Berhan Home Health Care Agency Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on policy review, supporting documentation review, personnel record review, and interview, the Home Health Agency failed to maintain a comprehensive Emergency Preparedness program as evidenced by the following: The home health agency failed to update the Emergency Preparedness plan every 2 years. See Tag E0004.The home health agency failed to update hazard vulnerability assessments. See Tag E0006.The home health agency failed to inform local emergency preparedness officials regarding homebound patients in need of evacuation from their residence at any time during an emergency situation. See Tag E0019.The home health agency failed to maintain a current communication plan for the readily identification and notification of on duty staff. See Tag E0021. The home health agency failed to routinely test the Emergency Preparedness plan. See Tag E0036.The home health agency failed to provide Emergency Preparedness education for four (4) out of five (5) personnel records reviewed. See Tag E0037.”

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on policy review, supporting documentation review, and interviews, the Home Health Agency failed to meet the Condition of Participation for Reporting Outcome and Assessment Information Set (OASIS) Information by failing to electronically report all OASIS data as evidenced by the following: 1.The Home Health Agency failed to encode individual client assessment data within 30 days. See Tag G372. 2.The Home Health Agency failed to submit OASIS data that accurately reflected the patient’s status at the time of filing. See Tag G374.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on policy review, supporting documentation review, and interviews, the Home Health Agency (HHA) failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) by failing to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program as evidenced by the following: 1.The Home Health Agency’s Quality Assessment and Performance Improvement (QAPI) failed to establish a program driven on quality indicators and patient care data. See Tag G642. 2. the Home Health Agency’s Quality Assessment and Performance Improvement (QAPI) program failed to track identified patient specific data as required. See Tag G644. 3. The Home Health Agency’s Quality Assessment Performance Improvement (QAPI) program failed to adhere to a planned performance improvement program and failed to document progress or modifications. See Tag G658. 4. The Home Health Agency’s Governing Body failed to maintain documentation of communicating with the agency’s Quality Assessment and Performance Improvement (QAPI) program. See Tag G660.”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on policy review, observation, supporting documentation review, and interview, the Home Health Agency failed to meet the Condition of Participation for Infection Prevention and Control by failing to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases as evidenced by the following: 1.The Home Health Agency’s rehabilitation staff failed to comply with Infection Prevention policy. See Tag G682. 2.The Home Health Agency’s Infection Control program failed to utilize tracking of patients and staff with suspected infections. See Tag G684.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the home health agency failed to update the Emergency Preparedness plan. A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed: “A drill with evaluation will be held yearly.” A review of the Agency’s Emergency Preparedness plan revealed no documentation of testing of the emergency plan during the three year lookback survey period. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged that the agency’s Emergency Preparedness Plan has not been updated every two years.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview the Home Health Agency failed to update hazard vulnerability assessments. Findings Include: A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed: “A hazard risk assessment will be done annually and PRN [as needed].” A review of the facility’s Emergency Preparedness plan revealed one (1) hazard vulnerability assessment that is undated. Further review revealed no documentation of annual risk assessments conducted for the three-year certification lookback period. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 confirmed that the agency has not performed annual risk assessments. Employee #1 was unable to provide a completion date for when the risk assessment in the Emergency Preparedness plan was conducted.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the home health agency failed to inform local emergency preparedness officials regarding homebound patients in need of evacuation from their residence at any time during an emergency situation. Findings Include: A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed: “13. Inform State and local emergency preparedness officials about patients in need for patient evacuations from their residences during and due to emergencies including the clinical care needed for the identified patients, based on their medical, psychiatric condition and home environment.” Further review of agency’s Emergency Contact list revealed no communication to District of Columbia Health Systems and Preparedness Administration (HSPA). Further review of the agency’s Emergency Preparedness plan revealed last notification to District of Columbia Fire and Emergency Medical Services Department being documented as 05/02/2018. On 07/22/2025 at approximately 10:00 AM the surveyors conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged the above finding.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the home health agency failed to maintain a current communication plan for the readily identification and notification of on duty staff. Findings Include: A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed under communication: “a. Maintain a current listing of staff and all applicable contact numbers. This will be updated monthly at a minimum.” A review of the agency’s employment roster revealed that they have 243 actively employed Home Health Aides. A review of the agency’s emergency preparedness communication plan revealed no listing of Home Health Aides in contact list. On 07/22/2025 at approximately 10:00 AM the surveyors conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged the above finding.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview the home health agency failed to routinely test the Emergency Preparedness plan. A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed: “A drill with evaluation will be held yearly.” A review of the agency’s Emergency Preparedness plan revealed no documentation of drills or testing of the emergency preparedness plan during the past three years 2022 to 2025. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged that the agency has not provided annual testing of the Emergency Preparedness plan.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, personnel file review, and interview the home health agency failed to provide Emergency Preparedness education for four (4) out of five (5) personnel records reviewed (Employee #4, #8, #18, and #19). A review of the agency’s Policy and Procedure for Emergency Preparedness last updated and reviewed 12/16/2021, revealed: “ [Agency’s name] will provide initial training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all new and existing staff...” A review of Employee #4’s personnel record revealed a hire date of 10/01/2024 for the position of Registered Nurse. Further review revealed no documentation of Emergency Preparedness initial education. A review of Employee #8’s personnel record revealed a hire date of 12/04/2023 for the position of Licensed Practical Nurse. Further review revealed no documentation of Emergency Preparedness initial or annual education. A review of Employee #16’s personnel record revealed a hire date of 08/16/2023 for the position of Occupational Therapist. Further review revealed no documentation of Emergency Preparedness initial or annual education. A review of Employee #19’s personnel record revealed a hire date of 09/25/2024 for the position of Speech Therapist. Further review revealed no documentation of Emergency Preparedness initial education. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged that the above findings.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on policy review, medical record review, verification of encoded Outcome and Assessment Information Set (OASIS) data, and interview, the home health agency failed to encode individual client assessment data within 30 days for 11 out of 44 patients sampled (Patient #5, #11, #13, #18, #19, #21, #22, #29, #31, #33, and #34). Findings Include: A review of the Home Health Agency’s ‘Reporting OASIS Data’ policy, undated, revealed: “[Agency’s name] will encode individual client assessment data within (7) [seven] days of completing data set.” A review of Patient #5’s medical record revealed a start of care date of 03/06/2025 for skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) for surgical follow up. Further review of Patient #5’s OASIS agency validation report revealed submission of OASIS dated 04/17/2025. A review of Patient #11’s medical record revealed a start of care date of 04/25/2025 for SN, PT, and OT for metabolic encephalopathy. Further review of Patient #11’s OASIS agency validation report revealed submission of OASIS dated 05/30/2025. A review of Patient #13 medical record revealed a start of care date of 04/25/2025 for PT, OT, Speech Therapy (ST) for epileptic seizures related to external causes. Further review of Patient #13’s OASIS agency validation report revealed submission of OASIS dated 06/23/2025. A review of Patient #18’s medical record revealed a start of care of 03/17/2025 for PT and OT for type two diabetes. Further review of Patient #18’s OASIS agency validation report revealed submission of OASIS dated 04/30/2025. A review of Patient #19’s medical record revealed a start of care of 03/25/2025 for SN for an unspecified open wound. Further review of Patient #19’s OASIS agency validation report revealed submission of OASIS dated 05/09/2025. A review of Patient #21’s medical record revealed a start of care of 03/19/2025 for PT, OT, and Home Health Aide (HHA) for unspecified atrial fibrillation. Further review of Patient #21’s OASIS agency validation report revealed submission of OASIS dated 05/14/2025. A review of Patient #22’s medical record revealed a start of care of 05/07/2025 for SN and PT for hyperkalemia. Further review of Patient #22’a OASIS agency validation report revealed submission of OASIS dated 06/13/2025. A review of Patient #29’s medical record revealed a start of care of 03/12/2025 for SN, PT, OT, and HHA for weakness. Further review of Patient #29’s OASIS agency validation report revealed submission of OASIS dated 04/28/2025. A review of Patient #31’s medical record revealed a start of care of 04/02/2025 for SN, PT, OT, and HHA for atherosclerosis heart disease of native coronary artery. Further review of Patient #31’s OASIS agency validation report revealed submission of OASIS dated 05/29/2025. A review of Patient #33’s medical record revealed a start of care date of 03/26/2025 for SN and PT for type two diabetes. Further review of Patient #33’s OASIS agency validation report revealed submission of OASIS dated 05/21/2025. A review of Patient #34’s medical record revealed a start of care date of 12/28/2024 for PT and OT for other acquired deformities. Further review of Patient #34’s OASIS agency validation report revealed submission of OASIS dated 04/07/2025. On 07/15/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged the findings.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on policy review, medical record review, and interview, the Home Health Agency failed to submit Outcome and Assessment Information Set (OASIS) data that accurately reflected the patient’s status at the time of filing for one (1) out of seven (7) patients sampled (Patient #19). Findings Include: A review of the agency’s ‘Discharge Summary’ policy, last reviewed 12/2024, revealed: “The Discharge Summary shall include, but not limited to: e. Status at time of discharge.” and “3. Information gathered during the OASIS discharge assessment will be incorporated into the summary.” A review of Patient #19’s medical record from 05/06/2025 revealed that they had a resumption of Skilled Nursing services for the development of a gluteal wound. Further review of Patient #19’s medical record revealed they were discharged from the Home Health Agency on 05/08/2025. A review of Patient #19’s Discharge OASIS completed on 05/09/2025 revealed “Integumentary Status Locator: No Wounds.” On 07/24/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #3 Director of Nursing. Employee #3 acknowledged that patients with wounds at the time of discharge should have them identified on the discharge OASIS.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the Home Health Agency’s Quality Assessment and Performance Improvement (QAPI) failed to establish a program driven on quality indicators and patient care data. Findings Include: A review of the agency’s ‘Quality Assessment and Performance Improvement’ policy, last reviewed 12/2024, revealed: “Meetings will be held quarterly with additional meetings to be scheduled in response to identified needs.” and “Individual items/ aspects of care for monitoring, along with appropriate indicators, thresholds, data collection, methodology and evaluation tools will be developed on an on-going basis to accommodate need.” and “A QAPI committee, consisting of the Administrator, the Assistant Administrator, and a representative of the scope of practices, will assist with the operation of the QAPI program on an on-going basis.” A review of the agency’s QAPI Program revealed no documentation of quarterly meetings conducted during the three years look back period. There is no documentation of what patient data is being monitored by the agency’s QAPI program. There is no documentation of input by a representative for each of the skilled disciplines (Skilled Nursing, Occupational Therapy, Physical Therapy, and Speech Therapy) in the Agency’s QAPI program. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 reported that QAPI does meet and ongoingly improves the performance of the agency but acknowledged missing minutes per policy. Employee #1 reported that the QAPI program consists of the themself, Employee #2 Director of Human Resources, and Employee #3 Director of Nursing.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the Home Health Agency’s Quality Assessment and Performance Improvement (QAPI) program failed to track identified patient specific data. A review of the Agency’s ‘Quality Assessment and Performance Improvement Program’ policy, last reviewed 12/2024, revealed: “Objectives: 12. To develop effectiveness of the program and detection of trend, patterns of performance or potential problems that may affect different areas of the organization.” and “Risk Management: The steps to evaluating a risk include: other data as required by local, state, Federal regulatory bodies...” A review of the Agency’s ‘Evaluating and Maintaining Records of Infection Among Patients’ policy, last reviewed 12/2024, revealed: 7. A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the Professional Advisory Committee.” A review of the Agency’s Outcome and Assessment Information Set (OASIS) validation report from 07/15/2024 to 07/15/2025 revealed 11 patients had their OASIS encoded beyond the allowed 30-day timeframe. A review of the Home Health Agency’s unduplicated skilled admission patient list from 07/15/2024 to 07/15/2025 revealed that 13 patients were admitted to the agency with a primary diagnosis of an infectious disease. A review of the Agency’s QAPI program revealed no tracking of data related to OASIS validation or infection control. There is no documentation of a Performance Improvement Committee or Professional Advisory Committee. On 07/22/2025 at approximately 10:00 AM the surveyors conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 acknowledged the missing data tracking for the Agency’s QAPI. Employee #1 confirmed that the Agency does track late submissions to OASIS.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interviews, the Home Health Agency’s Quality Assessment Performance Improvement (QAPI) program failed to adhere to a planned performance improvement program and failed to document progress or modifications. A review of the agency’s ‘Quality Assessment and Performance Improvement’ policy, last reviewed 12/2024, revealed: “Committee Responsibilities: 7. In response to identified problems: A. Evaluate the process that failed or has the potential to fail. B. identify the areas of the process that coincide with acceptable standards of practice and those that do not. C. Develop a plan to change the cause of the problem or the potential problem. D. Test the plan with a pilot program will be at least two visits. E. Evaluate the results of the change. F. Propose policy and procedure changes to the PAC.” and “Meetings will be held quarterly with additional meetings to be scheduled in response to identified needs.” and “Report results of QAPI activities to the Governing Body, CEO [Chief Executive Officer]/ Administrator, and field personnel through written reports and staff meetings.” On 07/16/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 CEO. Employee #1 confirmed to be the administrator of the agency’s QAPI program. Employee #1 reported that the agency’s most recent performance improvement plan was in response to deficiencies cited during the January 2025 state licensure survey. Employee #1 confirmed that a Plan of Correction was submitted and accepted by the State Licensure agency that included auditing of 15 percent of charts monthly by the Director of Nursing with a completion date reported to the State Licensure agency of May 2025. A review of the agency’s QAPI program revealed the following: -No documentation of quarterly QAPI meetings for the three year look back period. -No documentation of a meeting related t the formulation of a performance improvement plan in response to identified deficiencies cited from January 2025 State Licensure survey. Further review of agency’s Quality Assessment monthly auditing revealed a lack of 15 percent of audits being obtained as evidenced by the following: -February total monthly census is reported at 124. Total number of audits: 5 -March total monthly census is reported as 132. Total number of audits: 6 -April total monthly census is reported as 144. Total number of audits: 4 -May total monthly census is reported as 149. Total number of audits: 2 -June total monthly census is reported as 157. Total number of audits: 2 Further review revealed that no audits were conducted by the Director of Nursing. There is no documentation of designee(s) being accepted. On 07/24/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #3 Director of Nursing. Employee #3 confirmed that the agency’s most recent performance improvement plan was in response to citations from the January 2025 State Licensure survey. Employee #3 confirmed that there are no QAPI minuets for the three-year lookback period. Employee #3 confirmed that they have not conducted audits for the performance improvement plan. Employee #3 confirmed that the plan is still ongoing with the expected 15 percent auditing per month.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on policy review, supporting documentation review, and interview, the Home Health Agency’s Governing Body failed to maintain documentation of communication with the agency’s Quality Assessment and Performance Improvement (QAPI) program. Findings Include: A review of the agency’s ‘Quality Assessment and Performance Improvement’ policy, last reviewed 12/2024, revealed under Annual Program Evaluation: “The Agency, through the Governing Body, and Agency Staff, shall annually evaluate the extent to which the Agency’s program is appropriate, effective, and efficient.” A review of the agency’s QAPI program revealed no documentation of information being communicated to the Agency’s Governing Body during the three year lookback period. A review of the agency’s Governing Body meetings for the years of 2023 and 2024 revealed no documentation of evaluation of the agency’s QAPI program. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 reported that members of QAPI and the same as members of the Governing Body. Employee #1 acknowledged the lack of documentation of corresponding between Governing Body and QAPI.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observation, and interview the Home Health Agency’s rehabilitation staff failed to comply with Infection Prevention policy in the direct care of one (1) out of two (2) patients sampled (Patient #48). Findings Include: Review of Home Health Agency policy “…Infection Control Plan” dated 12/2024 revealed “General work clothes, (e.g., uniforms, pants, shirts, or blouse) …” On 07/18/2025 at approximately 10:00 AM, the surveyors observed Employee #13, Physical Therapist, wearing open toe shoes while providing rehabilitative services to Patient #48. On 07/24/2025 at approximately 10:00 AM, the surveyors conducted a face-to-face interview with Employee #3, Director of Nursing. Employee #3 confirmed all staff should comply with all aspects of the Infection Prevention Guidelines.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on policy review, medical record review, supporting documentation review, and interview, the Home Health Agency’s Infection Control program failed to utilize tracking of patients and staff with suspected infections. Findings Include: A review of the agency’s ‘Evaluating and Maintaining Record of Infections Among Patients’ policy, last reviewed 12/2024, revealed: “All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of the infection being identified.” and “The [home health agency’s name] DON [director of nursing] or its designee will summarizes trends and analyzes the reports.” A review of the agency’s ‘Evaluating and Maintaining Records of Infections Among Personnel’ policy, last reviewed 12/2024, revealed: “All personnel with a new, actual, or suspected infection will have a personnel infection report completed within 24 hours of discovery.” and “A written statement from the physician will be necessary for the staff to return to work.” and “The [home health agency’s name] DON [director of nursing] or its designee will summarizes trends and analyzes the reports.” A review of the Home Health Agency’s unduplicated skilled admission patient list from 07/15/2024 to 07/15/2025 revealed that 13 patients were admitted to the agency with a primary diagnosis of an infectious disease. A review of the Home Health Agency’s transfer and hospitalization log from 07/15/2024 to 07/15/2025 revealed that 2 patients were transferred or hospitalized for care of an infectious disease. A review of Patient #45’s medical record for the certification period of 01/06/2025 to 03/06/2025 revealed that they were ordered to receive Skilled Nursing services one to two times a week for eight weeks. Further review of Patient #45’s Skilled Nursing visit note from 01/23/2025 revealed “The SN (Skilled Nurse), [Employee #4, Registered Nurse] is not well, no visit done.” Further review revealed that subsequent visits after 01/23/2025 were completed by Employee #4. A review of the agency’s Infection Control Log revealed no patient or personnel infection reports located. There is no documentation of a written statement from a physician clearing Employee #4 to resume direct care services. On 07/22/2025 at approximately 10:00 AM the surveyor conducted a face to face interview with Employee #3 Director of Nursing. Employee #3 acknowledged that patients with active or suspected infections are to be identified and tracked by the agency. Employee #3 was unable to identify any tracking logs speaking to this practice. Employee #3 reported that sick employee management is handled by human resources.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on policy review, medical record reviews, and interview, the Home Health Agency failed to complete comprehensive assessments within the permitted five (5) day timeframe for two (2) out of eight (8) patients sampled (Patient #13 and #45). Findings Include: A review of the agency’s ‘Comprehensive Client Assessment’ policy, last reviewed 12/2024, revealed: “A through, well-organized, comprehensive, and accurate assessment, consistent with the clients immediate needs will be completed in a timely manner, but no later than five (5) calendar days after start of care.” A review of Patient #13’s medical record revealed a referral date of 4/17/2025. Further review revealed an initial and comprehensive assessment completed on 04/25/2025. A review of Patient #45’s medical record revealed a referral date of 12/31/2024. Further review revealed an initial and comprehensive assessment completed on 01/06/2025. On 07/24/2025 at approximately 10:00 AM the surveyors conducted a face to face interview with Employee #3 Director of Nursing. Employee #3 confirmed that if the patient requests to be seen for their initial or comprehensive assessment in a timeframe outside of the policy, a note will be included under care coordination. Employee #3 was unable to identify notes for Patient #13 and #45.”

“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 policy review, medical record review, and interview, Home Health Agency’s nursing, rehabilitative, and skilled nursing failed to (1) comply with physician’s order regarding wound care for three (3) of nine (9) patients reviewed, (Patients #19, #45, and #49), (2) frequency of visits per physician’s order for three of (3) of nine (9) reviewed (Patients # 13, 46, and #49) and (3)failed to reconcile medication orders for one (1) of nine (9) patients reviewed (Patient #49). Findings Include: 1. Findings Related to failure to comply with physician’s wound care orders A review of the home health agency’s “Wound Care Policy” reviewed 12/2024 revealed: “Wound care is administered per physician’s order.” A review of Patient #13’s “Home Health Certification and Plan of Care” dated 04/25/2025 revealed: “OT [Occupational Therapy]: 1x [one time] week x4 [times four] weeks Assessment for ADL [Activities of Daily Living] Independently.” Further review of Patient #13’s medical record revealed no documentation of OT visits. A review of Patient #50’s “Home Health Certification and Plan of Care” dated 06/26/2025 revealed: “OT: 1x [one time] weekly x4 [times weekly] weeks, evaluate and treat.” Further review of Patient #50’s medical record revealed no documentation of OT visits. A review of Patient #46’s “Home Health Certification and Plan of Care Certification Period 05/01/2025 thru 04/30/2026” revealed: “SN [Skilled Nursing] 1x [one time] monthly and 2x prn [two times when necessary] x12 months.” Further review of Patient #46’s medical record revealed no documentation of Skilled Nursing visit for the following months 12/2023, 01/2024, 02/2024, 06/2024, 07.2024, 10/2024, and 03/2024. A review of Patient #19’s Home Health Certification and Plan of Care dated 03/25/2025 revealed “cleanse open wound left thigh with NSS/wet/dry/dsd [normal saline solution/wet to dry/dressing] daily.” Further review of Patient #19’s medical record revealed wound care as follows: On 03/28/2025 at 10:30 AM documented “Left Hip incision would cleansed wound with Alcohol swab dressing applied, covered with gause [sp], secured with paper tape.” On 04/03/2025 at 16:45 (4:45 PM), documented “Left hip surgical wound cleansed with normal saline, wet to dry dressing applied.” On 04/05/2025 at 12:00, documented “Left Hip Incision wound cleansed with alcohol. Dressing applied: covered with dry gause [sp], secured with paper tape.” On 04/09/2025 at 13:00 (1:00 PM), documented “Left Hip wound cleansed with alcohol prep dressing applied: covered with dry 4x4 gause [sp], taped secured.” On 04/11/2025 at 14:00 (2:00 PM), documented “Left Hip wound cleansed with alcohol prep dressing applied: covered with dry 4x4 gause [sp], taped secured.” On 04/16/2025 at 12:00, documented “Left hip wound cleansed with alcohol, covered with dry gause [sp], secured with tape.” On 04/18/2025 at 12:00, documented “Left hip wound cleansed with alcohol, covered with dry gause [sp], secured with tape.” On 04/23/2025 at 10:00 AM, documented “Left hip wound cleansed with alcohol, covered with dry gause [sp], secured with tape.” On 04/25/2025 at 12:00, documented “Left hip wound cleansed with alcohol, covered with dry gause [sp], secured with tape.” On 04/30/2025 at 16:00 (4:00 PM), documented “Left hip wound cleansed with alcohol, covered with dry gause [sp], secured with tape.” Further review of Patient #19’s medical record revealed no documentation of change in wound care orders. Review of Patient #45’s Home Health Certification And Plan of Care Certification Period 01/06/2025 thru 03/03/3035 revealed “cleanse bil [bilateral] LE [legs] with Phytoplex Foam cleanser pat dry apply Aquaphor Ointment. Apply Coan Dsg 2 layer compression wrap and tape change 2x weekly.” Further review of Patient #45’s medical record revealed on 01/14/2025 at 12:40 PM, “cleansed bilateral lower legs with N/S [normal saline] pat dry applied Aquahor [sp], secured with Coban 2 layer wrap dressings.” Review of Patient #49’s Home Health Certification And Plan of Care revealed “ clean with lateral lower leg wound with NSS. Apply Aquacell every other day. Cover with gauze and Profore dressing [sp]. A review of Patient #49’s medical record revealed wound care as follows: On 06/30/2025 wound care provided as ordered. On 07/01/2025 wound care documented as being done. No documentation regarding the rationale wound care was done more frequently than ordered by the physician. The surveyors conducted a face-to-face interview on 07/24/2025, at approximately 10:00 AM with Employee #3, Director of Nursing. Employee #3 acknowledged wound care should be done per physician’s orders and nursing should document any change in physician orders. 2.Finidngs related to failure to adhere to frequency of visits per physician’s order A review of the home health agency’s “Therapy Services Policy” reviewed 12/2024 revealed: “Any therapy services offered by [Home Health Agency Name], directly or under contractual arrangement, shall be provided by or under the supervision of a qualified Therapist in accordance with the Plan of Care…” A review of the home health agency’s “Plan of Care” reviewed 12/2024 revealed: “Home care services are furnished under the supervision and direction of the client’s physician…” “Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care…” “The prn orders will be accompanied by a description of the client’s medical signs and symptoms that would warrant a visit.” A review of the home health agency’s “Services Provided”, reviewed 12/2024 revealed: “Services shall be available seven (7) days a week, 24 hours per day.” A review of Patient #13’s “Home Health Certification and Plan of Care” dated 04/25/2025 revealed: “OT [Occupational Therapy]: 1x [one time] week x4 [times four] weeks Assessment for ADL [Activities of Daily Living] Independently.” Further review of Patient #13’s medical record revealed no documentation of OT visits. A review of Patient #46’s “Home Health Certification and Plan of Care Certification Period 11/2023 thru 04/30/2026” revealed: “SN [Skilled Nursing] 1x [one time] monthly and 2x prn [two times when necessary] x12 months.” Further review of Patient #46’s medical record revealed no documentation of Skilled Nursing visit for the following months 12/2023, 01/2024, 02/2024, 06/2024, 07.2024, 10/2024, and 03/2024. A review of Patient #49’s medical record revealed they were ordered to receive skilled nursing services one to two times a week. Further review of Patient #49’s medical record revealed skilled nursing visits recorded on 07/08/2025, 07/09/2025, and 07/11/2025. There is no documentation of provider notification for the one additional prn visit required for that week. The surveyors conducted a face-to-face interview on 07/24/2025, at approximately 10:00 AM with Employee #3, Director of Nursing. Employee #3 also confirmed rehabilitative, OT and SN services were not followed per physician’s order. 3.Findings related to failure to reconcile medication orders A review of policy “Physician orders” dated 12/2024 revealed: “A physician must order all drugs and care provided to clients…” A review of policy “Plan of Care” dated 12/2024 revealed: “2. The Plan of Care shall be completed in full to include: l. Medications, treatments, and procedures…” On 07/18/2025 at approximately 1:00 PM the surveyors observed the direct patient care of Patient #49 at their residence. The following was observed: -One (1) bottle of ammonium lactate lotion prescribed to Patient #49 with the “instructions to apply liberally to affected area.” A review of Patient #49 “Home Health Certification and Plan of Care Certification Period 06/24/2025 thru 08/22/2025” did not reveal nursing documentation of Ammonium lactate on medication profile. There is no documentation of updates to wound care order to include medication. On 07/18/2025 at approximately 1:15 PM the surveyors conducted a face to face interview with Patient #49. Patient #49 confirmed that the ammonium lactate lotion is to be applied to their legs for wound care. The surveyors conducted a face-to-face interview on 07/24/2025, at approximately 10:00 AM with Employee #3, Director of Nursing. Employee #3 confirmed the expectation is that all medications taken by the patient, documented on the medication reconciliation.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on policy review, personnel record review, and interview, the home health agency failed to comply with employment policies for background checks and preemployment health screening for 16 out of 17 records reviewed (Employee #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19). Findings Include: A review of the home health agency’s ‘Employment Policy”, reviewed 12/2024 revealed: “Criminal Background Check- a criminal background check must be done for any candidate who has received a job offer.” A review of the home health agency’s ‘Criminal Background Check’ policy, reviewed 12/2024 revealed: “The selected candidate in the hiring process must satisfactorily clear a criminal background check prior to starting work.” A review of the home health agency’s ‘Health Screening’ policy, reviewed 12/2024, revealed: “Each employee having direct contact with patients must have documentation of baseline health screening prior to providing care to patients.” A review of Employee #4’s personnel record revealed a hire date of 10/01/2024 for the position of Registered Nurse. Further review revealed no documentation of background check conducted. A review of Employee #5’s personnel record revealed a hire date of 09/03/2010 for the position of Registered Nurse. Further review revealed no documentation of background check conducted. A review of Employee #6’s personnel record revealed a hire date of 11/16/2009 for the position of Registered Nurse. Further review revealed no documentation of background check conducted. A review of Employee #7’s personnel record revealed a hire date of 06/15/2015 for the position of Registered Nurse. Further review revealed no documentation of background check conducted. A review of Employee #8’s personnel record revealed a hire date of 12/04/2023 for the position of Licensed Practical Nurse. Further review revealed no documentation of background check conducted. A review of Employee #9’s personnel record revealed a hire date of 08/18/2021 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #10’s personnel record revealed a hire date of 03/23/2005 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #11’s personnel record revealed a hire date of 12/27/2011 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #12’s personnel record revealed a hire date of 01/31/2019 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #13’s personnel record revealed a hire date of 04/05/2004 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #14’s personnel record revealed a hire date of 01/10/2012 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #15’s personnel record revealed a hire date of 06/03/2019 for the position of Physical Therapist. Further review revealed no documentation of background check conducted. A review of Employee #16’s personnel record revealed a hire date of 08/16/2023 for the position of Occupational Therapist. Further review revealed no documentation of background check conducted. A review of Employee #17’s personnel record revealed a hire date of 03/16/2009 for the position of Occupational Therapist. Further review revealed no documentation of background check conducted. A review of Employee #18’s personnel record revealed a hire date of 07/18/2008 for the position of Occupational Therapist. Further review revealed no documentation of background check conducted. A review of Employee #19’s personnel record revealed a hire date of 09/25/2024 for the position of Speech Therapist. Further review revealed no documentation of background check conducted. Further review of Employee #19’s health screening revealed it was conducted on 07/13/2025. On 07/17/2025 at approximately 11:00 AM the surveyors conducted a face to face interview with Employee #2 Director of Human Resources. Employee #2 reported that the home health agency does not perform background checks on licensed clinical staff. Employee #2 acknowledged the late pre employment screening for Employee #19. On 07/22/2025 at approximately 10:00 AM the surveyors conducted a face to face interview with Employee #1 Chief Executive Officer. Employee #1 reported that the home health agency does not conduct background checks on licensed clinical staff. Employee #1 acknowledged that the home health agency does have a policy requiring background checks on all staff.”