V M H Comunity & Home Care

“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 review of the agency’s emergency preparedness plan/policies, agency document review and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff for 1 of 5 sampled staff (Staff F, Registered Nurse). Lack of emergency preparedness (EP) training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the agency policy titled Emergency Preparedness, dated August 2026, staff are educated on their roles and responsibilities in the event of an emergency on an annual basis. In an interview on 8/26/25 at 10:47 AM, the Administrator reported that if Staff F’s, Registered Nurse (RN), name is not on the emergency preparedness training lists, that means that Staff F did not receive the training. Review of the agency’s emergency preparedness training file lacked documentation of EP training for Staff F for 2024 and 2025. The agency failed to ensure all staff completed annual training in emergency preparedness. The above finding was reviewed with the Administrator and Assistant Administrator.”

“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 clinical record review and agency policy, the agency failed to transmit accurate Outcome Assessment and Information Set (OASIS) date items collected with the comprehensive assessment for 1 of 1 sampled patients (Patient #2) with a wound. Failure to transmit accurate OASIS data for adult patients did not provide accurate information to those payers in order to accurately reflect the patient’s status at the time of assessment which could negatively affect the patient’s outcome with home health services. Findings include: According to the agency policy titled Comprehensive Assessment, dated May 2024, the comprehensive assessment will include the standard core data set OASIS for adult and non-maternity clients receiving skilled care. The comprehensive assessment should accurately reflect the client’s current health status and include information that demonstrates the client’s progress toward achievement of desired outcomes. Patient #2 had a start of care date of 3/12/26. Clinical record review revealed the following: a. The plan of care (POC), dated 3/12/26 to 5/10/26, identified a diagnosis of pressure ulcer of unspecified buttock, unspecified stage and physician orders for skilled nursing services. b.The comprehensive skilled nurse assessment, dated 3/12/26, completed by Staff L, Registered Nurse (RN), identified that the patient had a pressure area to intergluteal cleft. The OASIS section for the integumentary system of the comprehensive assessment failed to identify the patient’s pressure ulcer. The agency failed to accurately encode the patient’s OASIS assessment to reflect that the patient had a pressure ulcer. The above finding was reviewed with the Administrator, Assistant Administrator and Assistant Clinical Manager.”

“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 agency policy review, personnel file review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 1 of 3 sampled home health aides (Staff G). Failure to ensure home health aides were competent in a skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to agency policy titled Home Care Aide Services, dated January 2021, home care aide services may include, but are not limited to, assistance with activities directly supportive of skilled therapy, for example, routine maintenance exercises. Guidelines for training and competency adhere to state regulations, which are included in the agency manual. During an interview on 8/26/26 at 12:58 PM, the Administrator reported that Staff G, Home Health Aide (HHA), has not been trained in home exercise program and that Staff G has not had a visit with Patient #5. Patient #5 had a start of care date of 11/11/25. Clinical record review revealed the following: a. The home health aide care plan dated 11/11/25 directed the aides to assist Patient #5 with a home exercise program. The clinical record identified that Staff G provided care to the patient. b, Staff G had a hire date of 3/18/26, Staff G’s personnel filed lacked documentation of competency testing to ensure competency evaluation was completed for assisting patients with a home exercise program. The agency failed to provide competency testing for aides assisting patients with a home exercise program. The above finding was reviewed with the Administrator and Assistant Administrator.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on staff interview, clinical record review and agency policy review, the agency failed to ensure the registered nurse (RN) developed home health aide (HHA) instructions for patient care that were specific and individualized to the patient’s needs for 1 of 3 sampled patient receiving HHA services (Patient #5). Failure to identify specific tasks for the HHA to perform increases the potential risk that patients may fail to receive necessary services ordered on the plan of care (POC) in a safe and effective manner. Findings include: According to agency policy titled Home Care Aide Services, dated January 2021, when a patient assessment by the home care nurse indicates the need for HHA services, the nurse will provide the HHA with a written care plan which will be specific as to the duties involved and will follow agency policy. During an interview on 8/25/26 at 9:23 AM, the Administrator and Assistant Clinical Manager reported that an RN creates the HHA care plan. Patient #5 had a start of care date of 11/11/25. Clinical record reviewaled: a.The POC dated, 11/11/25 to 1/9/26, identified the patient had a primary diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal dialysis and included physician orders for skilled nurse and HHA services. b.The POC, dated 11/11/25 to 1/9/25, did not include an order for oxygen. The POC did not include that crutches are used by the patient as an assistive device. c.The HHA care plan, dated 11/11/25, included HHA instructions to ambulate using an assistive device of either a cane, walker, crutches or oxygen. The home health RN failed to include specific instruction to the aide on what assistive device the patient uses. The above findings were reviewed with the Administrator, Assistant Administrator and Assistant Clinical Manager.”

“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 agency staff interview, clinical record review and agency policy review, the agency failed to ensure authentication of entries made in each patient’s clinical record included the employee’s title, date and was locked within the required time frame for 5 of 7 sampled patients (Patients #2, #4, #5, #6 and #7). Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient’s condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: 2. Patient #2 had a start of care date of 3/12/26. Clinical record review revealed the following: a. The POC, dated 7/10/26 to 9/7/26, identified a primary diagnosis of chronic ischemic heart disease and physician orders for skilled nursing services. b.The skilled nurse visit note, dated 7/29/26, completed by Staff D, RN, locked 8/4/26, 6 days after the visit, 2 days late. 3. Patient #4 had a start of care date of 11/9/25. Clinical record review revealed: a.The POC dated 7/7/26 to 9/4/26, included a primary diagnosis of Type 2 Diabetes Mellitus with hyperglycemia and physician orders for skilled nursing and home health aide (HHA) services. b.The skilled nurse visit note, dated 7/23/26, completed by Staff D, locked 7/28/26, 5 days after the visit, 1 day late. c.The HHA visit note, dated 8/4/26, completed by Staff E, HHA, locked 8/11/26, 7 days after the visit, 3 days late. d.The skilled nurse visit note, dated 8/11/26, completed by Staff D, locked 8/17/26, 6 days after the visit, 2 days late. 4. Patient #5 had a start of care date of 11/11/25. Clinical record review revealed: a.The POC dated, 7/9/26 to 9/6/26, identified the patient had a primary diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal dialysis and included physician orders for skilled nurse and HHA services. b.The skilled nurse visit note, dated 8/4/26, completed by Staff M, RN, locked 8/9/26, 5 days after the visit, 1 day late. 5. Patient #7 had a start of care date of 2/26/26 and a discharge date of 3/20/26. Clinical record review revealed the following: a. The POC, dated 2/26/26 to 4/26/26, identified a primary diagnosis of encounter for change or removal of surgical wound dressing and physician orders for skilled nursing services. b. The skilled nurse visit note, dated 2/26/26, signed completed 3/4/26 by Staff K, 6 days after the visit and 2 days late per policy expectation. The above findings were reviewed with the Administrator, Assistant Administrator and Assistant Clinical Manager. According to the agency’s policy, titled Clinical Record Documentation Policy, dated 05/2024, documentation of nursing visit is to be placed in clinical record within 2-4 business days. During an interview on 8/25/26 at 9:23 AM, Staff C, Assistant Clinical Manager, reported staff are encouraged to complete charting in the home but they have a couple days to complete. During an interview on 8/26/26 at 10:30 AM, Staff C, Assistant Clinical Manager, confirmed staff have 4 days to complete documentation. 1. Patient #6 had a start of care date of 10/23/25 and a discharge date of 1/26/26. Clinical record review revealed: a. Plan of Care (POC), dated 10/23/25 to 12/21/25, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Hand-written Home Health Physical Therapy Evaluation, dated 10/29/23, completed by Staff H, Physical Therapist (PT), included hand-written name and date but lacked discipline title. c. Physical therapy progress report, dated 11/25, completed by Staff H, PT, included staff hand-written signature and discipline title but lacked a completed date of service. d. Skilled nurse visit note, dated 12/10/25, completed by Staff J, Registered Nurse (RN), locked 12/15/25, 5 days after the visit, 1 day late. e. Home health aide visit note, dated 11/19/25, completed by Staff I, Home Health Aide (HHA), locked 11/26/25, 7 days after the visit, 3 days late.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff advised patients of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 2 of 7 sampled patients (Patients #2 and #7). Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient’s rights being violated and the patient being unexpectedly charged for services. Findings include: According to the undated agency policy titled Form Instructions Advance Beneficiary Notice of Non-coverage (ABN), when Medicare is not likely to cover a specific item or service, healthcare providers and suppliers must use the ABN to let the patient know they may be financially liable before they get the items or services. Under the estimated cost header, ensure the patient has all available information to make an informed decision about whether or not to get services that may not be covered by Medicare. Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under the item, test, service or care column. During an interview on 8/24/26 at 10:32 AM, Staff B, Assistant Administrator, reported that the estimated cost header of the Advance Beneficiary Notice of Non-Coverage (ABN) should be completed with an estimated cost of services listed on the ABN. 1. Patient #2 had a start of care date of 3/12/26. Clinical record review revealed the following: a. The plan of care (POC), dated 5/11/26 to 7/9/26, identified a primary diagnosis of chronic ischemic heart disease and physician orders for skilled nursing services. b.The patient’s clinical record included an ABN signed by Patient #2, dated 3/12/26. The estimate cost header on the ABN did not include the estimated cost for skilled nurse services. The agency failed to complete the ABN accurately in order to inform the patient of the estimated cost of skilled nurse services. 2. Patient #7 had a start of care date of 2/26/26 and a discharge date of 3/20/26. Clinical record review revealed the following: a. The POC, dated 2/26/26 to 4/26/26, identified a primary diagnosis of encounter for change or removal of surgical wound dressing and physician orders for skilled nursing services. b.The patient’s clinical record included an ABN signed by Patient #7, dated 2/26/26. The estimate cost header on the ABN did not include the estimated cost for skilled nurse services. The agency failed to complete the ABN accurately in order to inform the patient of the estimated cost of skilled nurse services. The above findings were reviewed with the Administrator, Assistant Administrator and Assistant Clinical Manager.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure completion of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 4 sampled patients requiring a recertification assessment (Patient #6). Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment Policy, dated 05/2024, the comprehensive recertification assessment must be done no earlier than 5 calendar days before and no later than 1 calendar day before the recertification date. Patient #6 had a start of care date of 10/23/25 and a discharge date of 1/26/26. Clinical record review revealed: a. Plans of Care, dated 10/23/25 to 12/21/25 and 12/22/25 to 2/19/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing services. b. Recertification Comprehensive Assessment, dated 12/17/25, completed by Staff J, Registered Nurse, locked 12/23/25, 2 days after the start of the new certification period, 2 days late. The assessment was not completed by day 60 as required by regulation. The surveyor reviewed the above stated findings with Staff A, Administrator, Staff B, Assistant Administrator and Staff C, Assistant Clinical Manager Administrator.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on agency staff interview, clinical record review and agency policy review, the agency failed to ensure completion of the update of the comprehensive assessment at discharge within 2 calendar days of identification of the need to discharge a patient for 1 of 2 sampled patients requiring a discharge comprehensive assessment (Patient #6). Failure to accurately and thoroughly update comprehensive assessments at discharge in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment Policy, dated 05/2024, the comprehensive assessment must be completed within 48 hours of a patient’s discharge from home health. Patient #6 had a start of care date of 10/23/25 and a discharge date of 1/26/26. Clinical record review revealed: a. Plans of Care, dated 10/23/25 to 12/21/25 and 12/22/25 to 2/19/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing services. b. Discharge Comprehensive Assessment, dated 1/26/26, completed by Staff J, Registered Nurse, locked 2/5/26, 10 days after the visit, 8 days late. The assessment was not completed within 48 hours as required by agency policy and regulation. The above stated findings were reviewed with Staff A, Administrator, Staff B, Assistant Administrator and Staff C, Assistant Clinical Manager Administrator.”

“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 a home observation visit, patient/caregiver interview, clinical record review, staff interview and agency policy review, the agency failed to ensure accurate completion of all components comprising the plan of care (POC), including all medical supplies/equipment and all medication for used by the patient for 1 of 3 home visits (Patient #2). Failure to maintain complete and accurate POCs with current orders placed the patient at risk to not receive services, supplies, and/or medication according to assessed needs and physician orders. Findings include: According to the agency policy titled Care Planning Process, last revised October 2024, the patient specific clinical plan of care includes: supplies and equipment required and medications including dose/frequency/route/purpose. Patient #2 had a start of care date of 3/12/26. Clinical record review revealed the following: a. The POC, dated 7/10/26 to 9/7/26, identified a primary diagnosis of chronic ischemic heart disease and included physician orders for medications and medical supplies/equipment used by the patient including: gait/transfer belt, cane, shower chair, scooter/power chair, hand held shower, grab bars/safety rails and 4 wheeled walker and cholecalciferol 25 micrograms (mcg) (1,000 international units) 1 tablet once per day and guaifenesin 1200 mg take 1 tablet every 12 hours for congestion. The POC identified the patient received skilled nursing visits every other week. b.During a home observation visit on 8/25/26 at 9:00 AM with Staff D, Registered Nurse (RN), the patient had a blood pressure cuff on the dining room table and a scale in the bathroom. Staff D filled the patient’s pill planners with medication and used a pill splitter during the procedure. c.During an interview on 8/24/26 at 9:00 AM, Patient #2 reported that he has been using a blood pressure cuff and scale daily since 2/3/26. d. During the same home observation visit, medication reconciliation revealed that the bottle of cholecalciferol in the home was labeled with a strength of 50 mcg (2,000 international units). e.During an interview on 8/25/26 at 9:00 AM, Staff D reported that the cholecalciferol has always been the 2,000 international units strength and Staff D did not know when the medication changed. f.During an interview on 8/25/26 at 9:00 AM, the patient’s caregiver reported that the patient stopped taking guaifenesin a long time ago, the patient took this for a cold that lasted a short time. The agency failed to ensure the patient’s POC accurately reflected the patient’s current medications and the agency failed to include all medical supplies/equipment on the patient’s POC, including a scale, blood pressure cuff, and pill splitter. The above findings were reviewed with the Administrator, Assistant Administrator and Assistant Clinical Manager.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency staff interview, clinical record review and policy review, the agency failed to update the Plan of Care with all new physician orders for 1 of 3 sampled patients with interim therapy orders. (Patient #6). Failure to update the Plan of Care increased the potential for inaccurate and inappropriate provision of care. Findings include: According to agency policy, titled Plan of Care for Health and Safety, dated 05/2022, plan of care is constantly updated within the electronic medical record software and not less than every 60 days. During an interview on 8/25/26 at 9:23 AM, Staff A, Administrator, reported computer system automatically updates the plan of care with all interim physician orders. Patient #6 had a start of care date of 10/23/25 and a discharge date of 1/26/26. Clinical record review revealed: a. Plan of Care, dated 10/23/25 to 12/21/25, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing once a week, physical therapy to evaluate, occupational therapy to evaluate and home health aide services once a week. b. Hand-written Home Health Physical Therapy Evaluation, dated 10/29/25, completed by Staff H, Physical Therapist, included physician orders for 1-2 physical therapy visits a week for 4 weeks. The agency failed to update the plan of care with the physical therapy orders dated 10/29/25. The above stated findings were reviewed with Staff A, Administrator, Staff B, Assistant Administrator and Staff C, Assistant Clinical Manager Administrator.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 3 sampled patients who received hands on personal care services in conjunction with skilled service provision (Patient #6). Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency policy titled, Supervision of Home Health Aide Policy, dated 06/2022, patients receiving home health aide services will require supervision of the home health aide cares not less than every two weeks. This may be direct or indirect supervision in the patient’s home. All supervision shall be recorded in the clinical record. Patient #6 had a start of care date of 10/23/25 and a discharge date of 1/26/26. Clinical record review revealed: a. Plans of Care, dated 10/23/25 to 12/21/25 and 12/22/25 to 2/19/26, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing and home health aide services. b. Skilled nurse visit note, dated 10/28/25, completed by Staff J, Registered Nurse (RN), included documentation of aide supervision. c. Skilled nurse visit note, dated 12/1/25, completed by Staff J, RN, included documentation of aide supervision, 34 days after the last aide supervision, 20 days late. d. Skilled nurse visit note, dated 12/17/25, completed by Staff J, RN, included documentation of aide supervision, 16 days after the last aid supervision, 2 days late. The nurse failed to complete home health aide supervision every 14 days as required per regulations. The above stated findings were reviewed with Staff A, Administrator, Staff B, Assistant Administrator and Staff C, Assistant Clinical Manager Administrator.”