At Home Care Agency

“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 policy review, record review, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that patient care plans were individualized, updated, and executed. Failure to ensure all aspects of patients’ care were included in individualized care plans and to properly execute those plans could prolong recovery periods. Findings include: §484.60(a)(2) Standard: The individualized plan of care must include the following… §484.60(c) Standard: Review and revision of the plan of care §484.60(c)(1) Standard: The HHA must promptly alert the relevant physician(s)…”

“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 and staff (EMP) interview, the Home Health Agency (HHA) failed to develop and maintain a data-driven Quality Assurance Performance Improvement (QAPI) program. This deficient practice had the potential to result in inadequate care for all patients receiving care from the HHA, as issues and concerns regarding patient care were not identified or resolved. Findings include: Cross reference: §484.65(a) Standard: Program scope §484.65(b)(1)-(3) Standard: Program data §484.65 (d) Standard: Performance improvement projects”

“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 policy reviews, record review, and staff (EMP) interviews, the Home Health Agency (HHA) failed to ensure that skilled professionals participated in ongoing interdisciplinary patient assessments and in the Quality Assurance and Performance Improvement (QAPI) program. This deficient practice had the potential to prolong patient recovery periods and result in inadequate patient care. Findings include: Cross reference: §484.75(b)(1) Standard: Ongoing interdisciplinary assessment of the patient §484.75(b)(8) Standard: Participation in the QAPI program”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on policy reviews, medical record reviews, and staff (EMP) interviews, the Home Health Agency (HHA) failed to ensure that the Governing Body maintained oversight of the management and operations of the HHA’s home health services, including the Quality Assessment and Performance Improvement Program. Lack of oversight by the Governing Body has the potential to affect all patients on service, as issues and concerns regarding the quality of care go unaddressed. Findings include: Cross reference: §484.105(a) Standard: Governing body §484.105(f) Standard: Services furnished”

“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, and staff (EMP) interview, it was determined that the Home Health Agency (HHA) failed to conduct testing of the emergency plan. Findings include: Review of policy “Emergency Preparedness Policies and Procedures”, undated, stated, “…At Home Care Agency shall maintain documentation of compliance with emergency preparedness…At Home Care Agency will conduct exercises to test the Emergency Plan at least annually will include the following…Participation in full-scale exercise that is community-based or…When a community-based exercise is not accessible, an individual, facility-based exercise will be completed…At Home Care Agency will review/analyze, at least annually and as needed, its Disaster Plan responses after every drill, tabletop exercise and emergency event that occurs through its Professional Advisory Committee…At Home Care Agency will follow the emergency requirements during a disaster and will document in the Agency’s records attempts of staff to follow procedures in the event they are unable to comply with any of the requirements...Training & Drills…The Agency conducts: One full-scale community-based drill annually, OR An internal functional drill if community-based not available...After-action reports and corrective action plans are documented…” During an interview on 12/22/2025 between 10:29 AM and 10:39 AM, EMP3 confirmed that the agency has no documented evidence of emergency preparedness drills being conducted in 2024 or 2025. EMP 3 stated that they provide staff education on emergency preparedness; however, the emergency plan is not being tested.”

“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, and staff (EMP) interviews, the Home Health Agency (HHA) failed to identify quality indicators through measurement, analysis, and tracking of adverse or negative patient outcomes. Findings include: Review of policy “Quality Assessment and Performance Improvement (QAPI) Manual,” undated, revealed, “At Home Care Agency shall develop, implement, evaluate, and maintain an effective, agency-wide, data-driven QAPI program. The QAPI Program must be ongoing and have a written plan of implementation. Identification of Problems. 1. Problems may be identified through: incident/occurrence reports; patient, family, or staff complaints; chart audits and record reviews; outcome and process data (e.g., infection rates, readmissions, hospitalization rates, OASIS indicators); patient satisfaction and employee surveys; state or federal survey findings; internal or external audits. 2. All identified issues are documented using the QAPI Data Collection Tool or Incident/Problem Identification Form…” During an interview on 12/18/2025 at 2:05 PM, EMP3 stated “There is nothing in writing” regarding the QAPI program, including tracking and trending of adverse events, infections, chart audits, and compliance assessments, and confirmed that PIPs (Performance Improvement Projects) have not been completed for 2024 and 2025. During an interview on 12/18/2025 at 3:13 PM, EMP2 confirmed there was no documentation of an ongoing QAPI program.”

“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 and staff (EMP) interviews, the Home Health Agency (HHA) failed to collect and incorporate data for the Quality Assurance Performance Improvement (QAPI) program indicators. Findings include: Review of policy “Quality Assessment and Performance Improvement (QAPI) Manual,” undated, revealed, “Data collection is a uniform and systematic process that ensures that only relevant, useful, and necessary data is collected. It includes measuring functions, processes and outcomes that affect the dimensions of care, client and family involvement in care and customer quality and satisfaction…” During an interview on 12/18/2025 at 2:05 PM, EMP3 stated, “We have not collected any data,” and confirmed that tracking and trending of adverse events, infections, chart audits, and compliance assessments have not been completed for 2024 and 2025. During an interview on 12/18/2025 at 3:13 PM, EMP2 confirmed that no data collection was conducted for the QAPI program.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on policy review, and staff (EMP) interview, the Home Health Agency (HHA) failed to conduct performance improvement projects based on high risk, high volume and problem-prone areas. Findings include: Review of policy “Quality Assessment and Performance Improvement,” undated, revealed, “Performance improvement activities must: 1. Focus on high-risk, high volume, or problem-prone areas... 2. Consider incidence, prevalence, and severity of problems in those areas. 3. Lead to an immediate correction of any identified problem that directly or potentially threaten [sic] the health and safety of patients. 4. Track adverse patient and personnel events, analyze their causes, and implement preventative actions. 5. Take actions aimed at performance improvement, and, after implementing those actions, the agency must measure its success and track performance to ensure that improvements are sustained…” During an interview on 12/18/2025 at 2:05 PM, EMP3 confirmed that performance improvement projects for 2024 and 2025 have not been completed. During an interview on 12/18/2025 at 3:13 PM, EMP2 confirmed there was no documentation of an ongoing QAPI program, including performance improvement projects.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on policy review, personnel file review, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that two of three (EMP1 and EMP5) skilled nursing staff sampled were competent to perform skilled tasks prior to providing patient care. Findings include: Review of policy “Performance evaluation/Skills Competency Evaluations,” undated, revealed “Performance evaluations are required for every employee and skills competency evaluations are required for all Field Staff. Skills competency evaluations are required for all Field Staff on hire before a field staff member can visit a patient in their home…” Review of personnel files revealed no documentation that competency evaluations were performed for the following: EMP1 - Date of hire: 2/24/2025 EMP5 – Date of hire: 10/15/2025 During an interview on 12/22/2025 at 11:00 AM, EMP3 was unable to provide documentation that competency evaluations were completed for EMP1 and EMP5.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on document reviews, policy review, record reviews, and staff (EMP) interviews, the Home Health Agency (HHA) failed to ensure that the governing body was providing oversight of all home health services including the Quality Assurance and Performance Improvement (QAPI) program. Findings include: Review of “Governing Body Meeting Minutes,” dated 11/22/2024, revealed, “…Integrate compliance activities with quality assurance and performance improvement (QAPI) programs…Enforce agency policies and procedures to reflect regulatory compliance…” Review of “Annual Program Evaluation,” dated 11/17/2025, revealed, “…This evaluation incorporates data from clinical chart reviews, Quality Assurance and Performance Improvement (QAPI) activities…and compliance assessments. The findings demonstrate measurable improvements in patient outcomes, staff performance, service coordination, and administrative infrastructure…” Review of policy “Quality Assessment and Performance Improvement (QAPI) Manual,” undated, revealed “Section 2: Governing Body Authority & Oversight. The Governing Body retains ultimate responsibility for QAPI and shall: Approve the QAPI plan and all PIPs [performance improvement plans]; review QAPI reports at least quarterly; ensure corrective actions are implemented; allocate resources necessary for improvement; hold leadership accountable for outcomes. Evidence of oversight includes: Signed QAPI approval; and meeting minutes….” During an interview on 12/18/2025 at 2:05 PM, EMP3 stated, “There is nothing in writing” regarding the QAPI program, including tracking and trending of adverse events, infections, chart audits, and compliance assessments, and confirmed that PIPs have not been completed for 2024 and 2025. During an interview on 12/18/2025 at 2:20 PM, EMP2 confirmed there were no governing body meeting minutes for 2025.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on policy review, record review, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that documentation in one of four (PT1) active patient samples was correct and complete. Findings include: Review of PT1’s record revealed incorrect clinical documentation for the following: PT1 - “Plan of Treatment,” dated 9/26/2025, revealed, “Direct care nurse to change foley catheter, size FR 22 10 ML/Balloon every 4 weeks and as needed for malfunction.” “Skilled Nurse Visit Note,” dated 12/1/2025, 12/5/2025, 12/9/2025, 12/12/2025, and 12/16/2025, revealed, “Foley catheter changed today, client tolerated it well.” During an interview on 12/19/2025 between 2:00 PM and 3:00 PM, EMP1 stated “The notes carry over from visit to visit. The Foley was not changed on those dates.” PT1 - “Skilled Nurse Visit Note,” dated 12/5/2025, 12/9/2025, and 12/12/2025, revealed, under the “General Notes” section, “Patient alert, oriented X3, able to make her needs known. C/O pain to sacral area at this time stated she had pain meds an hour ago. Patient turned [sic] and repositioned [sic] on side to elevate pain/pressure. Open areas to sacrum, cleansed with wound cleanser, applied zinc oxide ointment and covered [sic] with gauze and tape. Caregiver instructed on wound care and the need to offload areas to allow for better blood perfusion and fast healing; caregiver verbalized understanding. Wound to left buttock healing well, cleansed with wound cleanser alginate applied and covered with clean gauze and tape, no signs and symptoms [sic] of infection noted. Client tolerated it well. Foley catheter intact and draining yellow urine.” During an interview on 12/19/2025 between 2:00 PM and 3:00 PM, EMP1 stated, “The same notes frequently carry over from week to week. I need to go in and change the note after each visit.” EMP1 confirmed that the notes for the above visits were not changed, and the notes were incorrect.”

“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 policy reviews, record reviews, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that care plans were accurate and followed for four of four (PT1, PT2, PT3, and PT4) active patients sampled. Findings include: Review of policy “Physician/Allowed Practitioner’s Plan of Care,” undated, revealed, “… [Name of HHA] must provide services in accordance with an individualized written plan of care...” Review of “Wound Care Policy,” undated, revealed, “...Ongoing Reassessment: Reassess wounds at each visit or as ordered. Document progress toward healing, lack of improvement, or deterioration...” Review of records revealed the following: PT1 – (1) “Home Health Certification and Plan of Care,” dated 9/26/2025, revealed “Skilled nursing to assess and evaluate wound care…”. “Skilled Nursing Visit Notes,” dated 11/25/2025, 12/1/2025, 12/5/2025, 12/9/2025, 12/12/2025, and 12/16/2025, revealed the patient was receiving skilled nursing services for two pressure ulcers. No documentation was found indicating that wound assessments were performed during the six nursing visits. (2) “Home Health Certification and Plan of Care,” dated 9/26/2025, revealed “Observation and Assessment Vital Signs to Monitor: … Pain Management.” “Skilled Nursing Visit Notes,” dated 11/25/2025 and 12/12/2025, revealed no documentation that pain assessments were performed. PT2 – (1) “Home Health Certification and Plan of Care,” dated 11/4/2025, revealed “Skilled nursing … Observation and Assessment Wound Healing Status, Measure Wound(s) Weekly; Instructions/Teaching Pain levels and management…”. “Skilled Nursing Visit Notes,” dated 10/29/2025 and 11/14/2025, revealed no documentation that wound assessments, including wound measurements, or pain assessments were performed. (2) “Skilled Nursing Visit Notes,” dated 12/5/2025 and 12/19/2025, revealed no documentation that wound assessments, including wound measurements, were performed. PT3 – “Home Health Certification and Plan of Care,” dated 10/28/2025, revealed “Observation and Assessment Wound for Signs and Symptoms of infection….” “Skilled Nursing Visit Notes,” dated 11/24/2025 and 12/5/2025, revealed no documentation that wound assessments were performed. PT4 – “Home Health Certification and Plan of Care,” dated 10/27/2025, revealed “Instructions/Teaching signs and symptoms of hypo/hyperglycemia and appropriate actions to take.” “Skilled Nursing Visit Note” dated 11/11/2025, 11/13/2025, 12/5/2025, 12/12/2025, and 12/19/2025 revealed no documentation that education regarding symptoms of hypo/hyperglycemia was provided. During an interview on 12/19/2025 at 2:30 PM, EMP1 confirmed that the wound and pain assessments were not performed for three of four patients, and hypo/hyperglycemia education was not provided to PT4.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on policy reviews, record reviews, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that patient care plans were updated for four of four (PT1, PT2, PT3, and PT4) active patients sampled. Findings include: Review of policy “Agency Supervision,” undated, revealed, “…Other duties of the clinical director include, but are not limited to…Assure the development, implementation, and updates of the individualized plan of care….” Review of policy “Physician/Allowed Practitioner’s Plan of Care,” undated, revealed, “…The plan of care shall include reference to at least the following: … Types of services, frequency and duration of services to be provided, medications, diet, treatments, procedures…The plan of care must be reviewed as often as the severity of the patient’s condition requires, but at least every 60 calendar days…” Review of PT1’s record revealed the following: (1) “Home Health Certification and Plan of Care,” dated 9/26/2025, indicated the patient was prescribed the medication oxycodone-acetaminophen (pain medication) tablets for “moderate to severe pain” and reported a pain level of 10 out of 10 on nursing visits performed on 12/5/2025, 12/12/2025, and 12/16/2025. There were no goals or interventions listed for pain management; (2) “60 Day Clinical Summary,” dated 9/26/2025, indicated, “…Patient reports [he/she] has stopped taking all her medications…”. Medication education/compliance was not included in the patient’s care plan. Review of PT2’s “Home Health Certification and Plan of Care,” dated 11/4/2025, revealed PT2’s goals of care included the following: (1) “Patient will have decreased peripheral edema as an indication that fluids are in balance within episode.” There were no interventions listed for this goal; (2) “Patient/caregiver will verbalize understanding of measures to alleviate pain and factors that increase pain within 4 weeks.” No interventions were listed for the goal. Review of PT3’s “Home Health Certification and Plan of Care,” dated 10/28/2025, revealed that PT3’s goals of care included “Patient will be free from side effects of pain medications (nausea/vomiting/constipation).” No interventions were listed for the goal. Review of PT4’s record revealed the following: (1) “Medication Profile,” dated 12/19/2025, indicated the patient was ordered three different laxative medications (medications used for constipation); (2) “Visit Note,” dated 12/19/2025, indicated “Patient reports no BM [bowel movement] since 12/14.” Interventions for constipation were not listed on the care plan. During an interview on 12/22/2025 at 12:20 PM, EMP1 confirmed the above findings.”

“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 policy review, record review, and staff (EMP) interview, the Home Health Agency (HHA) failed to ensure that skilled nursing staff communicated with patient’s physician regarding care plans for one of four (PT1) active patients sampled. Findings include: Review of policy “Physician/Allowed Practitioner’s Plan of Care,” undated, revealed, “The physician/allowed practitioner is immediately notified when: There is significant change in the patient’s condition; and/or If assessment findings fall outside [sic] any specific parameters identified in the plan of care...” Review of PT1’s medical records revealed “Home Health Certification and Plan of Care,” dated 9/26/2025, “Parameters to notify physician: … Pain Levels >7.” (a) “Skilled Nursing Visit Note,” dated 12/5/2025, revealed PT1 rated his/her pain level a 10 on a scale of 0 to 10. There was no acceptable pain level documented. (b) “Skilled Nursing Visit Notes,” dated 12/9/2025 and 12/16/2025, revealed the patient rated his/her pain level a 10 on a scale of 0 to 10. P1’s acceptable pain level was documented as a “3” on a scale of 0 to 10. No documentation was found indicating that the nurse notified the physician of the pain level of 10. During an interview on 12/19/2025 at 9:20 AM, EMP1 stated, “I called the pain clinic, but I did not document that I called.””

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on policy review, record reviews, and staff (EMP) interview, the Home Health Agency (HHA) failed to perform on-going interdisciplinary team assessments for four of four (PT1, PT2, PT3, and PT4) active patients sampled. Findings include: Review of policy “Case Conferences,” undated, revealed, “… [Name of agency] shall conduct regularly scheduled case conferences for all active patients to promote effective communication among members of the healthcare team. These meetings are intended to: Ensure that the patient’s plan of care remains appropriate and individualized. Review clinical findings, interventions, and outcomes…Participation at case conferences is scheduled usually every 60 days but more often if needed…Case Conference Summary Form or Electronic Note must include: Date and time of conference. Participants and disciplines present. Summary of each patient’s clinical status. Changes in condition, medications, or care needs. Modifications to the Plan of Care. Follow-up actions, responsible staff, and due dates. Signature of Clinical supervisor or Chairperson. Notes shall be filed in the patient’s clinical record within 48 hours of the meeting….” Review of records revealed no documentation that the interdisciplinary team met to discuss the patients’ care plans and health status during any of the certification periods for the following: PT1: Admitted 5/29/2025 and was in the fourth certification period. PT2: Admitted 8/29/2025 and was in the second certification period. PT3: Admitted 9/2/2025 and was in the second certification period. PT4: Admitted 8/28/2025 and was in the second certification period. During an interview on 12/18/2025 at 2:20 PM, EMP2 stated, “We meet to discuss any patient concerns on Teams, but we don’t document what we talked about.””

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on policy review, and staff (EMP) interviews, the Home Health Agency (HHA) failed to ensure that skilled nursing staff were participating in the agency’s Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of policy “Quality Assessment and Performance Improvement (QAPI),” undated, revealed, “It is the policy of [name of agency] to implement and maintain a Quality Assessment and Performance Improvement (QAPI) Program...The committee members consisting of the Director, Clinical Director, Quality Assurance Director, community registered nurse, and a member from each service discipline the agency offers…” During an interview on 12/18/2025 at 2:20 PM, EMP1 confirmed that he/she does not participate in a QAPI program. During an interview on 12/18/2025 at 3:13 PM, EMP2 confirmed there was no documentation of an ongoing QAPI program.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, record review, and staff (EMP) interview, the Home Health Agency (HHA) failed to complete a discharge summary and forward it to the health care professional who was responsible for providing care and services to the patient after discharge for one of two (PT6) sampled discharged patients. Findings include: Review of HHA policy “Electronic Medical Records”, not dated, revealed “... At Home Care Agency shall maintain a separate record at the home health agency for each patient which shall contain the following information... A discharge summary...” Review of HHA policy “Discharge / Transfer Policy”, not dated, revealed “... All discharges and transfers must be documented in the patient’s medical record... At Home Care Agency shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the patient upon discharge... Develop a discharge/ transfer summary... Ensure this summary is sent to the receiving provider (hospital, SNF [skilled nursing facility], hospice, or new HHA...” Review of MR6 revealed that PT6 was admitted to the HHA on July 24, 2025, and discharged on August 6, 2025. There is no evidence of a discharge summary in the medical record. This finding was confirmed on December 22, 2025, at 12:20 PM by EMP1. Review of policy “Electronic Medical Records”, undated, revealed “... At Home Care Agency shall maintain a separate record at the home health agency for each patient which shall contain the following information... A discharge summary...” Review of HHA policy “Discharge / Transfer Policy”, undated, revealed “... All discharges and transfers must be documented in the patient’s medical record... At Home Care Agency shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the patient upon discharge... Develop a discharge/ transfer summary... Ensure this summary is sent to the receiving provider (hospital, SNF [skilled nursing facility], hospice, or new HHA...” Review of PT6’s record revealed that PT6 was admitted to the HHA on 7/24/2025 and discharged on 8/6/2025. There is no evidence of a discharge summary in the medical record. This finding was confirmed on 12/22/2025, at 12:20 PM by EMP1”