Lincoln Home Health Care, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biennially. 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 03/16/26 at 1:00 PM. The plan and policies lacked documentation of Agency review/revised dates. 2. During an interview conducted with the Administrator on 03/18/26 at 10:30 AM, the above finding was confirmed.”

“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 Program and Plan, and staff interview, the Agency failed to ensure that full -scale facility or community-based exercises were conducted as required, to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. This has the potential to affect Pts. receiving services at the Agency. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 03/17/26 at 1:00 PM. The plan lacked documentation of full-scale facility/community- based, or tabletop exercises for the years 2023, 2024 and 2025. 2. During an interview conducted with the Administrator on 03/18/26 at 10:30 AM, the above finding was 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 that in 378 of 940 reports submitted for the last 12 months, the Agency failed to submit the report within 30 days after the assessment was completed resulting in a warning. Findings include: 1. The OASIS Error Summary report for 01/01/25 to 03/03/26 was reviewed on 03/18/26. The report included a warning for the error: 378 of the 940 assessments were submitted late; 40.21 % of the OASIS reports were submitted more than 30 days after the assessment was completed. 2. During staff interview with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, the above findings were confirmed.”

“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 review of clinical records and staff interviews, for 4 of 7 (Pts. #1, 2, 4, and 7) the Agency failed to ensure the POC was followed. 4. Pt. #7 was admitted to home health services on 07/23/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/17/26 and included the POC for the certification period of 07/23/25 to 09/20/25. The POC required, “Orders and Treatments… SN: 1wk 1 ,. PT: Eval and treat ,. The PT failed to visit/ assess the patient upon admission for treatment. 5. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 06/12/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 03/17/26. The clinical record included a referral from the Physician dated 06/10/25 which contained orders for “PT/OT/ST/MSW.” The clinical record lacked documentation of a Speech Therapy evaluation or visit. 2. Pt. #2 was admitted to home health services on 11/07/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/18/26. The clinical record included a referral from the Physician dated 11/02/25 which contained orders for “PT/OT.” The clinical record lacked documentation of an Occupational Therapy evaluation or visit. 3. Pt. #4 was admitted to home health services on 09/20/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/17/26. The clinical record included a referral from the Physician dated 09/18/25 which contained orders for “PT/OT.” The clinical record lacked documentation of an Occupational Therapy evaluation or visit. 4. Pt. #7 was admitted to home health services on 07/23/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/17/26 and included the POC for the certification period of 07/23/25 to 09/20/25. The POC required, “Orders and Treatments… SN: 1wk 1 ,. PT: Eval and treat ,. The PT failed to visit/ assess the patient upon admission for treatment. 5. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record reviews, policy review and staff interviews, for 5 of 7 (Pts. # 2, 4, 3, 5 and 7) record reviews, the Agency failed to ensure that medical record forms were accurate and complete. 3. Pt. #3 was admitted to home health services on 09/24/25 with the diagnosis of Essential (primary) hypertension. The clinical record was reviewed on 03/16/26 and included the “Beneficiary Elected Transfer” document signed by the Pt. upon admission and the name of the previous health agency was left blank. 4. Pt. #5 was admitted to home health services on 12/04/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/16/26 and included a “Notice of Medicare Non-Coverage” document, which was signed by the Pt. on 12/04/25, the date of admission. The date when the current Home Health services will end was left blank. The “Beneficiary Elected transfer” document was signed by the Pt. upon admission and the name of the previous health agency was left blank. 5. Pt. #7 was admitted to home health services on 07/23/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/17/26 and included a “Notice of Medicare Non-Coverage” document, which was signed by the Pt. on 07/23/25, the date of admission. The date when the current Home Health services will end was left blank. The form “Beneficiary Elected transfer” was signed by the Pt. upon admission and the previous health agency name was left blank. 6. The Agency policy titled, “Clinical Records: was reviewed on 03/19/26 and required, “3. All entries in the record must be legible and accurate… 5. The clinical record is reviewed for completeness…” 7. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services on 11/07/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/18/26. The clinical record included the form “Notice of Medicare Non-Coverage.” The forms were signed by the Pt. on 11/07/25, but the areas containing “Effective Date of Coverage your current home health services will end” was left blank. The form “Beneficiary Elect transfer” was also signed by the Pt. at SOC, but the area containing name of the previous home health agency was left blank. 2. Pt. #4 was admitted to home health services on 09/20/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/17/26. The clinical record included the form “Notice of Medicare Non-Coverage.” The forms were signed by the Pt. on 09/20/25, but the areas containing “Effective Date of Coverage your current home health services will end” was left blank.”

“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 clinical records, and staff interviews, in 3 of 7 (Pts. #3, 6, and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and/or the frequency of visits provided by each discipline. Findings include: 1. The following clinical records were reviewed 03/16/7/26 and 03/17/26. Pt. #3. SOC 09/24/25. Pt. received SN services. Pt. #6. SOC 12/16/24. Pt. received SN, HHA, PT, OT and ST services. Pt. #7. SOC 4/14/24. Pt. received SN and PT services. The records lacked documentation that the Pt. or legal guardian was notified in writing of the services to be provided and the frequency. 2. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, the above findings were confirmed.”

“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 clinical record review and staff interviews, for 3 of 7 (Pts. #2, 5 and 6) clinical records reviewed, the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for home health care services. 2. Pt. #5 was admitted to home health services on 12/04/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/16/26. The referral for home health services signed by Physician on 12/01/25 and received by Agency on the same date documents: “Referral order, order name Skilled nursing referral, Occupational Therapist referral and Physical Therapist referral.” As of 03/19/26. The record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #6 was admitted to home health services on 12/16/24 with the diagnoses of Intracranial abscess and granuloma and Dysphagia. The clinical record was reviewed on 03/17/26. Pt. was discharged from an inpatient facility on 12/13/25 with Home Health orders for PT, OT, RN, ST, HHA. As of 03/19/26, the record lacked documentation, the Agency initiated service within the required time frame. 4. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed. 1. Pt. #2 was admitted to home health services on 11/07/26 with the diagnosis of Polyosteoathritis. The clinical record was reviewed on 03/18/26. The record contained a referral document faxed on from the physician’s office dated 11/02/25. The SOC initial assessment was conducted by the RN on 11/07/25. The record lacked a Physician ordered SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date.”

“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 observation and interview during home visit, clinical records reviews and staff interviews, in 4 of 7 (Pts. #1, 2, 4 and 6) clinical records reviewed, the PsOC did not include all the requirements. 4. Pt. #6 was admitted to home health services on 12/16/24 with the diagnoses of Intracranial abscess and granuloma and Dysphagia. The clinical record was reviewed on 03/17/26. The record included the POC for the certification period of 06/14/25 to 08/12/25 that required SN to assess the patient 1 time per week for 9 weeks. The POC lacked the orders for the Gastrostomy tube site care management. 5. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 06/12/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 03/17/26. A home visit on 03/18/26 was conducted with the HHA. During the home visit, it was observed that Pt. #1 had a suprapubic catheter attached to a urine bag. The POC effective 02/07/26 lacked documentation of the frequency of changing the suprapubic catheter and the equipment/supplies used for its care and maintenance. 2. Pt. #2 was admitted to home health services on 11/07/25 with the diagnosis of Polyosteoarthritis. During a home visit conducted with the Physical Therapy Assistant on 03/17/26, a review of the patient’s medications was conducted; a vial of cyanocobalamin 1000 mcg per ml and a bottle of “Myrbetric” were observed at the home. The patient’s family stated that these medications have been taken since at least January 2026. The clinical record was reviewed on 03/18/26. The record included the documentation on Skilled Nurse visit notes dated 01/13/26, “SN administered Vit (Vitamin) B 12 injection of Left Shoulder. Patient tolerated the procedure well.” The POC effective 03/07/26 lacked a complete list of the patient’s medications. 3. Pt. #4 was admitted to home health services on 09/20/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/17/26. The SN notes included documentation that the Pt. was on oxygen therapy. The POC effective 01/18/26 lacked documentation of dose, route and supplies used for oxygen therapy, care and maintenance.”

“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 clinical records review, Agency’s Pt. admission booklet review and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the name and contact information of the Agency Supervisor to the patient and / or representative on admission. Findings include: 1.The admission booklet was reviewed on 03/16/26. The booklet lacked documentation of the Agency Supervisor’s name and contact information. 2. The following patient clinical records were reviewed between 03/17/26 and 03/18/26. The clinical records lacked documentation that the patient or representative were notified of the Agency Supervisor’s name and contact information. Pt. #1 SOC 06/12/25 Pt. #2 SOC 11/07/25 Pt. #3 SOC 09/24/25 Pt. #4 SOC 09/20/25 Pt. #5 SOC 12/04/25 Pt. #6 SOC 12/16/24 Pt. #7 SOC 07/23/25 3. During a staff interview with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:30 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation and interviews during a home visit, clinical record review, and staff interview, it was determined for 4 of 4 (Pt. #1, 4, 5 and 6) clinical records reviewed, wherein the Pt. received HHA services, the Agency failed to ensure the Home HHA followed the plan directed on the Aide Care Plan. 3. Pt. #5 was admitted to home health services on 12/04/25 with the diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 03/16/26. The record included the POC for the certification period of 02/02/26 to 04/02/26 that included an Aide Care Plan that required the HHA to provide the patient a “Partial bath/Sponge every visit.” The HHA visit notes from 01/11/26 to 03/14/26 document “Partial Bath/Sponge every visit.” The record lacked an individualized Aide Care Plan that was based on the assessment of the SN. 4. Pt. #6 was admitted to home health services on 12/16/24 with the diagnoses of Intracranial abscess and granuloma and Dysphagia. The clinical record was reviewed on 03/17/26. The record included the POC for the certification period of 06/14/25 to 08/12/25 that included an Aide Care Plan that required the HHA to provide the patient a “Complete bath every visit and a Shower every visit or as needed.” The record lacked an individualized Aide Care Plan that was based on the assessment of the SN. 5. During staff interviews with the Administrator and Agency Supervisor (Director of Nursing) on 03/18/26 at 3:00 PM, and 4:30 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 06/12/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. During the home visit conducted with the HHA on 03/17/26, it was stated that Pt. #1 is assisted to walk to the bathroom, assisted to sit on a shower chair and a shower is provided by the HHA and family member. During the same home visit the HHA showed the bathroom and the shower chair that Pt. #1 used. The clinical record was reviewed on 03/17/26. The record contained the “Aide Care Plan” completed by the RN and dated 02/07/26. The Plan required the HHA to provide the following personal care every visit: “Complete Bath.” The HHA notes also included documentation that the HHA provided showers on 02/16/26, 02/21/26, 02/28/26, 03/02/26, 03/07/26 and 03/09/26. The personal care provided by the HHA was not in accordance with the Aide Care Plan. 2. Pt. #4 was admitted to home health services on 09/20/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/17/26. The record contained the “Aide Care Plan” completed by the RN and dated 02/07/26. The Plan required the HHA to provide the following personal care every visit: “Partial/Sponge Bath.” The HHA notes also included documentation that the HHA provided bed baths on01/26/26, 02/02/26,02/04/26, 02/09/26, 02/11/26 and 02/26/26. The personal care provided by the HHA was not in accordance with the Aide Care Plan.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy and staff interviews, for 1 of 7 (Pts. #2) clinical record reviews, the Agency failed to ensure that medications were administered in accordance with accepted clinical standards of practice. Findings include: 1. Pt. #2 was admitted to home health services on 11/07/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/18/26. The record included the documentation on SN visit note dated 01/13/26, “SN administered Vit (Vitamin) B 12 injection of left Shoulder. Patient tolerated the procedure well.” The Vitamin B 12 Injection compliance: Package insert/prescribing information dated 10/16/25 was reviewed on 03/19/26 and required, “Cyanocobalamin Injection... is a sterile solution of cyanocobalamin for intramuscular or subcutaneous injection. Each mL contains 1,000 mcg cyanocobalamin…” The record also included documentation on the SN note dated 02/03/26, “Flu vaccine given to right Shoulder.” The CDC document “Seasonal Influenza Vaccine Dosage & Administration Oct. 16, 2024 For Health Care Providers” was reviewed on 03/19/26 and required, “For adults 19 years of age and older, the deltoid muscle in the upper arm is the preferred site, although the vastus lateralis muscle in the anterolateral thigh may be used if the deltoid site cannot be used.” The above-mentioned medications were not administered according to accepted standards of practice. 2. The Agency policy titled, “Subcutaneous injections” was reviewed on 03/18/26 and required, “Procedure: Select appropriate injection sites.” The American Diabetes Association document on subcutaneous injection sites was reviewed on 03/19/26 and has the following recommendations, “Upper arms: The back or side of the upper arms above the elbow and at least 3 inches below the shoulder…thighs… abdomen… buttocks…” The Agency policy titled, “Intramuscular Injections/Z-track” was reviewed on 03/18/26 and required, “4. Select appropriate injection site. Assess size and integrity of muscle…Palpate for areas of tenderness or hardness. Note areas of bruising or infection. Possible sites include a. Vastus Lateralis; b. Ventrogluteal; c. Dorsogluteal; d. Deltoid…” 3. During interviews conducted with the Administrator and Agency Supervisor (Director of Nurssing) on 03/18/26 at 4:00 PM, the above finding was confirmed.”