Beacon Skilled Care LLC

“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, QUALITY OF CARE 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. A total of 15 clinical records were reviewed for compliance with the Condition and Standards for Care Planning, Coordination and Quality of Care. Record review revealed a pattern of failures in regard to the establishment and implementation of patients’ plans of care. Specifically, the agency failed to ensure each patient received home health services in accordance with a complete and accurate written plan of care established; to ensure services and treatments were provided in conformance with physician’s orders; to ensure services and treatments were provided only as ordered by the physician; to ensure verbal orders were in compliance with state laws and regulations; to ensure each patient’s total plan of care was reviewed by the physician at least every 60 days; and that physicians were promptly notified of any deviations from the plan of care. The following standard level deficiencies were also cite: G580- Standard: Only as ordered by the physician - The agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician. G584- Standard: Verbal Orders- (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’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 in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. G574-Standard: Plan of care must include the following - The agency failed to ensure each patient’s plan of care included all medications, interventions, equipment, goals, and/or types of services and treatments. G590-Standard: Promptly alert relevant physicians of changes- The HHA must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 4840.70- SKILLED PROFESSIONAL SERVICES 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. A total of 15 clinical records were reviewed for compliance with the Condition and Standards for Skilled Professional Services. Record review revealed a pattern of failures in regard to the establishment and implementation of patients’ plans of care. Specifically, the agency failed to ensure each patient received services from skilled professionals who were responsible for ensuring patients’ received ongoing interdisciplinary assessment, received services in accordance with their plan of care as ordered by their physician and that all physicians involved in their plan of care as well as appropriate other health care practitioners related to the current plan of care were included in the coordination of their care. The following standard level deficiency was also cited: G704- Standard- Responsibilities of skilled professionals: Skilled professionals must assume responsibility for, but not be restricted to, the following: G710- Standard- Providing services that are ordered by the physician as indicated in the plan of care; and G718- Standard- Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure the skilled professional assumed responsibility for the needs of the patients. Specifically, the Registered Nurse (RN #3) failed to ensure the individualized plan of care (POC) was complete and accurate to include all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow for 7 of 15 records reviewed (Patients #1, #3, #4, #5, Focus Patients B, C, and G). Findings include: 1. The clinical record for Patient #3 was reviewed on 7/16/25. POC orders for the certification periods dated 5/1/25 to 6/29/25 and 6/30/25 to 8/28/25 revealed a start of care date of 5/1/25; primary diagnoses included type 2 diabetes mellitus, blindness in left eye, lymphedema, encounter for change or removal of nonsurgical wound dressing and chronic obstructive pulmonary disease, unspecified. POC orders included skilled nursing (SN) five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and home health aide (HHA) services six days per week for nine weeks to assist with activities of daily living (ADLs) and independent activities of daily living (IADLs). a. The agency failed to ensure the skilled professional assumed responsibility for ensuring the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow. Review of Patient #3’s POC dated 5/1/25 to 6/29/25 revealed Patient #3 was to receive SN five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and HHA services six days per week for nine weeks to assist with ADL and IADLs. Review of this POC failed to reveal specific wound care treatments or frequency for wound care. Review of Patient #3’s POC dated 6/30/25 to 8/28/25 revealed Patient #3 was to receive SN five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care effective 5/1/25; and HHA services six days per week for nine weeks to assist with ADL and IADLs effective 5/1/25. Review of this POC also failed to reveal specific wound care treatments or frequency for wound care as well as the effective date (5/1/25) not updated to reflect the current certification period. 2. The clinical record for Patient #4 was reviewed on 7/16/25. POC orders for the certification periods dated 5/8/25 to 7/6/25 and 7/7/25 to 9/4/25 revealed a start of care date of 5/8/25; diagnoses included type 2 diabetes mellitus with hyperglycemia and with foot ulcer, encounter for change or removal of non surgical wound dressing and heart failure. POC orders included SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. a. The agency failed to ensure the skilled professional assumed responsibility for ensuring the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made, and specific treatment orders to follow. Review of Patient #4’s POC dated 5/8/25 to 7/6/25 revealed Patient #4 was to receive SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. This POC revealed the specific wound care treatment to be provided to Patient #4; however, failed to indicate the frequency wound care should be provided. Additionally, Patient #4 was identified at the SOC comprehensive assessment to benefit from HHA services to assist with ADL and IADLs; however, HHA services were not maintained on the POC. Service documentation between 5/8/25 to 7/6/25 revealed Patient #4 was provided HHA services six days per week without a valid order to do so. (Cross Reference G580) Review of Patient #4’s POC dated 7/7/25 to 9/4/25 revealed Patient #4 was to receive SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. This POC revealed the specific wound care treatment to be provided to Patient #4; however, failed to indicate the frequency wound care should be provided. Additionally, Patient #4 had received HHA services six days per week during the previous certification period, 5/8/25 to 7/6/25, and was identified to continue to benefit from these services; however, HHA services were not maintained on the POC. Service documentation between 7/7/25 to the notification of Immediate Jeopardy to agency administration on 7/16/25 revealed Patient #4 was provided HHA services six days per week without a valid order to do so. (Cross Reference G580) 3. The clinical record for Patient #5 was reviewed on 7/16/25. POC orders for the certification periods dated 5/2/25 to 6/30/25 and 7/1/25 to 8/29/25 revealed a start of care date of 5/2/25; diagnoses included pressure ulcer of left buttock (stage 3), pressure ulcer of right buttock (stage 2), paraplegia, low back pain, neurogenic bowel and neuromuscular dysfunction of bladder. POC orders included SN one day per week for nine weeks and five as needed visits for assessment, wound care, education, safety and disease process. a. The agency failed to ensure the skilled professional assumed responsibility for ensuring the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made, and specific treatment orders to follow. Review of Patient #5’s POC dated 5/2/25 to 6/30/25, signed by Patient #5’s physician on 5/12/25, revealed Patient #5 was to receive SN visits one day per week for nine weeks and five as needed visits for wound care, education, safety and disease process. This POC revealed specific wound care treatment orders per wound; however, failed to indicate the frequency for each specific wound care to be performed. Further review of Patient #5’s record revealed on 5/2/25, a verbal order was documented as received at 11:00 a.m. which indicated SN were to provide services five days per week for nine weeks for assessment, wound care, education, safety and disease process as well as wound care treatment orders which were not delineated with specific wound care frequencies per wound. Service documentation following the physician’s signature on the POC between 5/12/25 to 6/30/25 revealed RN #3 provided services to Patient #5 five days per week which included wound care was performed at each visit, which was not in accordance with the physicians’ signed POC. (Cross Reference G580) Review of Patient #5’s POC dated 7/1/25 to 8/29/25, unsigned by a physician, revealed Patient #5 was to receive SN two times per day, five days per week (Monday through Friday) for nine weeks and five as needed visits for wound care, education, safety and disease process effective 5/2/25. In addition to the effective date not having been updated to reflect the current certification period; wound care treatment orders which were updated by a physician and received by the agency via faxed physician order and verbal confirmation on 6/16/25 for the left buttock wound were not updated on the POC. Service documentation between 7/1/25 to the date an Immediate Jeopardy notification was provided to agency administration for provision of services without a physician’s order on 7/16/25, revealed RN #3 had provided wound care treatment in accordance with the wound care orders updated on 6/16/25, which was not in accordance with the physicians’ POC. Cross Reference G580 4. Similar findings of the failure to ensure the skilled professional ensured the individualized POC was complete and accurate was revealed in the records of Patients #1, Focus Patients B, C and G. Specifically: -Patient #1’s POC failed to reveal an updated effective discipline and frequency date for certification period beginning 7/5/25; -Focus Patient B’s POC failed to reveal physical therapy (PT) had been ordered to evaluate and treat which was also received during a verbal order for SOC and treatment received on 6/2/25; -Focus Patient C’s POC failed to reveal PT had been ordered to evaluate and treat; and -Focus Patient G’s POC failed to reveal frequency for wound care dressing changes. 5. During an interview on 7/22/25 at 12:55 p.m., RN #3 and the agency administrator stated the comprehensive assessment was expected to update the POC orders with the current effective date(s) and current treatment orders when entered into the agency’s electronic medical record (EMR); however, had not been completed as expected. RN #3 stated she had not reviewed the POC’s in order to determine the POC was updated, complete and accurate prior to the effective date of the certification period. The agency administrator stated she had not reviewed POC’s for completion or accuracy as part of quality assurance measures. RN #3 stated moving forward they would ensure all POCs are complete and accurate and include all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow. During a follow up interview on 7/23/25 at 2:31 p.m. the administrator and intake coordinator stated RN #3 was in charge of the patients she brought over from another home health agency. Neither the administrator nor intake coordinator stated they hadn’t gotten around to auditing the records for these clients. Further, both admitted they were unaware what was going on with each patient individualized POC. The administrator nor the intake coordinator could provide information for the incomplete patient POC. Additionally, the administrator acknowledged she was unaware of what was happening with each patient RN #3 provided care for.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on record review and interview, the agency failed to respect the patient’s rights. Specifically, the agency failed to uphold the patient’s right to a confidential clinical record in 12 of 13 patients who transferred from a previous agency. (Patients #1, #3, #4, #5, #6, Focus A, B, C, D, E, F, and G). Findings Include: I. The agency failed to uphold the patient’s right to a confidential clinical record by not retrieving client-protected health information along the accepted standards of practice. 1.The clinical record for Patient #1 was reviewed on 7/14/25. The record review revealed a start of care date of 5/6/25 and a referral on 5/7/25, one day after the start of care. The plan of care dated 5/6/25 revealed a certification period of 5/6/25 to 7/4/25. Record review completed on 7/14/25, revealed Patient #1’s facesheet documentation from Shalom Homecare Agency within the quality management program (QMP) documentation. This facesheet included protected health information (PHI) such as Patient #1’s name, address, date of birth, and medical record number (MRN). 2. The clinical record for Patient #3 was reviewed on 7/14/25. The record review revealed a start of care date of 5/1/25 and a referral on 5/1/25. The plan of care dated 5/1/25 revealed a certification period of 5/1/25 to 6/29/25. Record review completed on 7/14/25 revealed Patient #3’s facesheet documentation from Shalom Homecare Agency within the quality management program documentation. This facesheet included PHI such as Patient #3’s name, address, date of birth, and MRN. 3. The clinical record for Patient #4 was reviewed on 7/14/25. Record review revealed a start of care date of 5/8//25 and a referral on 5/1/25. The plan of care dated 5/8/25 revealed a certification period of 5/8/25 to 7/6/25. Record review completed on 7/14/25 revealed Patient #4’s facesheet documentation from Shalom Homecare Agency within the quality management program documentation. This facesheet included protected health information PHI such as Patient #4’s name, address, date of birth, and MRN. 4. During an interview on 7/15/25, at 10:30 a.m., Registered Nurse Case Manager (RNCM) #3 stated they could not explain how the face sheets from Shalom Homecare Agency were introduced into the binder, nor did they have any involvement. Upon returning to the agency on 7/15/25 at 3:00 p.m., the survey team identified all documentation previously noted by surveyors from Shalom Healthcare Agency were removed from the QMP Binder. During an interview on 7/15/25 at 3:00 p.m., the Administrator/Director of Nursing (DON) stated they removed the Shalom Homecare Agency, face sheet prior to the survey team’s arrival at the agency that morning. State surveyors requested the Release of Information documentation in which the administrator stated they did not have that information in the record, as Shalom “would have deleted that.” Email correspondence on 7/15/25 at 11:49 p.m., from the administrator to the survey team, revealed the agency was aware the face sheets from Shalom Homecare Agency were included in the QMP binder and stated they were utilized to stay in compliance. During a follow-up interview on 7/23/25 at 2:31 p.m., the administrator/DON confirmed the documents were provided to the agency by RNCM #3. When surveyors requested documentation to support the PHI was obtained with patient consent, the agency was unable to provide additional documentation. The administrator stated they understood these were not obtained through the standard of practice, and continued education would be provided to RNCM #3. 5. Review of Patients #5, #6, and Focus A, B, C, D, E, F, G revealed similar findings of the agency’s failure to uphold the patient’s right to a confidential clinical record by not retrieving client-protected health information along the accepted standards of practice.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care (POC) was complete, accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow in 7 of 15 patient records reviewed (Patients #1, #3, #4, #5, Focus Patients B, C and G). Findings include: 1. The clinical record for Patient #3 was reviewed on 7/16/25. POC orders for the certification period dated 5/1/25 to 6/29/25 revealed a start of care (SOC) date of 5/1/25; primary diagnosis included type 2 diabetes mellitus, blindness in left eye, lymphedema, encounter for change or removal of nonsurgical wound dressing and chronic obstructive pulmonary disease, unspecified. POC orders included skilled nursing (SN) five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and home health aide (HHA) services six days per week for nine weeks to assist with activities of daily living (ADL) and independent activities of daily living (IADLs). a. The agency failed to ensure the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow. Review of Patient #3’s POC dated 5/1/25 to 6/29/25 revealed Patient #3 was to receive SN five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and HHA services six days per week for nine weeks to assist with ADL and IADLs. Review of this POC failed to reveal specific wound care treatments or frequency for wound care which the SN was to provide. Review of Patient #3’s POC dated 6/30/25 to 8/28/25 revealed Patient #3 was to receive SN five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care effective 5/1/25; and HHA services six days per week for nine weeks to assist with ADL and IADLs effective 5/1/25. In addition to the effective date not having been updated to reflect the current certification period; wound care treatments which were specified on this POC failed to reveal the frequency wound care would be provided. 2. The clinical record for Patient #4 was reviewed on 7/16/25. POC orders for the certification period dated 5/8/25 to 7/6/25 revealed a start of care date of 5/8/25; primary diagnosis included type 2 diabetes mellitus with hyperglycemia and with foot ulcer, encounter for change or removal of non surgical wound dressing and heart failure. POC orders included SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. a. The agency failed to ensure the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow. Review of Patient #4’s POC dated 5/8/25 to 7/6/25 revealed Patient #4 was to receive SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. This POC revealed the specific wound care treatment to be provided to Patient #4; however, failed to indicate the frequency wound care should be provided. Additionally, Patient #4 was identified at the SOC comprehensive assessment to benefit from HHA services to assist with ADL and IADLs; however, HHA services were not maintained on the POC. Service documentation between 5/8/25 to 7/6/25 revealed Patient #4 was provided HHA services six days per week without a valid order to do so. Cross Reference G580 Review of Patient #4’s POC dated 7/7/25 to 9/4/25 revealed Patient #4 was to receive SN two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. This POC revealed the specific wound care treatment to be provided to Patient #4; however, failed to indicate the frequency wound care should be provided. Additionally, Patient #4 had received HHA services six days per week during the previous certification period, 5/8/25 to 7/6/25, and was identified to continue to benefit from these services; however, HHA services were not maintained on the POC. Service documentation between 7/7/25 to the notification of Immediate Jeopardy to agency administration on 7/16/25 revealed Patient #4 was provided HHA services six days per week without a valid order to do so. Cross Reference G580 3. The clinical record for Patient #5 was reviewed on 7/16/25. POC orders for the certification period dated 5/2/25 to 6/30/25 revealed a start of care date of 5/2/25; primary diagnosis included pressure ulcer of left buttock (stage 3), pressure ulcer of right buttock (stage 2), paraplegia, low back pain, neurogenic bowel and neuromuscular dysfunction of bladder. POC orders included SN one day per week for nine weeks and five as needed visits for assessment, wound care, education, safety and disease process. a. The agency failed to ensure the individualized POC was complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow. Review of Patient #5’s POC dated 5/2/25 to 6/30/25, signed by Patient #5’s physician on 5/12/25, revealed Patient #5 was to receive SN one day per week for nine weeks and five as needed visits for wound care, education, safety and disease process. This POC revealed specific wound care treatment orders per wound; however, failed to indicate the frequency for each specific wound care to be performed which the SN would follow. Further review of Patient #5’s record revealed on 5/2/25, a verbal order was documented as received at 11:00 a.m. which indicated SN were to provide services five days per week for nine weeks for assessment, wound care, education, safety and disease process as well as wound care treatment orders which were not delineated with specific wound care frequencies per wound. Service documentation following the physician’s signature on the POC between 5/12/25 to 6/30/25 revealed RN #3 provided services to Patient #5 five days per week which included wound care was performed at each visit, which was not in accordance with the physicians’ signed POC. Cross Reference G580 Review of Patient #5’s POC dated 7/1/25 to 8/29/25, unsigned by a physician, revealed Patient #5 was to receive SN two times per day, five days per week (Monday through Friday) for nine weeks and five as needed visits for wound care, education, safety and disease process effective 5/2/25. In addition to the effective date not having been updated to reflect the current certification period; wound care treatment orders which were updated by a physician and received by the agency via faxed physician order and verbal confirmation on 6/16/25 for the left buttock wound were not updated on the POC. Service documentation between 7/1/25 to the date an Immediate Jeopardy notification was provided to agency administration for provision of services without a physician’s order on 7/16/25, revealed RN #3 had provided wound care treatment in accordance with the wound care orders updated on 6/16/25, which was not in accordance with the physicians’ signed POC. Cross Reference G580 4. Similar findings of the failure to ensure the individualized POC was complete and accurate was revealed in the records of Patients #1, Focus B, Focus C and Focus G. Specifically: -Patient #1’s POC failed to reveal an updated effective discipline and frequency date for certification period beginning 7/5/25; -Focus Patient B’s POC failed to reveal physical therapy (PT) had been ordered to evaluate and treat which was also received during a verbal order for SOC and treatment received on 6/2/25; -Focus Patient C’s POC failed to reveal PT had been ordered to evaluate and treat; and -Focus Patient G’s POC failed to reveal frequency for wound care dressing changes. 5. During an interview on 7/22/25 at 12:55 p.m., RN #3 and the agency administrator stated the comprehensive assessment was expected to update the POC orders with the current effective date(s) and current treatment orders when entered into the agency’s electronic medical record (EMR); however, had not been completed as expected. RN #3 stated they had not reviewed the POC’s in order to determine the POC was updated, complete and accurate prior to the effective date of the certification period. The agency administrator stated they had not reviewed POC’s for completion or accuracy as quality assurance either. RN #3 stated moving forward they would ensure all POCs are complete and accurate and included all services and treatments to be provided, the frequency and duration of visits to be made and specific treatment orders to follow.”

“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 ensure services and treatments were provided only as ordered by a physician in accordance with professional standards of practice in 12 of 15 Patient records reviewed (Patients #1, #3, #4, #5, #6, Focus Patients A, B, C, D, E, F and G). The state agency (SA) determined these failures posed an immediate potential risk to the health, safety, and welfare of Patients served by the agency and on 7/16/25 at 3:15 p.m. the agency was advised these failures created a situation of Immediate Jeopardy. The administration was advised to develop a plan to immediately address the circumstances of the Immediate Jeopardy. The agency submitted a plan to remove the Immediate Jeopardy, which was accepted on 7/17/25 at 11:11 a.m. Additionally, the Immediate Jeopardy was determined to be remediated by the SA prior to survey exit on 7/28/25. Findings Include: AGENCY POLICY According to the agency policy titled, “Plan of Care,” dated 2/2023 (in pertinent parts): “There is a written Plan of Care established based on the assessment of the patient, in consultation with the physician, agency staff, the patient and members of the patient’s family. The plan of care includes: the physician’s signature and date.” “Consultation with the physician on any modification in the plan of care will be documented and the physician’s signature obtained within a timely manner, or according to state law.” “Physician verbal orders are: put in writing, signed and dated with the date of receipt by an RN or therapist responsible for furnishing or supervising ordered services.” 1. During an interview on 7/15/25 at 10:00 a.m., Registered Nurse (RN #3) was asked about their process in ensuring physician orders were received prior to the delivery of services, particularly at the start of care (SOC). RN #3 stated they had not had permissions to review referrals or ensure orders were received prior to the provision of services and depended on the agency administrator and intake coordinator to verify orders were received prior to scheduling the start of care for RN #3 to complete. RN #3 stated brief record review of admission and referral paperwork, completed on 7/14/25, had failed to reveal physician orders or referral information had been maintained within the Patient records and RN #3 had completed SOC visits which included treatments without verification of orders in the Patient records. RN #3 stated they were not aware the orders were not in place prior to the visits; however, RN #3 had been aware of the Patients they completed SOC visits with because they had been their primary RN case manager for years prior and was aware the Patients were transitioning from one agency to another agency with them continuing to be their primary RN. RN #3 stated they would be more aware to ensure physician orders are confirmed prior to the provision of any services for Patients, whether they are aware of the Patients’ history or not, and that the responsibility to verify physician orders prior to service delivery was necessary for the RN, clinical manager and administration jointly to confirm. During an interview on 7/15/25 at 2:30 p.m., the agency administrator stated RN #3 was hired with the knowledge that two (2) Patients were expected to transfer home health care agencies with her and RN #3 had indicated to the agency administration the Patients’ were to be transferred quickly and RN #3 was worried about a potential lapse in services between the agencies. The agency administrator instructed RN #3 to ensure physician orders were obtained prior to providing services to Patients at the receiving home health agency; however, the agency administration trusted RN #3 to obtain and verify physician orders were sufficient to provide care prior to completion of any visits and had not conducted verification of orders themselves. 2. The clinical record for Patient #4 was reviewed on 7/16/25. Plan of care (POC) orders for the certification period dated 5/8/25 to 7/6/25 revealed a start of care date of 5/8/25; primary diagnosis included type 2 diabetes mellitus with hyperglycemia and with foot ulcer, encounter for change or removal of non surgical wound dressing and heart failure. POC orders included skilled nursing (SN) two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. a. The agency failed to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards. Review of Patient #4’s record revealed a start of care comprehensive assessment, wound care to a left heel diabetic ulcer was performed and medications were administered including insulin injections by RN #3 between 9:50 a.m. and 10:14 a.m. on 5/8/25. Record review revealed a start of care referral order was received by fax from Patient #4’s physician on 5/1/25 at 10:211 a.m., seven days before the SOC, and indicated SN was ordered to evaluate Patient #4 for admission to home health care next week (undefined). After the start of care visit had been completed, record review revealed a verbal start of care and treatment order was documented at 3:00 p.m.; however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.520) indicating the verbal order was complete and included the full identification of the healthcare professional who authorized the order. The verbal order documented on 5/7/25 at 3:00 p.m. indicated SN to complete SOC and SN to provide assessment, wound care, diabetic management, medication management and administration, insulin preparation/administration, education, safety and disease process; SN to cleanse right heel diabetic ulcer with normal saline (NS)/wound cleanser, apply xeroform to wound bed, cover with abdominal gauze pads (ABD) and wrap with kerlix. The verbal order also indicated five as needed visits for changes in condition, medication or needed for recertification visits. Additionally, the verbal order included an order for home health care aid (HHA) six times per week for nine weeks to assist with activities of daily living (ADLs) and independent activities of daily living (IADLs). Review of this order failed to reveal the specific frequency of treatments to each wound which skilled professionals would provide. (Cross Reference G584, G574) Record review revealed Patient #4’s physician signed the POC dated 5/8/25 to 7/6/25 on 6/4/25; which failed to maintain specific wound care or medication box fill frequencies to be provided to Patient #4, or maintain an order for any HHA services to be provided. Review of service documentation provided to Patient #4 between 5/8/25 to 6/9/25 revealed a HHA provided services six times per week, 22 visits total, without a valid physicians’ order to do so. On 6/9/25, a verbal order was was documented at 3:30 p.m.; which increased the frequency of HHA services from one time per day, six days per week to two times per day, six days per week; however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.520) indicating the verbal order was complete and included the full identification of the healthcare professional who authorized the order. Review of service documentation provided to Patient #4 between 6/9/25 to 7/5/25 revealed a HHA provided services two times per day six days per week, 46 visits total, without a valid physicians’ order to do so. Review of the POC for certification period date 7/7/25 and 9/4/25, unsigned by a physician, revealed SN was to provide services two times per day, five days per week (Monday through Friday) and five as needed visits for assessment, wound care and medication management including insulin injections. This POC failed to reveal specific wound care or medication box fill frequencies to be provided to Patient #4, or maintain an order for any HHA services to be provided. Review of service documentation provided to Patient #4 between 7/7/25 to the notification of an Immediate Jeopardy to agency administration on 7/16/25, revealed a HHA provided services two times per day, six days per week, 10 visits total, without a valid physicians’ order to do so. During an interview on 7/22/25 at 1:07 p.m., RN #3 reviewed the requirements as outlined in Federal regulation with the surveyors regarding complete and sufficient physician orders; as well as reviewed the requirements to have a complete plan of care. RN #3 acknowledged they had not obtained or verified physician orders were received and contained sufficient information prior to the provision of services to Patient #4. RN #3 additionally acknowledged they failed to accurately document verbal orders in accordance with federal regulations and failed to ensure plans of care and verbal orders were sufficient prior to providing services. 3. The clinical record for Focus Patient C was reviewed on 7/16/25. Record review revealed a start of care (SOC) date of 5/1/25. Further record review revealed a plan of care dated 6/30/25 with certification period of 6/30/25 to 8/28/25; diagnosis included multiple conditions including type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, and age-related cognitive decline. POC orders for discipline and treatment included skilled nursing (SN) two times a day, Monday through Friday, with an effective date of 5/1/25 for medication management/administration, diabetic management, safety, education, and disease process. Additional record review revealed an initial certification period of 5/1/25 to 6/29/25, diagnosis included the same multiple conditions as the current certification period. SOC POC orders included SN frequency two times a day, Monday through Friday with an effective date of 5/1/25 for medication management/administration, diabetic management, safety, education, and disease process. a. The agency failed to provide drugs, services, and treatment only as ordered by a physician. Record review revealed a Patient referral order dated 6/9/25 was sent to the agency by Focus Patient C’s physician on 6/9/25 at 4:26 p.m. by fax. Additional review of the patient’s record revealed the SOC POC was signed and dated by the physician of record on 5/9/25. Record review revealed a verbal order signed and dated on 5/1/25 by RN #3. Review of the verbal order failed to reveal information which included the full identification of the healthcare professional; therefore, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.52). The verbal order dated 5/1/25 revealed a physician of record signature dated 5/9/25. Complete record reveal failed to reveal a valid signed order for Focus Patient C dated before 5/9/25. Record review revealed a SN visit was completed by RN #3 on 5/2/25 at 8:09 a.m. The visit note indicated RN #3 provided skilled care which included assessment, vital signs monitoring, medication management, medication administration, and diabetic management. Review revealed a visit narrative which read SN assessment completed, vital signs monitored, Patient’s AM medications were administered with a glass of water. No swallowing issues observed. Patient’s blood sugar was monitored and written down in the log for the doctor. Patient tolerated the care well. Continued record review disclosed a SN visit note dated 5/2/25 at 3:35 p.m.. by RN #3. According to this visit note, RN #3 completed care consisting of an assessment, vital signs monitoring, medication management, medication administration, and diabetic management. The visit narrative note read SN assessment was completed, vital signs monitored, Patient’s PM medications were administered with a glass of water, no swallowing issues observed, Patient’s blood sugar was monitored and written down in the log for the doctor, Patient tolerated care well. Additional record review revealed similar SN visit notes were documented by RN #3 on 5/5/25 at 8:11 a.m. and 3:27 p.m., 5/6/25 at 8:10 a.m. and 2:46 p.m., 5/7/25 at 8:11 a.m. and 2:33 p.m., and 5/8/25 at 8:15 a.m. and 4:25 p.m. The agency failed to provide care only as ordered by a physician for six visits before obtaining signed physician orders. During an interview on 7/22/25 at 11:40 a.m., RN #3 verified completing visits prior to obtaining written or verbal orders from Focus Patient C’s physician. RN #3 indicated she had been providing care to this patient for some time before she started work at this agency. Additionally, RN #3 explained due to her previous employment at another home health agency, she knew what care to provide to this Patient at the SOC. Record review revealed a recertification OASIS visit was completed on 6/27/25 by RN #3 for Focus Patient C. A POC order was created on 6/27/25 which included SN frequency two times a day from Monday through Friday with an effective date of 5/1/25. Review of the recertification POC indicated no changes were made to SOC orders. Additional record review revealed a verbal order charted by RN #3 dated 6/30/25 stated a verbal order was attempted, but the physician’s office did not give out verbal orders and requested a fax. Continued record review failed to reveal a fax date for both the POC and verbal order to the physician’s office for signature. Additional record review failed to reveal communication or coordination documentation for Focus Patient C. During an interview on 7/22/25 at 11:33 a.m., RN #3 was questioned about the order dated 6/30/25. RN #3 admitted to not getting a valid verbal order from the physician’s office due to their policy of not giving verbal orders. Additionally, RN #3 stated she was not aware if the order was faxed or not. During an interview on 7/22/25 at 11:38 a.m., the administrator acknowledged the order dated 6/30/25 was not signed by the physician and had not been faxed to the physician’s office. Record review of Focus Patient C revealed 20 SN visits were completed between the certification period dated 6/30/25 to 8/28/25 without a valid physician order. During an interview on 7/22/25 at 11:33 a.m., RN #3 confirmed the visits since 6/30/25 had been completed by her. Further, RN #3 stated she was unaware the current POC and verbal order were not signed by the physician. 4. The clinical record for Patient B was reviewed in its entirety on 7/16/25. POC orders for the certification period dated 5/6/25 to 6/9/25 revealed a start of care date of 5/6/25. Primary diagnosis include hypertension secondary to other renal disorders, patient’s other noncompliance with medication regimen, chronic kidney disease, type 2 diabetes mellitus, acquired absence of left leg below knee, acquired absence of right leg below knee, homelessness, and dependence on renal dialysis. POC orders included skilled nursing (SN) two times a day, Monday through Friday for medication management. a. The agency failed to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards. Record review of Patient B revealed a comprehensive assessment was completed on 5/6/25 between 9:18 to 9:38 a.m. by RN #3 for the SOC which included discipline orders and treatment for SN frequency of two times a day, Monday through Friday, five as needed visits, effective 5/6/25 to develop a plan of care with patient/caregiver involvement to be countersigned by physician; SN to perform complete physical assessment each visit with emphasis on medication management and medication administration; SN to assess other conditions that present themselves during this episode of care; SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals. The visit narrative read SN assessment completed; vital signs monitored; medication box was refilled without missing doses; morning medications were given; no swallowing issues observed; has bilateral below the knee amputations; has bilateral prosthetic legs, but is unable to put prosthetics on; is refusing physical therapy/occupational therapy; goes to dialysis Monday, Wednesday, Friday; has a history of missing dialysis for weeks and then having to go to Denver Health Emergency to get dialysis through the hospital; was released from Denver Health on 5/4/25 for this issue; is non-compliant with medications unless administered by SN. Additional record review presented a documented physician order dated 5/6/25 at 4:52 p.m. and signed by RN #3. The verbal order failed to include the full identification of the healthcare professional, however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.52). The verbal order called for a frequency change for nursing two times a day, Monday through Friday, five as needed visits, effective 5/6/25, certify for SOC episode SN two times a day, Monday through Friday, for assessment, medication management, medication administration, education, safety, and disease process, five as needed SN visits for changes in condition/medication or needed for recertification visit. Record review failed to reveal a documented referral for Patient B. A referral dated 6/9/25 which referenced Patient C was uploaded to this chart. Review of the record indicated the initial POC and verbal order were signed by the physician on 5/23/25. Record review revealed 23 skilled nursing visits with care provided by the RN which includes assessment and medication administration between 5/6/25 to 5/23/25. Further review failed to show communication notes between the agency and the physician during this timeframe. During an interview with the Administrator and RN #3 on 7/22/25 at 1:45 p.m., both employees acknowledged orders were not signed before the SOC for Patient B. Additionally, both employees verbalized understanding of the requirements as outlined in the Federal regulations for physician order to be considered valid to include the full name, title, date, time, and ordering physician. During further discussion, RN #3 and the administrator acknowledged the SOC for Patient B occurred before obtaining valid physician orders. 5. The clinical record for Patient #6 was reviewed on 7/16/25. POC orders for the certification period dated 5/7/25 to 7/5/25 revealed a start of care date of 5/7/25; primary diagnosis included type 2 diabetes mellitus with diabetic polyneuropathy, pressure ulcer of sacral region (stage 2) and encounter for change or removal of nonsurgical wound dressing. POC orders included SN two times a day, five days per week (Monday through Friday) for wound care and medication management. a. The agency failed to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards. Review of Patient #6’s record revealed a start of care comprehensive assessment, wound care to a left lower leg diabetic ulcer and a sacral pressure sore was performed, medications administered, blood glucose was monitored by RN #3 between 8:51 a.m. and 9:20 a.m. on 5/7/25. Record review revealed a verbal start of care and treatment order was documented after the visit at 10:00 a.m.; however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.520) indicating the verbal order was complete and included the full identification of the healthcare professional who authorized the order. The verbal order documented on 5/7/25 at 10:00 a.m. indicated SN to complete SOC and SN to provide assessment, medication administration, diabetic management, weekly trulicity injection preparation and administration, wound care, disease process, safety, and education two times per day Monday through Friday; SN to cleanse left lower leg diabetic ulcer with normal saline (NS)/wound cleanser, apply xeroform to wound bed, cover with abdominal gauze pads (ABD) and wrap with kerlix; as well as SN to cleanse sacral pressure sore with NS/wound cleanser and apply mepilex. The verbal order also indicated five as needed visits for changes in condition, medication or needed for recertification visits. Review of this order failed to reveal the specific frequency of treatments to each wound; frequency of trulicity injections or specifics of diabetic management in which skilled professionals would provide. (Cross Reference G584) Continued record review revealed a start of care referral order was received by fax from Patient #6’s physician on 5/21/25 signed at 2:11 p.m., 14 days after the SOC, and indicated SN and home health aide (HHA) were ordered to evaluate Patient #6 for admission to home health care for assistance with activities of daily living (ADLs), medication management and wound care (unspecified). Review of service documentation between SOC on 5/7/25 to date of received referral on 5/21/25 revealed RN #3 had provided 21 visits without a sufficient order. Additional record review revealed Patient #6’s physician signed the POC dated 5/7/25 to 7/5/25 on 5/25/25; which failed to maintain specific wound care frequencies to be provided to Patient #6. Review of the record failed to reveal RN #3 received a sufficient and complete order prior to the end of the certification period on 7/5/25; therefore, RN #3 failed to ensure a sufficient and complete order had been received in order to provide services to Patient #6 in accordance with a complete plan of care on 80 completed visits which included treatment between 5/7/25 to 7/5/25. (Cross Reference G574) Record review revealed a verbal recertification and treatment order was attempted to be received on 7/3/25; however, the physician office informed RN #3 that verbal orders were no longer provided by the office and written orders would be needed to provide treatment. Review of the POC for certification period dated 7/6/25 to 9/3/25 revealed SN to provide assessment, medication administration, diabetic management, weekly trulicity injection preparation and administration, wound care, disease process, safety, and education two times per day Monday through Friday effective 5/7/25. The POC also indicated wound care orders, without specific frequencies identified, of SN to cleanse left lower leg diabetic ulcer with normal saline (NS)/wound cleanser, apply xeroform to wound bed, cover with abdominal gauze pads (ABD) and wrap with kerlix; as well as SN to cleanse sacral pressure sore with NS/wound cleanser and apply mepilex. The POC also indicated five as needed visits for changes in condition, medication or needed for recertification visits. Review of the record failed to reveal this POC had been signed by Patient #6’s physician as of Immediate Jeopardy notification to agency administration on 7/16/25; therefore, RN #3 had provided 16 visits without a physician’s order between 7/6/25 and 7/21/25, when the POC was signed by the physician. During an interview on 7/22/25 at 11:55 a.m., RN #3 reviewed the requirements as outlined in Federal regulation with the surveyors regarding complete and sufficient physician orders; as well as reviewed the requirements to have a complete plan of care. RN #3 acknowledged they had not obtained or verified physician orders were received and contained sufficient information prior to the provision of services to Patient #6. RN #3 additionally acknowledged they failed to accurately document verbal orders in accordance with federal regulations and failed to ensure plans of care and verbal orders were sufficient prior to providing services. b. The agency failed to ensure Patient #6 received services only as ordered by a physician in accordance with their POC. Review of the POCs for certification periods 5/7/25 to 7/5/25 and 7/6/25 to 9/3/25 revealed SN was to provide provide assessment, medication administration, diabetic management, weekly trulicity injection preparation and administration, wound care, disease process, safety, and education two times per day Monday through Friday. The POC also indicated wound care orders, without specific frequencies identified, of SN to cleanse left lower leg diabetic ulcer with NS/wound cleanser, apply xeroform to wound bed, cover with ABD and wrap with kerlix; as well as SN to cleanse sacral pressure sore with NS/wound cleanser and apply mepilex. Review of service documentation completed between 5/7/25 to the notification of an Immediate Jeopardy to agency administration on 7/16/25, a total of 96 visits, in which RN #7 failed to document wound care was provided to the sacral wound and only documented wound care was provided to the left leg shin wound. RN #7 had documented both the sacral and left leg wounds were measured each Monday during morning visits; however, failed to document wound care treatment provided beyond measurements. During an interview on 7/22/25 at 2:20 p.m., RN #3 stated they provided Patient #6 with a trulicity injection, medication box fill and wound care measurements one time per week on Monday mornings and provided wound care to the left leg wound and sacral wound two times per day, five days per week (Monday through Friday). RN #3 stated they also provided insulin injections and monitored blood glucose at each visit, twice per day, five days per week which were the interventions referenced in the POC regarding diabetic management. RN #3 and the surveyor jointly reviewed service documentation which failed to indicate RN #3 had provided wound care to the sacral wound at visits provided to Patient #6 prior to the notification of Immediate Jeopardy to agency administration on 7/16/25; and confirmed RN #3 had documented appropriate wound care to both wounds at resumption of care on 7/21/25. 6. The clinical record for Patient #3 was reviewed on 7/16/25. POC orders for the certification period dated 5/1/25 to 6/29/25 revealed a start of care date of 5/1/25; primary diagnosis included type 2 diabetes mellitus, blindness in left eye, lymphedema, encounter for change or removal of nonsurgical wound dressing and chronic obstructive pulmonary disease, unspecified. POC orders included skilled nursing (SN) five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and HHA services six days per week for nine weeks to assist with ADL and IADLs. a. The agency failed to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards. Review of Patient #3’s record revealed a start of care comprehensive assessment, wound care to a right foot wound was performed and a medication box was filled by RN #3 between 9:38 a.m. and 10:02 a.m. on 5/1/25. At the end of the start of care visit, record review revealed a verbal start of care and treatment order was documented at 10:00 a.m.; however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.520) indicating the verbal order was complete and included the full identification of the healthcare professional who authorized the order. The verbal order documented on 5/1/25 at 10:00 a.m. indicated SN to complete SOC and SN to provide assessment, medication management, wound care, safety, disease process and education; as well as five as needed visits for changes in condition or medication as well as needed for recertification visit. The verbal order not only failed to identify the full identification of the healthcare professional who authorized the order, the verbal order also failed to indicate specific wound care treatments or frequency of treatments which skilled professionals would provide or that HHA services were required to assist with ADL/IADLs at all. (Cross Reference G584, G574) Record review revealed Patient #3’s physician signed the POC dated 5/1/25 to 6/29/25 on 5/16/25; which failed to maintain specific wound care treatment interventions or frequency of wound care to be provided. The POC included an order for HHA to provide services six days per week for nine weeks to assist with ADL/IADLs which was not included on the initial verbal order RN #3 obtained at the SOC on 5/1/25 at 10:00 a.m. Review of service documentation provided to Patient #3 between 5/1/25 to 6/29/25 revealed wound care was performed by RN #3 on 39 visits and included SN cleaning the right foot wound with NS/wound cleanser, application of xeroform, securing with kerlix and ace wrapping without a valid physician’s order to do so. Service documentation between 5/1/25 to 5/17/25 revealed an HHA provided services six times per week, 14 visits, before the plan of care was signed by a physician on 5/17/25 and HHA services were ordered. On 6/27/25, during a recertification visit, RN #3 documented they obtained a verbal recertification and treatment order was documented at 10:00 a.m.; however, this verbal order was not in compliance with federal regulations (10 CCR 2505-10, Section 8.520) indicating the verbal order was complete and included the full identification of the healthcare professional who authorized the order, invalidating the order. This verbal order included treatment orders for SN to provide services one time per day (Monday through Friday), undefined duration, for wound care, medication management, safety, education and disease process. The verbal order indicated SN to provide wound care which included cleansing the wound with NS/wound cleanser, cover with xeroform, and wrapping with kerlix/ace wrap as well as included five as needed visits for changes in medication or condition. The verbal order not only failed to identify the full identification of the healthcare professional who authorized the order, the verbal order also failed to indicate that HHA services were required to assist with ADL/IADLs at all. (Cross Reference G584, G574) Review of the POC for certification period dated 6/30/25 to 8/28/25, unsigned by physician, revealed SN was to provide services five days per week (Monday through Friday) for nine weeks and five as needed visits for assessment, medication management and wound care; and HHA services six days per week for nine weeks to assist with ADL and IADLs. Review of service documentation provided to Patient #3 between 6/30/25 to the notification of an Immediate Jeopardy to agency administration on 7/16/25, revealed a HHA provided services six days per week, 15 visits total, without a valid physicians’ order to do so. During an interview on 7/22/25 at 12:36 p.m., RN #3 reviewed the requirements as outlined in Federal regulation with the surveyors regarding complete and sufficient physician orders; as well as reviewed the requirements to have a complete plan of care. RN #3 acknowledged they had not obtained or verified physician orders were received and contained sufficient information prior to the provision of services to Patient #3. RN #3 additionally acknowledged they failed to accurately document verbal orders in accordance with federal regulations and failed to ensure plans of care and verbal orders were sufficient prior to providing services. During continued interview at 1:00 p.m., RN #3 stated they overlooked the integration of all services to be provided in obtaining verbal orders and overlooked the completion of the orders to ensure all services were provided with a valid physician’s order. 7. Similar findings of the failure to ensure services were provided only as ordered by a physician were revealed in the records of Patients #1, #5, Focus Patients A, D, E, F and G. Specifically: -Patient #1 was provided services without a valid order to do so on 5/6/25, 7/8/25 and 7/15/25; -Patient #5 was provided services without a valid order, or in accordance with an order, to do so on 38 visits between 5/2/25 and 5/27/25; -Patient A was provided services without a valid order to do so on 7/8/25 and 7/15/25; -Patient D was provided services without a valid order, or in accordance with an order, to do so on five visits between 5/5/25 to 6/19/25; and two visits between 7/4/25 to 7/15/25. -Patient E was provided services without a valid order to do so on 7/7/25 and 7/14/25. -Patient F was provided services without a valid order, or in accordance with an order, to do so for three visits between 5/5/23 to 5/27/25, and on 7/7/25 and 7/14/25. -Patient G was provided services without a valid order to do so on seven visits between 5/7/25 to 5/27/25 and eight visits between 7/1/25 and 7/16/25. 8. During an interview on 7/22/24 at 11:33 a.m. with RN #3 revealed staff were aware physician verbal orders required a first/last name, credential, date/time, and authorized by which physician for the order to be valid. Further questioning revealed that RN #3 did not get all of the information required for a valid verbal order before this survey started. During an additional interview on 7/22/25 at 11:33 a.m. with the administrator, it was revealed the agency did not have the nurses handle faxes with the physicians.Per the administrator, it is the responsibility of the office staff to send out faxes and to upload returned documents to charts. During a follow up interview on 7/23/25 at 2:31 p.m. with the intake coordinator and administrator, it was revealed the agency accepted Patients without obtaining referrals from the Patients’ physicians. Additionally, the intake coordinator admitted Patients were started with services for SN prior to verifying the Patients had valid physician orders.”

“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 ensure the proper authentication of verbal orders for 13 of 15 patients whose registered nurse received verbal orders. (Patients #1, #2, #3, #4, #5, #6, Focus A, B, C, D, E, F, and G). Findings Include: 1. The clinical record for Patient #1 was reviewed on 7/14/25. The record revealed a start of care date of 5/6/25. Verbal orders dated 5/6/25 included skilled nursing (SN) once weekly for nine weeks with five as-needed (PRN) visits. Further review indicated the order was received by Registered Nurse Case Manager (RNCM) #3 on 5/6/25. However, the obtained order did not include the full name of the individual from whom RNCM #3 obtained the verbal order to fully identify the personnel authorized to receive and confirm the order. The order was signed by the physician on 5/9/25. a. The agency failed to document the identification of the personnel authorized to receive and confirm verbal orders for insulin administration. Further record review revealed a second verbal order dated 7/1/25 which included SN visit once weekly for nine weeks with five PRN visits for the administration of “Trulicity 1.5mg/0.5ml injection preparation/administration, disease process, education and safety.” Review of the record revealed the order was incomplete to the standard of practice, and did not include administration route or dose. Further review indicated the order was received by RNCM #3. However, the obtained order did not include the full name of the individual whom RNCM #3 obtained the verbal order to fully identify the personnel authorized to receive and confirm the order. During an interview with RNCM #3 on 7/22/25 at 12:15 p.m., she recalled speaking to Patient #1’s Nurse Practitioner (NP) to obtain verbal orders, but failed to document the correspondence. RNCM #3 acknowledged this was an insufficient standard of practice, and services provided to Patient #1 were done so without a physician’s order. 2. The clinical record for Patient #4 was reviewed on 7/14/25. The record revealed a SOC date of 5/8/25. Verbal orders dated 5/8/25 included SN twice a day, Monday through Friday, for wound care on right heel ulcer, medication, and insulin administration. Further review indicated the order was received by RNCM #3 on 5/8/25. However, the obtained order did not include the full name of the individual from whom RNCM #3 obtained the verbal order to fully identify the personnel was authorized to receive and confirm the order. b.The agency failed to document the identification of the personnel authorized to receive and confirm verbal orders for insulin administration and wound care treatment. Further record review revealed a second verbal order dated 7/5/25, which included SN visits twice a day, Monday through Friday, for wound care and insulin administration. Further review indicated the order was received by RNCM #3 on 7/3/25. However, the obtained order did not include the full name of the individual from whom RNCM #3 obtained the verbal order, making it unclear whether personnel were authorized to receive and confirm the order. The clinical record for Patient #6 was reviewed on 7/14/25. The record revealed a SOC date of 5/7/25. Verbal orders dated 7/4/25 included SN two times a day, Monday through Friday, for wound care on the left lower leg ulcer, medication, and insulin administration. Review of the record revealed the order was incomplete to the standard of practice, and did not include the administration route or dose. RNCM #3 attempted to obtain a verbal order on 7/3/25. Documentation noted Patient #6’s primary care physician (PCP) requested the order be faxed, as they do not provide verbal orders. The signed physician order was not obtained by the agency until 7/21/25. 3. During an interview on 7/15/25 at 11:50 a.m., the administrator stated that the agency’s standard of practice was not to send an RN to complete any patient visits until orders are completed and verified. She confirmed verbal orders were received after the treatment was provided by RNCM #3, and without physician orders. During an interview on 7/22/25 at 11:33 a.m., RNCM #3 stated she was educated on all required standards of practice for obtaining and documenting a completed verbal order. She acknowledged the deficient practice of providing care and services without physician orders. 4. Patients #2, #3, #5 Focus A, B, C, D, E, and F revealed similar findings of the agency’s failure to document the identification of the personnel authorized to receive and confirm verbal orders for insulin administration, and wound care.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the patient’s physician to reflect changes in the patient’s condition to suggest client outcomes were not being achieved, and changes to the plan of care were found for 7 of 7 patients reviewed with missed visits. (Patients #3, #4, #5, #6, and Focus B, C, and G). Findings Include: 1. The clinical record for Focus Patient C was completed on 7/16/25. The record review revealed a start of care date of 5/1/25 and a referral on 6/9/25. The plan of care dated 5/1/25 revealed a certification period of 5/1/25 to 6/29/25. a.The agency failed to notify the physician of a patient’s change in condition. Specifically, the agency did not notify the physician of out-of-range blood glucose levels. Review of the care plan revealed physician orders to notify the physician of a fasting blood glucose greater than 180 mg/dL or less than 70 mg/DL or random blood glucose greater than 200 mg/dL or less than 70 mg/dL. Record review revealed documentation of a random blood glucose taken by Registered Nurse Case Manager (RNCM) #3 on 5/13/25 of 260 mg/dL. There was no documentation to reflect RNCM #3 notified Focus Patient C’s physician of the out-of-range blood glucose. Further record review revealed documentation of multiple blood glucose levels out of range, with at least 18 instances noted between 6/6/25 and 7/14/25. During an interview on 7/22/25 at 1:38 p.m., with RNCM #3, when questioned by the survey team about the 18 instances of out-of-range blood glucose levels and physician notification, they stated they could not recall if they had notified the physician, and if they had any documentation would be in the visit note or communication note. 2. The clinical record for Focus Patient B was completed on 7/14/25. The record review revealed a start of care date of 5/6/25 and a referral on 5/15/25. The plan of care dated 5/6/25 revealed a certification period of 5/6/25 to 7/04/25. Further review revealed the plan of care (POC) was signed by the patient’s physician on 6/4/25. b.The agency failed to notify the physician of a patient’s change in condition. Specifically, the agency did not communicate the updated need for a change in the plan of care after the patient’s surgery. Review of the record revealed a missed visit dated 5/29/25. The agency documented Focus Patient B refused the visit due to being tired after their fistula surgery. Further record review revealed a comprehensive assessment dated 5/30/25 was completed by RNCM #3. Assessment of the integumentary system (skin) stated there were no identified concerns related to the patient’s skin. During an interview on 7/22/25 at 1:49 p.m., RNCM #3 confirmed she did not document a skin assessment, nor did she know how to complete the assessment, as she had never had a patient with a fistula before. She confirmed she did not update the plan of care for the physician to review the change in condition, and the patient’s outpatient dialysis team was responsible for the care. 3. The clinical record for Patient #3 was completed on 7/14/25. The record review revealed a start of care date of 5/1/25 and a referral on 4/30/25. The plan of care dated 5/1/25 revealed a certification period of 5/1/25 to 6/29/25. c. The agency failed to notify the physician of any changes to suggest patient outcomes were not being achieved. Specifically, the agency did not notify the physician of missed skilled nursing visits. Record review completed on 7/14/25 revealed orders for skilled nursing five times a week for nine weeks, with five as-needed (PRN) visits Monday through Friday for assessment of the efficiency and potential complications related to anticoagulation therapy, medication box management, and education. Further review of orders revealed the skilled nurse is to complete a physical assessment, provide wound care, and perform medication review and reconciliation for all new and changed medications, as well as provide medication education every visit. Orders state the skilled nurse is to notify the physician immediately of any potential problems which impede the completion of patient recovery and the desired patient outcomes. Further record review revealed three missed visits on 5/21/25, 5/23/25, and 6/13/25. Further record review revealed no documentation to show the physician was notified. There was no documentation from RNCM #3 explaining the reason for the missed skilled nursing visits or documentation to determine patient outcome and how the patients’ needs were met. During an interview on 7/22/25 at 12:06 p.m., RNCM #3, when questioned about missed visits, states the process is to call and notify the physician utilizing the missed visit form. During an interview on 7/22/25 at 12:09 p.m., the administrator confirmed care coordination was not documented in the electronic medical record (EMR), nor was the physician notified. 4. Similar findings of the agency’s failure to notify the client’s physician to reflect changes in the patient’s condition to suggest patient outcomes were not being achieved, and changes to the plan of care were found for Patients # 4, #5, #6, and Focus G.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to assure communication with all physicians involved in the plan of care for 13 of 15 patient records reviewed (Patient #1, #3, #4, #5, #6, #7, Focus Patients A, B, C, D, E, F and G). Findings Include: 1. The clinical record for Focus Patient C was reviewed on 7/16/25. Plan of care (POC) orders for the certification period dated 6/30/25 to 8/28/25 revealed a start of care (SOC) date of 5/1/25; diagnoses included type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, age-related cognitive decline, abnormalities of gait and mobility, unsteadiness on feet, patient unintentional underdose of medication regimen due to age-related debility, muscle weakness, iron deficiency anemia, and history of falling. POC orders included skilled nursing (SN) two times a day, Monday through Friday, for medication management/administration, diabetic management, safety, education and disease process. a. The agency failed to ensure communication with the physician to obtain a referral or orders to start care before visits were completed. Record review revealed a comprehensive assessment was completed on 5/1/25. However, a referral was not provided to the agency until 6/9/25 at 4:26 p.m. A verbal order for the SOC was found dated on 5/1/25 by RN #3. The order read certify for SOC episode with the orders on the POC. Additional information read frequency change: nursing two times a day, Monday through Friday, with five as needed visits effective 5/1/25. The order indicated it was taken from a person named Elizabeth RN. This order lacked the healthcare professional’s full identification resulting in an invalid verbal order. During an interview on 7/22/25 at 1:38 p.m., RN #3 could not recall who she spoke to from the physician’s office for this order. Record review revealed a SN visit was completed by registered nurse (RN) #3 on 5/2/25 at 8:09 a.m. The visit note indicated RN #3 provided skilled care which included assessment, vital signs monitoring, medication management, medication administration and diabetic management. Review revealed a visit narrative which read “SN assessment completed, vital signs monitored, Patient’s a.m. medications were administered with a glass of water. No swallowing issues observed. Patient’s blood sugar was monitored and written down in the log for the doctor. Patient tolerated the care well.” Continued record review showed a skilled nursing visit note dated 5/2/25 at 3:35 p.m.. by RN #3. According to this visit note, RN #3 completed care consisting of an assessment, vital signs monitoring, medication management, medication administration, and diabetic management. The visit narrative note read “SN assessment was completed, vital signs monitored, patient’s p.m. medications were administered with a glass of water, no swallowing issues observed, patient’s blood sugar was monitored and written down in the log for the doctor, patient tolerated care well.” Additional record review revealed similar SN visit notes were documented by RN #3 on 5/5/25 at 8:11 a.m. and 3:27 p.m., 5/6/25 at 8:10 a.m. and 2:46 p.m., 5/7/25 at 8:11 a.m. and 2:33 p.m., and 5/8/25 at 8:15 a.m. and 4:25 p.m. Additional review of Focus Patient C’s record revealed the SOC POC and verbal order were not signed and dated by the physician of record until 5/9/25, eight days following the initiation of services by the agency. Clinical record review failed to reveal any evidence of communication between the agency and the physician between 5/1/25 to 5/9/25. During an interview on 7/22/25 at 11:40 a.m., RN #3 verified completing visits prior to obtaining written or verbal orders from Focus Patient C’s physician. RN #3 indicated she had been providing care to Focus Patient C for some time before she started working at this agency. Additionally, RN #3 explained due to her previous employment at another home health agency, she knew what care to provide to this patient at the SOC. b. The agency failed to ensure communication with the physician occurred for the recertification POC dated 6/30/25 to 8/28/25. Record review revealed a recertification Outcome and Assessment Information set (OASIS) visit was completed on 6/27/25 by RN #3 for Focus Patient C. A POC order was created on 6/27/25 which included SN frequency two times a day from Monday through Friday with an effective date of 5/1/25. Review of the recertification POC indicated no changes were made to SOC orders. Additional record review revealed a verbal order charted by RN #3 dated 6/30/25 which stated a verbal order was attempted, but the physician’s office did not give out verbal orders and requested a fax. Continued record review failed to reveal a fax date for both the POC and verbal order to the physician’s office for signature. Additional record review failed to reveal documentation of communication or coordination with the physician for Focus Patient C. During an interview on 7/22/25 at 11:33 a.m., RN #3 admitted to not getting a valid verbal order from the physician’s office due to their policy of not giving verbal orders. Additionally, RN #3 stated she was not aware if the order was faxed or not. During an interview on 7/22/25 at 11:38 a.m., the administrator acknowledged the order dated 6/30/25 was not signed by the physician and had not been faxed to the physician’s office. The administrator stated nurses do not handle faxes with the physician. Further, the administrator acknowledged the responsibility for faxes sent and received belongs to the office staff, indicating herself. Record review of Focus Patient #C revealed 20 skilled nursing visits were completed between the certification period dated 6/30/25 to 8/28/25 without a valid physician order. c. The agency failed to ensure communication with the physician on record for the POC occurred regarding Focus Patient C’s blood sugar orders. Review of Focus Patient C’s clinical record revealed an order for the RN to notify the physician of random blood sugar results greater than 200 mg/dL (milligrams per deciliter) and less than 70 mg/dL. Record review revealed blood sugar results documented by RN #3 which were greater than 200 mg/DL for visits dated 7/2/25, 7/4/25, 7/7/25 and 7/14/25. Review of visit notes dated 7/2/25, 7/4/25, 7/7/25, and 7/14/25 failed to show documented communication with the physician or healthcare provider regarding the blood sugar readings for Focus Patient #C. During an interview on 7/22/25 at 1:38 p.m., RN #3 stated that Focus Patient C was receiving blood sugar checks at each visit per her physician’s orders. RN #3 stated the physician was evaluating medication needs for Focus Patient C. RN #3 did not recall contacting the physician for blood sugars greater than 200 mg/dL during the current certification period. RN #3 stated she was aware of the order to notify the physician. RN #3 added any communication with the physician would be documented in the visit note or in the chart for each patient. 2. The clinical record for Patient #6 was reviewed on 7/16/25. POCorders for the certification period dated 5/7/25 to 7/5/25 revealed a start of care date of 5/7/25; diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, pressure ulcer of sacral region (stage 2) and encounter for change or removal of nonsurgical wound dressing. POC orders included SN two times a day, five days per week (Monday through Friday) for wound care and medication management. a. The agency failed to ensure communication with the physician to obtain a referral or orders to start care before visits were completed. Review of Patient #6’s record revealed a SOC comprehensive assessment was completed on 5/7/25 which included wound care to a left lower leg diabetic ulcer and a sacral pressure sore, medication administration and blood glucose monitoring by RN #3. Continued record review revealed a verbal start of care and treatment order for SN to complete SOC and provide assessment, medication administration, diabetic management, weekly trulicity injection preparation and administration, wound care, disease process, safety, and education two times per day Monday through Friday and five as needed visits for changes in condition, medication or needed for recertification visits; SN to cleanse left lower leg diabetic ulcer with normal saline (NS)/wound cleanser, apply xeroform to wound bed, cover with abdominal gauze pads (ABD) and wrap with kerlix; as well as SN to cleanse sacral pressure sore with NS/wound cleanser and apply mepilex.was entered into the chart on 5/7/25 at 10:00 a.m. after the visit. Record review failed to reveal any evidence of communication with Patient #6’s physician from the SOC5/7/25 to the receipt of the physician orders on 5/21/25, a span of 14 days during which RN #3 provided 21 visits to Patient #6. During an interview on 7/22/25 at 11:55 a.m., RN #3 indicated any communication with physicians would be documented as a communication note. RN #3 could not recall if she spoke to the physician after the initial SOC orders. RN #3 stated she changed the dressing with every visit due to soilage. b. The agency failed to ensure communication with the physician occurred for the recertification POC dated 7/5/25 to 9/3/25. Review of the POC for the certification period dated 7/6/25 to 9/3/25 revealed RN #3 attempted to obtain a verbal order on 7/3/25. Documentation noted Patient #6’s primary care physician (PCP) requested the order be faxed, as they do not provide verbal orders. The signed physician order was not obtained by the agency until 7/21/25. Further record review failed to reveal any evidence of communication with Patient #6’s physician during this time. During an interview on 7/22/25 at 2:20 p.m. with RN #3 and the administrator, RN #3 stated she made one attempt to contact the physician for recertification orders without follow up. RN #3 admitted to continuing to see Patient #6 for skilled visits without physician authorization. The administrator confirmed the agency nurses did not fax orders to the physician. 3. Similar findings of the agency’s failure to assure communication between the agency and the physician for referrals, SOC and recertification orders, and issues with patients as they arose were found with Patients #1, #3, #4, #5, #7, Focus Patients A, B, D, E, F and G . 4. During an interview on 7/22/25 at 11:33 a.m., RN #3 stated she was educated on all required standards of practice for obtaining and documenting a completed verbal order. She acknowledged the deficient practice of providing care and services without physician orders. During an interview on 7/15/25 at 11:50 a.m., the administrator stated that the agency’s standard of practice is not to send an RN to complete any patient visits until orders are completed and verified. She confirmed verbal orders were received after the treatment was provided by RN #3, and without physician orders. During an additional interview on 7/22/25 at 11:33 a.m. with the administrator, it was revealed the agency did not have the nurses handle faxes with the physicians.Per the administrator, it is the responsibility of the office staff to send out faxes and to upload returned documents to charts. During a follow up interview on 7/23/25 at 2:31 p.m. with the intake coordinator and administrator, it was revealed the agency knowingly accepted patients without obtaining referrals from the patients’ physicians. Additionally, the intake coordinator admitted patients were started with services for SN prior to verifying the patients had valid physician orders.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure the skilled professional ensured services provided only as ordered by the physician as indicated in the Plan of Care (POC) for 12 out of 15 patients (Patients #1, #3, #4, #5, #6, Focus Patients A, B, C, D, E, F and G). Findings include: AGENCY POLICY According to the agency policy titled, “Plan of Care,” dated 2/2023 (in pertinent parts): “There is a written Plan of Care established based on the assessment of the patient, in consultation with the physician, agency staff, the patient and members of the patient’s family. The plan of care includes: the physician’s signature and date.” “Consultation with the physician on any modification in the plan of care will be documented and the physician’s signature obtained within a timely manner, or according to state law.” “Physician verbal orders are: put in writing, signed and dated with the date of receipt by an RN [registered nurse] or therapist responsible for furnishing or supervising ordered services.” 1. During an interview on 7/15/25 at 10:00 a.m., registered nurse (RN) #3 was asked about the agency’s process in ensuring physician orders were received prior to the delivery of services, particularly at the start of care (SOC). RN #3 stated they had not had permissions to review referrals or ensure orders were received prior to the provision of services. RN #3 depended on the agency administrator and intake coordinator to verify orders were received prior to scheduling the start of care visit. RN #3 stated she was unaware orders were not in place prior to the visits. During an additional interview on 7/22/25 at 11:33, RN #3 verbalized prior knowledge of patients’ needs and care due to previous work with the patients while at another home health agency. RN #3 stated when she left the previous home health agency, she brought the patients’ information with her. RN #3 expressed a history of transitioning from one agency to another agency with the patients while continuing to be their primary RN. RN #3 stated after this survey, staff would be more diligent to ensure physician orders are confirmed prior to the provision of any services for patients. Regardless of the staff’s history with the patient, it is the responsibility of the agency to verify physician orders prior to providing care services. Both the clinical manager and administration confirmed this. During an interview on 7/15/25 at 2:30 p.m., the agency administrator stated RN #3 was hired with the belief that two (2) patients were expected to transfer home health care agencies with her and RN #3 had indicated to the agency administration the patients’ were to be transferred quickly as RN #3 was worried about a potential lapse in services between the agencies. The agency administrator instructed RN #3 to ensure physician orders were obtained prior to providing services. The administrator indicated she “trusted” RN #3 to obtain and verify physician orders were sufficient to provide care before any visits were provided. The administrator acknowledged she did not verify the orders. 2. The clinical record for Patient #4 was reviewed on 7/16/25. Plan of care (POC) orders for the certification period dated 5/8/25 to 7/6/25 revealed a start of care date of 5/8/25; diagnoses included type 2 diabetes mellitus with hyperglycemia and with foot ulcer, encounter for change or removal of non surgical wound dressing and heart failure. POC orders included skilled nursing (SN) two times per day, five days per week (Monday through Friday) for assessment, wound care and medication management including insulin injections. a. The agency failed to ensure the skilled professional provided services and treatments only as ordered by a physician in accordance with professional standards. Review of Patient #4’s record revealed a start of care referral order was received by fax from Patient #4’s physician on 5/1/25 which indicated SN was ordered to evaluate Patient #4 for admission to home health care “next week” (undefined). Continued record review revealed a verbal order documented on 5/7/25 at 3:00 p.m. which indicated SN was to complete the SOC and provide assessment, wound care, diabetic management, medication management and administration, insulin preparation/administration, education, safety and disease process; SN to cleanse right heel diabetic ulcer with normal saline (NS)/wound cleanser, apply xeroform to wound bed, cover with abdominal gauze pads (ABD) and wrap with kerlix. The verbal order also indicated five as needed visits for changes in condition, medication or needed for recertification visits. Additionally, the verbal order included an order for home health care aid (HHA) six times per week for nine weeks to assist with activities of daily living (ADLs) and independent activities of daily living (IADLs). However, the order failed to reveal the specific frequency of treatments to each wound and included the full identification of the healthcare professional who authorized the order. Additionally, the POC for the certification period dated 5/8/25 to 7/6/25 was not signed and authorized by the physician until 6/4/25. Further record review revealed RN #3 completed a start of care comprehensive assessment on 5/8/25, at which she provided wound care to a left heel diabetic ulcer and administered medications including insulin injections prior to ensuring the agency had complete and accurate physician orders for treatment. Additionally, the record showed Patient #4 received HHA services six times per week from 5/8/25 to 6/4/25 without a valid physician’s order for services. (Cross Reference G574, G584) During an interview on 7/22/25 at 1:07 p.m., RN #3 reviewed the requirements as outlined in Federal regulation with the surveyors regarding complete and sufficient physician orders; as well as reviewed the requirements to have a complete plan of care. RN #3 acknowledged she had not obtained or verified physician orders were received and contained sufficient information prior to the provision of services to Patient #4. RN #3 additionally acknowledged she failed to accurately document verbal orders in accordance with federal regulations and failed to ensure plans of care and verbal orders were sufficient prior to providing services. 3. The clinical record for Focus Patient C was reviewed on 7/16/25. The POC for the certification periods dated 5/1/25 to 6/29/25 and 6/30/25 to 8/28/25 revealed a SOC of 5/1/25; diagnoses included type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, and age-related cognitive decline. POC orders included SN two times a day, Monday through Friday, for medication management/administration, diabetic management, safety, education, and disease process. Both POCs indicated an effective date of 5/1/25. a. The agency failed to ensure the skilled professional provided services and treatments were provided only as ordered by a physician in accordance with professional standards. i. Review of Focus Patient C’s record showed an incomplete verbal order written by RN #3 dated 5/1/25 for initiation of care and services by the agency. The verbal order failed to include all necessary information including the full identification of the healthcare professional who authorized the order. (Cross Reference G584) The SOC POC was not authorized and signed by the physician until 5/9/25. Continued review revealed a skilled nursing visit was completed by RN #3 on 5/2/25 at 8:09 a.m. The visit note indicated RN #3 provided skilled care which included assessment, vital signs monitoring, medication management, medication administration, and diabetic management. Review revealed a visit narrative which read “SN assessment completed, vital signs monitored, Patient’s a.m. medications were administered with a glass of water. No swallowing issues observed. Patient’s blood sugar was monitored and written down in the log for the doctor. Patient tolerated the care well.” An additional skilled nursing visit note dated 5/2/25 at 3:35 p.m. indicated RN #3 completed care consisting of an assessment, vital signs monitoring, medication management, medication administration, and diabetic management. The visit narrative note read “SN assessment was completed, vital signs monitored, patient’s p.m. medications were administered with a glass of water, no swallowing issues observed, patient’s blood sugar was monitored and written down in the log for the doctor, patient tolerated care well.” The record review revealed similar skilled nursing visit notes were documented by RN #3 on 5/5/25 at 8:11 a.m. and 3:27 p.m., 5/6/25 at 8:10 a.m. and 2:46 p.m., 5/7/25 at 8:11 a.m. and 2:33 p.m., and 5/8/25 at 8:15 a.m. and 4:25 p.m. The agency failed to provide care only as ordered by a physician for six visits before obtaining signed physician orders on 5/9/25 and did not receive referral orders from Focus Patient C’s physician until 6/9/25. (Cross Reference G580) During an interview on 7/22/25 at 11:40 a.m., RN #3 verified she completed visits prior to obtaining written or verbal orders from Focus Patient C’s physician. RN #3 indicated she had been providing care to Focus Patient C for some time with a separately licensed and certified agency before she started working at this agency. Additionally, RN #3 explained she knew what care to provide to this patient at the SOC due to her previous employment at the other home health agency.. ii. Record review revealed a recertification Outcome and Assessment Information Set (OASIS) visit was completed on 6/27/25 by RN #3 for Focus Patient C. A POC order was created on 6/27/25 which included SN frequency two times a day from Monday through Friday with an effective date of 5/1/25. Review of the recertification POC indicated no changes were made to SOC orders. Additional record review revealed a verbal order charted by RN #3 dated 6/30/25 stating a verbal order was attempted, but the physician’s office did not give out verbal orders and requested a fax. Continued record review failed to reveal evidence of physician authorization for care and services following the recertification comprehensive assessment completed on 6/27/25, resulting in 20 skilled nursing visits completed between 6/30/25 and 7/16/25 without a valid physician’s order (Cross Reference G580) During an interview on 7/22/25 at 11:33 a.m., RN #3 admitted to not getting a valid verbal order from the physician’s office due to their policy of not giving verbal orders. RN #3 stated she was not aware if the order was ever faxed to the physician or not. She further confirmed she had been conducting SN visits to Focus Patient C since 6/30/25 and was unaware of the current POC or the verbal order had been authorized by the physician to date. During an interview on 7/22/25 at 11:38 a.m., the administrator acknowledged the order dated 6/30/25 was not signed by the physician and had not been faxed to the physician’s office. 4. Similar findings of the failure to ensure services were provided only as ordered by a physician were revealed in the records of Patients #1, #3, #5, #6, Focus Patients A, B, D, E, F and G. Specifically: -Patient #1 was provided services without a valid order to do so on 5/6/25, 7/8/25 and 7/15/25; -Patient #3 was provided services without a valid order to do so on 39 SN visits between 5/1/25 to 6/29/25 and 14 home health aide visits between 5/1/25 to 5/17/25. -Patient #5 was provided services without a valid order, or in accordance with an order, to do so on 38 visits between 5/2/25 and 5/27/25; -Patient #6 was provided services without a valid order, or in accordance with an order, to do so on 80 visits between 5/7/25 to 7/5/25. -Patient #8 was provided services without a valid order to do so on -Focus Patient A was provided services without a valid order to do so on 7/8/25 and 7/15/25; -Focus Patient B was provided services without a valid order, or in accordance with an order, to do so on 23 visits between 5/6/25 to 5/23/25. -Focus Patient D was provided services without a valid order, or in accordance with an order, to do so on five visits between 5/5/25 to 6/19/25; and two visits between 7/4/25 to 7/15/25. -Focus Patient E was provided services without a valid order to do so on 7/7/25 and 7/14/25. -Focus Patient F was provided services without a valid order, or in accordance with an order, to do so on three visits between 5/5/23 to 5/27/25, and on 7/7/25 and 7/14/25. -Focus Patient G was provided services without a valid order to do so on seven visits between 5/7/25 to 5/27/25 and eight visits between 7/1/25 and 7/16/25. 5. During an interview on 7/22/24 at 11:33 a.m. with RN #3 revealed staff were aware physician verbal orders required a first/last name, credential, date/time, and authorized by which physician for the order to be valid. Further questioning revealed that RN #3 did not get all of the information required for a valid verbal order before this survey started. During an additional interview on 7/22/25 at 11:33 a.m., the administrator stated the agency did not have the nurses handle faxes with the physicians and it was the responsibility of the office staff to send out faxes and to upload returned documents to charts. During a follow up interview on 7/23/25 at 2:31 p.m.,the intake coordinator and administrator stated the agency accepted patients without obtaining referrals from the patients’ physicians. Additionally, the intake coordinator acknowledged agency staff initiated services with patients prior to verifying the patients had valid physician orders.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on observation, record review and interview, the skilled professionals failed to communicate pertinent information regarding the patient’s plan of care to the physician for 5 of 15 records reviewed (Patient #1, #4, #6, Focus Patient C, and G). Findings Include: 1. The clinical record for Focus Patient C was reviewed on 7/16/25. Plan of care (POC) orders for the certification period dated 6/30/25 to 8/28/25 revealed a start of care date of 5/1/25; diagnoses include type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, age-related cognitive decline, abnormalities of gait and mobility, unsteadiness on feet, patient unintentional underdose of medication regimen due to age-related debility, muscle weakness, iron deficiency anemia, and history of falling. POC orders included skilled nursing (SN) two times a day, Monday through Friday, for medication management/administration, diabetic management, safety, education, and disease process. a. The agency failed to ensure the skilled professional communicated pertinent information to the physician related to the current POC. Specifically, the RN failed to notify the physician of blood sugar results which were out of range for Focus Patient C. Review of Focus Patient C’s clinical record revealed an order for the registered nurse (RN) to notify the physician of random blood sugar results greater than 200 mg/dL (milligrams per deciliter) and less than 70 mg/dL. Record review revealed blood sugar results documented by RN #3 which were greater than 200 mg/DL for visits dated 7/2/25, 7/4/25, 7/7/25, and 7/14/25. However, the visit notes dated 7/2/25, 7/4/25, 7/7/25, and 7/14/25 failed to show documented communication with the physician or healthcare provider for Focus Patient C. During an interview on 7/2/25 at 1:38 p.m. RN #3 stated that Focus Patient C was receiving blood sugar checks at each visit per her physician’s orders and the physician was evaluating medication needs for Focus Patient C. RN #3 stated that, although she was aware of the order to notify the physician about abnormal blood sugar levels, she did not recall contacting the physician for blood sugars greater than 200 mg/dL during the current certification period. 2. The clinical record for Patient #6 was reviewed on 7/16/25. POC orders for the certification period dated 5/7/25 to 7/5/25 revealed a start of care date of 5/7/25; primary diagnosis included type 2 diabetes mellitus with diabetic polyneuropathy, pressure ulcer of sacral region (stage 2) and encounter for change or removal of nonsurgical wound dressing. POC orders included SN two times a day, five days per week (Monday through Friday) for wound care and medication management. a. The agency failed to ensure the skilled professional communicated pertinent information to the physician related to the current POC. Specifically, the RN failed to obtain accurate orders for wound care frequencies. Review of Patient #6’s record revealed documentation from RN #3 indicating she attempted to obtain verbal orders for wound care for Patient #6. However, RN #3 documented the physician’s office informed her they did not provide verbal orders and she would need to fax an order for care and services to the physician’s office for signature. However, further review of the record failed to show any evidence an order for services, included complex wound care, was ever faxed to Patient #6’s physician. Further review failed to show any orders from the physician authorizing the care and services of Patient #6 by the agency. During an interview on 7/22/25 at 11:55 a.m., RN #3 reviewed the requirements as outlined in Federal regulation with the surveyors regarding complete and sufficient physician orders and acknowledged she had not obtained or verified physician orders were received and contained sufficient information prior to the provision of services to Patient #6. (Cross Reference G584, G574) 4. Similar findings of the failure of the skilled professionals to communicate pertinent information regarding the patient’s plan of care to the physician for active clinical records were revealed in Patient #1, #4 and Focus Patient G’s records. -Patient #1’s POC failed to reveal an updated effective discipline and frequency date for certification period beginning 7/5/25; -Patient #4’s POC failed to reveal complete wound care and medication box fill orders -Focus Patient G’s POC failed to reveal frequency for wound care dressing changes. 5. During an interview on 7/22/25 at 12:36 p.m., RN #3 acknowledged they had not obtained or verified physician orders were received and contained sufficient information before the provision of services to Patient #6. RN #3 additionally acknowledged they failed to accurately document verbal orders in accordance with federal regulations and failed to ensure plans of care and verbal orders were sufficient prior to providing services. During continued interview at 1:00 p.m., RN #3 stated they overlooked the integration of all services to be provided in obtaining verbal orders and overlooked the completion of the orders to ensure all services were provided with a valid physician’s order.”

“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 and record review, the Administrator failed to adequately and effectively organize and direct the agency’s day-to-day operations. Specifically, the agency was cited with failure to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards of practice, the skilled professionals assumed responsibilities for the needs of the patients under their care, communication with physicians involved in the plan of care occurred, and failure to respect the patients’ rights to a confidential clinical record in 12 of 15 patient records reviewed (Patients #1, #3, #4, #5, #6, Focus Patients A, B, C, D, E, F and G). Findings Include: Agency Policy: According to the agency policy titled, “Administrator: Defined, dated 2/2023 (in pertinent parts): “The Administrator of the Agency organizes and directs the Agency’s ongoing functions and has the overall responsibility to ensure the following: Ensures the Agency’s skilled health services are in compliance with all applicable regulations, Accrediting Organization standards (if applicable), and federal, state, and local laws. Employs qualified personnel in accordance with written job descriptions and ensures adequate staff education, supervision and evaluations Planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services.” 1. The administrator failed to ensure services and treatments were provided only as ordered by a physician in accordance with professional standards of practice. Specifically, record review and interviews revealed the administrator failed to ensure the agency received physician orders for treatment and services, including wound care, medication administration and blood sugar management, prior to the provision of services by agency registered nurses (RNs) to Patients #1, #3, #4, #5, #6, Focus Patients A, B, C, D, E, F and G). This failure created the potential for patients to receive inappropriate and inadequate care. During an interview on 7/15/25 at 2:35 p.m. the administrator stated she was unaware of patients receiving visits from agency RNs before receiving a referral or signed orders from a physician. She further stated it was the responsibility of the individual RN to obtain physician orders for agency patients and she was unaware of the RNs failure to get orders at the SOC. (Cross Reference G580) 2. The administrator failed to ensure skilled professionals assumed responsibilities for the needs of the patients under their care. The administrator failed to ensure patient charts were complete. Specifically, the administrator failed to ensure each patient had a physician ordered referral specific to the agency, an accurate, completed, and signed plan of care (POC), physician verbal orders in compliance with federal regulations and accurate and complete coordination of care documentation for missed visits and patient condition concerns for Patient #1, #3, #4, #5, #6, Focus Patient A, B, C, D, E, F and G). During an interview on 7/22/25 at 2:31 p.m., the administrator stated the agency has not completed reviewed patient records to ensure records were complete and accurate since May 2025 and she relied on the agency nurses and caregivers to alert the her to any issues or concerns with patients, their care and the status of physician orders. (Cross Reference G704) 3. The administrator failed to assure clinician communication with all physicians involved in the plan of care. Specifically, interview and record review revealed the administrator failed to ensure ongoing communication between Registered Nurse (RN) #3 and the physicians involved in the POC for Patient #1, #3, #4, #5, #6, Focus Patients A, B, C, D, E, F and G). During an interview on 7/22/25 at 2:31 p.m., the administrator indicated the RN takes care of all the aspects of patients assigned to her, including completing and documenting coordination with physicians. She further stated she was not fully aware of everything in the care plan nor specific physician orders for agency patients. (Cross Reference G718 and G584) 4. The administrator failed to respect the patients’ rights to a confidential clinical record. Specifically, the agency failed to uphold the patient’s right to a confidential clinical record in 12 of 13 patients who transferred from a secondary agency (Patients #1, #3, #4, #5, #6, Focus A, B, C, D, E, F and G). During an interview on 7/2/25 at 2:31 p.m., the administrator and intake coordinator/alternate administrator verified they were in charge of managing new patients. The intake coordinator/alternate administrator stated RN #3 reached out to her about bringing on new patients and the administrator acknowledged that the clinical information of 13 patients was obtained from the confidential record of a secondary agency not being surveyed. The administrator further stated that as of the start of this survey, that information has since been destroyed. (Cross Reference G438)”