Advantage Home Health Plus, Inc.

“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 staff interviews and a review of employee records in 2 of 6 (Employees #2 and 6) employee records reviewed, the Agency failed to ensure staff receive training pertaining to the Agency’s Emergency Preparedness Plan biennially. Findings include: 1. During the entrance interview with the Clinical Supervisor on 01/27/26 at 10:35 AM, the Clinical Supervisor stated employee in-service/education records are maintained in the employee records. 2. On 01/27/26 at 3:30 PM, the employee records were reviewed and contained the following: Employee #2. Date of hire 10/20/21. Emergency Preparedness education last provided on 03/15/22. Employee #6. Date of hire 07/20/20. Emergency Preparedness education last provided on 03/15/22. As of 01/27/26, the employee records lacked documentation the Agency provided in-services/education pertaining to the Agency’s Emergency Preparedness Plan every 2 years. 3. During an interview with the Clinical Supervisor on 1/27/26 at 3:30 PM 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 the review of the Error Summary report and staff interview, for 812 of 1792 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed which resulted in a warning. Findings include: 1. The Error Summary report for 10/01/24 to 12/19/25, was reviewed on 01/26/26 at 2:30 PM. The report included error # -3330 for 812 of 1792 late submissions, 45.31% of the OASIS reports were submitted more than 30 days after the assessments were completed. 2. During an interview with the Clinical Supervisor on 01/28/26 at 11:30 AM, it was confirmed that the error occurred.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of clinical records, policy review and staff interviews, in 5 of 10 (Pts. #2, 4, 3, 7, and 10) clinical records reviewed, the Agency failed to ensure staff provide service as indicated in the POC. 3. Pt. #3 was admitted for home health services on 12/28/25 with the diagnosis of Hematemesis. The clinical record was reviewed on 01/27/25. The POC effective 12/18/25 required, “SN to assess O2 [Oxygen] saturation on room air (frequency) weekly.” The SN note dated 01/16/26 lacked documentation of any vital signs and oxygen saturation results. 4. Pt. #7 was admitted for home health services on 12/03/25 with the diagnosis of Type 2 Diabetes mellitus with Hyperglycemia. The clinical record was reviewed on 01/27/25. The POC effective 12/03/25 required, “… Notify physician of Fasting Blood Sugar greater than (>)160 or less than ( 5. Pt. #10 was admitted for home health services on 11/03/25 with the diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 01/27/26 and included a POC for the certification period of 11/03/25 to 12/30/25. The clinical record included the PT frequency of 1w1, 2w3, 1w3.” The record included documentation that there were missed visits for the weeks of 11/30/25 to 12/06/25 and 12/07/25 to 12/13/25 but lacked documentation the Physician was notified of the missed visits. 6. The Agency Policy “Plan of Care” was reviewed on 01/28/26 and required, “20. Care and services provided will be provided according to physician/practitioner orders. Orders are current and updated…30. The patient’s orders for treatments and services are the foundation of the plan of care. If the Agency misses a visit or treatment or services as required by the plan of care, which results in any potential for clinical impact upon the patient, then the Agency must notify the responsible physician/practitioner of such missed treatment or service. The physician/practitioner decides whether the treatment or services may be skipped or whether additional intervention is required by the Agency due to the clinical impact on the patient…” 7. The Agency Policy, “Coordination of Patient Care” was reviewed on 01/28/36 and required, “Notifying the physician/practitioner and making sure he/she is aware of missed visits (must document).” 8. During an interview conducted with the Clinical Supervisor on 01/27/26 at 3:30 PM and on 01/28/26 at 11:30 AM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to Home Health services on 12/17/25 with diagnoses of, but not limited to, Chronic Prostatitis, Unspecified Heart Failure, and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 01/26/26. The clinical record contained the POC effective 12/17/25 that included instructions for the SN to monitor “…weight for cardiac and fluid status”. The weekly SN visit notes from 12/23/25 to 01/20/26 lacked documentation the SN monitored/assessed the patient’s weight. 2. Pt. #4 was admitted to Home Health services on 11/19/25 with diagnoses of, but not limited to, Essential (Primary) Hypertension, Hemiplegia following Cerebral Infarction Affecting Unspecified Side, and Unsteadiness on feet. The clinical record was reviewed on 01/26/26 and 01/27/26. The clinical record contained the POC effective 11/19/25 that required, “SN notify Physician of… weight greater than (>) 5 lbs or less than(<) 5 lbs…”. The weekly SN visit notes from 12/04/25 to 01/08/26, and the recertification assessment dated 01/16/26, lacked documentation the SN assessed the patient’s weight to determine whether a weight loss or gain had occurred.”

“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 observation during home visits, clinical record reviews, and staff interviews in 5 of 10 (Pts. #2, 4, 5, 6, and 9) clinical records reviewed, the Agency failed to ensure the Pts. were informed of the services to be provided in writing and the frequency of visits provided by each discipline, prior to the initiation of services. 3. Pt. #5 was admitted for home health services on 01/15/26 with the diagnosis of Flu due to other identified influenza virus with other respiratory manifestations. The clinical record was reviewed on 01/27/26. The admission consent included the service and frequency section. The information was left blank upon record review. The record lacked documentation that the Pt. or Pt.’s representative was notified of each discipline’s providing services (SN and PT) and frequency of visits, prior to providing Pt. care and services. 4. Pt. #6 was admitted for home health services on 12/08/25 with the diagnosis of Hemorrhage of anus and rectum. The clinical record was reviewed on 01/26/26. The admission consent included the service and frequency section. The information was left blank upon record review. The record lacked documentation that the Pt. or Pt.’s representative was notified of each discipline’s providing services (SN and PT) and frequency of visits, prior to providing Pt. care and services. 5. Pt. #9 was admitted for home health services on 04/24/25 with the diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation. The clinical record was reviewed on 01/27/26. The admission consent included the service and frequency section. The information was left blank upon record review. The record lacked documentation that the Pt. or Pt.’s representative was notified of each discipline’s providing services (SN and PT) and frequency of visits, prior to providing Pt. care and services. 6. During staff interview with the Clinical Supervisor on 1/27/26 at 3:30 PM, and on 01/28/26 at 11:00 AM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to Home Health services on 12/17/25 with diagnoses of, but not limited to, Chronic Prostatitis, Unspecified Heart Failure, and Unspecified Chronic Obstructive Pulmonary Disease. A home visit was conducted on 01/27/26 at 1:30 PM with Employee #3. During the home visit, the Agency’s booklet was observed and contained an “Admission Consent” form completed by the RN, with the hand-written signatures of the RN and Pt. The consent form includes a section to indicate the service(s) to be provided and visit frequency for each service. The consent form observed in the patient’s home lacked documentation of the disciplines (SN and PT) to provide service and frequency of the visits. During an interview with the Clinical Supervisor on 01/27/26 at 3:30 PM, the Clinical Supervisor was unable to provide a copy of the consent or locate the consent in the clinical record. On 01/28/25 a 9:30 AM, the Clinical Supervisor presented an “Admission Consent” form that included an electronic entry that Pt. #2 will receive “weekly” SN and PT services, dated 12/17/25. The Agency failed to provide in writing the services to be provided and frequency of visits, before providing services. 2. Pt. #4 was admitted to Home Health services on 11/19/25 with diagnoses of, but not limited to, Essential (Primary) Hypertension, Hemiplegia following Cerebral Infarction Affecting Unspecified Side, and Unsteadiness on feet. A home visit was conducted on 01/27/26 at 10:00 AM with Employee #7. During the home visit, the Agency’s booklet was observed. The booklet contained an “Admission Consent” form completed by the RN, with the hand-written signatures of the RN and Pt. The consent form observed in the patient’s home lacked documentation of the disciplines (SN and PT) to provide service and frequency of the visits. During an interview with the Clinical Supervisor on 01/27/26 at 3:30 PM, the Clinical Supervisor was unable to provide a copy of the consent or locate the consent in the clinical record. On 01/28/25 at 9:30 AM, the Clinical Supervisor presented an “Admission Consent” form that included an electronic entry that Pt. #4 will receive “weekly” SN and PT services, dated 11/19/25. The Agency failed to provide in writing the services to be provided and frequency of visits, before providing services.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of clinical records and staff interviews, in 2 of 10 (Pts. # 2 and 9) clinical records reviewed, the Agency failed to ensure the initial assessments were done within 48 of receiving the referral for home health services. 2. Pt. #9 was admitted for home health services on 04/24/25 with the diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation. The clinical record was reviewed on 01/27/26. The referral for home health services was faxed to agency on 04/19/25 and the Pt was discharged from the hospital on 4/21/25. The record lacked documentation the Agency initiated service within the required time frame. 3. During staff interview with the Clinical Supervisor on 1/27/26 at 3:30 PM, and on 01/28/26 at 11:00 AM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to Home Health services on 12/17/25 with diagnoses of, but not limited to, Chronic Prostatitis, Unspecified Heart Failure, and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 01/26/26. The clinical record contained a referral faxed from the Physician’s office to the Agency on 12/8/25. The record lacked documentation that Pt. #2 was discharged from an inpatient facility. As of 01/26/26, the record lacked a reason for the late SOC.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on a review of clinical records and staff interviews, for 10 of 10 patients (Pts. #1 to 10) the Agency failed to ensure that the Influenza and Pneumococcal Pneumonia assessments were complete. Findings include: 1. The following Pts. were admitted for skilled home health: Pt. #1 SOC 09/03/24 – lacked a completed influenza and pneumonia assessment. Pt. #2 SOC 12/17/25 – lacked a completed influenza and pneumonia assessment. Pt. #3 SOC 12/18/25 – lacked a completed influenza assessment. Pt. #4 SOC 11/19/25 - lacked a completed influenza and pneumonia assessment. Pt. #5 SOC 01/15/26 – lacked a completed influenza and pneumonia assessment. Pt. #6 SOC 12/08/25 – lacked a completed influenza and pneumonia assessment. Pt. #7 SOC 12/03/25 – lacked a completed influenza and pneumonia assessment. Pt. #8 SOC 05/29/25 – lacked a completed pneumonia assessment. Pt. #9 SOC 04/25/25 – lacked a completed influenza and pneumonia assessment. Pt. #10 SOC 11/03/25 – lacked a completed influenza and pneumonia assessment. 2. During an interview with the Clinical Supervisor on 01/27/26 at 3:30 PM and on 01/28/26 at 11:00 AM and 1:00 PM, it was stated that during the start of care, the patient’s Influenza and Pneumococcal Pneumonia vaccination status is assessed, and a completed assessment is documented in the SOC comprehensive assessment. During the same interview, the above finding was confirmed.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on a review of clinical records, and staff interview, in 1 of 3 (Pt. #8) closed clinical records reviewed, the Agency failed to ensure the SN notified the Physician of changes in the patients’ condition and POC. Findings include: 1. Pt. #8 was admitted to Home Health services on 05/29/25 with the diagnosis of, but not, limited to, Primary Generalized (Osteo) Arthritis. The closed clinical record was reviewed on 01/27/26. The closed clinical record contained the POC for the certification period of 05/29/25 to 07/27/25, and documentation the RN provided service 3 times: The SOC (assessment) on 05/29/25, SN visit on 06/05/25, and at Discharge (assessment) on 06/13/25. The SOC assessment form and SN visit note lacked documentation of skin breakdown. The Discharge assessment form included documentation that the Pt. had developed a Stage 2 pressure ulcer to the left lower buttock that measured 0.5 by 0.5 centimeters. The record lacked documentation that prior to the Agency’s discharge, the RN informed the Physician of the Stage 2 pressure ulcer, or of the early discharge (prior to the end of the certification period on 07/27/25). 2. During an interview with the Clinical Supervisor on 01/27/26 at 3:30 PM. the Clinical Supervisor confirmed the above findings.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on a review of clinical records, interviews and observations during home visits, Agency policy review, and staff interviews, in 2 of 4 (Pts. #2, and 4) home visits conducted, the Agency failed to coordinate care to provide service that is needed to meet Pt. needs. Findings include: 1. Pt. #2 was admitted to Home Health services on 12/17/25 with diagnoses of, but not limited to, Chronic Prostatitis, Unspecified Heart Failure, and Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 01/26/26. The clinical record contained the SOC assessment form that included documentation the Pt. lives alone,h experienced shortness of breath when walking more than 20 feet, and that the lung sounds were diminished. A home visit was conducted on 01/27/26 at 1:30 PM with Employee #3. During the home visit, the Pt. stated that the pulmonologist sent him to the emergency room on 01/20/26 because of low blood pressure, the patient’s blood pressure during the home visit was “95/62”. During an interview with the Pt. and Employee #3, the Pt. stated he experiences shortness of breath frequently, and it takes a while to bathe himself. Inquired about Home Health Aide services, the Pt. stated he could benefit from the assistance of a Home Health Aide. Employee #3 stated, “An Aide would be helpful.” As of 01/26/26, the Agency failed to coordinate care to meet the needs of the Pt. 2. Pt. #4 was admitted to Home Health services on 11/19/25 with diagnoses of, but not limited to, Essential (Primary) Hypertension, Hemiplegia following Cerebral Infarction Affecting Unspecified Side, and Unsteadiness on feet. The clinical record was reviewed on 01/26/26 and 01/27/26. The clinical record contained the SOC assessment form that included, the Pt. lives alone with occasional help from family and required assistance of another to shower or bathe. A home visit was made with Employee #7 on 01/27/26 at 10:00 AM. Observed Pt. #4 to have left-sided paralysis and ambulate with rollator walker. During the home visit, an interview was conducted with the Pt. that stated she bathes and dresses herself, but it is very difficult. Asked Pt. #4 whether the nurse offered to provide a Home Health Aide for assistance with personal care. The Pt. responded “No, never offered”. As of 01/26/26, the Agency failed to coordinate care to meet the needs of the Pt. 3. The Agency policy titled; “Coordination of Patient Care” was reviewed on 01/27/26 at 11:00 AM. The policy included, “…2. The Director of Clinical Services makes patient and personnel assignments and provides oversight of all patient care services. Oversight includes… Coordinating patient care. Coordinating referrals. Ensuring that patient needs are continually assessed…” 4. During an interview with the Clinical Supervisor on 01/27/26 at 3:30 PM, the Clinical Supervisor confirmed the Agency failed to coordinate care to provide service that is needed to meet Pt. needs.”

“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 and staff interviews, in 4 of 10 (Pts. #2, 4, 3, and 10) clinical records reviewed, the Agency failed to ensure the comprehensive assessments were accurate. 3. Pt. #3 was admitted for home health services on 12/18/25 with the diagnosis of Hematemesis. On 01/27/26, a home visit conducted with the PT, and the Pt. was interviewed. During the same interview, the Pt. was able to answer appropriately who, where, when and what questions and was able to communicate verbally. The clinical record was reviewed on 01/27/26 and included the initial comprehensive assessment completed by the RN at SOC. The SOC assessment included the following documentation: “A1110: A. What is your preferred language? English… B. Do you need an interpreter to communicate with a doctor or health care staff? No… C0100: Should Brief Interview for Mental Status (C0200-C0500) be conducted? No (Patient is rarely/never understood).” C0200 through C0500 is left blank. The same assessment also indicated the Pt is alert and orient to person, place and time. The SOC assessment was inaccurate. 4. Pt. #10 was admitted for home health services on 12/18/25 with the diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 01/27/26 and included the initial comprehensive assessment completed by the RN at SOC. The SOC assessment included the following documentation: “A1110: A. What is your preferred language? English… B. Do you need an interpreter to communicate with a doctor or health care staff? No… C0100: Should Brief Interview for Mental Status (C0200-C0500) be conducted? No (Patient is rarely/never understood).” C0200 through C0500 is left blank. The same SOC assessment also indicated the Pt. is alert and oriented to person, place and time. The PT and OT Evaluation notes indicates that Pt. #10 is alert and oriented and able to communicate verbally. The SOC assessment was inaccurate. 5. During interviews with the Clinical Supervisor on 01/28/26 at 1:00 PM and 1:50 PM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to Home Health services on 12/17/25 with diagnoses of, but not limited to, Chronic Prostatitis, Unspecified Heart Failure, and Unspecified Chronic Obstructive Pulmonary Disease. A home visit was conducted on 01/27/26 at 10:00 AM with Employee #3. During the home visit, observed the Pt. to follow all requests made by Employee #3. During an interview with Pt. #2, the Pt. was alert and oriented, able to answer questions without hesitation. The clinical record was reviewed on 01/26/26. The clinical record contained the SOC assessment form completed by the RN and dated 12/17/25. The assessment form required the RN to conduct a brief interview for mental status. The RN responded “No” that the interview was not conducted, due to “patient is rarely/never understood”. The same assessment form included the Pt. was alert and oriented to person, place, time, and situation. The SOC assessment form was inaccurate. 2. Pt. #4 was admitted to Home Health services on 11/19/25 with diagnoses of, but not limited to, Essential (Primary) Hypertension, Hemiplegia following Cerebral Infarction Affecting Unspecified Side, and Unsteadiness on feet. A home visit was conducted on 01/27/26 at 1:30 PM with Employee #3. During the home visit, observed the Pt. to follow all requests made by Employee #7. During an interview with Pt. #4, the Pt. was alert and oriented, answered all questions without hesitation. The clinical record was reviewed on 01/26/26. The clinical record contained the SOC assessment form completed by the RN and dated 11/19/25. The assessment form required the RN to conduct a brief interview for mental status. The RN responded “No” that the interview was not conducted, due to “patient is rarely/never understood”. The same assessment form included documentation that Pt. #4 was alert and oriented to person, place, time, and situation. The SOC assessment form was inaccurate.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on home visit observations, clinical records review, policy review, patient and staff interviews in 2 of 4 home visits (Pts # 1 and 3) the Agency failed to ensure that patient medication profile included all medications that the patient is currently taking. Findings include: 1. Pt. #1 was admitted to home health services on 09/01/24 with diagnosis of Acute systolic (congestive) heart failure. A skilled nurse home visit was conducted on 01/27/26. During the home visit an interview was conducted with Pt.#1 and agency’s SN. During the interview the patient stated that “some of the medications were changed on the last visit to the doctor”. The clinical record of Pt #1 was reviewed on 01/27/26. The clinical record included a Medication Profile for episode period of 01/23/26 to 03/23/26 the medication profile did not include Valsartan, Carvedilol, Clopidogrel, Furosemide, and Ezetimibe. No modification physician orders were found in the record. Findings include: 1. Pt. #1 was admitted to home health services on 09/01/24 with diagnosis of Acute systolic (congestive) heart failure. A skilled nurse home visit was conducted on 01/27/26. During the home visit an interview was conducted with Pt.#1 and agency’s SN. During the interview the patient stated that “some of the medications were changed on the last visit to the doctor”. The clinical record of Pt #1 was reviewed on 01/27/26. The clinical record included a Medication Profile for episode period of 01/23/26 to 03/23/26 the medication profile did not include Valsartan, Carvedilol, Clopidogrel, Furosemide, and Ezetimibe. No modification physician orders were found in the record. 2. Pt. #3 was admitted for home health services on 12/18/25 with the diagnosis of Hematemesis. On 01/26/26, an interview with the Clinical Supervisor conducted and it was confirmed that the medications listed on the POC were the current medications the Pt. was taking. During a home visit conducted with the PT on 01/27/26, Pt. #3’s caregiver presented medications that were currently taken by Pt. #3. The clinical record was reviewed on 01/28/26. The clinical record lacked documentation of the following medications found during the home visit: Ferrous Sulfate 325 mg, 1 tablet every other day, date refilled 01/08/26, Spironolactone 25 mg, ½ tablet once daily, date refilled 01/20/26, Metoprolol 50 mg, 1 tablet once daily, refilled 01/05/26. The clinical record did not include modification of Physician order 3. The Agency Policy titled “Medication Reconciliation” was reviewed on 01/28/26 and required, “2. Medications ordered while patient is receiving care will be compared to the medication list profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 4. During interviews with the Clinical supervisor on 01/28/26 at 11:00 AM and at 1:00 PM, the above findings were confirmed.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records and staff interview, for 2 of 7 (Pts. #8 and 9) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. Findings include: 2. Pt. #9 was admitted for home health services on 04/24/25 with the diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation. The clinical record was reviewed on 01/27/26. The record included the discharge summary completed by the SN dated 06/19/25. The record lacked documentation that a copy of the summary was sent to the Physician. 3. During staff interview with the Clinical Supervisor on 1/27/26 at 3:30 PM, and on 01/28/26 at 11:00 AM, the above findings were confirmed. Findings include: 1. Pt. #8 was admitted to Home Health services on 05/29/25 with the diagnosis of, but not, limited to, Primary Generalized (Osteo) Arthritis. The closed clinical record was reviewed on 01/27/26. The closed clinical record contained the Discharge Summary dated 06/13/25. As of 01/27/26, the record/Agency lacked documentation a copy of the summary was sent to the Physician.”