Nightingale Home Healthcare of Illinois, 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 a review of the Agency’s Emergency Preparedness Plan, staff in-service binder, personnel files, and staff interview, it was determined the Agency failed to update its facility and community-based risk assessment every two years, establish policies and procedures based on the risk assessment, ensure staff received training pertaining to the Agency’s Emergency Preparedness Plan, and conduct the required testing of its Emergency Preparedness Plan. Findings include: 1. The Agency failed to update its facility and community-based risk assessment every two years (E0006). 2. The Agency failed to establish policies and procedures based on the risk assessment (E0013). 3. In 9 of 9 personnel files reviewed, the Agency failed to ensure staff received training pertaining to the Agency’s Emergency Preparedness Plan (E0037). 4. The Agency failed to conduct the required testing of its Emergency Preparedness Plan (E0039). The cumulative effect of these systemic practices resulted in the Agency’s inability to provide appropriate direction or supervision in the event of an emergency or disaster.”

“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 clinical record reviews, policy review and staff interviews, it was determined, the Agency failed to ensure PsOC included all the requirements, that care and services provided were according to Physician orders and as indicated in the POC. Findings include: 1. In 6 of 7 clinical records reviewed, the Agency failed to ensure PsOC included all the requirements (G574). 2. In 4 of 7 clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders, and as indicated in the POC (G580). The cumulative effect of these systemic practices resulted in the Agency’s inability to provide care effectively, and ensure Pts. received the care required in the POC.”

“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 a review of clinical records, Agency policy and staff interviews, it was determined the Agency failed to ensure that care and services were provided in accordance with Physician orders as indicated on PsOC; and ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. Findings include: 1. In 4 of 7 clinical records reviewed, the Agency failed to ensure that care and services were provided in accordance with Physician orders as indicated on PsOC (G710). 2. In 4 of 7 clinical records reviewed, the Agency failed to ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. (G718). The cumulative effect of these systemic practices resulted in Agency’s inability for skilled professionals to provide care and services effectively.”

“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 observation, staff interviews, clinical record reviews, Agency policy review, administrative document review, and review of a written Business Associate Agreement, fiscal document review, Annual Agency Evaluation review, Shareholder meeting minutes, it was determined the Administrator failed to ensure the Administrator maintained responsibility for daily operations of the Agency, an annual budget was established, statistical data was used to complete the Agency Evaluation; and ensure an annual budget were established, and that statistical data was used to complete the Agency Evaluation. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency failed to ensure the Administrator maintained responsibility for daily operations of the Agency (G948). 2. The Administrator failed to ensure annual budget was established; and that statistical data was used to complete the Agency Evaluation (G988). The cumulative effect of these systemic practices resulted in the Agency’s inability to provide appropriate administrative supervision, and oversight of Agency fiscal affairs.”

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to update its facility and community-based risk assessment every two years. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 3/6/25 at 10:00 AM. The “Hazard Vulnerability Analysis Worksheet” (risk assessment) of the Emergency Preparedness Plan was last updated “04/2022.” The risk assessment was not updated when the Emergency Preparedness Plan was last updated on 3/15/23. 2. During an interview with the Director of Clinical Services on 3/10/25 at 11:35 AM, it was confirmed the Agency failed to review and update its risk assessment every two years.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. 1. The Agency’s Emergency Preparedness Plan was reviewed on 3/6/25 at 10:00 AM. The Emergency Preparedness Plan was last updated on 3/15/23 and the “Hazard Vulnerability Analysis Worksheet” (risk assessment) of the Emergency Preparedness Plan was last updated “04/2022.” The Assessment contained the following possible events; “Bioterrorism, Blizzard, Chemical Terrorism, Civil Disorder Incident (riot, strike), Earthquake, Epidemic (External), Epidemic (Internal), Explosion, Fire, Flood, Hail Storm, Hazardous Material Incident (Decontamination), Hazardous Material Incident (Nuclear Incident), Hazardous Material Incident (Radiological Events), Heat, Hostage Event, Hurricane, Ice Storm, Infant Abduction, Landslide, Mass-Casualty Incident, Thunderstorm, Tornado, Transportation Accident, Utility Failure (Communication), Utility Failure (Electrical), Utility Failure (Generator), Utility Failure (HVAC), Utility Failure (Medical Gas), Utility Failure (Sewer), Utility Failure (Steam), Utility Failure (Telephones), Utility Failure (Water), Workplace Violence.” As of 3/11/25 10:15 AM, the Emergency Preparedness Plan lacked the policies and procedures indicated above. 2. During an interview with the Director of Clinical Services on 3/10/25 at 11:35 AM, it was confirmed the Agency failed to establish policies and procedures based on the Agency’s risk assessment.”

“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 staff in-service binder, personnel files, and staff interview, it was determined in 9 of 9 (Employees #1, 2, 3, 4, 5, 6, 7, 8, and 9) personnel files reviewed, the Agency failed to ensure staff received training pertaining to the Agency’s Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The staff in-service binder and personnel files were reviewed on 3/6/25 at 10:00 AM. These documents lacked evidence that the following staff received education on the Agency’s Emergency Preparedness Plan: Employee #1 RN/date of hire 6/19/17. Employee #2 RN/ date of hire 1/2/24. Employee #3 PT/date of hire 3/2/20. Employee #4 PT/date of hire 11/27/23. Employee #5 PT/date of hire 12/29/23. Employee #6 PT/date of hire 1/30/24. Employee #7 OT/date of hire 12/18/23. Employee #8 OT/date of hire 1/15/24. Employee #9 OT/date of hire 2/12/24. 2. During an interview with the Director of Clinical Services on 3/10/25 at 11:35 AM additional documents were requested to show evidence of Emergency Preparedness Plan training. As of 3/10/25 at 5:00 PM, it was confirmed the Agency failed to train staff on the Plan as no further documents were produced as requested by 3:00 PM.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 3/15/23 was reviewed on 3/6/25 at 10:00 AM. The Plan lacked documentation that the Agency conducted or participated in any table-top drill, full-scale exercise, facility-based exercise, or activated the Agency’s Emergency Preparedness in 2024 and 2025 (as of 3/10/25 at 10:15 AM). 2. During an interview with the Director of Clinical Services on 3/10/25 at 11:35 AM, the above findings were confirmed.”

“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 review of the Error Summary report and staff interview, it was determined in 49 of 428 assessments submitted for the last 12 months, the Agency failed to submit reports timely, resulting in a warning. Findings include: 1. The Error Summary report for 2/1/24 to 2/25/25, was reviewed on 3/5/25. The report included error # -3330 for 49 of 428 (11.45 %) OASIS reports that were submitted more than 30 days, after the assessment was completed. 2. During an interview with the Director of Clinical Services and Director of Operations on 3/11/25 at 9:11 AM, the Director of Operations stated she is responsible for the submission of OASIS and confirmed the above findings.”

“Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This Standard is not met as evidenced by: Based on staff interview, fiscal document review, Annual Agency Evaluation, Shareholder meeting minutes, and Agency policy review, it was determined the Administrator failed to ensure annual budget was established; and that statistical data was used to complete the Agency Evaluation. This has a potential to affect all services provided by the Agency. Findings include: 1. During a staff interview with the Director of Clinical Services on 3/6/25 at 3:45 PM, a request was made to review the annual operating budget for 2023, 2024 and the proposed annual budget for 2025. As of 3/11/2025 the annual budget for 2023 and the proposed annual budget for 2025 had not been presented. 2. The Agency Evaluation for 2024 was reviewed on 3/10/24 at 3:35 PM. The Evaluation included, “…Topic G. Statistical Data… 2. An annual report of service provided by age and diagnosis is provided… 4. The agency can identify average lengths of care by diagnosis and age, and/or determine average number of visits per diagnosis… 6. Statistics are available regarding discharged patients to include, number, reason and disposition of case. 7. There are guidelines which identify how the statistical data is to be used and by whom…” On 3/6/25 at 3:45 PM, and 3/10/25 at 3:40 PM, a request was made to review all supporting documentation pertaining to the Agency Evaluation. As of 3/11/25 (9:00 AM), the Agency failed to provide any statistical documentation pertaining to services provided by age and diagnosis, lengths of care by diagnosis and age, and/or number of visits per diagnosis; numbers of Pts. discharged, reason, and disposition. 3. The Agency policy titled; “Standard HH#-1A, Standard HH3-1B, Standard HH3-1C, Standard HH3-1D.01, Standard HH3-3B.01…” was reviewed on 3/6/25 at 4:25 PM. The policy required, “…The Agency performs an annual review/update of the budget… The Governing Board prepares an overall and budget that outlines the annual operating budget…” 4. The Agency policy titled; “Standard HH1-2A” was reviewed on 3/6/25 at 4:35 PM. The policy required, “…The Governing Board shall… review the annual program evaluation … and provide oversight of the management and fiscal affairs of the organization…” 5. During a staff interview with the Director of Clinical Services, Director of Operations, and the Regional Clinical Director on 3/11/25 at 9:11 AM, the Director of Clinical Services and the Director of Operations confirmed the Agency failed to ensure annual budgets were established.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined for 1 of 7 (Pt. #6) clinical records reviewed, the Agency failed to obtain informed consent and failed to provide information related to the frequency of visits provided by each discipline. Findings include: 1. Pt. #6 was admitted for home health services on 10/19/24 with the diagnosis of Type 1 Diabetes Mellitus with Other Specific Complication. The clinical record was reviewed on 3/10/25 at 9:30 AM. The clinical record contained a discharge comprehensive assessment dated 11/6/24. As of 3/11/25, the clinical record lacked a signed consent for treatment and also lacked information regarding the frequency of visits of the discipline providing the service. 2. During an interview with the Director of Clinical Services on 3/10/25 at 1:30 PM, it was stated that a consent should be obtained prior to providing any services, and that if it was obtained it should have been uploaded to the software. During the same interview, the above finding was confirmed.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 1 of 7 (Pt. #7) clinical records reviewed, the Agency failed to ensure the Pt., and the patient’s care providers were notified of the Agency discharge. Findings include: 1. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The record included a POC for the certification period of 1/4/25 to 3/5/25. The record included documentation the RN provided care on 1/4/25, 1/11/25, and 1/18/25. The SN visit notes lacked documentation the RN notified the Pt., patient’s Physician, and /or the wound care specialist of plans to discharge the Pt. 2. The clinical record included a discharge assessment form dated 2/08/25 included documentation the Pt. received service from a wound care specialist, and that this person was contacted regarding the Agency’s discharge. The record lacked documentation of the name of the person, when the person was contacted, and how the information was communicated to the wound care specialist. The Discharge assessment form contained a section to document the name of the person(s) a conference was conducted, the issue or reason, and whether the Physician was contacted, all these sections were left blank. The Discharge assessment form included the inquiry, “Written notice of discharge provided to patient”, the SN was required to place a check mark next to this statement to indicate this task was done, this section was also left blank. The Agency’s Discharge Summary completed by the RN and dated 2/8/25 included the question, “Informed of discharge prior to discharge date, per agency policy & timeline?” This section was left blank, indicating the RN and/or the Agency did not inform Pt. #7 of the plan to discharge. As of 3/3/25, the record lacked documentation that the RN notified the Pt., patient’s Physician, and the wound care clinic of the Agency’s plan to discharge Pt. #7. 3. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM. The policy required; “... The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge”. 4. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical services stated she spoke with the RN case manager regarding this Pt. The RN case manager stated the Pt. was “noncompliant and not homebound”. The Director of Clinical Services confirmed the Agency failed to ensure the Pt. and the patient’s care providers were notified of the pending Agency discharge.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on a review of clinical records, Agency’s Pt. admission packet, Agency policy, and staff interview, it was determined in 1 of 7 (Pt. #7) clinical records reviewed, the Agency failed to present the Pt. with referral sources to continue wound care, prior to the Agency discharge. Findings include: 1. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the Discharge assessment form dated 2/8/25, completed by the RN and contained, “Continuing symptoms management needed… Wound Care”, and documentation of the presence of five (5) stage 4 wounds requiring skilled care. The record lacked documentation the patient was provided contact information and referral sources prior to discharge from Agency. 2. The Agency’s admission packet was reviewed on 3/3/25 at 1:00 PM and included the form titled, “Discharge Instructions” to be completed by the RN and reviewed with the Pt. prior to the Agency discharge. The form included multiple sections, including a section for “Treatment/Ongoing Care”. The record lacked documentation that this form was completed and provided to the Pt., prior to the Agency discharge on 2/8/25. 3. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM. The policy required; “...Any transfer or discharge of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient... Patients who have continuing care needs shall: Receive written and verbal instructions... Be informed of available community resources that can be utilized to meet those needs. Be assisted to arrange for services to meet their needs, as available.” 4. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical Services confirmed the Agency failed to present the Pt., with referral sources to continue wound care, prior to the Agency discharge.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 1 of 7 (Pt. #7) clinical records reviewed, the Agency failed to address Pt. issues, prior to Agency discharge. Findings include: 1. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the Discharge assessment form completed by the RN and dated 2/8/25. The form contained; “Skilled intervention… Patient has been discharged today due to noncompliance of regulation of Medicare protocol…. He drives his self to all his physician appointments. Has tendency to remove dressings… Does not elevate feet like instructed…” As of 3/3/24, the record lacked documentation the issues were discussed and efforts were made to resolve the issues with the Director of Clinical Services, wound care specialist, and/or the patient’s Physician, prior to Agency discharge. 2. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM The policy required; “...Procedure: The Registered Nurse begins discharge planning on admission when goals are mutually established. Discharge plans are documented in the patient record. 3. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical Services confirmed the Agency failed to address Pt. issues prior to the Agency discharging the Pt. from service on 2/8/25.”

“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 clinical record reviews, policy review and staff interviews, it was determined for 6 of 7 (Pts. #2, 5, 6, 1, 4 and 7) clinical records reviewed, the Agency failed to ensure PsOC included all the requirements. 6. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included a referral that contained; “Services needed is wound care and IV therapy… IV therapy 1 q 8 h & 1 q 12 h...meropenem Intravenous Solution… Use 1 gram Intravenously every 8 hours for Antibiotic for 6 weeks – Last day 1/12/25”. The POC for the certification period of 1/4/25 to 3/4/25 lacked the medication “meropenem”. 7. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM; and 3/10/25 at 11:35 AM and 1:45 PM, the Director of Clinical Services confirmed the Agency failed to ensure PsOC included all the requirements. 4. Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical record was reviewed on 3/4/25 at 10:00 AM. The comprehensive assessment dated 2/1/25 and all RN-Skilled Nursing Visit notes included documentation that Pt. #1 had a PICC line. The POC effective 2/1/25 lacked: needed equipment for PICC line dressing change, procedure for changing PICC line dressing, specific care interventions to prevent central line-associated bloodstream infection, and Pt./caregiver education for PICC line care. The POC effective 2/1/25 lacked a Pt. specific pain rating perimeters and orders when to notify physician when the Pt. is in pain. The RN-Skilled Nursing Visit notes lacked documentation of the RN contact nor was an order obtained for pain level perimeters. 5.Pt. #4 was admitted for home health services on 10/15/24 with the diagnoses of, but not limited to, Necrosis Of Amputation Stump Left Lower Extremity, Infection Of Amputation Stump left Lower Extremity, Cellulitis Of Left Lower Limb, Type 2 Diabetes Mellitus With Hyperglycemia, and Long Term (Current) Use Of Insulin. The PsOC dated 12/14/24 and 2/12/25 were reviewed on 3/6/25 at 2:00 PM. Both PsOC have an order for Novolin N Sliding Scale Insulin with no frequency. The RN-Skilled Nursing Visit notes lacked documentation of the RN attempting to reconcile this medication order with the ordering Physician. Findings include: 1. Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The comprehensive assessment dated 1/10/25 and all RN Skilled Nursing Visit notes included documentation that Pt. #2 had a urinary catheter. The POC effective 1/11/25 lacked procedure and equipment for urinary catheter use, removal and replacement and lacked specific care interventions and Pt./caregiver education for urinary catheter care. 2. Pt. #5 was admitted for home health services on 2/8/25 with the diagnosis Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 3/6/25 at 3:00 PM. The clinical record contained a POC effective 2/8/25. The POC lacked documentation of the frequency of SN visits and lacked interventions related to the care of the Pt.’s surgical wound. 3. Pt. #6 was admitted for home health services on 10/19/24 with the diagnosis of Type 1 Diabetes Mellitus with Other Specific Complication. The clinical record was reviewed on 3/10/25 at 9:30 AM. The clinical record contained a POC for the certification period of 10/19/24 to 12/17/24. The POC lacked documentation of the frequency of SN visits, lacked interventions addressing diabetes/care for diabetic ulcer and, lacked interventions related to the care and maintenance of a PICC (Peripherally Inserted Central Catheter) line.”

“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 clinical record reviews, policy review and staff interviews, it was determined that for 4 of 7 (Pts. #2, 3, 4 and 7) clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders, and as indicated in the POC. 4. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the POC for the certification period of 1/4/25 to 2/8/25 that required, “SN Interventions Patient to have wound vac placement 2x weekly by SN of 5 wounds. SN will clean wounds with NS/ white foam placed into q wound then covered with black foam cut to size of wound and using bridging technique to wound vacs use to accommodate 5 wounds. Drape tape is used to secure white/ black foam in place and pressure devices has setting of 150 ...to both vacs.” The Discharge assessment form completed by the RN and dated 2/8/25 contained documentation the SN cleaned the 5 wounds with NS, then applied a “wet to dry dressing and secured with… tape”. As of 3/3/25, the clinical record lacked a Physician order for the SN to apply a wet to dry dressing to the 5 wounds. 5. The policy “Confirmation of Verbal Orders” revised on 6/24/09 was reviewed on 3/4/25 and required, “To provide care, treatment and/or services according to state licensed physician or licensed practitioner’s orders or prescription... (Agency) provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order(s) or prescription(s)...All orders for medical care, treatment and/or services are reviewed for appropriateness and accuracy...prior to providing care, treatment and/or services...Care, treatment and/or services are provided according to the most recent order/prescription...” 6. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM and 11:30 AM, the Director of Clinical services stated that all care, treatment, or service should have an order from the Physician. During the same interview, the Director of Clinical Services confirmed the Agency failed to ensure the RN provided treatment according to Physician orders, and indicated in the POC. 3. Pt. #4 was admitted for home health services on 10/15/24 with the diagnoses of, but not limited to, Necrosis Of Amputation Stump Left Lower Extremity, Infection Of Amputation Stump left Lower Extremity, Cellulitis Of Left Lower Limb, Type 2 Diabetes Mellitus With Hyperglycemia, and Long Term (Current) Use Of Insulin. The Agency uploaded new wound care orders for the Pt. and assigned the orders to the RN on 1/15/25 and 1/22/25. The order read, “Do not cleanse wound…Perform dry sterile dressing change by using betadine (SMALL amount to dorsal midfoot)…cover with gauze, webril and ACE bandage.” On 1/17/25 and 1/24/25, the RN who was assigned the orders, visited the Pt. and documented, “cleansed with wound cleanser…dry dressing applied.” The RN did not document the use of sterile dressing change, betadine, webril, or an ACE bandage on 1/17/25 or 1/24/25. The RN failed to follow the wound treatment ordered by the Physician. 1.Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The record included documentation of Physician orders on 1/15/25, “Buttock wound, Santyl on Alginate, change every other day;” on 1/29/25, “…other wounds pack with pieces of Silver Alginate, cover with coverlet;” on 2/21/25, “buttocks wounds alginate with triple antibiotic change 3 per week…” The RN Skilled Nursing Visit notes from 1/17/25 through 2/19/25 contained the same repetitive entries by the RN on the wound care section, “Wound cleansed with NS/Santyl applied to 2 x 2 dressing and packed into wound and covered with ABD dressing and secured with tape;” The RN failed to follow the wound treatment ordered by the Physician. The RN Skilled Nursing Visit notes dated 1/15/25, 1/17/25, 1/21/25, 1/29/25, 2/5/25, 2/17/25 included documentation that the urinary catheter was changed by the RN. The clinical record lacked a Physician order for urinary catheter removal and replacement. 2. Pt. #3 was admitted for home health services on 2/24/25 with the diagnosis of Malignant Neoplasm of Left Kidney, except Renal Pelvis. The clinical record was reviewed on 3/10/25 at 10:30 AM. The record included a Physician order dated 2/14/25 for a referral order for “home PT/OT/RN/HHA.” The clinical record lacked documentation that HHA services were provided.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined the Agency failed to ensure that for 4 of 7 (Pts. #7, 1, 4 and 2) clinical records reviewed, care and services were provided in accordance with Physician orders as indicated on PsOC. 4. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the POC for the certification period of 1/4/25 to 2/8/25 that required, “Notify physician of… Pulse greater than (>) 100 or less than () 24 or less than () 170 or less than () 90 or less than (2. Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The POC dated 2/1/25 and clinical records were reviewed on 3/4/25 at 10:00 AM. The POC ordered SN frequencies of 3 visits per week for 8 weeks for wound vac care, IV antibiotic, SN assessment, and health teachings. The clinical record lacked documentation of 2 SN visits during the week of 2/2/25-2/8/25, 1 SN visit during the week of 2/9/25-2/15/25, and 2 SN visits during the week of 2/16/25-2/22/25. The clinical record lacked Missed Visit Forms reporting to the Physician and Director of Clinical Services of these missed visits. 3. Pt. #4 was admitted for home health services on 10/15/24 with the diagnoses of, but not limited to, Necrosis Of Amputation Stump Left Lower Extremity, Infection Of Amputation Stump left Lower Extremity, Cellulitis Of Left Lower Limb, Type 2 Diabetes Mellitus With Hyperglycemia, and Long Term (Current) Use Of Insulin. The POC dated 12/14/24 and clinical records were reviewed on 3/6/25 at 11:00 AM. The POC ordered SN frequencies of 2 visits per week for 8 weeks for continued wound management, wound assessment, dressing changes, and monitoring of patient’s condition/status. The clinical record lacked documentation of 2 SN visits during the week of 12/29/24-1/4/25. The clinical record lacked Missed Visit Forms reporting to the Physician and Director of Clinical Services of these missed visits. The POC dated 12/14/24 ordered for the SN to notify the Physician of abnormal vital signs. The perimeters for abnormal BPs are “Systolic BP greater than (>) 170 or less than () 100 or less than (RN-Skilled Nurse Visit note lacked documentation of BPs. The POC dated 12/14/24 ordered for the SN to notify the Physician of abnormal vital signs. The perimeter for an abnormal pulse is a “pulse greater than (>) 120 or less than (RN-Skilled Nurse Visit note lacked documentation of pulses. The POC dated 12/14/24 ordered for the SN to notify the Physician of abnormal blood sugars. The perimeters for abnormal blood sugars are “fasting blood sugar greater than (>) 180 or less than () 180 or less than (RN-Skilled Nurse Visit note lacked documentation of blood sugars. The RN-Skilled Nurse Visit note lacked documentation of contacting the ordering Physician for clarification of blood sugar perimeter orders. Findings include: 1.Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The POC effective 1/11/25 required, “Notify physician of: Temperature greater than (>) 100.5 or less than 96.” The RN Skilled Nursing Visit note dated 1/17/25 recorded a temperature of 100.7 F but lacked documentation of Physician notification.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 4 of 7 (Pts. #7, 1, 2, and 5) clinical records reviewed, the Agency failed to ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. 3. Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4, and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The RN Skilled Nursing Visit note dated 1/20/25 recorded a temperature of 100.5 F and included: “Urine is starting to have a slight odor.” The note lacked documentation of Physician or other Health Practitioner notification. The RN Skilled Nursing Visit notes dated 1/24/25, 1/27/25, 2/5/25, 2/7/25, 2/10/25 and 2/14/25 include documentation that Pt. #2 may benefit from PT resumption/evaluation/intervention. The record lacked documentation that Director of Clinical Services or the Physician was informed of this assessment. During an interview with the Director of Clinical Services on 3/4/25 it was stated that it wasn’t until 2/26/24 that she was informed the Pt. needed referral to PT and only then was an order was obtained for a PT referral. 4. Pt. #5 was admitted for home health services on 2/8/25 with the diagnosis Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 3/6/25 at 3:00 PM. The clinical record contained a PT Discharge note dated 2/19/25, “Reason for Discharge: discontinued service due to transfer to outpatient…Physician Notification: Case Manager to notify.” The record also contained an OT Discharge note dated 2/28/25, “Reason for Discharge: discontinued service due to patient/family request…Physician Notification: Case Manager to notify.” The record lacked coordination between the PT/OT with the Physician related to the plan of the Pt. for outpatient therapy and lacked Physician orders for the discontinuation of the PT/OT services at home. 5. The Agency policy titled “Standard HH5-3A, Standard HH5-3B, Standard HH5-5A, Standard HHA-5B, Standard HHA-9A” was reviewed on 3/4/25 at 3:00 PM, and required, “...Policy: The Physician is notified of any change in the patient’s needs/clinical status...Agency staff shall promptly inform the physician of any changes that suggest a need to alter the patient’s Plan of Care and to obtain verbal authorization for the same...” 6. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, and on 3/10/25 at 1:45 PM, the Director of Clinical Services confirmed the Agency failed to communicate changes or ongoing needs with the Physician or Health Practitioners involved with their care. 2. Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical records were reviewed on 3/4/25 at 10:00 AM. The POC ordered daily blood sugar checks. The clinical records on the 2/6/25 and 2/11/25 documented the blood sugar was not checked because “patient still does not have glucometer due to Walgreens does not have any in.” The clinical record lacked documentation of reporting to the Physician or the Director of Clinical Services that the Pt. is unable to obtain a glucometer and cannot obtain daily blood sugar checks as ordered. The RN-Skilled Nurse Visit note dated 2/6/25 included, Wound “Bed: Pink/Red-100%” and on next visit note, 2/11/25, the wound description changed to Wound “Bed: Slough-20%, Pink/Red-80%.” The clinical record lacked documentation of reporting to the Surgeon or Director of Clinical Services that the Pts. wound had become worse since the last visit. The RN-Skilled Nurse Visit note dated 2/11/25 reported that the Pt. was taking a dose of medication other than what the Physician ordered. The Pt. reported to only take one fourth of the prescribed dose daily. The clinical record lacked documentation of reporting to the pain clinic Physician or Director of Clinical Services that the Pt. is not taking pain medications as ordered. Pt. reported the pain level of 8/10 on 2/6/25 and 2/11/25 per the RN-Skilled Nurse Visit note. The clinical record lacked documentation of reporting to the pain clinic Physician or Director of Clinical Services these elevated pain levels. Findings include: 1. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25. The closed clinical record included the SOC assessment form dated 1/4/25 and completed by the RN which contained; “…Patient is paralysis waist down, but independent for transfer from chair to bed and anywhere else he needs to go.” The RN missed visit notes dated 1/7/25, 1/14/25 and 1/21/25 contained documentation that the Pt. attended a wound care clinic every Tuesday. The POC for the certification period of 1/4/25 to 2/8/25 included; “…Patient drives his self to doctors’ appointments and wherever he needs to go. Only thing that is done by others is wound care…” The record lacked documentation the RN conducted care coordination with the Physician, and/or wound care specialist/clinic regarding the ability to drive self, and arrangement of other resources/measures to continue wound care as ordered for the 5 wounds indicated above. The SOC assessment form completed by the RN on 1/4/25, RN visit notes dated 1/11/25, and 1/18/25 included documentation the Pt. had a Foley catheter. The RN visit note dated 1/18/25 contained, “Patient doesn’t remember when catheter was changed at urologist office.” The record lacked documentation the RN contacted the urologist to ascertain the status of the Foley catheter.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation, staff interviews, clinical record reviews, Agency policy review, administrative document review, and review of a written Business Associate Agreement, it was determined the Agency failed to ensure the Administrator maintained responsibility for daily operations of the Agency. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. Onsite survey conducted from 3/3/25 (10:45 AM) to 3/11/25, during the onsite survey observed that the Administrator was not onsite. Observed the Director of Clinical Services alone during the survey 3/3/25 to 3/10/25 answering phone calls, arranging home visits, providing administrative, personnel, and clinical policies/documents, and meeting with field staff. 2. A phone interview was conducted with the Administrator on 3/10/25 at 11:10 AM. The Administrator stated, the Alternate Administrator is the Director of Clinical Services and that he interviewed her for this position. The administrator stated, “I don’t get involved with clinical issues unless I am asked, the Director of Clinical Services handles those issues… I do handle complaint issues”. A question was asked for the reason why 2 different agency names are located on Agency policies and administrative records. The Administrator responded, “…. (Agency #2 - name of the other agency) should not be used for (Agency #1 - this agency), (Agency #2) is not associated with (Agency #1) …” 3. The clinical records of Pt. #3 (SOC 2/24/25,) and Pt. #6 (SOC 10/19/24) included “Patient Communication” indicating “… (Agency #2) was seeking approval from the insurance provider to provide Pt. care and/or services. The communication forms lacked the name of this Agency, as the Agency to provide care and/or services. 4. The Agency policy titled; “Standard HH1-2A.01” was reviewed on 3/6/25 at 11:55 AM. The policy included documentation that the Administrator “was the founder and sole owner of “… (Agency #2)”. The policy lacked the name of this Agency. 5. The Agency policy titled; “Administrator Job Description” was reviewed on 3/6/25 at 1:12 PM. The Job Description was signed by the Administrator and dated 9/25/19 and included the names of Agency #1 and Agency #2. 6. The Agency’s policy and procedure manual was reviewed on 3/6/25 at 4:35 PM. The manual included a cover page that included” … (name of Agency #2) Home Healthcare d/b/a (name of Agency #2) Home Healthcare (name of Agency #2) Visiting Nurses (name of Agency #2) Home Healthcare Home Health Policy and Procedure Manual”. The policy manual’s cover page lacked the name of this Agency. 7. The document titled; “Written Consent to Resolution in Lieu of a Meeting of the Sole Shareholder” dated 3/28/24 was reviewed on 3/11/25 at 10:16 AM. This record contained documentation that the Agency’s “policies and procedures were reviewed and approved by… (the Administrator and sole owner). However, there are multiple Agency policies and administrative documents that lacked the correct name of this Agency (Agency #1). 8. The written Business Associate Agreement dated 12/6/22 between Agency #1 and “… Therapy Services” was reviewed on 3/11/25 at 8:20 AM. The Agreement referred to Agency #2 in multiple sections of this Agreement. 9. During a staff interview with the Director of Clinical Services, Director of Operations, and the Regional Clinical Director on 3/11/25 at 9:11 AM, the Director of Clinical Services and the Director of Operations confirmed the above findings.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 3 of 7 (Pts. #1, 2, and 7) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical records was complete and accurate. 3. Pt. #7 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the SOC assessment completed by the RN and dated 1/4/25 which contained a description of the 5 wounds. Wound #1 was described as being located to the “low back 4 x 1 x 1 cm”, Wound #2 located to the “left hip 10 x 7 x 2 cm”, Wound #3 located to the “upper right gluteal and lacked a description or assessment of this wound, Wound #4 located to the “left upper gluteal 2 x 1 x 1 cm”, and Wound #5 located to the “left hip 3 x3 x 1 cm”. The next SN visit was conducted on 1/11/25 and included a description/location of Wound #1 “coccyx 3 x 1.5 x1 cm”, Wound #2 “left ischium 3 x 3 x 1 cm”, Wound #3 “right trochanter 7.5 x 10 x 2 cm”, Wound #4” left ischium 6 x 6 x 4 cm”, and Wound #5 “right trochanter 4 x 4 x 2 cm”. The SN visit note 1/18/25 included a description/location of Wound #2 “left ischium 3 x 3 x 1 cm” and Wound #3 “right trochanter” was not assessed. The RN visit notes lacked a consistent description and location of the patient’s 5 wounds, and the record lacked documentation the RN assessed and measured the wounds weekly, as required by the Agency’s policy. The SOC assessment dated 1/4/25 contained, “Patient goes to urologist for monthly changes of Foley catheter.” However, the POC for the certification period of 1/4/25 to 3/4/25 included, “SN Interventions… Catheter will be changed once monthly with 16 fr (French) catheter/ 10 ml balloon.” The SOC assessment and the POC included conflicting documentation as to who (Physician or RN) was responsible for the Foley catheter changes. 4. The Agency’s policy titled, “Standard HH5-1A, Standard H5-1A.01... The Agency has written policies and procedures relating to the required content of the patient record” was reviewed on 3/5/25 at 12:30 PM. The policy required, “... All records shall contain documentation of correct clinical information that is available to the patient’s attending physician and staff...” 5. The Agency’s policy titled, “Wound Assessment and Documentation” was reviewed on 3/5/25 at 11:40 AM. The policy included; “Document the following on the visit report: The treatment and condition of the wound (each visit) …Wound measurements (at least weekly), including length, depth, and width of the wound in centimeters...” 6. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, the Director of Clinical Services confirmed the Agency failed to ensure that documentation entered into the clinical records was complete and accurate. 2. Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4, and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The Physician Notes dated 1/15/25, 1/29/25 and 2/21/25 included documentation identifying the location of the 3 wounds as: Central Sacral Stage 4 Pressure Ulcer, Right Central Buttock Stage 4 Pressure Ulcer and Left Inferior Buttock Pressure Ulcer. The RN Skilled Nursing Visit Notes from 1/17/25 through 1/21/25 includes documentation of the location of the 3 wounds as Sacral Stage 4 Pressure Ulcer, Right Hip Stage 4 Pressure Ulcer and Left Hip Stage 4 Pressure Ulcer. During an interview with the Director of Clinical Services on 3/4/25 it was stated that as per her observation, the pressure ulcers were located on the sacral area, on the Right Buttock and not the Right Hip, and on the Left Buttock and not the Left Hip. The Director of Clinical Services confirmed that the documentation of the location of the pressure ulcers on the clinical record was inaccurate. The clinical record also included documentation of the Physician’s measurements of the sacral pressure ulcers and are as follows: 1/15/25 = 7 cm x 8 cm x 15 mm; 1/29/25 = 7 cm x 8 cm x 10 mm and 2/21/25 = 6.5 cm x 6 cm x 15 mm. The RN Case Manager’s documentation of the wound measurements was as follows: 1/10/25 = 8 cm x 9 cm x 1.3 cm; 1/17/25 and 2/17/25 = 4 cm x 4 cm x 1.5 cm; 1/31/25, 2/3/25, 2/7/25, 2/12/25 and 2/14/25 = 4 cm x 4 cm x 1 cm. The RN Case Manager’s documentation is inconsistent with the measurements documented by the Physician. Findings include: 1. Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical records were reviewed on 3/4/25 at 10:00 AM. The RN-Skilled Nurse Visit note on 2/11/25 had conflicting documentation regarding new medication: “Medication change since last visit? No” and “Comments: Patient placed on new medication for pain.” The RN-Skilled Nurse Visit Note on 2/11/25 had conflicting documentation regarding pain management and effectiveness. The RN documented, “Pain Intensity: 8... Current Pain Management & Effectiveness: Effective...Comments: Patient placed on new medication for pain. Patient has good results.” The RN-Skilled Nurse Visit note for 2/27/25 had conflicting documentation regarding pain rating: In the Pain category, “Pain Intensity: 5 Medium” and in Wound Care category, “Pain: 6”.”

“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 clinical record reviews, policy review and staff interviews, it was determined, the Agency failed to ensure PsOC included all the requirements, that care and services provided were according to Physician orders and as indicated in the POC. Findings include: 1. In 3 of 3 clinical records reviewed, the Agency failed to ensure PsOC included all the requirements (G574). 2. In 2 of 3 clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders, and as indicated in the POC (G580). The cumulative effect of these systemic practices resulted in the Agency’s inability to provide care effectively, and ensure Pts. received the care required in the POC.”

“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 a review of clinical records, Agency policy and staff interviews, it was determined the Agency failed to ensure that care and services were provided in accordance with Physician orders as indicated on PsOC; and ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. Findings include: 1. In 3 of 3 clinical records reviewed, the Agency failed to ensure that care and services were provided in accordance with Physician orders as indicated on PsOC (G710). 2. In 3 of 3 clinical records reviewed, the Agency failed to ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. (G718). 3. The cumulative effect of these systemic practices resulted in Agency’s inability for skilled professionals to provide care and services effectively.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 1 of 3 (Pt. #3) clinical records reviewed, the Agency failed to ensure the Pt., and the patient’s care providers were notified of the Agency discharge. Findings include: 1. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The record included a POC for the certification period of 1/4/25 to 3/5/25. The record included documentation the RN provided care on 1/4/25, 1/11/25, and 1/18/25. The SN visit notes lacked documentation the RN notified the Pt., patient’s Physician, and /or the wound care specialist of plans to discharge the Pt. 2. The clinical record included a discharge assessment form dated 2/08/25 included documentation the Pt. received service from a wound care specialist, and that this person was contacted regarding the Agency’s discharge. The record lacked documentation of the name of the person, when the person was contacted, and how the information was communicated to the wound care specialist. The Discharge assessment form contained a section to document the name of the person(s) a conference was conducted, the issue or reason, and whether the Physician was contacted, all these sections were left blank. The Discharge assessment form included the inquiry, “Written notice of discharge provided to patient”, the SN was required to place a check mark next to this statement to indicate this task was done, this section was also left blank. The Agency’s Discharge Summary completed by the RN and dated 2/8/25 included the question, “Informed of discharge prior to discharge date, per agency policy & timeline?” This section was left blank, indicating the RN and/or the Agency did not inform Pt. #7 of the plan to discharge. As of 3/3/25, the record lacked documentation that the RN notified the Pt., patient’s Physician, and the wound care clinic of the Agency’s plan to discharge Pt. #3. 3. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM. The policy required; “... The patient/family shall be an active participant, when possible, in planning his/her referral, transfer and/or discharge”. 4. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical services stated she spoke with the RN case manager regarding this Pt. The RN case manager stated the Pt. was “noncompliant and not homebound”. The Director of Clinical Services confirmed the Agency failed to ensure the Pt. and the patient’s care providers were notified of the pending Agency discharge.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on a review of clinical records, Agency’s Pt. admission packet, Agency policy, and staff interview, it was determined in 1 of 3 (Pt. #3) clinical records reviewed, the Agency failed to present the Pt. with referral sources to continue wound care, prior to the Agency discharge. Findings include: 1. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the Discharge assessment form dated 2/8/25, completed by the RN and contained, “Continuing symptoms management needed… Wound Care”, and documentation of the presence of five (5) stage 4 wounds requiring skilled care. The record lacked documentation the patient was provided contact information and referral sources prior to discharge from Agency. 2. The Agency’s admission packet was reviewed on 3/3/25 at 1:00 PM and included the form titled, “Discharge Instructions” to be completed by the RN and reviewed with the Pt. prior to the Agency discharge. The form included multiple sections, including a section for “Treatment/Ongoing Care”. The record lacked documentation that this form was completed and provided to the Pt., prior to the Agency discharge on 2/8/25. 3. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM. The policy required; “...Any transfer or discharge of patients shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient... Patients who have continuing care needs shall: Receive written and verbal instructions... Be informed of available community resources that can be utilized to meet those needs. Be assisted to arrange for services to meet their needs, as available.” 4. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical Services confirmed the Agency failed to present the Pt., with referral sources to continue wound care, prior to the Agency discharge. Findings include:”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 1 of 3 (Pt. #3) clinical records reviewed, the Agency failed to address Pt. issues, prior to Agency discharge. Findings include: 1. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the Discharge assessment form completed by the RN and dated 2/8/25. The form contained; “Skilled intervention… Patient has been discharged today due to noncompliance of regulation of Medicare protocol…. He drives his self to all his physician appointments. Has tendency to remove dressings… Does not elevate feet like instructed…” As of 3/3/24, the record lacked documentation the issues were discussed and efforts were made to resolve the issues with the Director of Clinical Services, wound care specialist, and/or the patient’s Physician, prior to Agency discharge. 2. The Agency policy titled, “Standard HH5-6A, Standard HH5-7A... The Agency develops written policies and procedures and implements those procedures regarding the process for discharge of a patient receiving Home Health Services...” was reviewed on 3/4/25 at 9:30 AM The policy required; “...Procedure: The Registered Nurse begins discharge planning on admission when goals are mutually established. Discharge plans are documented in the patient record. 3. During a staff interview with the Director of Clinical Services on 3/4/25 at 10:05 AM, the Director of Clinical Services confirmed the Agency failed to address Pt. issues prior to the Agency discharging the Pt. from service on 2/8/25. Findings include:”

“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 clinical record reviews, policy review and staff interviews, it was determined for 3 of 3 (Pts. #2, 1 and 3) clinical records reviewed, the Agency failed to ensure PsOC included all the requirements. 3. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included a referral that contained; “Services needed is wound care and IV therapy… IV therapy 1 q 8 h & 1 q 12 h...meropenem Intravenous Solution… Use 1 gram Intravenously every 8 hours for Antibiotic for 6 weeks – Last day 1/12/25”. The POC for the certification period of 1/4/25 to 3/4/25 lacked the medication “meropenem”. 4. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, the Director of Clinical Services confirmed the Agency failed to ensure PsOC included all the requirements. 2. Pt. #1 was admitted for home health services on 2/1/25 with the diagnosis of Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical record was reviewed on 3/4/25 at 10:00 AM. The comprehensive assessment dated 2/1/25 and all RN Skilled Nursing Visit notes included documentation that Pt. #1 had a PICC line (peripherally inserted central catheter). The POC effective 2/1/25 lacked procedure and equipment for PICC line dressing change, lacked specific care interventions to prevent central line associated blood steam infection, and Pt./caregiver education for PICC line care. The POC effective 2/1/25 lacked a Pt. specific pain rating perimeter ordering when to notify physician nor was an order obtained for pain level perimeters. Findings include: 1.Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The comprehensive assessment dated 1/10/25 and all RN Skilled Nursing Visit notes included documentation that Pt. #2 had a urinary catheter. The POC effective 1/11/25 lacked procedure and equipment for urinary catheter use, removal and replacement and lacked specific care interventions and Pt./caregiver education for urinary catheter care.”

“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 clinical record reviews, policy review and staff interviews, it was determined that for 2 of 3 (Pts. #2 and 3) clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders, and as indicated in the POC. 2. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the POC for the certification period of 1/4/25 to 2/8/25 that required, “SN Interventions Patient to have wound vac placement 2x weekly by SN of 5 wounds. SN will clean wounds with NS/ white foam placed into q wound then covered with black foam cut to size of wound and using bridging technique to wound vacs use to accommodate 5 wounds. Drape tape is used to secure white/ black foam in place and pressure devices has setting of 150 ...to both vacs.” The Discharge assessment form completed by the RN and dated 2/8/25 contained documentation the SN cleaned the 5 wounds with NS, then applied a “wet to dry dressing and secured with… tape”. As of 3/3/25, the clinical record lacked a Physician order for the SN to apply a wet to dry dressing to the 5 wounds. 3. The policy “Confirmation of Verbal Orders” revised on 6/24/09 was reviewed on 3/4/25 and required, “To provide care, treatment and/or services according to state licensed physician or licensed practitioner’s orders or prescription... (Agency) provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order(s) or prescription(s)...All orders for medical care, treatment and/or services are reviewed for appropriateness and accuracy...prior to providing care, treatment and/or services...Care, treatment and/or services are provided according to the most recent order/prescription...” 4. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM and 11:30 AM, the Director of Clinical services stated that all care, treatment, or service should have an order from the Physician. During the same interview, the Director of Clinical Services confirmed the Agency failed to ensure the RN provided treatment according to Physician orders, and indicated in the POC. Findings include: 1.Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The record included documentation of Physician orders on 1/15/25, “Buttock wound, Santyl on Alginate, change every other day;” on 1/29/25, “…other wounds pack with pieces of Silver Alginate, cover with coverlet;” on 2/21/25, “buttocks wounds alginate with triple antibiotic change 3 per week…” The RN Skilled Nursing Visit notes from 1/17/25 through 2/19/25 contained the same repetitive entries by the RN on the wound care section, “Wound cleansed with NS/Santyl applied to 2 x 2 dressing and packed into wound and covered with ABD dressing and secured with tape;” The RN failed to follow the wound treatment ordered by the Physician. The SN notes dated 1/15/25, 1/17/25, 1/21/25, 1/29/25, 2/5/25, 2/17/25 included documentation that the urinary catheter was changed by the RN. The clinical record lacked a Physician order for urinary catheter removal and replacement.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined the Agency failed to ensure that for 3 of 3 (Pts. #2, #1 and 3) clinical records reviewed, care and services were provided in accordance with Physician orders as indicated on PsOC. 3. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the POC for the certification period of 1/4/25 to 2/8/25 that required, “Notify physician of… Pulse greater than (>) 100 or less than ( Respirations greater than (>) 24 or less than ( Systolic BP (blood pressure) greater than (>) 170 or less than ( Diastolic BP greater than (>) 90 or less than ( The RN visit note dated 1/18/25 contained, “Pulse: 101 Radial, Resp (Respirations) 29, BP (R) 92/101”. The clinical record lacked documentation the RN notified the Physician of the pulse, respirations, and BP outside the parameters indicated above. The POC for the certification period effective 1/4/25 required; “SN Interventions Patient to have wound vac placement 2x weekly by SN of 5 wounds…” The record lacked documentation the SN provided any interventions during the weeks of 1/19/25 to 1/25/25 and 1/26/25 to 2/1/25. 4. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, the Director of Clinical Services confirmed the Agency failed to ensure Pts. received care and services according to Physician orders and/or PsOC. 2. Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The POC dated 2/1/25 was reviewed on 3/4/25 at 10:00 AM. The POC ordered SN frequencies of 3 visits per week for 8 weeks for wound vac care, IV antibiotic, SN assessment, and health teachings. The clinical record lacked documentation of 2 SN visits during the week of 2/2/25-2/8/25, 1 SN visit during the week of 2/9/25-2/15/25, and 2 SN visits during the week of 2/16/25-2/22/25. The clinical record lacked Missed Visit Forms reporting to the Physician and Director of Clinical Services of these missed visits. Findings include: 1.Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The POC effective 1/11/25 required, “Notify physician of: Temperature greater than (>) 100.5 or less than 96.” The RN Skilled Nursing Visit note dated 1/17/25 recorded a temperature of 100.7 F but lacked documentation of Physician notification.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 3 of 3 (Pts. #3, 1, and 2) clinical records reviewed, the Agency failed to ensure the RN contacted the Physician, and other health professionals that participate in the patient’s care regarding changes needed in the POC and/or ongoing needs of the Pt. 3. Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4, and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The RN Skilled Nursing Visit note dated 1/20/25 recorded a temperature of 100.5 F and included: “Urine is starting to have a slight odor.” The note lacked documentation of Physician or other Health Practitioner notification. The RN Skilled Nursing Visit notes dated 1/24/25, 1/27/25, 2/5/25, 2/7/25, 2/10/25 and 2/14/25 include documentation that Pt. #2 may benefit from PT resumption/evaluation/intervention. The record lacked documentation that Director of Clinical Services or the Physician was informed of this assessment. During an interview with the Director of Clinical Services on 3/4/25 it was stated that it wasn’t until 2/26/24 that she was informed the Pt. needed referral to PT and only then was an order was obtained for a PT referral. 4. The Agency policy titled “Standard HH5-3A, Standard HH5-3B, Standard HH5-5A, Standard HHA-5B, Standard HHA-9A” was reviewed on 3/4/25 at 3:00 PM, and required, “...Policy: The Physician is notified of any change in the patient’s needs/clinical status...Agency staff shall promptly inform the physician of any changes that suggest a need to alter the patient’s Plan of Care and to obtain verbal authorization for the same...” 5. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, the Director of Clinical Services confirmed the Agency failed to communicate changes or ongoing needs with the Physician or Health Practitioners involved with their care. 2. Pt. #1 was admitted for home health services on 2/1/25 with the diagnosis of Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical records were reviewed on 3/4/25 at 10:00 AM. The POC ordered daily blood sugar checks. On the 2/6/25 and 2/11/25 Skilled Nurse Visit notes, the blood sugar was not checked because “patient still does not have glucometer due to Walgreens does not have any in.” The SN Visit note lacked documentation of reporting this to the Physician or the Director of Clinical Services. SN Visit note dated 2/6/25 included, “Bed: Pink/Red-100%” and on next visit note, 2/11/25, the wound description changed to “Bed: Slough-20%, Pink/Red-80%.” The SN Visit note lacked documentation of reporting to the Surgeon or Director of Clinical Services that the Pts. wound had become worse since the last visit. SN Visit note dated 2/11/25 reported that the Pt. was taking a dose of medication other than what the Physician ordered. The Pt. reported to only take one fourth of the prescribed dose daily. The SN Visit note lacked documentation of reporting to the pain clinic Physician or Director of Clinical Services that the Pt. is not taking pain medications as ordered. Pt. reported the pain level of 8/10 on 2/6/25 and 2/11/25 per Skilled Nurse Visit notes. These pain levels were not reported to the Physician at the Pt.’s pain clinic. Findings include: 1. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25. The closed clinical record included the SOC assessment form dated 1/4/25 and completed by the RN which contained; “…Patient is paralysis waist down, but independent for transfer from chair to bed and anywhere else he needs to go.” The RN missed visit notes dated 1/7/25, 1/14/25 and 1/21/25 contained documentation that the Pt. attended a wound care clinic every Tuesday. The POC for the certification period of 1/4/25 to 2/8/25 included; “…Patient drives his self to doctors’ appointments and wherever he needs to go. Only thing that is done by others is wound care…” The record lacked documentation the RN conducted care coordination with the Physician, and/or wound care specialist/clinic regarding the ability to drive self, and arrangement of other resources/measures to continue wound care as ordered for the 5 wounds indicated above. The SOC assessment form completed by the RN on 1/4/25, RN visit notes dated 1/11/25, and 1/18/25 included documentation the Pt. had a Foley catheter. The RN visit note dated 1/18/25 contained, “Patient doesn’t remember when catheter was changed at urologist office.” The record lacked documentation the RN contacted the urologist to ascertain the status of the Foley catheter.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interview, it was determined in 3 of 3 (Pts. #1, 2, and 3) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical records was complete and accurate. 3. Pt. #3 was admitted for home health services on 1/4/25 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Hip, Stage 4 Pressure Ulcer of Right Buttock, and Stage 4 Pressure Ulcer of Left Buttock. The closed clinical record was reviewed on 3/3/25 at 2:30 PM. The closed clinical record included the SOC assessment completed by the RN and dated 1/4/25 which contained a description of the 5 wounds. Wound #1 was described as being located to the “low back 4 x 1 x 1 cm”, Wound #2 located to the “left hip 10 x 7 x 2 cm”, Wound #3 located to the “upper right gluteal and lacked a description or assessment of this wound, Wound #4 located to the “left upper gluteal 2 x 1 x 1 cm”, and Wound #5 located to the “left hip 3 x3 x 1 cm”. The next SN visit was conducted on 1/11/25 and included a description/location of Wound #1 “coccyx 3 x 1.5 x1 cm”, Wound #2 “left ischium 3 x 3 x 1 cm”, Wound #3 “right trochanter 7.5 x 10 x 2 cm”, Wound #4” left ischium 6 x 6 x 4 cm”, and Wound #5 “right trochanter 4 x 4 x 2 cm”. The SN visit note 1/18/25 included a description/location of Wound #2 “left ischium 3 x 3 x 1 cm” and Wound #3 “right trochanter” was not assessed. The RN visit notes lacked a consistent description and location of the patient’s 5 wounds, and the record lacked documentation the RN assessed and measured the wounds weekly, as required by the Agency’s policy. The SOC assessment dated 1/4/25 contained, “Patient goes to urologist for monthly changes of Foley catheter.” However, the POC for the certification period of 1/4/25 to 3/4/25 included, “SN Interventions… Catheter will be changed once monthly with 16 fr (French) catheter/ 10 ml balloon.” The SOC assessment and the POC included conflicting documentation as to who (Physician or RN) was responsible for the Foley catheter changes. 4. The Agency’s policy titled, “Standard HH5-1A, Standard H5-1A.01... The Agency has written policies and procedures relating to the required content of the patient record” was reviewed on 3/5/25 at 12:30 PM. The policy required, “... All records shall contain documentation of correct clinical information that is available to the patient’s attending physician and staff...” 5. The Agency’s policy titled, “Wound Assessment and Documentation” was reviewed on 3/5/25 at 11:40 AM. The policy included; “Document the following on the visit report: The treatment and condition of the wound (each visit) …Wound measurements (at least weekly), including length, depth, and width of the wound in centimeters...” 6. During staff interviews with the Director of Clinical Services on 3/4/25 at 10:05 AM, 11:30 AM, and 12:00 PM, the Director of Clinical Services confirmed the Agency failed to ensure that documentation entered into the clinical records was complete and accurate. 2. Pt. #2 was admitted for home health services on 11/12/24 with the diagnoses of, but not limited to Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 4, and Pressure Ulcer of Left Buttock, Unstageable. The clinical record was reviewed on 3/4/25 at 11:00 AM. The Physician Notes dated 1/15/25, 1/29/25 and 2/21/25 included documentation identifying the location of the 3 wounds as: Central Sacral Stage 4 Pressure Ulcer, Right Central Buttock Stage 4 Pressure Ulcer and Left Inferior Buttock Pressure Ulcer. The RN Skilled Nursing Visit Notes from 1/17/25 through 1/21/25 includes documentation of the location of the 3 wounds as Sacral Stage 4 Pressure Ulcer, Right Hip Stage 4 Pressure Ulcer and Left Hip Stage 4 Pressure Ulcer. During an interview with the Director of Clinical Services on 3/4/25 it was stated that as per her observation, the pressure ulcers were located on the sacral area, on the Right Buttock and not the Right Hip, and on the Left Buttock and not the Left Hip. The Director of Clinical Services confirmed that the documentation of the location of the pressure ulcers on the clinical record was inaccurate. The clinical record also included documentation of the Physician’s measurements of the sacral pressure ulcers and are as follows: 1/15/25 = 7 cm x 8 cm x 15 mm; 1/29/25 = 7 cm x 8 cm x 10 mm and 2/21/25 = 6.5 cm x 6 cm x 15 mm. The RN Case Manager’s documentation of the wound measurements was as follows: 1/10/25 = 8 cm x 9 cm x 1.3 cm; 1/17/25 and 2/17/25 = 4 cm x 4 cm x 1.5 cm; 1/31/25, 2/3/25, 2/7/25, 2/12/25 and 2/14/25 = 4 cm x 4 cm x 1 cm. The RN Case Manager’s documentation is inconsistent with the measurements documented by the Physician. Findings include: 1.Pt. #1 was admitted for home health services on 2/1/25 with the diagnoses of, but not limited to, Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus With Other Specified Complication. The clinical records were reviewed on 3/4/25 at 10:00 AM. The Skilled Nurse Visit note on 2/11/25 had conflicting documentation regarding new medication: “Medication change since last visit? No” and “Comments: Patient placed on new medication for pain.” The Skilled Nurse Visit Note on 2/11/25 had conflicting documentation regarding pain management and effectiveness. The SN documented, “Pain Intensity: 8... Current Pain Management & Effectiveness: Effective...Comments: Patient placed on new medication for pain. Patient has good results.” The Skilled Nurse Visit note for 2/27/25 had conflicting documentation regarding pain rating: In the Pain category, “Pain Intensity: 5 Medium” and in Wound Care category, “Pain: 6”.”