2/25 at 1:25 p.m., the administrator/Director of Nursing (DON) stated the agency completed OASIS assessments for patients during the initial assessment and reassessment. The administrator/DON stated the agency’s electronic medical record (EMR) system transmitted the OASIS information. During an e-mail exchange between the state agency (SA) and the IQIES help desk on 2/2/26 at 2:57 p.m., the IQIES help desk personnel confirmed the agency had not submitted any OASIS assessments since at least January 2023. 2. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification period dated 1/2/26 to 3/2/26 was not found in the record. Further review of the record for Patient #3 revealed a start of care date of 1/7/24. Diagnoses include, morbid (severe) obesity due to excess calories, essential (primary) hypertension and type 2 diabetes mellitus with diabetic neuropathy. There were no orders for the current certification period regarding skilled nursing (SN) frequency or what care was to be provided to Patient #3. a. The agency failed to complete an OASIS assessment for Patient #3. Review of the Patient #3’s clinical record between 10/20/25 and 2/3/26 failed to reveal a completed OASIS assessment for the current certification period of 1/2/26 to 3/2/26 or for the prior certification period 11/2/25 to 1/1/26. The agency failed to complete an assessment for Patient #3 which meant if they had been submitting OASIS data, the date for Patient #3 would not have been transmitted since the agency had failed to complete an OASIS assessment for the patient. During an interview on 2/9/26 at 3:25 p.m., the administrator/DON stated the reason for the missed assessments for Patient #3 was due to a nurse leaving and the agency not catching the assessments had not been completed. 3. The clinical record for Patient #5 was reviewed on 2/3/26. The plan of care for the certification period 12/16/25 to 2/14/26 revealed a start of care date of 4/21/25. Diagnoses included, paraplegia, intellectual disabilities, developmental disorder of speech and language and age related osteoporosis. The plan of care included SN visits once every 60 days for reassessment, and certified nursing aide (CNA) visits six times a day for 60 days, for assistance with activities of daily living. a. The agency failed to submit a completed OASIS for Patient #5. Review of the Patient #5’s clinical record revealed a start of care OASIS assessment that was completed on 4/22/25. Although the OASIS assessment was completed, the assessment was missing the signature of the clinician who completed the assessment. The OASIS assessment was completed within the search range of the IQIES report section, however it was still not properly transmitted to CMS. During an interview on 2/6/26 at 11:11 a.m., registered nurse (RN) #4 stated she had started working with the agency in April of 2025. RN #4 also stated she only worked with Patient #5 for the agency. RN #4 confirmed she did complete an assessment for Patient #5 every 60 days. 4. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON stated she had not completed the transmissions of the OASIS data in the last year. The administrator stated the previous administrator of the agency had completed the OASIS assessment transmission, but since the previous administrator had quit, the agency had not been transmitting any OASIS assessment to CMS. The administrator/DON again confirmed the agency had not transmitted OASIS assessments in one year.”

“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 staff interviews, review of agency documentation and clinical record review, it was determined the Condition of Participation 484.60 CARE PLANNING, COORDINATION, QUALITY OF CARE, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. G 572 - Based on interview and record review, the agency failed to ensure each patient had an established plan of care which identified patient-specific measurable outcomes and goals for 1 of 1 patient records reviewed who received insulin administration by a skilled nurse (SN) of the agency (Patient #3). G580 - Based on observation, interview and record review, the home health agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician or allowed practitioner for 8 of 8 active patient records reviewed (Patients #1, #2, #3, #4, #5, Focused Patients A, B, and C). G588 - Based on interview and record review, the agency failed to ensure each patient’s plan of care was reviewed by the physician at least every 60 days. This failure occurred for 5 of 8 active patient records reviewed who received care services from the agency for at least 60 days (Patients #2, #4, #5, and focus patients A & C).”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.65 QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT was out of compliance. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. Based on record review and interview, the home health agency failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven quality assessment and performance improvement (QAPI) plan. Findings include: 1. During the survey, the agency failed to produce a QAPI plan and program for review. a. The agency failed to have a working QAPI plan. During an interview on 2/5/26 at 1:50 p.m., the administrator stated the agency did not have a current QAPI plan. Additionally, the administrator explained a former employee was responsible for the QAPI plan management. Further, she stated no one had worked on the plan since that employee left sometime in September, 25. Multiple interviews completed on 2/9/26 revealed the administrator was aware of non-compliance issues related to missing documentation to include referrals, unsigned orders and plans of care, and incomplete OASIS documentation. Record review revealed the agency failed to develop improvement plans for known issues. (Cross Reference G370, G572, and G580).”

“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 staff interviews, review of agency documentation and clinical records, it was determined the Condition of Participation 484.105 ORGANIZATION AND ADMINISTRATION OF SERVICES, was out of compliance. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. G 948 - Based on interview, record review, and observation, the administrator failed to be responsible for all day-to-day operations of the home health agency (HHA). Specifically, the administrator failed to ensure the agency provided drugs, services, and treatments only as ordered by a physician; to develop and maintain an emergency preparedness plan; to develop and maintain a HHA-wide quality assessment and performance improvement (QAPI) plan; to coordinate care between the agency and physicians; to report all OASIS data collected; ensure patients had an established plan of care; ensure nursing staff complied with professional standards to provide care; ensure a discharge summary was provided to physicians; ensure a comprehensive assessment was completed in a timely manner; ensure supervisory visits were completed per regulations; plans of care were updated every 60 days; and ensure patient specific certified nurse aide (CNA) care plans were prepared by a registered nurse (RN). G 962 - Based on interview and record review, the administrator/director of nursing (DON) failed to coordinate patient care between the agency and physicians office by failing to receive updated orders, verbal or written, and failed to ensure plans of care were reviewed and revised by physicians for 5 of 5 active patient records reviewed (Patient #1, #2, #3, #4 and #5) and 3 of 3 focus patient records reviewed (Focus Patient A, B and C). G 968 - Based on interview and record review, the Administrator/Director of Nursing (DON) failed to provide oversight of all patient care services in accordance with requirements set forth in regulation. Specifically, the Administrator/DON failed to ensure the development, implementation and updates of the individualized plan of care that specified care and services to meet each patient’s specific identified needs for patients receiving services from the agency. G 984 - Based on observation, interview and record review, the agency failed to ensure nursing staff complied with professional standards and principles pertaining to providing care for patients without current physician orders for 5 of 5 current patients (Patient #1, #2, #3, #4 and #5) and 3 of 3 focused sample records reviewed (Focus Sample, A, B and C).”

“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 interview and record review, the agency failed to ensure each patient had an established plan of care which identified patient-specific measurable outcomes and goals for 1 of 1 patient records reviewed who received insulin administration by a skilled nurse (SN) of the agency (Patient #3). (Cross Reference G360 and Cross Reference G544 and Cross Reference G968) Findings include: 1.The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification 1/2/26 to 3/2/26 was not found in the record. Further review of the record for Patient #3 revealed a start of care date of 1/7/24. Review of an older plan of care dated 3/7/25 included the following information; diagnoses include, morbid (severe) obesity due to excess calories, essential (primary) hypertension and type 2 diabetes mellitus with diabetic neuropathy. There were no orders for the current certification period regarding skilled nursing (SN) frequency or what care was to be provided to Patient #3, but a plan of care dated 3/7/25 revealed a SN frequency of 14 times a week for nine weeks, for medication administration, admission and recertification. a. The agency failed to establish a plan of care for Patient #3. Review of Patient #3’s clinical record revealed between 10/20/25 and 2/3/26 failed to reveal the agency had created a plan of care for the certification periods dated 11/2/25 to 1/1/26 and 1/2/26 to 3/2/26. Further review of Patient #3’s clinical record failed to reveal a completed OASIS assessment five days prior to the end of the previous certification period which would be needed to develop the plan of care. During a home visit interview, in the home of Patient #3, on 2/3/26 at approximately 10:00 a.m., registered nurse (RN) #3 stated she believed there was copy of the plan of care for Patient #3 in the agency folder. Review of the agency folder of Patient #3 failed to reveal a plan of care. The only thing found in the folder was a copy of Patient #3’s medication profile. RN #3 reviewed the folder with the state agency (SA) surveyor and agreed there was no plan of care in the folder of Patient #3. RN #3 then reviewed the electronic medical record (EMR) system on her phone and confirmed she could not locate a plan of care in the EMR system either. During an interview on 2/3/26 at 3:15 p.m., the administrator/director of nursing (DON) stated the agency had a problem with the EMR system not creating the plan of care. The administrator/DON confirmed the agency had not established a plan of care for Patient #3. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON stated the agency’s EMR system sometimes failed to create a plan of care. The administrator/DON stated she had contacted the EMR company regarding this issue. The administrator/DON did confirm it was her responsibility to ensure a plan of care was established for all patients, and admitted she had not checked to ensure Patient #3 had an established plan of care.”

“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 agency failed to ensure patient-specific written care instructions for the certified nurse aides (CNA) were prepared by a registered nurse (RN) for 1 of 9 patient records reviewed who received CNA services (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 2/3/26. The Plan of Care for the certification period dated 12/16/25 to 2/14/26 revealed a start of care date of 4/21/25. Diagnoses included unspecified intellectual disability, developmental disorder of speech and language and iron deficiency anemia among others. Plan of Care orders included skilled nurse (SN) visits every 60 days and certified nurse aide (CNA) visits 6 hours a day to provide personal care. a) The agency failed to ensure the RN provided written patient specific care instructions for the CNA to work with. Record review revealed no evidence of a CNA care plan with written instructions detailing the frequency and tasks to be provided. The tasks the CNA was to perform included recording vital signs and blood glucose reading. Record review revealed the CNA was providing services without the care instruction. During an interview on 2/9/26 at 11:06 a.m., the Administrator/DON stated she would check in her files for the CNA plan of care for Patient #5. During an interview on 2/9/26 at 11:54 a.m., the Administrator/DON stated the agency had a paper CNA care plan for Patient #5 but she did not know where it had been misplaced. During an interview on 2/9/26 at 3:07 p.m., the Administrator/DON stated she could not find the CNA care plan for Patient #5.”

“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 agency failed to complete a comprehensive assessment for physical therapy, occupational therapy, and speech therapy in a timely manner consistent with the patient’s immediate needs for 1 of 7 active patients (Focused Patient A). Findings Include: 1.The clinical record for Focused Patient A was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/10/26 to 3/10/26 revealed a start of care date of 7/24/24; diagnoses include nontraumatic intracranial hemorrhage, muscle weakness, and dysphagia. Plan of care orders included skilled nursing (SN) every 30 days, home health aide (HHA) 12 hours a week, physical therapy (PT) to assess functional status, and occupational therapy (OT) to assess functional status. a) The agency failed to complete a comprehensive assessment.This failure to complete the comprehensive assessment no later than five calendar days after the Start of Care created the potential for unidentified and unmet patient needs. Record review failed to reveal a completed comprehensive assessment from the certification period ending 11/10/25. The home health aide continued to provide services as ordered on the plan of care. Record review revealed that a comprehensive assessment was completed by the skilled nurse on 9/11/25, and a recertification comprehensive assessment was subsequently completed on 1/9/26 by the administrator/Director of Nursing (DON). Review of communication notes failed to reveal documentation of a reason for the non-completed assessment. The administrator failed to provide documentation for missing assessments. During an interview on 2/9/26 at 11:30 a.m., the administrator/DON stated the comprehensive assessment was missed due to staff leaving the agency. b) The agency failed to complete therapy assessments as ordered in the plan of care. During an interview on 2/9/26 at 11:30 a.m.,the administrator/DON stated the PT, OT, and ST assessments were missed due to former staff not updating the plan of care. Further interview revealed, the agency did not have a chart audit procedure in place to catch issues with the orders and plan of care. (Cross Reference G640) Record review failed to reveal documentation for OT, PT, or ST services. Further review failed to reveal evidence of referrals for therapy assessments. Review of the communication and clinical notes failed to reveal evidence of why the PT, OT, and ST assessments were not completed.”

“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 observation, interview and record review, the home health agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician or allowed practitioner for 8 of 8 active patient records reviewed (Patients #1, #2, #3, #4, #5, Focused Patients A, B, and C). Findings include AGENCY POLICY According to the agency policy titled, “Physician Orders - Verbal Orders,” dated October, 2017 (in pertinent parts): “Drugs and treatments are administered by the agency staff only as ordered by the physician. Orders are obtained prior to the provision of any care, including changes in the plan of care.” 1. The clinical record for Patient #2 was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/19/26 to 3/19/26 revealed a start of care date of 7/28/24; diagnoses included congestive heart failure, cardiac pacemaker, chronic obstructive pulmonary disease, incontinence, and limitation of activities of daily living due to disability. Plan of care orders included skilled nursing (SN) one time a week for medication management and certified nurse aide (CNA) 42 hours a week for assistance with activities of daily living (ADL). a. The agency failed to obtain orders from a physician or allowed practitioner to provide services and treatments to Patient #2. During a home visit on 2/3/26 at 10:30 a.m. for Patient #2, state agency (SA) surveyors observed certified nurse assistant (CNA) #2 provide incontinent care and hygiene assistance. During the home visit on 2/3/26, Patient #2 stated he received CNA services for six hours a day, seven days a week. Additionally, Patient #2 confirmed the SN came in every week to fill his medication box and check his vital signs. Patient #2 stated no visits had been missed in months. Record review revealed a plan of care dated 1/19/26 without a physician signature. Further review failed to reveal documentation of a verbal order within the plan of care. Record review showed an order which was not signed placed by the administrator/Director of Nursing (DON) on 11/20/25 which included orders for SN one time a week and CNA 42 hours a week. Review of the order failed to reveal communication with the physician of record for Patient #2. During an interview on 2/9/26 at 1:09 p.m., the administrator/DON stated the agency faxed the plan of care to the physician to sign directly after the start of the new cert period. A review of a fax to Patient #2’s physician of record dated after the start of the survey revealed the fax failed to be sent to the physician. Review of the clinical record failed to reveal additional faxes or communication notes between the agency and the physician. The administrator/DON stated the agency did not have a procedure in place to call the physician for missing documentation. Record review failed to reveal a signed plan of care for the prior two certification periods. Additional review failed to reveal documentation of attempted faxes or physician communication. Review of clinical visit notes revealed CNA visits were completed daily for the current and prior two certification periods. Review revealed SN visits were completed once a week during the same period. During an interview on 2/9/26 at 3:10 p.m., the administrator/DON confirmed Patient #2 did not have a current signed POC nor valid verbal orders. 2. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification period dated 1/2/26 to 3/2/26 was not found in the record. Further review of the record for Patient #3 revealed a start of care date of 1/7/24. Diagnoses include, morbid (severe) obesity due to excess calories, essential (primary) hypertension and type 2 diabetes mellitus with diabetic neuropathy. There were no orders for the current certification period regarding SN visit frequency or what care was to be provided to Patient #3. a. The agency failed to obtain orders from a physician or allowed practitioner to provide drugs, services and treatments to Patient #3. Specifically, the agency failed to obtain orders for insulin administration. Review of the clinical record for Patient #3 failed to reveal a current plan of care for the certification period between 1/2/26 to 3/2/26. Record review failed to reveal documented verbal orders or communication for the physician of record during the current certification period. Review of the clinical record revealed SN completed visits which included insulin administration twice a day from 1/2/26 to 2/1/26 without a valid care plan for a total of 23 visits with one missed visit on 2/1/26. During a home visit for Patient #3 on 2/3/26 at 10:00 a.m., the state agency (SA) surveyors directly observed registered nurse (RN) #3 administer medication and provide care. The SA surveyors saw RN #3 assess Patient #3’s vital signs. Further observation during the visit showed RN #3 administered 50 units of insulin to Patient #3. Patient #3 verbally verified his insulin dosage was 50 units. During an interview on 2/3/26 at 10:00 a.m., RN #3 was asked to provide verification of a current plan of care for Patient #3. RN #3 failed to locate a current plan of care in the electronic clinical record. Review of visit notes revealed SN had provided care twice a day since 1/2/26, except on 2/1/26 where the morning SN visit was missed due to an agency scheduling error. 3. The clinical record for Patient Focus B was reviewed on 2/4/26. Plan of care orders for the certification period dated 1/13/26 to 3/13/26 revealed a start of care date of 6/8/21; diagnoses included Cerebral infarction unspecified, essential (primary) hypertension, and presence of cardiac pacemaker. Plan of care orders included SN seven days a week for medication set up, and medication management. a. The agency failed to obtain valid orders from a physician or an allowed practitioner to continue to provide services for Focus Patient B. Review of the clinical record for Focus Patient B’s Patient failed to reveal a signed plan of care for the current certification period. Further review failed to reveal documented communication notes between the agency and the physician of record. The agency was unable to provide evidence of completed faxes to the physician for Focus Patient B. 4. Similar findings were found for Patients #1, #4, #5 and Focus Patients A and C. 5. During an interview on 2/3/26 at 3:46 p.m., the administrator/(DON) stated she did not have signed plans of care for some of the agency’s patients including Patient #3. Additionally, she stated the agency had a problem with care plans. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON acknowledged she had not called physicians for verbal orders. The administrator/DON also stated she was not aware she could not provide care to patients without verbal or signed written orders. During an interview on 2/9/26 at 3:18 p.m., the administrator/DON acknowledged the agency was not ensuring patients had valid orders before providing care and services. Furthermore, the administrator/DON confirmed staff should have orders for every patient. Further interview revealed the agency failed to have a procedure in place to audit charts for missing or invalid orders.”

“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 agency failed to ensure each patient’s plan of care was reviewed by the physician at least every 60 days. This failure occurred for 5 of 8 active patient records reviewed who received care services from the agency for at least 60 days (Patients #2, #4, #5, and focus patients A & C). Findings include: 1. The clinical record for Patient #2 was reviewed on 2/3/26. The Plan of Care for the certification periods 11/20/25 to 1/18/26 and 1/19/26 to 3/19/26 revealed a start of care date of 7/28/24. Diagnoses included unspecified diastolic (congestive) heart failure, atrio-ventricular block (complete), presence of cardiac pacemaker and chronic obstructive pulmonary disease among others. Plan of Care orders for the certification period dated 1/19/26 to 3/19/26 included skilled nurse (SN) visits once a week and personal care for 42 hours a week. a. Record review showed the Plans of Care were not reviewed and approved by the physician at least every 60 days beginning with the start of care date as required. Review of Patient #2’s Plan of Care for the certification period dated 11/20/25 to 1/18/26 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed the plan of care was only signed by the agency Director of Nursing. During an interview on 2/9/26 at 1:12 p.m., the agency Administrator stated the Plan of Care was created and sent to the physician for signature but getting the physician to review and sign the Plan of Care was the issue. The administrator stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record 2. The clinical record for Patient #4 was reviewed on 2/3/26. The Plan of Care for the certification period 12/6/25 to 2/3/26 revealed a start of care date of 12/6/25. Diagnoses included altered mental status, unspecified, type II diabetes mellitus without complications, neuromuscular dysfunction of bladder and acquired absence of unspecified leg above knee. Plan of Care orders for the certification period dated 12/6/25 to 2/3/26 included SN visits once a month. a. Record review showed the Plan of Care was not reviewed and approved by the physician for the 60 days beginning with the start of care date as required. Review of Patient #4’s Plan of Care for the certification period dated 12/6/25 to 2/3/26 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed the plan of care was only signed by the agency Director of Nursing. During an interview on 2/9/26 at 1:12 p.m., the agency Administrator stated the Plan of Care was created and sent to the physician for signature but getting the physician to review and sign the Plans of Care was the issue. The administrator stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record 3. The clinical record for Patient #5 was reviewed on 2/3/26. The Plans of Care for the certification periods 10/18/25 to 12/16/25 and 12/16/25 to 2/14/26 revealed a start of care date of 4/21/25. Diagnoses included unspecified Intellectual Disability, developmental disorder of speech and language and iron deficiency anemia. Plan of Care orders for the certification period dated 12/16/25 to 2/14/26 included SN visit once every 60 days and personal care for 42 hours a week. a. Record review showed the Plan of Care for the certification period 10/18/25 to 12/16/25 was not reviewed and approved by the physician at least every 60 days beginning with the start of care date as required. Review of Patient #5’s Plan of Care for the certification period dated 10/18/25 to 12/16/25 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed both plans of care were only signed by the agency Director of Nursing. During an interview on 2/9/26 at 1:12 p.m., the agency Administrator stated the Plan of Care was created and sent to the physician for signature but getting the physician to review and sign the Plan of Care was the issue. The administrator stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record 4. Similar findings of the agency’s failure to ensure each patient’s plan of care was reviewed by the physician at least every 60 days was found on review of focus Patients A and C.”

“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 agency failed to ensure a registered nurse made onsite supervisory visits to the home no less frequently than every 14 days for 1 of 5 active patients (Focused Patient A). Findings include: AGENCY POLICY According to the agency policy titled, “Home Health Aide Supervision,” dated January, 22 (in pertinent parts): “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 must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during the visit” 1. The clinical record for Focused Patient A was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/10/26 to 3/10/26 revealed a start of care date of 7/24/24; diagnoses include nontraumatic intracranial hemorrhage, muscle weakness, and dysphagia. Plan of care orders included SN every 30 days, home health aide (HHA) 12 hours a week, physical therapy (PT) to assess functional status, and occupational therapy (OT) to assess functional status. a) The agency failed to complete supervisory visits every 14 days. Record review failed to reveal supervisory visits were completed between 7/1/25 to 2/1/26. The record review revealed a Home Health Aide form was completed on 9/11/25 but was not signed nor dated. 2. During an interview conducted on 02/9/26 at 3:10 p.m, the administrator/director(DON) stated the agency did not complete supervisory visits between the September and January certification dates. The DON stated the nurse quit and they were missed. The administrator confirmed supervisory visits that were not found in the clinical record were not completed for Focus Patient A.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on record review and interviews, the agency failed to complete supervisory visits every 60 days for 1 of 1 patients who received only certified nurse aide (CNA) services (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 2/3/26. The plan of care for the certification period 12/16/25 to 2/14/26 revealed a start of care date of 4/21/25. Diagnoses included, paraplegia, intellectual disabilities, developmental disorder of speech and language and age related osteoporosis. The plan of care included skilled nurse (SN) visits once every 60 days for reassessment, and certified nursing aide (CNA) visits six times a day for 60 days, for assistance with activities of daily living. a. The agency failed to complete supervisory visits every 60 days. Record review failed to reveal supervisory visits were completed from 10/18/25 to the start of this survey on 2/2/26. The record review revealed six hourly home health visit notes were completed daily between 10/18/25 to 1/26/26 for a total of 60 visits. An Oasis recertification completed on 12/12/25 failed to include home health aide supervision. The administrator/DON failed to provide documentation of supervisory visits upon request. During an interview on 2/9/26 at 11:54 a.m. the administrator/director of nursing (DON) stated supervisory visits were the responsibility of a former employee who had left the agency. The administrator/DON confirmed that any supervisory visits not found in the clinical record were not completed.”

“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 interview, record review, and observation, the administrator failed to be responsible for all day-to-day operations of the home health agency (HHA). Specifically, the administrator failed to ensure the agency provided drugs, services, and treatments only as ordered by a physician; to develop and maintain an emergency preparedness plan; to develop and maintain a HHA-wide quality assessment and performance improvement (QAPI) plan; to coordinate care between the agency and physicians; to report all OASIS data collected; ensure patients had an established plan of care; ensure nursing staff complied with professional standards to provide care; ensure a discharge summary was provided to physicians; ensure a comprehensive assessment was completed in a timely manner; ensure supervisory visits were completed per regulations; plans of care were updated every 60 days; and ensure patient specific certified nurse aide (CNA) care plans were prepared by a registered nurse (RN). Findings include: AGENCY POLICY According to the agency policy titled, “Administrator: Defined,” dated October 17 ( in pertinent parts): “The Administrator is responsible for the Agency’s functions and all day-to-day operations of the Agency.” Further review of the policy stated: “The administrator has the following responsibilities: Planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services Complying with applicable laws and regulations Directing and monitoring organizational Quality Assessment and Performance Improvement activities” 1. The state agency (SA) initiated a federal recertification survey on 2/2/26. Based on initial and ongoing findings during the survey the agency was found to be substantially out of compliance with federal regulations. The failure of the administrator to adequately and effectively organize and direct the agency’s ongoing functions created a systemic lack of direction, organization and quality oversight which led to condition level deficiencies being cited. Five condition level deficiencies were cited: 484.45 REPORTING OASIS INFORMATION 484.60 CARE PLANNING, COORDINATION, QUALITY OF CARE 484.105: CONDITION: ORGANIZATION AND ADMINISTRATION OF SERVICES 484.45 EMERGENCY PREPAREDNESS 484.65 QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT Additionally, 12 standard level deficiencies were cited. 2. The administrator failed to ensure the agency electronically reported all OASIS data collected in accordance with §484.55 - Condition of Participation, Comprehensive Assessment of Patients - each patient must receive and an agency must provide a specific comprehensive assessment as required. Reference G370. 3. The Administrator failed to ensure each patient receiving care and services had a complete and accurate plan of care that included all drugs and treatments ordered by the physician and was established timely with the physician following the start of care, recertification and resumption of care. Further, the administrator failed to ensure all services and treatments were administered by agency clinicians in conformance with physician orders and failed to ensure the agency communicated changes to the plan of care. Additionally, the agency failed to coordinate patient care between the agency and physicians office by failing to receive updated orders, verbal or written, and failed to ensure plans of care were reviewed and revised by physicians. Reference G520, G580, G572, G588, G814, G808, G962, G984 4. The administrator failed to ensure patient-specific written care instructions for the certified nurse aides (CNA) were prepared by a registered nurse. Reference G798 5. The administrator failed to implement a quality assessment and performance improvement (QAPI) program which had documented evidence it evaluated all agency services and complied with the requirements and standards set forth in CFR 484.65 creating the potential for the agency to overlook trends which affect the quality of services and care provided and may potentially put patients’ safety at risk. Reference G640 6. The administrator failed to ensure a discharge summary was sent to the primary care practitioner within five days of the patient’s discharge. Reference G1022 7. The administrator failed to ensure the agency to develop and maintain an emergency preparedness plan that included strategies for addressing emergency events, assessment of the patient population to identify persons at-risk, the type of services the agency has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Reference E-0001”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on interview and record review, the administrator/director of nursing (DON) failed to coordinate patient care between the agency and physicians office by failing to receive updated orders, verbal or written, and failed to ensure plans of care were reviewed and revised by physicians for 5 of 5 active patient records reviewed (Patient #1, #2, #3, #4 and #5) and 3 of 3 focus patient records reviewed (Focus Patient A, B and C). (Cross Reference G580 and G588) Findings include: A. Orders 1. The clinical record for Patient #2 was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/19/26 to 3/19/26 revealed a start of care date of 7/28/24; diagnoses included congestive heart failure, cardiac pacemaker, chronic obstructive pulmonary disease, incontinence, and limitation of activities of daily living due to disability. Plan of care orders included skilled nursing (SN) one time a week for medication management and certified nurse aide (CNA) 42 hours a week for assistance with activities of daily living (ADL). a. The administrator/DON failed to oversee care coordination between the agency and physician office for orders being received for Patient #1. Record review revealed a plan of care dated 1/19/26 without a physician signature. Further review failed to reveal documentation of a verbal order within the plan of care. Record review showed an order which was not signed, placed by the administrator/Director of Nursing (DON) on 11/20/25 which included orders for SN one time a week and CNA 42 hours a week. Review of the order failed to reveal communication with the physician of record for Patient #2. Record review failed to reveal a signed plan of care for the prior two certification periods. Additional review failed to reveal documentation of attempted faxes or physician communication. Review of Patient #2’s clinical record failed to reveal a current plan of care, written orders for the care the patient is receiving, or verbal orders for the care the patient is receiving. There was no documentation of the administrator/DON overseeing or ensuring the agency contacted the physician office for orders for the current certification period or previous certification period. During an interview on 2/9/26 at 3:10 p.m., the administrator/DON confirmed Patient #2 did not have a current signed POC nor valid verbal orders. 2. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification 1/2/26 to 3/2/26 was not found in the record. Further review of the record for Patient #3 revealed a start of care date of 1/7/24. Review of an older plan of care dated 3/7/25 included the following information; diagnoses include, morbid (severe) obesity due to excess calories, essential (primary) hypertension and type 2 diabetes mellitus with diabetic neuropathy. There were no orders for the current certification period regarding SN frequency or what care was to be provided to Patient #3, but review of a plan of care dated 3/7/25 revealed a SN frequency of 14 times a week for nine weeks, for medication administration, admission and recertification. a. The administrator/DON failed to oversee care coordination between the agency and physician office for orders being received for Patient #3. Review of Patient #3’s clinical record failed to reveal a current plan of care, written orders for the care the patient is receiving, or verbal orders for the care the patient is receiving. There was no documentation of the administrator/DON overseeing or ensuring the agency contacted the physician office for orders for the current certification period. Review of Patient #3’s clinical record failed to reveal a signed plan of care, signed written orders, or verbal orders for the previous certification period of 11/2/25 to 1/1/26. There was no documentation of the administrator/DON overseeing or ensuring the agency contacted the physician office for orders for the previous certification period. During an interview on 2/9/26 at 3:10 p.m., the administrator/DON confirmed Patient #3 did not have a current signed POC nor valid verbal orders. 3. The clinical record for Patient Focus B was reviewed on 2/4/26. Plan of care orders for the certification period dated 1/13/26 to 3/13/26 revealed a start of care date of 6/8/21; diagnoses included Cerebral infarction unspecified, essential (primary) hypertension, and presence of cardiac pacemaker. Plan of care orders included SN seven days a week for medication set up, and medication management. a. The administrator/DON failed to oversee care coordination between the agency and physician office for orders being received for Patient Focus B. Review of the clinical record for Focus Patient B’s Patient failed to reveal a signed plan of care for the current certification period. Further review failed to reveal oversight by the administrator/DON for documented communication notes between the agency and the physician of record. During an interview on 2/9/26 at 3:10 p.m., the administrator/DON confirmed Patient Focus B did not have a current signed POC nor valid verbal orders. 4. Similar findings were found for Patients #1, #4, #5 and Focus Patients A and C. 5. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON stated the DON of the agency was ultimately responsible for the oversight of the care coordination. The administrator/DON stated she did not call for verbal orders and stated she was not aware of not being able to treat the patients without orders. B. Review of plan of care. 1. The clinical record for Patient #2 was reviewed on 2/3/26. The Plan of care for the certification periods 11/20/25 to 1/18/26 and 1/19/26 to 3/19/26 revealed a start of care date of 7/28/24. Diagnoses included unspecified diastolic (congestive) heart failure, atrio-ventricular block (complete), presence of cardiac pacemaker and chronic obstructive pulmonary disease among others. Plan of care orders for the certification period dated 1/19/26 to 3/19/26 included SN visits once a week and personal care for 42 hours a week. a. The administrator/DON failed to oversee communication coordination between the agency and physicians office regarding signed plans of care for Patient #4. Review of Patient #2’s Plan of Care for the certification period dated 11/20/25 to 1/18/26 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed the plan of care was only signed by the agency administrator/DON. Further review failed to reveal documented oversight by the administrator/DON regarding phone calls to the physicians office to receive a reviewed plan of care within the 60 day certification period. During an interview on 2/9/26 at 1:12 p.m., the agency administrator/DON stated the plan of care was created and sent to the physician for signature but getting the physician to review and sign the plan of care was the issue. The administrator/DON stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record. 2. The clinical record for Patient #4 was reviewed on 2/3/26. The Plan of care for the certification period 12/6/25 to 2/3/26 revealed a start of care date of 12/6/25. Diagnoses included altered mental status, unspecified, type II diabetes mellitus without complications, neuromuscular dysfunction of bladder and acquired absence of unspecified leg above knee. Plan of care orders for the certification period dated 12/6/25 to 2/3/26 included SN visits once a month. a. The administrator/DON failed to oversee communication coordination between the agency and physicians office regarding signed plans of care for Patient #4. Review of Patient #4’s Plan of Care for the certification period dated 12/6/25 to 2/3/26 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed the plan of care was only signed by the administrator/DON. Further review failed to reveal documented oversight by the administrator/DON regarding phone calls to the physicians office to receive a reviewed plan of care within the 60 day certification period. During an interview on 2/9/26 at 1:12 p.m., the administrator/DON stated the plan of care was created and sent to the physician for signature but getting the physician to review and sign the plans of care was the issue. The administrator/DON stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record. 3. The clinical record for Patient #5 was reviewed on 2/3/26. The Plans of Care for the certification periods 10/18/25 to 12/16/25 and 12/16/25 to 2/14/26 revealed a start of care date of 4/21/25. Diagnoses included unspecified Intellectual Disability, developmental disorder of speech and language and iron deficiency anemia. Plan of Care orders for the certification period dated 12/16/25 to 2/14/26 included SN visit once every 60 days and personal care for 42 hours a week. a. The administrator/DON failed to oversee communication coordination between the agency and physicians office regarding signed plans of care for Patient #5. Review of Patient #5’s Plan of Care for the certification period dated 10/18/25 to 12/16/25 revealed the physician had not reviewed and signed the Plan of Care for the entire 60 day service period. Further review showed both plans of care were only signed by the administrator/DON. Further review failed to reveal documented oversight by the administrator/DON regarding phone calls to the physicians office to receive a reviewed plan of care within the 60 day certification period. During an interview on 2/9/26 at 1:12 p.m., the agency Administrator stated the plan of care was created and sent to the physician for signature but getting the physician to review and sign the plan of care was the issue. The administrator/DON stated they attempted numerous phone calls to the physician to get POCs signed, however there was no documentation of this in the record 4. Similar findings of the agency’s failure to ensure each patient’s plan of care was reviewed by the physician at least every 60 days was found on review of focus Patients A and C. 5. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON stated the DON of the agency was ultimately responsible for the oversight of the care coordination. The administrator/DON stated she did not call for verbal orders and stated she was not aware of not being able to treat the patients without orders.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on interview and record review, the Administrator/Director of Nursing (DON) failed to provide oversight of all patient care services in accordance with requirements set forth in regulation. Specifically, the Administrator/DON failed to ensure the development, implementation and updates of the individualized plan of care that specified care and services to meet each patient’s specific identified needs for patients receiving services from the agency. Findings include: 1. Survey findings revealed the agency had failed to ensure an individualized plan of care that specified care and services to meet each patient’s specific identified needs had been established for 1 of 1 active patient records who received insulin administration reviewed (Patient #3). a. Record review revealed Patient #3 had a start of care date of 1/7/24. The last Plan of Care expired on 7/5/25. Diagnoses for Patient #3 included Type II Diabetes Mellitus with neuropathy, essential hypertension and morbid obesity. Orders for Patient #3 for the certification period 1/2/26 to 3/2/26 included injection of Lantus Insulin given subcutaneously twice a day by a Registered Nurse. Record review revealed that this service was being provided regularly without a current Plan of Care. During an interview on 2/9/26 at 10:36 a.m., the administrator/DON stated the agency failed to develop the Plan of Care. The administrator/DON stated this failure was because she had not taken on all the duties of the agency administrator.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure nursing staff complied with professional standards and principles pertaining to providing care for patients without current physician orders for 5 of 5 current patients (Patient #1, #2, #3, #4 and #5) and 3 of 3 focused sample records reviewed (Focus Sample, A, B and C). Findings include: Professional reference According to the Colorado Revised Statues 2025 Title 12 Profession and Occupations “Article 255: Nurses and Nurse Aides” “’Delegated Medical Function’ means an aspect of care that implements and is consistent with the medical plan as prescribed by a licensed or otherwise legally authorized, physician, podiatrist, dentist and is delegated to a registered professional nurse or a practical nurse by physician, podiatrist, dentist or physician assistant. For purposes of this subsection (4), ‘medical’ means a written plan, verbal order, standing order or protocol whether patient specific or not that authorizes specific or discretionary medical action which may include but is not limited to the section of medication.” 1. The clinical record for Patient #3 was reviewed on 2/3/26. The plan of care for the certification 1/2/26 to 3/2/26 was not found in the record. Further review of the record for Patient #3 revealed a start of care date of 1/7/24. Review of an older plan of care dated 3/7/25 included the following information; diagnoses include, morbid (severe) obesity due to excess calories, essential (primary) hypertension and type 2 diabetes mellitus with diabetic neuropathy. There were no orders for the current certification period regarding skilled nursing (SN) frequency or what care was to be provided to Patient #3, but a plan of care dated 3/7/25 revealed a SN frequency of 14 times a week for nine weeks, for medication administration, admission and recertification. a. The agency failed to ensure nursing staff provided care to Patient #3 within the professional nursing standard. Review of Patient #3’s clinical record revealed the patient had no current plan of care for the certification period 1/2/26 to 3/2/26. Further review of the record revealed the agency had not contacted the physician of Patient #3 for verbal orders at the start of the certification period. Further review of the record revealed the agency had not contacted the physician of Patient #3 to receive signed written orders for the care to be provided to Patient #3. During a home visit, at the home of Patient #3, on 2/3/26 at approximately 10:00 a.m., the state agency (SA) surveyors observed registered nurse (RN) #3 provide medication administration and vital signs assessment to Patient #3. Continued observation of RN #3 showed the RN assessing the blood sugar levels of Patient #3, as well as his pulse and Oxygen levels and blood pressure. SA surveyors also observed RN #3 injecting Patient #3 with 50 units of lantus insulin. During a home visit interview, at the home of Patient #3, on 2/3/26 at approximately 10:00 a.m., RN #3 was asked if she had a plan of care for Patient #3 and the tasks she was providing for him. RN #3 checked both the folder of the agency left at the home of Patient #3, as well as the electronic medical record (EMR) system application she had on her phone and was unable to locate a current plan of care for Patient #3. Review of the SN visit from 1/2/26 to 2/3/25 revealed a SN had provided care twice a day since 1/2/26, except on 2/1/25 where the morning SN visit was missed due to an agency scheduling error. 2. The clinical record for Patient #2 was reviewed on 2/3/26. Plan of care orders for the certification period dated 1/19/26 to 3/19/26 revealed a start of care date of 7/28/24; diagnoses included congestive heart failure, cardiac pacemaker, chronic obstructive pulmonary disease, incontinence, and limitation of activities of daily living due to disability. Plan of care orders included SN one time a week for medication management and home health aide (HHA) 42 hours a week for assistance with activities of daily living (ADL). a. The agency failed to ensure nursing staff provided care to Patient #2 within the professional nursing standard. Patient #2’s plan of care for the current certification period of 1/19/26 to 3/19/26 was unsigned by the physician as of 2/9/26. Further review of the Patient #2’s clinical record revealed the agency had not contacted the physician of Patient #2 for verbal orders at the start of the certification period. Further review of the record revealed the agency had not contacted the physician of Patient #2 to receive signed written orders for the care to be provided to Patient #2. Review of SN visits from 1/19/26 to 2/3/26 revealed a SN had provided a visit once a week. 3. The clinical record for Patient Focus B was reviewed on 2/4/26. Plan of care orders for the certification period dated 1/13/26 to 3/13/26 revealed a start of care date of 6/08/21; diagnoses included Cerebral infarction unspecified, essential (primary) hypertension, and presence of cardiac pacemaker. Plan of care orders included SN seven days a week for medication set up, and medication management. a. The agency failed to ensure nursing staff provided care to Patient Focused B within the professional nursing standard. Patient focused B’s plan of care for the current certification period of 1/13/26 to 3/13/26 was unsigned by the physician as of 2/9/26. Further review of the Patient Focus B clinical record revealed the agency had not contacted the physician of Patient Focus B for verbal orders at the start of the certification period. Further review of the record revealed the agency had not contacted the physician of Patient Focus B to receive signed written orders for the care to be provided to the patient. 4. Similar findings were found for Patients #1, #3, #5 and Patient Focus A and C. 5. During an interview on 2/3/26 at 3:46 p.m., the administrator/director of nursing (DON) stated she did not have signed plans of care for some of the agency’s patients including Patient #3. The administrator/DON also stated she understood it was a problem the agency was providing care without plans of care. During an interview on 2/4/26 at 12:08 p.m., the administrator/DON acknowledged she had not called physicians for verbal orders. The administrator/DON also stated she was not aware she could not provide care to patients without verbal or signed written orders. During an interview on 2/9/26 at 3:18 p.m., the administrator/DON acknowledged the agency was not ensuring that standards of nursing services were being followed by the SN of the agency.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interviews and record reviews the agency failed to ensure a discharge summary was sent to the primary care practitioner within five days of the patient’s discharge for 1 of 2 discharged records reviewed (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 2/3/26. The plan of care for the certification period of 9/4/25 to 11/2/25 revealed a start of care date of 9/4/25; diagnoses included mild cognitive impairment of uncertain or unknown etiology, age-related cognitive decline and unsteadiness on feet. Plan of care orders include skilled nursing (SN) visits once weekly for nine weeks for medication management, admission, hospitalization and care coordination. a. The agency failed to send a discharge summary to the physician within five days of discharge of Patient #7. Review of Patient #7’s record failed to reveal an exact date of discharge from the agency. Further review of Patient #7’s clinical record revealed a SN visit on 11/22/25 which stated the visit was missed due to the patient not opening the door for services. Further review of Patient #7’s chart failed to reveal any further SN visits, or assessments, or plans of care after the date of 11/22/25. Further review failed to reveal a discharge summary had been sent to the physician at any point between 11/22/25 and 2/3/26. During an interview on 2/4/26 at 3:47 p.m., the administration/director of nursing (DON) stated Patient #7 was hard to get a hold off and would not be there when nurses came for SN visits. The administrator/DON stated the agency discharged the patient after not being able to get a hold of him the last time. During an interview on 2/9/26 at 3:06 p.m., the administrator/DON stated the agency had not sent a discharge summary to the physician of Patient #7, and confirmed again Patient #7 was discharged from the agency.”