Inspiration Home Health Care LLC

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.50, Patient Rights was out of compliance. A total of 7 clinical records were reviewed for compliance with the Condition and Standards for Patient Rights. Record review revealed a pattern of failures in regard to ensuring the patients were free from neglect and not provided physician ordered services. Specifically by not providing necessary services to prevent physical harm and mental anguish. These failures had the potential to affect all patients served by the home health agency. G430 - Based on record review, observation and interview, the agency failed to ensure the patients were free from neglect by not providing necessary services to prevent physical harm and mental anguish on 4 of 7 patients reviewed (Patients #1,#2,#3,#4). G436 - Based on record review, observation and interview, the agency failed to ensure the patient had received all services outlined in the plan of care on 4 of 7 patients reviewed (Patients #1 , #2, #3 and #4).”

“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 the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.60, Care Planning, Coordination of Services, and Quality of Care was out of compliance. A total of 7 clinical records were reviewed for compliance with the Condition and Standards for Care planning, coordination of services and quality of care. Record review revealed a pattern of failures in regard to patient plan of care, communication of the physician and medication administration without physician orders. These failures had the potential to affect all patients served by the home health agency. G572- Based on record review, observation and interview the agency failed to follow the plan of care, specifically by not providing all services outlined in the plan of care for 3 of 7 patient records reviewed. (Patients #1, #2, and #3) G580- Based on record review and interview the agency failed to administer drugs services and treatments only as ordered by a physician for 1 of 1 patients records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) G608-Based on record review and interview the agency failed to coordinate care delivery to meet the patients needs, or involve the patient as appropriate in the coordination of care activities for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. Findings related to G570 are as follows: Based on record review and interview the agency failed to meet the patients medical, nursing, rehabilitative, and social needs in their place of residence. Specifically they did not provide an individualized written plan of care which included revisions or additions for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) 1. The clinical record for patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease, dependence on renal dialysis and acquired absence of left leg below knee. a. The agency failed to provide an individualized written plan of care including revisions or additions. Record review revealed the last signed and dated plan of care for Patient #4 was completed on 10/28/24. The plan of care completed for the certification period of 12/18/24 to 2/15/25 was incomplete as there was no documentation of review or revision completed by the physician. Continued record review revealed no documentation of a completed plan of care for the current certification period dated 2/16/25 to 4/16/25 within Patient #4’s electronic medical record (EMR). During an interview on 2/27/25 at 12:45p.m., the Director of Nursing (DON) when questioned about the status of the incomplete plans of care agreed the plan of care was incomplete, and it was not documented in the EMR. They acknowledged the plan of care needed to be completed and sent to the physician to review. No further documentation was provided by the agency at the time of survey.”

“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 and Performance Improvement (QAPI) was out of compliance. A total of 7 clinical records were reviewed for compliance with the Condition and Standards for Quality Assessment and Performance Improvement (QAPI). Record review revealed a pattern of failures in regard to patient care, documentation and governing body. These failures had the potential to affect all patients served by the home health agency. G658- §484.65(d) Standard: Performance improvement projects. G658- The agency failed to conduct an adequate number or scope of distinct improvement projects annually, which should have reflected the complexity and past performance of its services and operations. Furthermore, the agency lacked proper documentation for the quality improvement projects undertaken, including the rationale for each project and any measurable progress achieved. This deficiency indicates a significant failure in the agency’s commitment to improving care quality and demonstrates a lack of accountability in its operational practices. G660- §484.65(e) Standard: Executive responsibilities. G660- The agency failed in its governing body’s responsibilities concerning quality improvement and patient safety. The agency-wide quality assessment and performance improvement initiatives did not adequately address priorities for improving quality of care and patient safety, nor were improvement actions effectively evaluated for their impact. Furthermore, the agency failed to establish, implement, or maintain clear expectations for patient safety, compromising the integrity of care provided. Lastly, there was no evidence of appropriate action taken in response to findings of fraud or waste, indicating a serious lack of accountability within the governing body. These deficiencies highlight a critical failure in the HHA’s commitment to ensuring high-quality and safe care for its patients.”

“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 record review, observation and interview the agency failed to follow the plan of care, specifically by not providing all services outlined in the plan of care for 3 of 7 patient records reviewed. (Patients #1, #2, and #3) Findings Include: I. The agency failed to ensure all patients received skilled nursing (SN) services in accordance with the plan of care. 1. The clinical record for Patient #1 was reviewed on 2/24/25. Record review revealed a start of care date of 4/3/24. Further record review revealed a current certification period of 1/28/25 to 3/28/25. A plan of care revealed Patient #1 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic neuropathy, musculoskeletal system symptoms, hypertension, hyperlipidemia, prostatic hyperplasia with lower tract symptoms, urge incontinence, tremors, gastro-esophageal reflux, vitamin D deficiency, history of malignant neoplasms of bronchus and lungs, history of falling and need for assistance with personal care. a. The agency failed to provide the required skilled nursing services outlined in the plan of care Review of the plan of care orders included skilled nurse visits twice a day for 60 days for administration of oral medications,weekly medication organizer refills, patient education, assessment of vital signs and all body systems, assessment of medication compliance and blood sugar checks every visit. The skilled nurse is to administer medications in the morning and in the evening. Patient #1’s medication regimen includes antiparkinson and related therapy agents, hematopoietic agents, diuretics, urinary antispasmodics, proton pump inhibitors (PPIs), electrolyte supplements, psychotherapeutic and neurological agents for disease management. During a home visit on 2/25/25, Personnel #4 was observed failing to administer medication, educate the patient, or document vital signs and blood glucose readings. Patient #1 reported self-administering medications while nurses only filled the medication organizer and monitored vital signs. During a follow up interview on 2/25/25 Personnel #4 admitted to not bringing a computer for documentation and stated they relied on memory to record patient data later. No medication administration record was available to the time of survey for Patient #1. 2.The clinical record for Patient #3 was reviewed on 2/26/25. Record review revealed a start of care date of 8/25/24. Further record review revealed a current certification period of 2/21/25 to 4/21/25. The plan of care revealed Patient #3 was diagnosed with multiple chronic conditions including Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Ehlers-Danlos Syndrome, and Postural Orthostatic Tachycardia Syndrome (POTS). Further review of the plan of care revealed the patient was ordered to receive skilled nursing for medication administration and assessment once daily in the morning. Patient #3’s medication regimen includes cardiac, psychotropic, and narcotics and medications for disease management. The patient is unable to self-administer oral medications due to poor vision, forgetfulness, anxiety and Ehlers-Danlos disease. No family members or the pharmacy are able to assist with medication set up or provide pre-arranged medications. a. The agency failed to adhere to the ordered frequency in the plan of care. Record review revealed a total of eight missed skilled nursing visits in the certification period of 12/28/24 to 2/20/25, and a total of four missed skilled nursing visits in the certification period of 2/21/25 to 4/21/25. None of these visits were accounted for in documentation. During an interview on 3/3/35 at 2:16p.m., the Director of Nursing (DON) revealed they were aware of and investigating the missed visits. They continued to state they had notes in for some missed visits but not all of them. Surveyor stated those were not included in the sample provided and there were still outstanding visits without documentation of completion, or proof the patient’s needs were met. No further documentation to support the missed skilled nursing visits was provided at time of survey for Patient #3. II. The agency failed to maintain accurate documentation to verify all patients received skilled nursing (SN) services in accordance with the plan of care. 1. The clinical record for Patient #2 was reviewed on 2/26/25. Record review revealed a start of care date of 7/5/24. Further record review revealed a current certification period of 1/1/25 to 3/1/25. A plan of care dated 11/01/24 revealed Patient #2 was diagnosed with multiple chronic conditions which include but are not limited to type 2 diabetes mellitus with hyperglycemia, essential hypertension, and was undergoing chemolytic treatments for cancer. a. The agency failed to provide the required skilled nursing services outlined in the plan of care Further the plan of care revealed the patient was ordered to receive skilled nursing twice daily for administration of oral medications. To ensure safety and prevent overdose all medications were stored in a locked medication box. Patient #2’s orders included narcotics for moderate pain management with pain reporting to the physician if above a level five, a skilled nurse assessment of body systems, and vital signs. The patient is unable to self-administer oral medication due to blurred vision, forgetfulness, anxiety, a posterior cervical spinal fusion (C3-T2) and dysphagia. No family members or the pharmacy are able to assist with medication set up or provide pre-arranged medications. Further review of records revealed documentation of two visits completed for Patient #1 and Patient #2 by Personnel #2 for the same date and time. An interview on 2/26/25 at 10:10a.m., with a third party vendor revealed they identified documentation which supports Personnel #2 (Director of Nursing) had recorded visits for Patient #1 and Patient #2 on the same date during the same time frame. The conflict in visits revealed one or both patients’ needs were potentially unmet.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review the agency failed to comply with regulatory requirements regarding quality improvement projects. Specifically, the agency did not conduct an adequate number or scope of distinct improvement projects annually, which should have reflected the complexity and past performance of its services. Additionally, the agency lacked proper documentation for the quality improvement initiatives undertaken, including the rationale for each project and measurable progress achieved for 2023 and 2024. Findings include: On 03/03/25, the agency’s quality assurance performance improvement (QAPI) program was reviewed. Review of the QAPI program for 2023 and 2024 showed no evidence the agency had conducted any performance improvement projects (PIPs) for 2023 and 2024. Further review revealed the agency had no evidence to show the systematic review of patient care had been performed to lead to the development of PIPs to ensure quality of care concerns were appropriately identified, monitored and corrected. During an interview on 3/4/25 at 2:02 p.m., the director of nursing (DON) acknowledged the agency had failed to conduct quality performance improvement projects for the years 2023 and 2024 and the agency did not follow a formal process for improving agency performance, but followed up informally and verbally with staff.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and record review the agency’s governing body failed to assume authority and responsibility for the overall management, operations, and provision of home health services resulting in systemic failures in care coordination, oversight, and quality assurance for all patients. Findings Include: AGENCY POLICY According to agency policy titled,”Governing Body,” dated 1/2018 (read in pertinent parts): “The agency is directed by a governing body, which assumes full legal authority and responsibility for the operations of the organization. Quality patient care.” A. The agency’s administration failed to demonstrate appropriate oversight of patients served by the agency. 1. The agency was unable to provide a true and accurate representation of all patients served by the agency to ensure all patients received appropriate care. On 2/24/25, at 10:38a.m., an interview with the Director of Nursing (DON) revealed an active patient census of 59 patients. On 2/24/25,at 10:40 a.m., the DON and administrator were asked to provide an active patient census for the agency. At 12:30 p.m., the administrator was observed typing patients on a list in a document. At 1:17 p.m., the administrator gave an active patient census of 15 patients. The DON then started documenting visit schedules on the list and at that time it was noted that Patient #1 was not listed on the agency active patient census. The administrator and DON were then asked to print a patient census directly from the electronic medical record (EMR). The administrator left the room and refused to provide assistance. The DON was able to obtain a census from the EMR which listed 168 patients, but no clear way to determine the status of the patients on the list. The DON then stated the list was incorrect but she did not know how to provide an accurate list. On 2/24/25, the DON was asked to provide a list of discharged patients for the year of 2024 to present day. She then was observed preparing to type a list on a document, however stated the agency had only discharged one patient in the last year and showed a nearly blank document. She was then asked to print a discharge list from the EMR, which showed the agency had discharged 119 patients from the agency. On 2/25/25, the DON was asked to review the active patient list from the EMR and highlight active patients to assess the number of patients for whom the agency provided services. She attempted to highlight all active patients on the list but was unable to identify them all, which resulted in an inaccurate active patient census and demonstrated the agency was not aware of all patients being served by the agency. 2. The agency did not maintain a mechanism for patients served by the agency to consistently communicate with the agency, especially in the event of an emergency. On 2/27/25, the state department placed a telephone call to the home health agency but the phones were disconnected. At 12:50 p.m., the DON stated the agency was in the process of moving the agency to another location and the phones had been disconnected. She acknowledged the patients were not made aware of the change before they had disconnected the agency’s phone service but she was certain the patients would be informed of the phone service being disconnected in two days via mail from the agency The DON was adamant that all patients had her phone number for emergencies, despite not being able to identify all the patients being served by the agency. B. The agency failed to ensure any findings of fraud or waste were appropriately addressed. A review of Patient #1’s record revealed a start of care of 4/3/24; diagnosis included type 2 diabetes mellitus with diabetic neuropathy, musculoskeletal system symptoms, hypertension, hyperlipidemia, prostatic hyperplasia with lower tract symptoms, urge incontinence, tremors, gastro-esophageal reflux, vitamin d deficiency, history of malignant neoplasms of bronchus and lungs, history of falling and need for assistance with personal care. Plan of care orders for certification period 1/28/25 to 3/28/25 included skilled nurse (SN) visits twice a day for 60 days to administration oral medications, blood sugar checks, assessment of vital signs, all body systems and medication compliance, disease and medication management, safety education, and prefill medications weekly; and home health aide (HHA) services twice a day for 60 days for activities of daily living Patient #1’s medications included Antiparkinson and Related Therapy Agents, Hematopoietic Agents, Diuretics, Urinary Antispasmodics, Proton Pump Inhibitors (PPIs), Electrolyte Supplements, Psychotherapeutic and Neurological Agents - Miscellaneous, Thyroid Hormones, Selective Serotonin Reuptake Inhibitors (SSRIs), and Antihyperlipidemics. On 2/24/25, the DON was asked to provide access to the medical records for Patient #1 and to include all certification periods. The DON provided access to certification periods that covered December 2023 to February 2024 and late January 2025 to March 2025. The DON was asked if the agency provided care for Patient #1 between April 2024 and December 2024 and she stated the agency had discharged the patient in February 2024 and completed a new start of care for Patient #1 on 1/28/25. During an interview on 2/24/25 at 6:00 p.m., with an insurance case manager, the case manager confirmed that the agency had provided care to Patient #1 from April 2024 up to the time of the survey. She noted the agency failed to visit the patient during the week of 12/31/24 to 1/5/25 and the patient had expressed concerns of frustration and worry about the missed visits. Review of the clinical record on 2/24/25 revealed Patient #1’s current plan of care indicated a start of care date of 4/3/24. However, the records from 4/3/24 to 1/27/25 were not made available for review. The following day, the DON was asked to provide access to the records that she had failed to provide the previous day. A review of the records provided by the DON following the request showed the agency had indeed provided care to Patient #1 on 4/3/24 and continued through to the present day. The DON was then asked to explain why she withheld the records and why the records did not match her statements; however, she refused to elaborate on her rationale and remained silent. Patient #1’s record showed no evidence of missed visits week of 12/31/24 to 1/5/2025. Continued review of Patient #1’s record revealed a schedule set up for a skilled nurse two visits a day, and labeled AM and PM visits. The dates of 1/28/25 to 2/8/25 showed 21 scheduled visits, only 4 of the visits had complete documentation by Licensed Practical Nurse (LPN #3) . On 2/25/25 the following day, Patient #1’s record had been changed to reflect skilled nurse visits once a day and 16 visit notes were then available in the chart for review and the records for LPN #3 had been modified and were now incomplete records. The 16 visit notes that were reviewed on 2/24/25 had been backdated and timed to match the schedule in the record and not when they were entered into the EMR. On 2/25/25 at 12:11 p.m., the DON and administrator were asked how 16 visit notes had been entered into the system overnight for visits dated 1/28/25 to 2/8/25. They initially remained silent, but after further questioning, stated the clinician had entered the documentation at the time of the visits. They both then finally acknowledged the clinician had actually entered all the notes on 2/24/25. When asked how the nurses remembered blood sugar results, vital signs, medications, and assessments to include in the notes, the DON explained the nurses wrote down the results to ensure they had access to the assessments after the visits. Additionally, when questioned about why the documentation was backdated to the dates and times the visits were supposed to occur, the DON was unable to provide an explanation. During an interview on 2/25/25 at 10:05 a.m., Patient #1 revealed he took his medication twice a day and the skilled nurses did not administer medication to him. He stated the nurses visited his home every day but sometime back in January, they did not show up for scheduled visits and he was quite worried about it. He went on to say the nurses have been consistent with the visit frequency more recently. During a home visit on 2/25/25 at 10:05 a.m. at Patient #1’s home, LPN #4 was observed entering the home and interacting with Patient #1. However, LPN #4 was not observed administering any medications, educating the patient, or documenting performed assessment including the results from the blood sugar test. Following the completion of the home visit at 10:45 a.m, LPN #4 stated he did not write down the results of his patient assessments because he had a “great memory” and he would complete his charting at the end of the day. He further explained that he visited the patient once a day and looked at the pill box to make sure the patient took his medication for the morning but did not administer medication to Patient #1. During an interview on 2/26/25 at 8:08 a.m., LPN #4 revealed the agency’s leadership team had entered his visit notes for the time period of 1/28/25 to 2/8/25 into the EMR on 2/24/25. He stated the agency leadership team then asked him to sign off on the notes and he did so to avoid implicating the agency in any wrongdoing. When asked what dates he put on the notes when he signed off on them, he could not recall during the time of questioning. During an interview on 2/26/25 at 5:52 p.m., LPN #3 revealed she completed documentation for skilled nurse visits at the end of each day and she had not made any changes to Patient #1’s record. She then stated any changes made to the patient’s record were made by the agency without her permission. On 2/27/25 at 12:50 p.m., the DON was questioned about the records for Patient #1 and she refused to answer any questions. Throughout the survey period, the DON and administrator, who are also the agency owners, were questioned about the noncompliance issues, but they refused to provide clear explanations for the systemic failures in care coordination, oversight, and quality assurance affecting all patients. However, on 3/3/25, they acknowledged the findings, stating that they had work to do and were committed to addressing the issues.”

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on interview and record review the agency failed to implement an OASIS privacy notice to all patients for whom the OASIS data is collected for 7 of 7 patient records reviewed. Findings Include: A review of agency records on 2/27/25 showed no evidence of an OASIS privacy notice. During an interview on 3/3/25 at 2:55 p.m., the administrator acknowledged that he was unaware of the contents of the OASIS privacy notice. He then took the initiative to research the privacy notice and subsequently stated that the agency was not compliant with that regulation. During the exit conference on 3/3/25, the director of nursing and administrator acknowledged the findings.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure that patients were free of neglect for 4 of 7 patients reviewed (Patients #1, #2, #3 and #4). Findings included: 1. The clinical record for Patient #1 was reviewed on 2/24/25. The Plan of Care for the certification period dated 1/28/25 to 3/28/25 revealed a start of care date of 4/3/24; diagnoses include type 2 diabetes and hypertension. Plan of Care orders included skilled nurse (SN) visits twice daily for medication administration, vital signs and education. a)The agency failed to ensure Patient #1 was free from neglect. Specifically, Patient #1 was scheduled to receive one visit per day instead of the ordered twice daily visits and did not receive the daily scheduled visits. Review of visit notes on 2/24/25 for the time of 1/28/25 through 2/8/25 showed Patient #1 received five completed visits on 1/28/25, 1/31/25, 2/5/25, 2/6/25 and 2/7/25. Review of visit note on 2/25/25 for the time of 1/28/25 through 2/8/25 showed Patient #1 had 16 more visit notes entered in the electronic medical record (EMR) on 1/29, 1/30, 2/1, 2/2, 2/3/25, 2/4, 2/8, 2/9, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15 and 2/16/25. There was no evidence to show that Patient #1 was scheduled to receive or received Carbidopa-Levodopa 25-100 mg twice daily which could lead to potential harm related to Parkinson’s disease. There was no evidence Patient #1 received Varenicline-Tartrate 1 mg twice a day and Escitalopram 10 mg once daily which could lead to potential harm related to psychiatric diagnosis. Furthermore, there was no evidence to show Patient #1 was scheduled to receive the twice daily visits for medication administration as ordered on the Plan of Care leading to the neglect of Patient #1’s needs and potential for harm. During an interview with the agency administrator on 2/25/25 at 12:00 p.m., surveyors asked why the visits that were missing were now uploaded and why the frequency had changed. The administrator stated the clinician had not put in their notes on time. The administrator could not provide documentation to support the physician’s approval of changing the frequency from twice daily to once daily. During a home visit with Employee #4 on 2/25/25 at 10:00 a.m., Employee #4 was observed taking vitals signs, checking blood sugar level and listening to Patient #1’s heart and lungs. Employee #4 was not observed documenting the vital signs, helping with medication administration or educating Patient #1 according to the plan of care. Employee #4 stated they only provided one visit per day. Employee #4 stated he charted at the end of the day and did not bring a computer with him on visits. During an interview with Employee #4 on on 2/26/25 at approximately 8:00 a.m., Employee #4 admitted to the surveyors that the administrator had added the notes for him and he just signed off on them on 2/25/25. During an interview with Patient #1 on 2/25/25 at 10:00 a.m., Patient #1 stated earlier this year, the agency had missed multiple visits and he was very concerned about that. 2. The clinical record for Patient #3 was reviewed on 2/26/25. The Plan of Care for the certification period dated 2/21/25 to 4/21/25 revealed a start of care date of 8/25/24; diagnoses included chronic fatigue syndrome, chronic pain and anxiety disorder. Plan of Care orders included SN visits once daily for medication administration and assessments. a) Record review and interview revealed the agency failed to ensure Patient #3 was free of neglect. Specifically, the agency failed to show Patient #3 received Modafinil 100 mg once daily in the morning for chronic fatigue syndrome and Methocarbamol 500 mg once daily in the morning for muscle spasms leading to the neglect of Patient #3’s needs and potential for harm and discomfort. Record review of the EMR system revealed missed visits on 2/9/25, 2/12/25, 2/13/25, 2/14/25, 2/17/25, 2/18/25, 2/19/25 and 2/20/25 for the previous cert period. There were missed visits on 2/21/25, 2/22/25, 2/23/25 and 2/26/25 for the current cert period. There was no evidence to show Patient #3 received her medications on these 12 dates leading to the neglect of Patient #3’s needs. During an interview with the administrator on 3/3/25 at 2:15 p.m., surveyors asked what happened during these missed visits and if the physician was notified. The administrator stated she was unable to answer or provide documentation regarding Patient #3’s care and services with the visits or whether the physician was notified of the missed visits. 3. The clinical record for Patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease(ESRD), dependence on renal dialysis and acquired absence of left leg below knee. a) The agency failed to ensure Patient #4 was free of neglect. Specifically, the agency did not receive an updated physicians order for the administration of insulin prior to providing care. Review of the plan of care completed on 12/17/24 by the administrator. The plan of care included orders for skilled nursing twice daily for blood glucose checks, and the administration of long-acting insulin 30iu subcutaneous every morning and 20iu in the evening, and rapid-acting insulin 5iu subcutaneous twice daily. The patient was unable to set up her own medications or inject insulin due to forgetfulness, a period of confusion and deficient knowledge related to medications, fear, and ESRD. No family members or the pharmacy were able to assist with medication set up or provide pre-arranged medications. Further record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24. However skilled nursing visits and insulin medication administration were being completed twice daily for Patient #4 by Employee #6 from 12/18/24 to 12/26/25. During an interview on 2/27/25 at 12:45p.m., the administrator when questioned about missing orders stated she was aware there were no completed orders for Patient #4. They continued to state, Patient #4 had a change in physicians. When the survey team questioned further in regards to a verbal order, the DON stated they took a verbal order from the patient’s physician on 12/18/25 but it was not documented in the patient record. When questioned about where this was documented if not in the patient record, the DON stated they kept it in their memory but did not have the chance to input it into the EMR. The administrator acknowledged the order was not documented to standard and the importance of the order being documented to prevent medication errors. 4. The clinical record for Patient #2 was reviewed on 2/24/25. The Plan of Care for the certification period dated 1/1/25 to 3/1/25 revealed a start of care date of 8/25/24; diagnoses include type 2 diabetes and hypertension. Plan of Care orders included SN visits twice daily for medication administration and assessments. a) The agency failed to ensure accurate documentation of visits potentially leading to possible neglect. No evidence to show that Patient #2 received oxycodone-acetaminophen 5-325mg tablets as needed for moderate pain which could have led to severe pain and discomfort for Patient #2. Review of a visit note dated 12/22/24 revealed Employee #2 documented the visit occurring from 10:30 p.m. to 10:52 p.m. According to review of another patient’s visit notes (Patient #1), Employee #3 documented she completed a visit on 12/22/24 from 10:30 p.m. to 11:38 p.m. This conflict in documentation showed one or both patients’ needs were potentially unmet leading to potential neglect on this date and time. During interview with SANDATA (third party EVV) on 2/26/25 at 10:10 a.m., the representative confirmed that Employee #2 had been clocked into Patient #1 and Patient #2 at the same time. During an interview with the Administrator on 2/25/25 at 12:00 p.m., surveyors asked how entries were put into the EVV system. The Administrator replied they were only done via phone call and not done manually. The surveyor then asked how an employee could be clocked in at two places at once? Administrator refused to answer and was unable to provide proof of calling in to the EVV system.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure the patient had received all services outlined in the plan of care on 4 of 7 patients reviewed (Patients #1, #2, #3 and #4). Findings include: 1. The clinical record for Patient #1 was reviewed on 2/24/25. The Plan of Care for the certification period dated 1/28/25 to 3/28/25 revealed a start of care date of 4/3/24; diagnoses include type 2 diabetes and hypertension. Plan of Care orders included skilled nurse (SN) visits twice daily for medication administration, vital signs and education. a) The agency failed to ensure Patient #1 received all services outlined in the Plan of Care. Specifically, Patient #1 was scheduled to receive one visit per day instead of the ordered twice daily visits and did not receive the daily scheduled visits. Review of visit notes on 2/24/25 for the time of 1/28/25 through 2/8/25 showed Patient #1 received five completed visits on 1/28/25, 1/31/25, 2/5/25, 2/6/25 and 2/7/25. Review of visit note on 2/25/25 for the time of 1/28/25 through 2/8/25 showed Patient #1 had 16 more visit notes entered in the electronic medical record (EMR) on 1/29, 1/30, 2/1, 2/2, 2/3/25, 2/4, 2/8, 2/9, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15 and 2/16/25. There was no evidence to show that Patient #1 was scheduled to receive or received Carbidopa-Levodopa 25-100 mg twice daily which could lead to potential harm related to Parkinson’s disease. There was no evidence Patient #1 received Varenicline-Tartrate 1 mg twice a day and Escitalopram 10 mg once daily which could lead to potential harm related to psychiatric diagnosis. Furthermore, there was no evidence to show Patient #1 was scheduled to receive the twice daily visits for medication administration as ordered on the Plan of Care. During an interview with the agency administrator on 2/25/25 at 12:00 p.m., surveyors asked why the visits that were missing were now uploaded and why the frequency had changed. The administrator stated the clinician had not put in their notes on time. The administrator could not provide documentation to support the physician’s approval of changing the frequency from twice daily to once daily. During a home visit with Employee #4 on 2/25/25 at 10:00 a.m., Employee #4 was observed taking vitals signs, checking blood sugar level and listening to Patient #1’s heart and lungs. Employee #4 was not observed documenting the vital signs, helping with medication administration or educating Patient #1 according to the plan of care. Employee #4 stated they only provided one visit per day. Employee #4 stated he charted at the end of the day and did not bring a computer with him on visits. During an interview with Employee #4 on on 2/26/25 at approximately 8:00 a.m., Employee #4 admitted to the surveyors that the administrator had added the notes for him and he just signed off on them on 2/25/25. During an interview with Patient #1 on 2/25/25 at 10:00 a.m., Patient #1 stated earlier this year, the agency had missed multiple visits and he was very concerned about that. 2. The clinical record for Patient #3 was reviewed on 2/26/25. The Plan of Care for the certification period dated 2/21/25 to 4/21/25 revealed a start of care date of 8/25/24; diagnoses included chronic fatigue syndrome, chronic pain and anxiety disorder. Plan of Care orders included SN visits once daily for medication administration and assessments. a) Record review and interview revealed the agency failed to prove that services outlined in the plan of care were received by Patient #3. Specifically, the agency failed to show Patient #3 received Modafinil 100 mg once daily in the morning for chronic fatigue syndrome and Methocarbamol 500 mg once daily in the morning for muscle spasms which could lead to potential harm and discomfort. Record review of the EMR system revealed missed visits on 2/9/25, 2/12/25, 2/13/25, 2/14/25, 2/17/25, 2/18/25, 2/19/25 and 2/20/25 for the previous cert period. There were missed visits on 2/21/25, 2/22/25, 2/23/25 and 2/26/25 for the current cert period. There was no evidence to show Patient #3 received his medications on these 12 dates. During an interview with the administrator on 3/3/25 at 2:15 p.m., surveyors asked what happened during these missed visits and if the physician was notified. The administrator stated she was unable to answer or provide documentation regarding Patient #3’s care and services with the visits or whether the physician was notified of the missed visits. 3. The clinical record for Patient #2 was reviewed on 2/24/25. The Plan of Care for the certification period dated 1/1/25 to 3/1/25 revealed a start of care date of 8/25/24; diagnoses include type 2 diabetes and hypertension. Plan of Care orders included SN visits twice daily for medication administration and assessments. a) The agency failed to ensure accurate documentation of visits potentially leading to services having not been received according to the Plan of Care. No evidence to show that Patient #2 received oxycodone-acetaminophen 5-325mg tablets as needed for moderate pain which could have led to severe pain and discomfort for Patient #2. Review of a visit note dated 12/22/24 revealed Employee #2 documented the visit occurring from 10:30 p.m. to 10:52 p.m. According to review of another patient’s visit notes (Patient #1), Employee #2 documented she completed a visit on 12/22/24 from 10:30 p.m. to 11:38 p.m. This conflict in documentation showed one or both patients’ needs were potentially unmet on this date and time. During interview with SANDATA (third party EVV) on 2/26/25 at 10:10 a.m., the representative confirmed that Employee #2 had been clocked into Patient #1 and Patient #2 at the same time. During an interview with the Administrator on 2/25/25 at 12:00 p.m., surveyors asked how entries were put into the EVV system. The Administrator replied they were only done via phone call and not done manually. The surveyor then asked how an employee could be clocked in at two places at once then? Administrator could not answer and was unable to provide proof of calling in to the EVV system.”

“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 record review and interview the agency failed to administer drugs services and treatments only as ordered by a physician for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) Findings Include: 1. The clinical record for patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease(ESRD), dependence on renal dialysis and acquired absence of left leg below knee. a. The agency failed to receive an updated physicians order for the administration of insulin prior to providing care. Review of the plan of care completed on 12/17/24 by the Administrator. The plan of care included orders for skilled nursing twice daily for blood glucose checks, and the administration of long-acting insulin 30iu subcutaneous every morning and 20iu in the evening, and rapid-acting insulin 5iu subcutaneous twice daily. The patient is unable to set up her own medications or inject insulin due to forgetfulness, a period of confusion and deficient knowledge related to medications, fear, and ESRD. No family members or the pharmacy are able to assist with medication set up or provide pre-arranged medications.. Further record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24. However skilled nursing visits and insulin medication administration were being completed twice daily for Patient #4 by Personnel #6 from 12/18/24 to 12/26/25. During an interview on 2/27/25 at 12:45p.m., the Director of Nursing (DON) when questioned about missing orders stated she was aware there were no completed orders for Patient #4. They continued to statePatient #4 had a change in physicians. When the survey team questioned further in regards to a verbal order the DON states they took a verbal order from the patient’s physician on 12/18/25 but it was not documented in the patient record When questioned about where this was documented if not in the patient record the DON stated they kept it in their memory but did not have the chance to input it into the EMR. The DON acknowledged the order was not documented to standard and the importance of the order being documented to prevent medication errors.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview the agency failed to document verbal orders received in accordance with regulatory requirements in the patients clinical record for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) Findings Include: 1. The clinical record for patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease (ESRD), dependence on renal dialysis and acquired absence of left leg below knee. a. The agency failed to document verbal orders received in accordance with regulatory requirements. Record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24 including approval of the plan of care. No documentation of an order including the date and time, signed by the allowed practitioner was within the clinical record. During an interview on 2/27/25 at 12:45p.m., the Director of Nursing (DON) when questioned about missing orders states she was aware there were no completed orders for Patient #4. When the survey team questioned further in regards to a verbal order the DON stated they took a verbal order from the patient’s physician on 12/18/25 but it was not documented in the patient record. The DON continued to state they kept it in their memory but did not have the chance to input it into the EMR. During an interview on 2/27/25 at 1:27p.m., the DON when questioned who completed the medication administration stated Personnel #6. When questioned further about how the clinician would verify the medication order, the DON stated they called the clinician (personnel #6) and notified them of the order. The DON acknowledged the order was not documented to standard and the importance of the order being documented to prevent medication errors. No further documentation was provided by the agency at the time of survey.”

“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 record review and interview the agency failed to ensure the individualized plan of care was reviewed and revised by the physician no less frequently than once every 60 days for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) Findings Include: 1. The clinical record for patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease (ESRD), dependence on renal dialysis and acquired absence of left leg below knee. a.The agency failed to ensure the individualized plan of care was reviewed and revised by a physician every 60 days. Record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24 indicating approval of the plan of care or recertification for the certification periods of 12/18/24 to 2/15/25 and 2/16/25 to 4/16/25. Continued record review revealed a note attached to the 12/18/24 plan of care which included documentation of a new primary care physician however no note indicating an order. During an interview on 2/27/25 at 12:45p.m., the DON when questioned about missing orders states she was aware there was no completed orders for Patient #4. They continued to state Patient #4 had a change in physicians as her physician had retired and she was assigned to a new physician. During an interview on 2/27/25 at 1:02 p.m., the DON acknowledged at the time they did not know which physician was taking over Patient #4’s care, however as of 2/20/25 they do know which physician will be her primary care and will send the orders and plan of care to be reviewed and approved. No further documentation was provided by the agency at the time of survey.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview the agency failed to coordinate care delivery to meet the patients needs, or involve the patient as appropriate in the coordination of care activities for 1 of 1 patient records reviewed who were receiving skilled nursing for insulin administration. (Patient #4) Findings Include: 1. The clinical record for patient #4 was reviewed on 2/26/25. Record review revealed a start of care date of 8/20/24. Further record review revealed a current certification period of 2/16/25 to 4/16/25. A plan of care dated 12/17/24 revealed Patient #4 was diagnosed with multiple chronic conditions which include type 2 diabetes mellitus with diabetic polyneuropathy, depression, end stage renal disease (ESRD), dependence on renal dialysis and acquired absence of left leg below knee. a.The agency failed to coordinate care delivery appropriately to agency clinicians to meet the patients needs. Record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24 including approval of the plan of care. However skilled nursing visits and insulin medication administration were being completed twice daily for Patient #4 by Personnel #6 from 12/18/24 to 12/26/25. During an interview on 2/27/25 at 12:45p.m., the Director of Nursing (DON) when questioned about missing orders states she was aware there were no completed orders for Patient #4. When the survey team questioned further in regards to a verbal order the DON stated they took a verbal order from the patient’s physician on 12/18/25 but it was not documented in the patient record. The DON continued to state \ they kept it in their memory but did not have the chance to input it into the EMR. During an interview on 2/27/25 at 1:27p.m., the DON when questioned who completed the medication administration stated Personnel #6. When questioned further about how the clinician would verify the medication order, the DON stated they called the clinician (personnel #6) and notified them of the order. The DON acknowledged the order was not documented to standard and the importance of the order being documented to prevent medication errors. b. The agency failed to coordinate care delivery appropriately with the physician to meet the patient’s needs. Record review revealed no documentation of verbal or written orders received from the physician for Patient #4 since 10/28/24 including approval of the plan of care. However skilled nursing visits and insulin medication administration were being completed twice daily for Patient #4 by Personnel #6 from 12/18/24 to 12/26/25. Continued record review revealed a note attached to the 12/18/24 plan of care which included documentation of a new primary care physician however no note indicating an order. During an interview on 2/27/25 at 12:45p.m., the DON when questioned about missing orders states she was aware there was no completed orders for Patient #4. They continued to state Patient #4 had a change in physicians as her physician had retired and she was assigned to a new physician. During an interview on 2/27/25 at 1:02 p.m., the DON acknowledged at the time they did not know which physician was taking over Patient #4’s care, however as of 2/20/25 they do know which physician will be her primary care and will send the orders and plan of care to be reviewed and approved. No further documentation was provided by the agency at the time of survey.”