Apex Home Health Care, Inc.

“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, the Agency failed to ensure that staff participated in the required testing of its Emergency Preparedness Plan. Findings include: 1. The Emergency Preparedness Plan was reviewed on 09/17/25. The Emergency Preparedness Plan included the following documentation: Full Scale Exercise for Cyber Menace dated 03/22/23 Table top Exercise for Continuity of Operations Plan dated 08/14/24 Full Scale Exercise for Continuity of Operations Plan dated 05/28/25 These exercises lacked documentation that the following Employees participated in Emergency Preparedness testing for 2023, 2024 and or 2025: Employee #1 (Registered Nurse/Date of Hire 01/01/12) Employee #2 (Registered Nurse/Date of Hire 11/06/24) Employee #3 (Registered Nurse/Date of Hire 01/01/12) Employee #4 (Licensed Practical Nurse/Date of Hire 08/26/24) Employee #5 (Home Health Aide/Date of Hire 12/18/16) Employee #6 (Home Health Aide/Date of Hire 09/15/17) Employee #7 (Physical Therapist/Date of Hire 08/23/24) 2. During an interview with the Administrator and Director of Nursing on 09/17/25 at 3:05 PM, the Administrative Team confirmed the above findings.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined, in the last 12 months, the Agency failed to submit 206 of 790 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 08/01/24 to 07/31/25 was reviewed on 09/17/25. The report included error # -3330 for 206 of 790 late submissions and 26.08 % of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and Director of Nursing on 09/18/25 at 9:05 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, observation during a home visit, and staff interviews, it was determined in 5 of 10 (Pts. # 7, 8, 2, 5, and 9) clinical records reviewed, the Agency failed to ensure the staff provided services as ordered on the PsOC and written order. Findings include: 1. Pt. #7 was admitted to home health services on 06/11/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus with Foot Ulcer. The clinical record was reviewed on 09/16/25. The clinical record included a wound care order for the left 2nd toe/left heel dated 07/10/25 and time stamped by fax on 07/11/25 at 10:20.The wound order stated to cleanse with saline, apply Medi-honey, and bordered gauze. On the 07/16/25, 07/23/25, and 07/30/25 SN notes, the SN documented, “Wound care: Cleanse wound with saline, pat dry, apply xeroform to wound surface, cover with gauze and anchor with kerlix and tape.” The SN failed to follow wound care orders. 2. Pt. #8 was admitted to home health services on 06/10/24 with the diagnoses of, but not limited to, Displaced Trimalleolar Fracture of the Right Lower Leg, Type 2 Diabetes Mellitus without Complications, Bladder Disorder Unspecified, Long Term (Current) Use of Insulin, and Dependence on Supplemental Oxygen. The clinical record was reviewed on 09/16/25. The clinical record included the closed record for the certification period of 08/09/24 to 10/07/24. The POC included Physical Therapy frequency and duration as once per week for eight weeks starting 08/14/24. The POC included, “Per physician orders, care of incision is as follows: Referral to SN.” The clinical record lacked SN notes from SOC on 06/10/24 until the Pts. discharge from the agency on 10/04/25. The Agency failed to follow Physician orders by providing the Pt. a SN referral. The POC for the certification period of 08/09/24 to 10/07/24 included “Orders For Discipline and Treatment,” stating the Physician to be notified for vital signs out of range and these vital signs include blood sugars. During the certification period of 08/09/24 to 10/07/24 the blood sugar was not recorded in the clinical record during any Physical Therapy visit. The Agency failed to ensure the blood sugars were monitored and reported as ordered. The POC for the certification period of 08/09/24 to 10/07/24 included “Orders For Discipline and Treatment,” stating “PT to assess integumentary status...report any significant changes to physician...PT to assess surgical site for healing/complications; teach patient/caregiver care of incision to prevent infection.” During the certification period of 08/09/24 to 10/07/24 the clinical record lacked documentation of the patient’s integumentary status, and lacked patient/caregiver education related to incision care. 3. Pt. # 2 was admitted to home health services on 08/25/25 with diagnoses of Pressure Ulcer Buttocks, Stage 2 and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 08/25/25to 10/23/25 that included: “….SN to assess/monitor weights and edema QV or Q week. SN to notify physician/provider of weight gain of 2 lbs/1 day; 5 lbs/1week….” The Skilled Nursing notes dated 09/03/25 and 09/10/25 lacked weight assessments as ordered. A home visit was conducted with Employee #1 (Registered Nurse) on 09/16/25 at 10:00 AM and did not perform a weight assessment as ordered. 4. Pt. # 5 was admitted to home health services on 04/14/25 with diagnosis of Hypertensive Chronic Kidney disease with stage 1-4 unspecified chronic kidney. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 08/12/25 to 10/10/25, that included: “….SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function….” The following Skilled Nursing notes dated 08/22/25, 08/29/25, 09/05/25 and 09/12/25, lacked weight assessments, as ordered. During an interview with the Director of Nursing on 09/17/25 at 3:05 PM, it was stated that weights are part of a cardiovascular assessment. 5. Pt. #9 was admitted to Home Health Services on 12/10/24 with diagnosis of Hereditary Ataxia, Unspecified. The clinical record was reviewed on 09/16/25. The clinical record included a PsOC effective 12/10/24 to 02/07/25 and 02/08/25 to 04/08/25, that included: “….Orders for Discipline and Treatment….Notify Physician of vital sign parameters out of range:….Heart Rate….Temperature….Respirations….Pain level….O2 Saturation….Systolic Blood Pressure….Diastolic Blood Pressure….” The Skilled Nursing assessment dated 02/04/25, lacked vital signs assessment to report to the Physician, as ordered. 6. During interviews with the Administrator and Director of Nursing on 09/16/25 at 2:50 PM and on 09/17/25 at 3:05 PM, the Administrative team confirmed the above findings.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observations during home visits, review of clinical records, and staff interviews, in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 09/15/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 09/15/25, 09/16/25, and 09/17/25. Pt. #1. SOC 06/24/25 Pt. #2. SOC 08/25/25 Pt. #3. SOC 03/07/25 Pt. #4. SOC 04/27/25 During the home visits, the Pt. admission folder was observed, and lacked the name and contact information of the Administrator. 3. The clinical records of the following Pts. were reviewed from 9/15/25 to 9/16/25: Pt. #1 SOC: 06/24/25 Pt. #2 SOC: 08/25/25 Pt. #3 SOC: 03/07/25 Pt. #4 SOC: 04/27/25 Pt. #5 SOC: 04/14/25 Pt. #6 SOC: 07/16/25 Pt. #7 SOC: 06/11/25 Pt. #8 SOC: 06/10/24 Pt. #9 SOC: 12/10/24 Pt. # 10 SOC: 11/29/2 The clinical records reviewed lacked documentation that the Pt./patient’s representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During an interview with the Administrator and Director of Nursing (DON) on 09/17/25 at 12:45 PM, the administrative team confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator’s name and contact information.”

“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 review of Agency’s Pt. Admission folder, clinical record review, observation during home visits, and staff interviews, the Agency failed to ensure that the Pt. / representative was informed in writing of the services to be provided and the frequency of visits for 10 of 10 (Pts. # 1,2 ,3, 4, 5, 6, 7, 8, 9, and 10) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 09/15/25 and included a form titled: “Admission and Consent Agreement” which lacks spaces to document discipline frequencies. 2. The following clinical records were reviewed from 09/15/25 to 09/16/25 and lacked documentation of the service(s) to be provided and visit frequencies. Pt. #1 SOC: 06/24/25. Received SN and PT services. Pt. #2 SOC: 08/25/25. Received SN and PT services. Pt. #3 SOC: 03/07/25. Received SN, PT and HHA services. Pt. #4 SOC: 04/27/25. Received SN and PT services. Pt. #5 SOC: 04/14/25. Received SN, PT, OT, and HHA services. Pt. #6 SOC: 07/16/25. Received SN, and PT services. Pt. #7 SOC: 06/11/25. Received SN services. Pt. #8 SOC: 06/10/24. Received PT services. Pt. #9 SOC: 12/10/24. Received SN, PT, and HHA services. Pt. # 10 SOC: 11/29/24. Received SN, PT, OT services. 3. The following home visits were conducted on 09/15/25, 09/16/25, and 9/17/25: Pt. #1. SOC 06/24/25 Pt. #2. SOC 08/25/25 Pt. #3. SOC 03/07/25 Pt. #4. SOC 04/27/25 During the home visits, the Pt. admission folders were observed, including the “Admission and Consent Agreement” form and lacked documentation indicating the Pt. / representative was notified of the discipline (s) to provide service, and the frequency of visits in writing. 4. During interview with the Administrator and the Director of Nursing on 09/17/25 at 1:45 PM, the Administrative staff confirmed the above findings.”

“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 record review and Staff interview, the Agency failed to ensure the initial assessment was done within 48 hours upon receipt of a referral for 4 of 7 (Pts.#2, 5, 3 and 7) clinical records reviewed. Findings include: 1. Pt. # 2 was admitted to Home Health Services on 08/25/25 with diagnoses of Pressure Ulcer Buttocks, Stage 2 and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/16/25. The clinical record included a fax cover sheet and Physician progress notes with orders for Home Health to the Agency, dated 08/22/25. The clinical record included a SOC assessment dated 08/25/25, indicating service was initiated. The record lacked documentation that the Agency initiated service within 48 hours after receipt of the referral. 2. Pt. # 5 was admitted to Home Health Services on 04/14/25 with diagnosis of Hypertensive Chronic Kidney disease with stage 1-4 unspecified chronic kidney. The clinical record was reviewed on 09/16/25. The clinical record included a facility discharge orders for home health dated 04/11/25. The clinical record included a SOC assessment dated 04/14/25, indicating service was initiated. The record lacked documentation that the Agency initiated service within 48 hours after receipt of the referral. 3. Pt. #3 was admitted to home health services on 03/07/25 with diagnosis of “Hypertensive Heart disease with Heart failure.” The clinical record was reviewed on 09/16/25. The Face-to Face was completed by Physician on 02/20/25 and faxed to Agency on 03/03/25. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 09/18/25, the record lacked documentation the Agency initiated service within the required time frame.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on a review of clinical records and staff interviews, the Agency failed to ensure the PsOC included Pt. specific interventions for 4 of 10 (Pts. #5, 6, 1 and 8) clinical records reviewed. Findings include: 1. Pt. # 5 was admitted to home health services on 04/14/25 with diagnosis of Hypertensive Chronic Kidney disease with stage 1-4 unspecified chronic kidney. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 08/12/25 that included: “….SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function….” The POC lacked Pt. specific interventions to include weight parameters, indicated for Pt.#5’s diagnosis. 2. Pt. #6 was admitted to home health services on 07/16/25 with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer, End stage renal disease and Dependence on Renal Dialysis. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 07/16/25, a resumption POC effective 08/29/25 and recertification POC effective 09/14/25, that lacked Pt. specific interventions to include Dialysis access site care and management. Findings include: 1. Pt. # 5 was admitted to home health services on 04/14/25 with diagnosis of Hypertensive Chronic Kidney disease with stage 1-4 unspecified chronic kidney. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 08/12/25 that included: “….SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function….” The POC lacked Pt. specific interventions to include weight parameters, indicated for Pt.#5’s diagnosis. 2. Pt. #6 was admitted to home health services on 07/16/25 with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer, End stage renal disease and Dependence on Renal Dialysis. The clinical record was reviewed on 09/16/25. The clinical record included a POC effective 07/16/25, a resumption POC effective 08/29/25 and recertification POC effective 09/14/25, that lacked Pt. specific interventions to include Dialysis access site care and management. 3. Pt. #1 was admitted to home health services on 06/24/25 with the diagnoses of, but not limited to, Pressure Ulcer of Right Buttock Stage 3, Unspecified Severe Protein-Calorie Malnutrition, Hypertensive Heart Disease with Heart Failure, Unspecified Atrial Fibrillation, Presence of Prosthetic Heart Valve, Encounter for Therapeutic Drug Level Monitoring, and Acute Combined Systolic and Diastolic Congestive Heart Failure. A home visit was performed with the patient, a family member, and PT on 09/15/25 at 11:30 AM. During an interview with the Pt. and a family member, it was stated that during the patient’s last hospital stay, before the Pt. was re-admitted to the Agency on 08/11/25, her weight decreased from “115 pounds to 93 pounds, but now she is 95 pounds.” The family member was asked how the patient eats now to prevent further weight loss and promote wound healing, the family stated, “I try the best I can. She wanted pancakes and I found some high protein pancakes.” The clinical record was reviewed on 09/15/25 and 09/16/25. The clinical record included the POC for the certification period of 08/23/25 to 10/21/25. The record included a baseline weight of 103 pounds on 07/15/25 before the patient’s discharge to the hospital on 07/22/25. The SN notes included the following weights: 08/14/25- 97 pounds, 08/25/25- 91 pounds, 09/02/25-93 pounds, and 09/08/25-95 pounds. The SN notes included the Nutrition assessment “Weight Loss... Comment recent weight loss” on the following dates: 08/14/25, 09/02/25, and 09/08/25. The POC “Orders For Discipline and Treatment” lacked weight assessment orders and out-of-range weight perimeters to inform to the Physician. The Agency failed to ensure the POC included Pt. specific interventions. During the home visit, the family member stated that the Pt. has a “home INR machine” due to her qualifying diagnoses. On 07/15/25, the SN note documentation for Endocrine/Hematologic assessment comment section states, “Warfarin now on hold. Last INR 5.3 with new home INR machine done yesterday.” The “home INR machine” is documented in the SN note Endocrine/Hematologic assessment comment section on 08/14/25, 09/02/25, and 09/08/25. The POC does not include orders for the use and care of the home INR machine, orders for INR labs, documentation instructions, Pt./family teaching, and perimeters for informing MD when INR is out of range. During an interview with the Administrator and Director of Nursing on 09/16/25 at 02:50 PM, the Director of Nursing stated she was unaware the Pt. had a home INR machine. The Agency failed to ensure the POC included Pt. specific interventions and education. 4. Pt. #8 was admitted to home health services on 06/10/24 with the diagnoses of, but not limited to, Displaced Trimalleolar Fracture of the Right Lower Leg, Type 2 Diabetes Mellitus without Complications, Bladder Disorder Unspecified, Long Term (Current) Use of Insulin, and Dependence on Supplemental Oxygen. The clinical record was reviewed on 09/16/25. The clinical record included the POC for the certification period of 08/09/24 to 10/07/24. The POC lacked a respiratory diagnosis to support the diagnosis of Dependence on Supplemental Oxygen. The Agency failed to ensure all applicable diagnoses were listed on the POC. On 09/10/24, the PTA documented, the PT. had a “L arm dialysis site procedure” and on 09/24/24, the PTA documented, “pt stated she had additional dialysis today.” The POC lacked a renal diagnosis to support the Pt. receiving dialysis, and lacked care and precautions for the hemodialysis catheter/site. The Agency failed to ensure all applicable renal diagnoses, education, care, and precautions were listed on the POC. On 08/22/24, the PTA documented, “talked to pt’s son, who stated that his mom can’t get cortisone injection for knee pain because of the wounds that are not healed yet.” The POC and clinical record lacked wound care orders and wound documentation. The Agency failed to ensure all treatments are on the POC. The POC for the certification period of 08/09/24 to 10/07/24 Included the medications Hydrocodone-Acetaminophen and Acetaminophen for pain. The PTA documented on 08/14/24 the pain level prior to therapy was 8/10 and after therapy was 8/10, on 08/22/24 the pain level prior to therapy was 7/10 and after therapy was 8/10, 08/27/24 the pain level prior to therapy was 7/10 and after therapy was 7/10, 08/27/24 PTA Assessment “Pt ...stated that it is usually 10/10,” and 09/10/24 the pain level prior to therapy was 7/10 and after therapy was 8/10. The POC “Orders For Discipline and Treatment” lacked pain perimeters and when to inform the Physician when this vital sign is out of range. The Agency failed to ensure the POC included Pt. specific interventions. 5. During interviews with the Administrator and Director of Nursing on 09/16/25 at 02:50 PM and 09/17/25 at 02:05 PM, the above findings were confirmed.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 2 of 10 (Pts. #1 and 8) clinical records reviewed, the Agency failed to ensure all aspects of patient care are communicated and coordinated with all disciplines. Findings include: 1.Pt. #1 was admitted to home health services on 06/24/25 with the diagnoses of, but not limited to, Pressure Ulcer of Right Buttock Stage 3, Unspecified Severe Protein-Calorie Malnutrition, Hypertensive Heart Disease with Heart Failure, Unspecified Atrial Fibrillation, Presence of Prosthetic Heart Valve, Encounter for Therapeutic Drug Level Monitoring, and Acute Combined Systolic and Diastolic Congestive Heart Failure. The clinical record was reviewed on 09/15/25 and 09/16/25. The clinical record included the POC for the certification period of 08/23/25 to 10/21/25. The POC Nutritional Requirements listed “Heart Healthy” and clinical record included SN notes documenting recent weight loss. The clinical records lacked Pt./caregiver education regarding nutrition and lacked communication with the Physician regarding weight loss. The Agency failed to coordinate the patient’s care with the Physician. 2. Pt. #8 was admitted to home health services on 06/10/24 with the diagnoses of, but not limited to, Displaced Trimalleolar Fracture of the Right Lower Leg, Type 2 Diabetes Mellitus without Complications, Bladder Disorder Unspecified, Long Term (Current) Use of Insulin, and Dependence on Supplemental Oxygen. The clinical record was reviewed on 09/16/25. The clinical record included the POC for the certification period of 08/09/24 to 10/07/24. On 09/10/24, the PTA documented, “pt stated she just got back from MD appointment and feels tired. She had general anesthesia for L arm dialysis site procedure” and “pt instr. in seated...with Yellow T-band and 1.5 lb cuff wts including B UE rowing biceps/triceps curls.” On 09/17/24, the PTA documented, “knee pain seems to be worse since she started having medical procedures on her legs...Pt required frequent rest periods due to fatigue, pain, and c/o dizziness...Pt requires increased physical assistance during sit to stand...displays decreased ambulation distance...pt’s son states that his mother will have one more vein procedure on R LE to clean up the obstruction.” The clinical record lacked documented communication with the Physician regarding Physical Therapy orders post procedures and lacked documented communication between the PTA and PT regarding patient’s change in condition. The Agency failed to ensure the staff are communicating with each other and the Physician. 3. During an interview with the Administrator and Director of Nursing on 09/16/25 at 02:50 PM, the above findings were confirmed.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation during home visits, clinical record reviews and staff interviews, the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor (Director of Nursing) and their contact information in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 09/15/25. The folder lacked the name and information to contact the Agency Supervisor. 2. The following home visits were conducted on 09/15/25, 09/16/25, and 09/17/25. Pt. #1. SOC 06/24/25 Pt. #2. SOC 08/25/25 Pt. #3. SOC 03/07/25 Pt. #4. SOC 04/27/25 During the home visits, the Pt. admission folder was observed, and lacked documentation of the Agency’s Agency Supervisor/Director of Nursing. 3. The clinical records of the following Pts. were reviewed from 9/15/25 to 9/16/25: Pt. #1 SOC: 06/24/25 Pt. #2 SOC: 08/25/25 Pt. #3 SOC: 03/07/25 Pt. #4 SOC: 04/27/25 Pt. #5 SOC: 04/14/25 Pt. #6 SOC: 07/16/25 Pt. #7 SOC: 06/11/25 Pt. #8 SOC: 06/10/24 Pt. #9 SOC: 12/10/24 Pt. # 10 SOC: 11/29/24 The clinical records reviewed lacked information identifying the Director of Nursing/Agency Supervisor name and contact information. 4. During a staff interview with the Administrator and Director of Nursing, on 09/17/25 at 12:45 PM, it was confirmed the same admission folder is given to all Pts. The administrative staff confirmed the Agency failed to identify the Director of Nursing/Agency Supervisor name.”

“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 a review of clinical records and staff interview, the Agency failed to ensure a discharge summary was sent to the Physician for 1 of 3 (Pt. # 9) discharged records reviewed. Findings include: 1. Pt. #9 was admitted to home health services on 12/10/24 with a diagnosis of Hereditary Ataxia, Unspecified. The clinical record was reviewed on 09/16/25. The clinical record included a Discharge Summary, electronically signed 09/15/25, and the last visit date of 04/05/25. The clinical record lacked timely documentation that the discharge summary was sent to the Physician. 2. During an interview with the Administrator and Director of Nursing on 09/17/25 at 3:05 PM, the Administrative staff confirmed the above findings.”

“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 the clinical records review, policy review and staff interview, it was determined in 2 of 4 (Pts. #1 and 2 ) records reviewed, the Agency failed to provide services ordered by the physician in the plan of care. Findings include: 1. Patient #1 was admitted to Home Health Services on 02/28/24 with the diagnoses of Unspecified Dementia, Mild without Behavior/Psych/Mood and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/28/24. The clinical record contained a POC dated 02/28/24 that required PT service 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 6 weeks. The clinical record lacked a PT visit for week #2, week #5 and week #6. No modification orders were documented in the clinical record. 2. Patient #2 was admitted to the Home Health Services on 11/17/23 with the Diagnosis of: Radiculopathy, Cervical Region. The clinical record was reviewed on 05/28/24. The clinical record contained a POC dated 01/16/24, that required PT services 1 times a week for 6 weeks. The clinical record lacked the PT visit for week #5. 3. The Agency’s policy titled “Missed Visits” was reviewed on 05/28/24 at 1:00 PM. The policy required “…PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician…ordered frequency is maintained…” 3. The above findings were confirmed during an interview with the Administrator, on 05/28/24 between 11:45 AM and 12:30 PM.”