Paragon Home Healthcare

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients were provided the correct telephone number to place a complaint with the department of health for 1 of 1 agency. Findings include: 1. Review of the undated “Patient Admission Booklet” failed to evidence the correct contact information for the state department of health. 2. During an interview on 12/09/25 at 11:47 AM, the Alternate Administrator was unsure if the telephone number for the state department of health was correct in the Patient Admission Booklet.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to collaborate with the patient and physician regarding possible discharge for cause for 2 of 2 discharge for noncompliance patient records reviewed (Patient #1 and 4). Findings include: 1. The February 2024 agency policy “Patient Bill of Rights and Responsibilities” indicated the agency will advise the patient and physician who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered; make efforts to resolve the problem(s); provide the patient with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the clinical record. 2. Patient #1’s clinical record evidenced a SOC on 8/27/25 and included a POC for the certification period 8/27/25 to 10/25/25. The record also included a complaint entry completed by the Alternate Administrator on 9/12/25. The complaint form did not include any documentation of discussion with the patient regarding discharge. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for cause. During an interview on 12/09/25 at 11:05 AM, RN 1 relayed she was unsure if she discussed the possibility of discharge for noncompliance with the patient or the physician prior to the actual discharge. During an interview on 12/09/25 at 11:47 AM, the Alternate Administrator relayed she was unsure if the agency had a timeframe for giving the patient and/or physician notice of a possible discharge and she indicated a discharge for noncompliance was on a case-by-case basis depending on what was discussed and what the resolution was. She verified Patient #1 was not given any notice prior to discharge on 9/12/25. During an interview on 12/09/25 at 12:28 PM, OT 1 relayed she had a discussion with Patient #1 about discharge and Patient #1 did not want to be discharged. She also notified the physician on 9/10/25 about the difficulties in scheduling visits with the patient. This documentation failed to include any discussion about a possible discharge for noncompliance. 3. Patient #4’s clinical record evidenced a SOC on 10/29/25 and included a POC for the certification period 10/29/25 to 12/27/25. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for cause. During an interview on 12/09/25 at 2:41 PM, RN 1 relayed she thought Patient #4 did not want any further services and she thought the Alternate Administrator addressed the situation. During an interview on 12/09/25 at 3:01 PM, the Alternate Administrator relayed she was unsure if the patient and/or physician had been notified of possible discharge for noncompliance.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to make efforts to resolve the noncompliance problems for 2 of 2 discharge for noncompliance patient records reviewed (Patient #1 and 4). Findings include: 1. The February 2024 agency policy “Patient Bill of Rights and Responsibilities” indicated the agency will advise the patient and physician who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered; make efforts to resolve the problem(s); provide the patient with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the clinical record. 2. Patient #1’s clinical record evidenced a SOC on 8/27/25 and included a POC for the certification period 8/27/25 to 10/25/25. The clinical record failed to evidence efforts to resolve the noncompliance problem with Patient #1 prior to discharge. During an interview on 12/09/25 at 11:05 AM, RN 1 relayed she was unsure if any efforts were made to resolve the noncompliance problem prior to discharge. During an interview on 12/09/25 at 11:47 AM, the Alternate Administrator indicated there were no efforts made to resolve the problem and she spoke with Patient #1 on 9/12/25 and informed her of the discharge. 3. Patient #4’s clinical record evidenced a SOC on 10/29/25 and included a POC for the certification period 10/29/25 to 12/27/25. The clinical record failed to evidence efforts to resolve the noncompliance problem with Patient #4 prior to discharge. During an interview on 12/09/25 at 2:41 PM, RN 1 relayed she thought Patient #4 did not want any further services and she indicated there were not any efforts made to resolve the problem. During an interview on 12/09/25 at 3:01 PM, the Alternate Administrator verified the agency did not make any efforts to resolve the problem prior to discharge.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient with contact information for other home health agencies who may be able to provide care for 2 of 2 discharge for noncompliance patient records reviewed (Patient #1 and 4). Findings include: 1. The February 2024 agency policy “Patient Bill of Rights and Responsibilities” indicated the agency will advise the patient and physician who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered; make efforts to resolve the problem(s); provide the patient with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the clinical record. 2. Patient #1’s clinical record evidenced a SOC on 8/27/25. The record included a POC for the certification period 8/27/25 to 10/25/25 and evidenced a discharge for noncompliance effective 9/12/25. The clinical record failed to evidence any information was given to Patient #1 regarding other home health agencies who may be able to provide care. During an interview on 12/09/25 at 11:47 AM, the Alternate Administrator relayed Patient #1 was not given any contact information for other home health agencies who may have been able to provide care prior to the discharge. 3. Patient #4’s clinical record evidenced a SOC on 10/29/25. The record included a POC for the certification period 10/29/25 to 12/27/25 and evidenced a discharge for noncompliance effective 11/03/25. The clinical record failed to evidence any information was given to Patient #4 regarding other home health agencies who may be able to provide care. During an interview on 12/09/25 at 3:01 PM, the Alternate Administrator relayed Patient #4 was not given any contact information for other home health agencies who may have been able to provide care prior to the discharge.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to document the problem and efforts made to resolve the problem in the clinical record for 2 of 2 discharge for noncompliance patient records reviewed (Patient #1 and 4). Findings include: 1. The February 2024 agency policy “Patient Bill of Rights and Responsibilities” indicated the agency will advise the patient and physician who will be responsible for providing care and services to the patient after discharge that a discharge for cause is being considered; make efforts to resolve the problem(s); provide the patient with contact information for other agencies or providers who may be able to provide care and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the clinical record. 2. Patient #1’s clinical record evidenced a SOC on 8/27/25. The record included a POC for the certification period 8/27/25 to 10/25/25 and evidenced a discharge for noncompliance effective 9/12/25. The clinical record failed to evidence documentation of the problems and efforts to resolve the problem prior to discharging Patient #1 for noncompliance. During an interview on 12/09/25 at 11:47 AM, the Alternate Administrator relayed the clinical record for Patient #1 did not include any documentation of efforts to resolve the problems prior to discharge. 3. Patient #4’s clinical record evidenced a SOC on 10/29/25. The record included a POC for the certification period 10/29/25 to 12/27/25 and evidenced a discharge for noncompliance effective 11/03/25. The clinical record failed to evidence any information was given to Patient #4 regarding other home health agencies who may be able to provide care. During an interview on 12/09/25 at 3:01 PM, the Alternate Administrator relayed the clinical record for Patient #4 probably did not include any documentation of efforts to resolve the problems prior to discharge.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the recertification POC was established and reviewed by the attending physician/practitioner (See G572); failed to ensure all verbal orders were recorded in the POC (See G576); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580); failed to ensure the POC was reviewed with the physician or attending practitioner no less frequently than once every 60 days (See G588); failed to promptly alert the physician for a change in the patient condition and/or need to alter the POC (See G590); failed to provide a plan of care to the patient in a timely manner (See G620); and failed to provide the patient and/or caregiver with accurate clinical manager information (See G622). Findings include: 1. Patient #15’s clinical record evidenced Patient was discharged from a local hospital on 5/09/2025 and SOC date was 5/12/2025. Patient was referred for SN, PT, and OT services. A POC for the initial certification period of 5/12/2025 – 7/10/2025 included orders for SN visits three times a week, HHA visits three times a week, a MSW, PT, and OT evaluation. SN interventions included but were not limited to performing wound care to wounds on both heels. The record evidenced a SOC visit was completed on 5/12/2025. RN 4 noted Patient lived alone with no available caregiver, was legally blind with “highly impaired” ability to see in adequate light, and required assistance with grooming, dressing, bathing, ambulating, and meal set-up. The record failed to evidence a subsequent SN visit was conducted until 5/22/2025, which was 10 days between visits, and failed to evidence a HHA visit nor OT evaluation were conducted while Patient was on services. Patient was discharged from the agency on 5/22/2025 due to hospitalization. 2. Messages sent between home health staff on Secure Messaging App B evidenced the following: a. On 5/09/2025 at 11:44 AM, Intake Manager 7 informed staff to contact Person C, healthcare advocate for Patient, if staff were unable to reach Patient to schedule visits. b. On 5/21/2025 at 8:07 AM, Former Employee D, an OT, informed staff that when speaking with Patient on the phone on 5/20/2025, Patient reported a fall had occurred earlier that day. c. On 5/21/2025 at 3:33 PM – 3:38 PM, MSW 1 reported Person C was “stressed out” as “no one is calling [him/her].” MSW 1 reported Person C asked when PT would begin and how Patient’s wound care was being performed. d. On 5/21/2025 at 4:24 PM, Scheduler 7 documented Person C called the office “upset that nursing has not seen patient since SOC ….” e. On 5/22/2025 at 1:38 PM, LPN 1 documented Patient’s pain was an “8” out of 10 on a numeric pain scale. The messages failed to evidence nursing and aide staff attempted to contact Person C after being unable to schedule visits with Patient. 3. Clinical records from Entity H, a hospital, evidenced Patient was hospitalized beginning 5/22/2025 due to multiple falls resulting in rib and pubic ramus (one of the bones which makes up the pelvis) fractures. The records indicated Patient had fallen around midnight on 5/22/2025 and remained on the floor until approximately 12:00 PM. 4. During an interview on 6/16/2025 beginning at 8:30 AM, Person C reported they and Patient had no record of calls from agency staff attempting to schedule visits. Person C stated agency staff did not show for visits on multiple occasions. The healthcare advocate reported Patient was unable to perform wound care and did not have any available caregivers to perform the wound care when SN staff did not come for the visits. 5. During an interview on 6/17/2025 beginning at 11:17 AM, LPN 1 reported she had not been told by the agency to contact Person C to arrange for visits until the visit on 5/22/2025. The nurse was unsure who was performing wound care when nursing was unable to conduct visits. LPN 1 stated when she arrived for the SN visit on 5/22/2025, Patient was found on the floor and he/she reported a fall. The nurse stated patient had no “broken bones” but reported pain to the hip. Patient reportedly declined to have EMS called and she advised Patient to take a dose of his/her pain medication. The record failed to evidence documentation of the nurse’s assessment nor Patient declination of EMS. 6. During an interview on 6/18/2025 beginning at 2:04 PM, HHA 2 thought she had attempted to contact Patient and Person C to schedule a HHA visit but was unsure where these attempts were documented. 7. During an interview on 6/19/2025 beginning at 10:57 AM, Alternate Administrator reported the agency had delays in conducting the PT and/or OT evaluation visits due to requiring an order from the physician prior to the evaluation. A deficient practice citation was also evidenced at this standard as follows: Findings include: The cumulative effect of these systemic problems had the potential to impact all 165 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA was qualified to provide home health services (See G754); failed to ensure the HHA obtained the appropriate HHA training (See G760); failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (See G768); failed to ensure HHA’s had the required in-service training hours (See G774); failed to ensure the RN supervised the HHA every 14 days (See G808); and failed to ensure the RN completed an on-site HHA supervisory visit every 14 days (See G810). Findings include: The cumulative effect of these systemic problems had the potential to impact all 61 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.80 Home health aide services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient address was in accurate the medical record (See G1018); failed to submit the discharge summary to the physician within 5 days of discharge (See G1022); and failed to ensure documentation was complete, accurate, and authenticated (See G1024). Findings include: The cumulative effect of these systemic problems had the potential to impact all 165 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.110 Clinical records”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on EP communication plan review, policy review, and interview, the home health agency failed to develop and maintain an EP communication plan which includes contact information for regional and local EP staff of all counties served, which had the potential to affect all active patients and staff. Findings include: 1. The undated agency policy “Emergency Operations Plan and Policies” indicated resources which may be used in an emergency included “local, regional … emergency preparedness organizations ….” 2. The agency’s Geographic Area Served form, completed on 6/16/25 at 4:16 PM by Alternate Administrator, evidenced the agency serviced the following counties: Adams, Allen, Decatur, Dekalb, Elkhart, Huntington, LaPorte, Noble, St. Joseph, Wells, and Whitley. 3. The agency’s EP communication plan failed to evidence contact information for regional and local EP staff for all counties served. 4. During an interview on 6/19/25 beginning at 3:45 PM, Administrator reported the EP communication plan did not include contact information for regional and local EP staff outside of Allen county.”

“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 record review and interview, the home health agency failed to ensure all office staff were trained in EP for 1 of 1 office staff file reviewed (Admin 9). Findings include: 1. Admin 9’s personnel evidenced a hire date of 3/23/24. The file failed to evidence completion of EP training upon hire or annually. 2. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator relayed she thought EP training wasn’t required by office staff and she verified the personnel file for Admin 9 did not include any EP training.”

“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 EP review and interview, the home health agency failed to conduct an after-action review of its tabletop exercises, which had the potential to affect all active patients and staff. Findings include: 1. The agency’s EP documentation evidenced it conducted EP tabletop exercises on 5/02/2024 and 11/01/2024. The documentation failed to evidence the agency conducted an after-action review and revised the EP plan as needed. 2. During an interview on 6/19/2025 beginning at 3:45 PM, Administrator reported the agency did not document an after-action review of its 2024 EP testing.”

“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 record review and interview, the home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency. Findings include: 1. The agency policy “Reporting of OASIS Information” indicated the agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly. 2. The “OASIS Error Summary by Agency Report” evidenced a 19.58% late submission rate for the period of 1/01/24 to 12/31/24. 3. The “OASIS Error Detail Report” evidenced 375 late submissions for the period 1/01/24 to 12/31/24. 4. During an interview on 6/13/25 at 4:01 PM, the Alternate Administrator relayed she was unsure when the OASIS should be submitted and she was unsure who was responsible for submitting the OASIS data. 5. During an interview on 6/17/25 at 5:04 PM, the Administrator relayed the billing department was responsible for submitting the OASIS within 30 days of completion of the assessments.”

“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 record review and interview, the agency failed to ensure the recertification POC was established and reviewed by the attending physician/practitioner for 3 of 7 patient records reviewed with a recertification (Patient #2, 4 and 7). Findings include: 1. The undated agency policy “Plan of Care-CMS #485 and Physician/ Practitioner Orders” each patient must receive the home health services that are written in an individualized plan of care which is established, periodically reviewed (every 60 days or more frequently when indicated by changes in the patient’s condition) and signed by a physician or authorized practitioner. 2. Patient #2’s clinical record was reviewed on 6/12/25 and evidenced a SOC on 4/03/25 and a current certification period of 6/02/25 to 7/31/25. The record failed to include a recertification POC had been created for the certification period beginning 6/02/25 and failed to include documentation of a verbal or written order for SN services to continue. During an interview on 6/13/25 at 2:45 PM, RN 2 relayed she completed an updated comprehensive assessment on 5/29/25 and she failed to create the recertification POC as she was waiting to hear back from the physician’s office. 3. Patient #4’s clinical record was reviewed on 6/12/25 and evidenced a SOC on 3/26/25 and a current certification period of 5/25/25 to 7/23/25. The record evidenced a recertification POC was created on 6/05/25, 13 days after the recertification comprehensive assessment visit and failed to evidence collaboration with the physician for the recertification POC. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed he thought he collaborated with the physician but was unsure if he documented the collaboration. 4. Patient #7’s clinical record was reviewed on 6/13/25 and evidenced a SOC on 5/19/25 and a ROC on 5/28/25. The record failed to include a ROC POC had been created beginning 5/28/25 and failed to include documentation of a verbal or written order for SN services to continue. During an interview on 6/17/25 at 4:00 PM, RN 2 relayed she thought she spoke with the physician’s office for orders but she was unsure. She also confirmed she did not create a ROC POC after the 5/28/25 ROC visit.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on QAPI documentation review, policy review, and interview, the home health agency failed to measure, analyze, and track patient use of emergent care services, which had the potential to affect all agency patients. Findings include: 1. The undated agency policy “Quality Assurance and Performance Improvement (QAPI) Plan and Program) indicated the agency’s QAPI program would collect and analyze data on patient “use of emergent care services.” 2. The agency’s QAPI meeting minutes from 2/16/2024 – 4/25/2025 failed to evidence the agency collected and analyzed data on patient use of emergent care services. 3. During an interview on 6/19/2025 beginning at 1:42 PM, Administrator reported that agency’s QAPI committee did not track patient use of emergent care services.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on QAPI documentation review and interview, the home health agency failed to document the measurable progress achieved on performance improvement projects (PIP), which had the potential to affect all active patients. Findings include: 1. The agency’s QAPI documentation indicated a PIP related to fall prevention was enacted for 1/01/2025 – 12/31/2025. The PIP documentation evidenced a goal to reduce the incident of patient falls by 20% within 12 months and objectives to “conduct comprehensive fall risk assessments for 100% of new admissions … educate 100% of staff on fall prevention protocols and safe mobility practices … perform environmental safety assessments for 90% of high-risk patients to identify hazards and implement modifications ....” The committee was to “provide quarterly reports to leadership on fall rates, interventions implemented, and outcomes achieved. QAPI meeting minutes for a meeting held 4/25/2025 failed to evidence the committee documented the measurable progress it had achieved towards its PIPs, including interventions implemented, outcomes achieve, and potential need to modify interventions. 2. During an interview on 6/19/2025 beginning at 1:42 PM, Administrator reported during the 4/25/2025 QAPI meeting, the agency discussed the number of patient falls which occurred during the previous quarter, but did not discuss anything further regarding the status of the PIP.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure employees followed standards of practice for hand hygiene, bag technique and cleaning of equipment to reduce the spread of infections for 2 of 3 home visit observations with a SN (Patient #1 and 11) and 1 of 1 home visit observation with a PTA (Patient #10). Findings include: 1. The undated agency “Hand Hygiene Policy and Compliance Program” indicated staff should perform hand hygiene before and after direct patient care, before re-entering the nursing bag or patient’s clean supplies 2. During a home visit observation conducted with Patient #1 and the CM on 6/13/25 beginning at 9:27 AM, the CM removed supplies from Patient #1’s wound supply box. The CM failed to perform hand hygiene prior to obtaining clean wound supplies. The CM was also observed getting in the nurse bag to gather additional gloves five times throughout the visit. The CM failed to perform hand hygiene after closing the nurse bag. During an interview on 6/13/25 at 1:27 PM, the CM relayed hand hygiene should be performed before the start and at the end of every visit, anytime you are soiled and when accessing the bag, hand hygiene should be performed before getting in the bag. 3. Pt #10-EC 4. Pt #11-SH 3. During a home visit observation on 6/16/2025 beginning at 1:38 PM, PTA 5 was observed obtaining Patient #10’s vital signs with a thermometer and oxygen saturation (SpO2) monitor. After cleaning the equipment with a Clorox wipe, PTA 5 laid the equipment down to dry on the same side of a barrier field which had been used to store the dirty equipment (“dirty” side). During an interview on 6/16/2025 beginning at 2:28 PM, PTA 5 reported her barrier field was divided by a “clean” side and a “dirty” side, separated by her supply bag in the middle. PTA 5 reported used equipment was not to be moved from one side to the other. 4. During a home visit observation conducted with Patient #11 and LPN 2 on 06/16/2025 beginning at 02:30 PM, LPN 2 completed Patient #11’s assessment and donned gloves. LPN 2 failed to use alcohol – based hand rub before donning new gloves. LPN 2 removed the wound dressing, cleaned the wound, and applied the clean wound dressing. LPN 2 failed to use alcohol- based hand rub before donning gloves and failed to complete hand hygiene and don new gloves after removing the soiled wound dressing. During an interview immediately after the visit, LPN 2 indicated they thought they used alcohol- based hand rub between glove changes. LPN 2 indicated they were not sure they completed hand hygiene and donned new gloves after removing the soiled bandage.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (person acting as a patient) for 2 of 2 new hired HHA’s in the past year (HHA 2 and HHA 3). Findings include: 1. The undated agency policy “Home Health Aide Services and Training Program” indicated a home health aide training program must address each of the following subject areas: communication skills; observation of patient status; reading and recording temperature, pulse, and respiration; basic infection prevention and control procedures; basic elements of body functioning and changes in body function; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of instituting emergency procedures and their application; the physical, emotional, and developmental needs of and ways to work with the populations served by the HHA; appropriate and safe techniques in performing personal hygiene and grooming tasks; safe transfer techniques and ambulation; normal range of motion and positioning; adequate nutrition and fluid intake; recognizing and reporting changes in skin condition; and any other task that the HHA may choose to have an aide perform as permitted under state law. 2. HHA 2’s personnel file evidenced a hire date of 6/20/24 and included a document titled “Initial Competency Checklist” dated 6/14/25, signed by OTA 7. The skills included reading and recording temperature, pulse, blood pressure and respiration; shower bath, sink, tub or bed shampoo, safe transfer techniques, recognition of emergencies and knowledge of emergency procedures were marked as met via observation in the home with a patient. The document failed to evidence all required competencies were completed. A telephone call was placed to HHA 2 on 6/19/25 at 1:33 PM with no response. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator relayed HHA 2 trained with OTA 7 one day to do the skills competencies. She also verified that OTA 7 is not an RN. 3. HHA 3’s personnel file evidenced a hire date of 4/16/25 and included a document titled “Initial Competency Checklist” dated 4/24/25. The skills included reading and recording temperature, pulse, blood pressure and respiration; bed bath; sponge, tub or shower bath; shampoo; sink, tub or bed; oral hygiene; toileting and elimination; normal range of motion; positioning; safe transfer techniques; ambulation; fluid intake; adequate nutrition; communication skills; infection control: standard precautions; observing and reporting patient status and care furnished; documenting patient status and care furnished; maintenance of clean, safe and healthy environment; elements of body function and changes to report to supervisor; recognition of emergencies; knowledge of emergency procedures; physical, emotional and developmental needs and ways to work with patients; respect for patient; respect for patient privacy; and respect for patient property were marked as met via observation. The document failed to evidence if the competencies were performed on a patient or pseudo-patient and failed to include the Observer signature/Title. During an interview on 6/19/25 at 1:11 PM, HHA 3 relayed she shadowed HHA 2 and did not complete any skills check-off competencies with a nurse. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator relayed she thought HHA 3 was checked off by RN 1 and was unsure if the competencies were completed on a patient or pseudo-patient. She also relayed that HHA 3 trained with HHA 2 one time before taking on patients alone.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on personnel file review and interview, the home health agency failed to ensure HHA’s had the required in-service training hours for 2 of 2 HHA’s who have been employed greater than 12 months (HHA 2 and HHA 3). Findings include: 1. The undated agency policy “Home Health Aide Services and Training Program” indicated a home health aide must receive at least 12 hours of in-service training during each 12-month period and in-service training may occur while an aide is furnishing care to a patient. 2. HHA 2’s personnel file evidenced a hire date of 6/20/24. The file included certificates of attendance for 6.0 hours of HHA training. The file failed to evidence at least 12 hours of in-service training had been completed in the past 12 months. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator verified the personnel file for HHA 2 did not include at least 12 hours of required in-service training. 3. HHA 4’s personnel file evidenced a hire date of 1/11/22. The file included certificates of attendance for 10.0 hours of HHA training. The file failed to evidence at least 12 hours of in-service training had been completed in the past 12 months. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator verified the personnel file for HHA 4 did not include at least 12 hours of required in-service training.”

“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 record review and interview, the agency failed to ensure documentation was complete, accurate, and authenticated for 5 of 12 active records reviewed (Patients #4, 5, 9, 11, and 12). Findings include: .Patient #4’s clinical record included a “Re-cert Verbal Oder for Home Care: dated 5/23/25 at 1:44 AM completed by RN 3. The comprehensive assessment visit note failed to evidence the patient signature confirming the visit. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed he thought he collaborated with the physician but was unsure if he documented the collaboration and he confirmed he did not receive any orders at 1:44 AM. .Patient #9’s clinical record included an “OASIS Recertification” completed by RN 1 dated 5/02/25. The recertification visit note failed to include the patient’s signature for the visit. Review of the notes from the Secure Messaging Application B for Patient #9 evidenced an entry by RN 1 on 5/04/25 at 5:49 PM indicated she would see Patient #9 on 5/06/25 at 12:00 PM. Another entry made by RN 1 on 5/06/25 at 3:02 PM indicated the recertification visit had been completed. The “OASIS Recertification” visit note failed to evidence the accurate date that the visit occurred on. During an interview on 6/13/25 at 1:27 PM, the CM relayed the recertification comprehensive assessment should be completed within the last five days of the certification period. During an interview on 6/17/25 at 4:25 PM, RN 1 relayed she did not complete the recertification visit on 5/02/25 and she confirmed the visit was completed on 5/06/25. 1.The undated agency policy “Timely Submission of Patient Documentation” indicated documentation must be completed within 14 calendar days. 3. Patient #5’s medical record evidenced a comprehensive assessment for the SOC dated 03/14/2025, completed by RN 2. Patient #5 signed the Consent for Service, Fall Safety Education, and the Emergency plan on 03/14/2025. The agency required these documents to be reviewed and signed at the SOC. The Secure Messaging application B notes included a note by RN 2 that they completed the SOC on 03/14/2025. Patient #5’s POC completed for certification period 05/13/2025 – 07/11/2025, identified the SOC date 03/13/2025. During an interview on 06/13/2025 at 03:50 PM, Intake Manager 7 indicated they had the SOC as 03/13/2025. The Alternate Administrator confirmed the SOC was 03/14/2025. 5.Patient #11’s medical record evidenced documentation of supervisory visits for LPN 2 dated 05/14/2025 and 06/12/2025, completed by RN 1. There was no global positioning services documentation of RN 1 at Patient #11’s home on 05/14/2025 or 06/12/2025. The record included “SN Follow -Up/ Goals Re- Assessment Note” completed by RN 1 on 05/22/2025 and 06/16/2025. Global positioning services documentation indicated RN 1 was at Patient #11’s home on those dates. During an interview on 06/18/2025 beginning at 12:30 PM, RN 1 indicated they did supervisory visits on 05/22/2025 and 06/16/2025 but did not put the correct date on the supervisory visit notes. 6.Patient #12’s medical record evidenced documentation of a supervisory visit for LPN 2 dated 06/09/2025, completed by RN 1. The record included a SN Follow -Up/ Goals Re- Assessment Note dated 06/09/2025, completed by RN 1. Global positioning services documentation indicated RN 1’s presence at Patient #12’s home was 06/11/2025 not 06/09/2025. The record failed to evidence global positioning documentation for RN 1 on 06/09/2025. During an interview on 06/18/2025 beginning at 12:30 PM, RN 1 indicated the dates on the supervisory visit note and the SN Follow -Up/ Goals Re- Assessment Note were incorrect. The agency failed to ensure clinicians’ documentation included the correct date of service.”

“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 record review and interview, the home health agency failed to ensure patients were informed about and received the initial therapy assessment for 2 of 4 active records reviewed with a referral for therapy services in the past 40 days (Patient #9 and 12) and 1 of 2 discharge records reviewed with discharge in the past 30 days (Patient #15). Findings include: 1. The undated agency policy “Patient Admission Criteria” indicated during the initial visit, the admitting professional will verify the information on the referral form. 2. The undated agency policy “Patient Bill of Rights and Responsibilities” indicated patients have the right to be admitted by the Agency only if it has the resources needed to provide care safely and at the required level of intensity, as determined by a professional assessment and the patient has the right to receive all services in the plan of care. 3. Patient #9’s clinical record included a recertification POC for the certification period 5/06/25 to 7/04/25. The POC included orders for SN visits two times a week for one week and then three times a week for three weeks; HHA visits two times a week for four weeks; OT visits one time a week for one week, two times a week for three weeks and one time a week for one week; and PT re-eval and treat. The record failed to evidence a PT Evaluation was performed and failed to evidence documentation that the Patient was notified of the delay in PT services. During an interview on 6/13/25 at 1:07 PM, the CM relayed the PT evaluation should be done within five days of the comprehensive assessment. During an interview on 6/17/25 at 2:26 PM, Patient #9 relayed he was told all of the PT’s went on vacation at the same time and someone would be calling him to do the PT evaluation when they returned from vacation and he stated he was “still waiting on someone to call him for the PT evaluation.” 5. Patient #15’s clinical record included a POC for the initial certification period of 5/12/2025 – 7/10/2025. The POC included orders for SN visits three times a week and HHA visits three times a week. SN interventions included but were not limited to performing wound care to wounds on both heels. The record evidenced a SOC visit was completed on 5/12/2025. RN 4 noted Patient lived alone with no available caregiver, was legally blind with “highly impaired” ability to see in adequate light, and required assistance with grooming, dressing, bathing, ambulating, and meal set-up. The record failed to evidence a subsequent SN visit was conducted until 5/22/2025 and failed to evidence a HHA visit was conducted. Patient was admitted to a local hospital on 5/22/2025 and discharged from the agency. A review of messages sent between home health staff on Secure Messaging App B evidenced on 5/09/2025 at 11:44 AM, Intake Manager 7 informed staff to contact Person C, healthcare advocate for Patient, if staff were unable to reach Patient to schedule visits. The record failed to evidence nursing and aide staff attempted to contact Person C after being unable to schedule visits with Patient. During an interview on 6/16/2025 beginning at 8:30 AM, Person C reported they and Patient had no record of calls from agency staff attempting to schedule visits. Person C stated agency staff did not show for visits on multiple occasions. During an interview on 6/17/2025 beginning at 11:17 AM, LPN 1 reported she had not been told by the agency to contact Person C to arrange for visits until the visit on 5/22/2025. During an interview on 6/18/2025 beginning at 2:04 PM, HHA 2 thought she had attempted to contact Patient and Person C to schedule a HHA visit, but was unsure where these attempts were documented. 4. Patient #12’s medical record evidenced documentation of a verbal SOC order dated 05/19/2025 and included an order for physical therapy to evaluate and treat. The record failed to evidence a physical therapy evaluation. Documentation failed to evidence the patient was notified there would be no physical therapy assessment. During an interview on 06/17/2025 at 03:50 PM, the Alternate Administrator confirmed Patient #12 did not receive a physical therapy evaluation and was unsure if the MD discontinued the order for the evaluation.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient received all visits as ordered on the POC for 4 of 5 active records reviewed with SOC in the past 40 days (Patient #1, 3, 7 and 13) and 2 of 2 discharged records reviewed with discharge in the past 30 days (Patient #14 and 15). 6. Patient #15’s clinical record evidenced Patient was discharged from a local hospital on 5/09/2025 and SOC date was 5/12/2025. Patient was referred for SN, PT, and OT services. A POC for the initial certification period of 5/12/2025 – 7/10/2025 included orders for SN visits three times a week, HHA visits three times a week, and an OT evaluation. SN interventions included but were not limited to performing wound care to wounds on both heels. The record evidenced a SOC visit was completed on 5/12/2025. RN 4 noted Patient lived alone with no available caregiver, was legally blind with “highly impaired” ability to see in adequate light, and required assistance with grooming, dressing, bathing, ambulating, and meal set-up. The record failed to evidence a subsequent SN visit was conducted until 5/22/2025. Patient was admitted to a local hospital for multiple falls on 5/22/2025 and discharged from the agency. The record failed to evidence a HHA visit was conducted while Patient was on services, and failed to evidence an OT evaluation was conducted while Patient was on services. A review of messages sent between home health staff on Secure Messaging App B evidenced on 5/09/2025 at 11:44 AM, Intake Manager 7 informed staff to contact Person C, healthcare advocate for Patient, if staff were unable to reach Patient to schedule visits. The record failed to evidence nursing and aide staff attempted to contact Person C after being unable to schedule visits with Patient. The messages also failed to evidenced Former Employee D, an OT, attempted to contact Patient or Person C to schedule the OT evaluation until 5/19/2025, which was seven days after the SOC. During an interview on 6/16/2025 beginning at 8:30 AM, Person C reported they and Patient had no record of calls from agency staff attempting to schedule visits. Person C stated agency staff did not show for visits on multiple occasions. The healthcare advocate reported Patient was unable to perform wound care and did not have any available caregivers to perform the wound care when SN staff did not come for the visits. During an interview on 6/17/2025 beginning at 11:17 AM, LPN 1 reported she had not been told by the agency to contact Person C to arrange for visits until the visit on 5/22/2025. During an interview on 6/18/2025 beginning at 2:04 PM, HHA 2 thought she had attempted to contact Patient and Person C to schedule a HHA visit, but was unsure where these attempts were documented. During an interview on 6/19/2025 beginning at 10:57 AM, Alternate Administrator reported the agency had delays in conducting the PT and/or OT evaluation visits due to requiring an order from the physician prior to the evaluation. Findings include: 1. The undated agency policy “Patient Bill of Rights and Responsibilities” indicated patients have the right to be admitted by the Agency only if it has the resources needed to provide care safely and at the required level of intensity, as determined by a professional assessment and the patient has the right to receive all services in the plan of care. 2. Patient #1’s clinical record evidenced a SOC on 5/13/25 and included a POC for the certification period 5/13/25 to 7/11/25. The POC indicated the patient was to receive SN visits three times a week for five weeks; OT visits one time a week for one week, two times a week for three weeks, one time a week for one week; and PT evaluation and treat visit effective 5/13/25. The clinical record evidenced the PT evaluation was completed by PT 1 on 5/26/25, 13 days after SOC. The record failed to evidence documentation that Patient #1 and the physician were notified of the delay in the PT Evaluation as ordered on the POC. During an interview on 6/13/25 at 1:07 PM, the CM relayed the PT evaluation should be done within five days of the SOC comprehensive assessment. During an interview on 6/13/25 at 1:54 PM, PT 1 relayed she was hired and completed the PT evaluation on 5/26/25. She was unsure if the patient or physician was notified of the delay of PT services. 3. Patient #3’s clinical record evidenced a SOC on 5/06/25 and included a POC for the certification period 5/06/25 to 7/04/25. The POC indicated the patient was to receive an OT evaluation and treat visit and a PT evaluation and treat visit effective 5/06/25. The clinical record evidenced the OT evaluation was completed by OT 2 on 5/12/25, 6 days after SOC. The clinical record failed to evidence the PT evaluation had been completed and failed to include documentation that Patient #3 and the physician were notified of the delay in the OT and PT Evaluations as ordered on the POC. During an interview on 6/13/25 at 1:07 PM, the CM relayed the OT and PT evaluations should be done within five days of the SOC comprehensive assessment. During an interview on 6/13/25 at 1:45 PM, OT 1 relayed she thought the initial OT evaluation should be done within 24 hours and she was unsure if the patient or physician was notified of the delay of OT services. During an interview on 6/17/25 at 12:17 PM, PT 4 relayed the PT evaluation should be done within 24 to 48 hours of initial patient encounter and he was not the PT originally assigned to do the evaluation. He also relayed he was unsure if the patient or physician was notified of the delay of PT services. 4. Patient #7’s clinical record evidenced a SOC on 5/19/25 and included a ROC POC effective 6/03/25. The ROC indicated the patient was to receive an OT evaluation and treat visit and a PT evaluation and treat visit. The clinical record evidenced the OT evaluation was completed by OT 3 on 6/12/25, 9 days after ROC and the PT evaluation was completed by PT 2 on 6/12/25, 9 days after ROC. The clinical record failed to include documentation that Patient #7 and the physician were notified of the delays in the OT and PT Evaluations as ordered on the ROC. During an interview on 6/13/25 at 2:42 PM, OT 3 relayed she completed the evaluation when she had time and she was unsure if Patient #7 or the physician had been notified of the delay in the OT Evaluation. During an interview on 6/13/25 at 2:30 PM, PT 2 verified the PT evaluation was not completed within five days of ROC and he was unsure if Patient #7 or the physician had been notified of the delay in the PT Evaluation. 5. Patient #13’s clinical record evidenced a SOC on 6/10/25 and included a POC for the certification period 6/10/25 to 8/08/25. The POC indicated the patient was to receive SN visits three times a week for one week, two times a week for two weeks and one time a week for one week; an OT evaluation visit one time a week for one week; and a PT evaluation visit one time a week for one week. The clinical record evidenced the OT evaluation was completed by OT 4 on 6/13/25 and SN visits were completed by the CM on 6/10/25 and 6/13/25. The record failed to evidence Patient #13 received three SN visits as ordered on the POC. The PT evaluation was completed by PT 1 on 6/16/25, 6 days after SOC. The record failed to evidence documentation that Patient #13 and the physician were notified of the delay in the PT Evaluation as ordered on the POC. During an interview on 6/16/25 at 12:35 PM, the CM verified Patient #13 did not receive three SN visits as ordered during the week of 6/10/25 and he stated he needed to mark it as a missed visit. During an interview on 6/18/25 at 10:29 AM, PT 1 relayed she discussed the delay in PT evaluation on Sunday 6/15/25 and she left a message with the physician on 6/16/25 after the PT evaluation visit. She also verified she had not completed any documentation of the discussion of the delay with the patient and had not documented the PT evaluation visit yet. 6. Patient #14’s clinical record evidenced a SOC on 4/11/25 and included a POC for the certification period 4/11/25 to 6/09/25. The POC indicated the patient was to receive a PT evaluation and treat visit and OT visits one time a week for one week, two times a week for three weeks and then one time a week for one week. Review of the agency complaint log evidenced Patient #14 filed a complaint on 5/01/25 due to not receiving the PT evaluation. The clinical record evidenced the PT evaluation was completed on 5/02/25, 21 days after SOC. The record failed to evidence documentation that Patient #14 and the physician were notified of the delay in the PT Evaluation as ordered on the POC. During an interview on 6/18/25 at 10:59 AM, PT 2 relayed he was not sure why the PT evaluation was delayed and he was unsure if the patient or physician had been notified of the delay in PT services.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on record review, policy review, and interview, the home health agency failed to document and investigate complaints regarding treatment of care which failed to be furnished for 1 of 2 records reviewed which evidenced a report was made to the agency that treatment failed to be furnished by staff (Patient #15). Findings include: 1. The undated agency policy “Complaint Resolution,” indicated the agency would document the existence, investigate, and document the resolution of a complaint. 2. Patient #15’s clinical record evidenced a SOC of 5/12/2025. The agency noted Patient was discharged from a local hospital on 5/09/2025. Patient was referred for SN, PT, and OT services. A POC for the initial certification period of 5/12/2025 – 7/10/2025 evidenced Patient was to receive SN visits three times a week, HHA visits three times a week, and a MSW, PT, and OT evaluation. SN interventions were to include wound care to be performed at each visit to wounds on both of Patient’s heels. The record evidenced Patient received only one subsequent SN visit, and no HHA, MSW, PT, or OT visits prior to being re-admitted to a hospital on 5/22/2025. Review of messages sent between staff on Secure Messaging Application B evidenced on 5/21/2025, MSW 1 reported she spoke with Person C, healthcare advocate for Patient #15. Person C was reportedly “stressed out” as “no one is calling [him/her],” and asking when Patient’s wound care and therapy would begin. On 5/21/2025 at 4:24 PM, Scheduler 7 sent a message to staff reporting Person C called the office “upset that nursing has not seen Patient since SOC.” 3. The agency’s log of complaints received 1/01/2025 – 6/12/2025 failed to evidence a complaint regarding failure to furnish care to Patient #15 was documented, investigated, and resolved. 4. During an interview on 6/16/2025 beginning at 8:30 AM, Person C stated they spoke with Alternate Administrator to report their concerns of visits not being conducted with Patient. Person C reported they were not notified an investigation of the concern would be conducted nor a resolution of the complaint. 5. During an interview on 6/18/2025 beginning at 1:07 PM, Scheduler 7 stated Person C called the agency “a few times” to report complaints regarding staff not conducting visits within a timely manner. Scheduler 7 stated she reported Person C’s complaints to Alternate Administrator. 6. During an interview on 6/18/2025 beginning at 1:32 PM, Alternate Administrator reported she spoke with Person C, who reported Patient was not getting their nursing visits as ordered and that staff had not contacted Person C to schedule visits. Alternate Administrator reported she did not document or investigate this report as a complaint.”

“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 interview, the home health agency failed to conduct an initial assessment to determine the patient’s immediate care and support needs within 48 hours of referral for 4 of 5 active records reviewed with SOC in the past 40 days (Patient #1, 3, 12 and 13) and 1 of 1 discharged record reviewed with SN services in the past 30 days (Patient #15). Findings include: 1. The undated agency policy “Initial Assessments/ Comprehensive Assessments” indicated a RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner-ordered start of care date. 2. Patient #1’s clinical record evidenced a referral was received on 5/06/25 and an initial assessment/SOC visit was conducted on 5/13/25. The record failed to evidence documentation of the reason for delay in conducting an initial assessment. During an interview on 6/13/25 at 1:27 PM, the CM verified the initial assessment was not completed within 48 hours for Patient #1 and relayed it should have been documented in the communication notes or the Secure Messaging Application B that is used internally. Review of the Secure Messaging Application B notes for Patient #1 failed to evidence any documentation of the delay in the initial assessment. 3. Patient #3’s clinical record evidenced a referral was received on 4/29/25 with a planned discharge from the skilled nursing facility on 5/02/25. The initial assessment/SOC visit was conducted on 5/06/25. The record failed to evidence documentation of the reason for delay in conducting an initial assessment. During an interview on 6/13/25 at 1:27 PM, the CM verified the initial assessment was not completed within 48 hours for Patient #3 and relayed it should have been documented in the Secure Messaging Application B. Review of the Secure Messaging Application B notes for Patient #3 failed to evidence any documentation of the delay in the initial assessment. 5. Patient #13’s clinical record evidenced a referral was received on 6/04/25 with a planned discharge from the skilled nursing facility on 6/06/25. The initial assessment/SOC visit was conducted on 6/10/25. The record failed to evidence documentation of the reason for delay in conducting an initial assessment. During an interview on 6/17/25 at 12:35 PM, the CM verified the initial assessment was not completed within 48 hours for Patient #13. Review of the Secure Messaging Application B notes for Patient #13 failed to evidence any documentation of the delay in the initial assessment. 6. Patient #15’s clinical record evidenced Patient was referred to the agency on 5/06/2025 and was discharged from a local hospital on 5/09/2025. On 5/09/2025 at 10:43 AM, Scheduler 7 messaged RN 4 thru the EMR, informing her that Patient needed to be seen for a SOC visit on 5/10/2025. The record failed to evidence an initial assessment was conducted until 5/12/2025, which was three days after Patient’s hospital discharge. The record failed to evidence the reason for this delay. The review of messages sent between staff on Secure Messaging Application B failed to evidence RN 4 attempted to contact Patient and Person C, healthcare advocate for Patient, to schedule an initial assessment until 5/12/2025. During an interview on 6/16/2025 beginning at 8:30 AM, Person C reported they spoke with Scheduler 7 prior to Patient’s discharge from the hospital to ensure agency staff would be able to conduct a visit on 5/10/2025, as Patient lived alone, did not have a caregiver available, and was legally blind. Person C stated Scheduler 7 reported a nurse would conduct an initial assessment on 5/10/2025, however no staff conducted the visit or called to report a delay until 5/12/2025. Person C reported they were later told by RN 4 the delay was due to staff availability. During an interview on 6/17/2025 beginning at 2:05 PM, RN 4 reported she would conduct an initial assessment within three to five days of the agency receiving the referral, depending on if the referral was received prior to the weekend. The nurse did not recall if Patient’s initial assessment was delayed for any reason. The nurse stated she did attempt to contact Patient multiple times to schedule the visit, but could not recall the date she began attempting to schedule the visit. During an interview on 6/18/2025 beginning at 1:30 PM, Scheduler 7 reported she had informed Person C that an initial assessment was to be conducted on 5/10/2025. Patient #12’s medical record evidenced documentation of a verbal SOC order dated 05/19/2025. The SOC order stated, “Patient seen and evaluated for Start of Care with [agency].” The Secure Messaging application B notes included a note by RN 1, which indicated a SOC date of 05/19/2025. During an interview on 06/18/2025 at 12:30 PM, RN 1 indicated the SOC assessment must be completed within 48 hours of the referral, but RN 1 did not know if Patient #12’s assessment was completed within that time frame. During an interview on 06/18/2025 at 01:25 PM, Intake Manager 7 indicated the referral date for Patient #12 was 05/16/2025. The agency failed to ensure the comprehensive assessment was completed within 48 hours of the referral.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the RN performed a wound assessment during the recertification comprehensive assessment for 1 of 1 active clinical record reviewed with wounds and HHA services (Patient #9). Findings include: 1. The undated agency policy “Initial Assessments/Comprehensive Assessments” indicated the comprehensive assessment must include integumentary status. 2. Patient #9’s clinical record included a comprehensive assessment completed by RN 1 on 5/6/25. The comprehensive assessment evidenced Patient #9 had a pressure ulcer and wound care was performed earlier that day. Patient #9 showed RN 1 a picture of the wound. RN 1 failed to assess Patient #9’s wound during the comprehensive assessment. During an interview on 6/18/25 at 1:49 PM, RN 1 confirmed she did not perform a skin assessment on Patient #9 during the comprehensive assessment. She stated he is comfortable with the LPN and they have a routine. When asked when she had performed a skin assessment on Patient #9, she relayed it was done on SOC on 11/07/24, six months prior. During an interview on 6/19/25 at 4:34 PM, the Administrator relayed the nurse who is taking care of the patient is responsible for wound assessment and the RN should assess the wound upon every supervisory visit.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the comprehensive assessment included an accurate review of all medications the patient was currently taking for 2 of 6 home visit observations conducted (Patients #1, #10). 2. Patient #1’s clinical record evidenced a SOC on 5/13/25 and included a comprehensive assessment completed by the CM on 5/13/25 and a POC for the certification period 5/13/25 to 7/11/25. SN visits completed on 5/15/25, 5/16/25, 5/19/25, 5/23/25, 5/26/25, 5/28/25, 6/02/25 and 6/09/25 which evidenced drug regimen review was completed. During a home visit observation conducted with Patient #1 and the CM on 6/13/25 at 9:27 AM, Surveyor comparison of the home health agency’s POC medication list against the medications in the home evidenced the following discrepancy: a) Levofloxacin (an antibiotic used to treat a bacterial infection) 750 milligrams (mg), 1 tablet by mouth at bedtime for 14 days. Per Patient #1, they finished this medication a couple of weeks ago. During the entrance conference on 6/12/25 at 9:27 AM, the Alternate Administrator relayed medications should be reconciled on a regular basis. During an interview on 6/17/25 at 12:35 PM, the CM relayed mediations should be reconciled in the home every visit, at least once a week. Findings include: 1. The undated agency policy “Medication Reconciliation” indicated during the admission comprehensive assessment, the admitting clinician should “create and document a complete list of medications that [the] patient is taking at home, including dose, strength, route, and frequency.” 3. Patient #10’s clinical record evidenced RN 2 conducted an initial comprehensive assessment on 4/23/2025. RN 2 documented Patient’s Hydrocodone-acetaminophen order was 5-325 mg, one tablet every four hours PRN. During a home visit observation on 6/16/2025 beginning at 1:38 PM, Patient #10’s medication bottles were reviewed. The bottles evidenced Patient’s prescription for Hydrocodone-acetaminophen (a combination of an opioid and Tylenol used to treat pain) was 10-325 milligrams (mg), one tablet five times a day as needed (PRN). During an interview on 6/16/2025 beginning at 2:45 PM, Patient reported they had been on the Hydrocodone-acetaminophen dose of 10-325 mg, one tablet five times a day PRN, prior to admission to the home health agency. During an interview on 6/19/2025 beginning at 2:13 PM, RN 2 reported on admission, she would review all medication bottles in the home and compare to the ordering physician’s medication list.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the RN failed to update the comprehensive assessment within 5 days of recertification for 2 of 5 active records reviewed with wounds (Patient #2 and 9). Findings include: 1. The undated agency policy “Reassessments/Update of the Comprehensive Assessment” indicated the comprehensive assessment must be updated and revised the last 5 days of every 60 days, e.g. days 56-60 of the current period. 2. Patient #2’s clinical record was reviewed on 6/12/25 and evidenced a SOC on 4/03/25 and a current certification period of 6/02/25 to 7/31/25. The record failed to include an updated comprehensive assessment had been completed in the last five days of the previous certification period. During an interview on 6/13/25 at 2:45 PM, RN 2 relayed she completed an updated comprehensive assessment on 5/29/25 and she failed to document the assessment until 6/12/25. 3. Patient #9’s clinical record was reviewed on 6/17/25 and evidenced a SOC on 11/07/24 and included a POC for the certification period 5/06/25 to 7/04/25. The record failed to include an updated comprehensive assessment had been completed in the last five days of the previous certification period. During an interview on 6/17/25 at 4:25 PM, RN 1 indicated the updated comprehensive assessment was completed late for Patient #9 due to a scheduling conflict.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all verbal orders were recorded in the POC according to agency policy for 5 of 16 records reviewed (Patients #5, 6, 7, 10, 15). 5. Patient #7’s clinical record evidenced a SOC on 5/19/25 and a ROC on 6/03/25. The record included a verbal order for Patient’s ROC, documented on 6/03/25 by RN 2. The order failed to evidence the person who provided the order to RN 2. During an interview on 6/17/25 at 4:00 PM, RN 2 relayed she collaborated with the physician regarding the ROC and documented the order in a communication note on 6/09/25. She confirmed the communication notes are not sent to the physician for signature. During an interview on 6/13/25 at 1:27 PM, the CM relayed all verbal orders should be placed on a physician’s order form that is sent to the physician for signature and he verified the communication notes are not sent to the physician. Findings include: 1. The undated agency policy “Plan of Care – CMS #485 and Physician/Practitioners Orders” indicated “all patient care orders, including verbal orders, must be recorded in the plan of care.” Verbal orders were to be “put in writing, signed, timed and dated with the date of receipt by an RN or therapist … It is the RN’s or therapist’s responsibility to make any necessary revisions to the Plan of Care based on that order(s).” 2. The agency policy “Physician/Practitioner Orders – Verbal Orders,” dated 11/22/2023, indicated all verbal orders should be “written down, read back to verify order and receive confirmation from individual who gave [the] order. A record of this order is documented on a supplemental order form. All orders include: … Physician/practitioner’s name. Date and time the order is taken. The signature of the person taking the order. The specific orders(s) ….” 5. Patient #10’s clinical record evidenced a SOC of 4/23/2025. The record included a verbal order for delay in SOC, dated as received on 4/23/2025 and documented on 6/15/2025 by RN 2. The order failed to evidence the person who provided the order to RN 2. During an interview on 6/19/2025 beginning at 2:13 PM, RN 2 could not recall who provided the order to begin services for Patient. 7. Patient #15’s clinical record evidenced a SOC of 5/12/2025. The record included a verbal order for delay in SOC documented on 5/13/2025 by RN 4. The order failed to evidence the person who provided the order to RN 4. During an interview on 6/17/2025 beginning at 2:05 PM, RN 4 could not recall who provided the order to delay the SOC for Patient. 3. Patient #6’s medical record evidenced documentation of two verbal orders. One dated 05/22/2025 for wound care, documented by RN 2. The other for the resumption of care dated 06/13/2025, documented by RN 2. The orders failed to evidence who gave the verbal orders to RN 2. During an interview on 06/19/2025 at 02:20 PM, RN 2 indicated verbal orders required the name of the person giving the verbal order. 6. Patient #12’s clinical record evidenced an “Order for Delay in SOC Verbal Order” dated 05/19/2025. RN 1 completed the order, which stated, “Delay SOC, Unable to reach pt [patient]”. During an interview on 06/18/2025 at 12:30 PM, RN 1 indicated the order was not documented as a verbal order as it did not include that the order was read back and verified. During an interview on 6/18/2025 at 1:25 PM, the Administrator explained they did not get an order from the physician to delay the SOC; this was to let the physician know the assessment would not be completed in 48 hours. The Administrator indicated an internal communication process caused the delay.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 6 of 7 active patient records reviewed with wounds (Patient #1, 2, 4, 7, 9 and 11) and 1 of 1 patient record reviewed with a home visit observation with a PTA (Patient #10). 6. Patient #10’s clinical record evidenced a SOC of 4/23/2025. Patient was to receive one PT visit for one week then two PT visits for four weeks. On 5/22/2025, PT 2 completed a PT re-evaluation visit and documented a physician order to continue PT services for another four weeks. The record failed to evidence the order was signed by Patient’s physician. A home visit observation was conducted on 6/16/2025 beginning at 1:38 PM with Patient. PTA 5 was observed performing a PTA visit with Patient. During an interview on 6/19/2025 beginning at 11:15 AM, PT 2 reported he did not obtain a verbal order to continue Patient’s therapy services. PT 2 stated Patient’s initial order for PT services covered all subsequent continuation orders, so a verbal order to continue services was not needed. .Patient #11’s medical record evidenced a physician order dated 05/14/2025 for a SN frequency change. The new SN frequency was one visit for one week (effective 05/14/2025), 2 visits for three weeks, and three visits for one week. Patient #11 received SN visits on 05/27/2025, 05/29/2025, 06/03/2025, 06/04/2025, 06/09/2025, 06/11/2025, and 06/16/2025. During an interview on 06/18/2025, RN 1 indicated this was not a verbal order, but an order request which was faxed to the physician. RN 1 indicated the order was not valid without a verbal order or a signed order from the physician. SN services were provided without an order. Findings include: 1. The undated agency policy “Plan of Care-CMS #485 and Physician/ Practitioner Orders” each patient must receive the home health services that are written in an individualized plan of care which is established, periodically reviewed (every 60 days or more frequently when indicated by changes in the patient’s condition) and signed by a physician or authorized practitioner. 2. Patient 1’s clinical record included a POC for certification period 5/13/25 to 7/11/25 with orders for SN visit frequencies of three times a week for five weeks effective 5/13/25; PT visit frequencies of one time a week for one week, two times a week for three weeks and one time a week for one week effective 5/26/25 and OT visit frequencies of one time a week for one week, two times a week for three weeks and one time a week for one week effective 5/15/25 . The record evidenced PT visits were performed on 5/26/25, 6/03/25, 6/05/25, 6/10/25 and 6/12/25 and OT visits were performed on 5/15/25, 5/19/25, 5/22/25, 5/27/25, 5/28/25, 6/02/25, 6/06/25 and 6/09/25. The clinical record for Patient #1 failed to include a verbal or signed written order for PT and OT frequencies was obtained prior to the above visits performed. During an interview on 6/13/25 at 1:45 PM, OT 2 relayed she did not collaborate with the physician after the OT Evaluation, and the office faxed the OT POC to the physician for signature. During an interview on 6/13/25 at 1:54 PM, PT 1 relayed she created the PT POC and it was sent to the physician for signature. 3. Patient 2’s clinical record included a POC for certification period 6/02/25 to 7/31/25 with orders for SN visit frequencies of two times a week for four weeks effective 6/02/25; PT visit frequencies of two times a week for four weeks effective 6/02/25 and OT visit frequencies of two times a week for four weeks effective 5/30/25. The record evidenced SN visits were performed on 6/02/25, 6/05/25, 6/09/25 and 6/12/25; PT visits were performed on 6/02/25, 6/06/25 and 6/09/25 and OT visits were performed on 6/02/25 and 6/06/25. The clinical record for Patient #2 failed to include a verbal or signed written order for SN, PT and OT frequencies was obtained prior to the above visits performed. During an interview on 6/13/25 at 2:42 PM, OT 3 relayed she writes up the evaluation visit and order for OT services and it is sent to the physician for signature. During an interview on 6/13/25 at 2:30 PM, PT 2 relayed he completed the PT reevaluation on 5/29/25 and thought he called the physician for orders. He also relayed the nurse is responsible for sending it to the physician for orders. During an interview on 6/13/25 at 2:45 PM, RN 2 relayed she didn’t have time to complete the recertification comprehensive visit note from 5/29/25 and she was unsure if she received a physician’s order for the above SN visit frequencies. 4. Patient 4’s clinical record included a POC for certification period 5/25/25 to 7/23/25 with orders for SN visit frequencies of three times a week for two weeks then two times a week for two weeks effective 5/26/25. The record evidenced SN visits were performed on 5/31/25 and 6/02/25. The clinical record for Patient #4 failed to include a verbal or signed written order for SN frequencies was obtained prior to the above visits performed. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed he could not remember if he received a call back from the physician’s office with orders for the recertification POC frequencies. 5. Patient 7’s clinical record included a ROC on 6/03/25 with orders for SN visit frequencies of two times a week for one week, three times a week for five weeks and then two times a week for one week effective 6/03/25; a PT evaluation and treat effective 6/10/25 and an OT evaluation and treat effective 6/10/25. The record evidenced SN visits were performed on 6/03/25, 6/06/25, 6/09/25, 6/10/25 and 6/13/25 and PT and OT evaluations were performed on 6/12/25. The clinical record for Patient #7 failed to include a verbal or signed written order for the ROC frequencies was obtained prior to the above visits performed. During an interview on 6/17/25 at 4:00 PM, RN 2 relayed she collaborated with the physician regarding the ROC and documented it in a communication note on 6/09/25. She confirmed the communication notes were not sent to the physician for signature. During an interview on 6/13/25 at 1:27 PM, the CM relayed all verbal orders should be placed on a physician’s order form that is sent to the physician for signature and he verified the communication notes are not sent to the physician. 6. Patient 9’s clinical record included a POC for certification period 5/06/25 to 7/04/25 with orders for SN visit frequencies of two times a week for one week then three times a week for three weeks; HHA visit frequencies of two times a week for four weeks; PT re-eval and treat; and OT visit frequencies of one time a week for one week, two times a week for three weeks and one time a week for one week. The record evidenced SN visits were performed on 5/07/25, 5/09/25, 5/12/25, 5/14/25, 5/16/25, 5/18/25, 5/23/25, 5/24/25, 5/26/25, 5/28/25, 5/30/25, 6/03/25, 6/05/25, 6/07/25, 6/09/25, 6/11/25, 6/13/25 and 6/16/25; HHA visits were performed on 5/09/25, 5/23/25, 5/24/25, 5/30/25, 5/31/25, 6/07/25 and 6/13/25; and OT visits were performed on 5/06/25, 5/08/25, 5/12/25, 5/15/25, 5/19/25, 5/22/25 and 5/26/25 . The clinical record for Patient #9 failed to include a verbal or signed written order for SN frequencies was obtained prior to the above visits performed. During an interview on 6/13/25 at 1:45 PM, OT 2 relayed she created a physician’s order after the 5/02/25 OT reevaluation and it was sent to the physician for signature. During an interview on 6/17/25 at 4:25 PM, RN 1 relayed she was unsure if she spoke with the physician for the recertification POC.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all verbal orders were authenticated and signed by the ordering physician or practitioner within 30 days for 2 of 14 complete records reviewed (Patients #10, #15). Findings include: 1. The agency policy “Physician/Practitioner Orders – Verbal Orders,” dated 11/22/2023, indicated after a verbal order was documented, it was to be sent to the physician for signature and authentication. 2. The agency QAPI documentation for 2025 evidenced the agency tracked the number of verbal orders received authenticated and signed from the ordering physician within 30 days. 3. Patient #10’s clinical record evidenced a SOC of 4/23/2025. The record evidenced the following verbal orders were obtained: a. An order to delay SOC, dated 4/23/2025 and signed by RN 2. The order was entered in the EMR by RN 2 on 6/15/2025. b. An order to begin home health services, including a PT and OT evaluation, dated 4/23/2025 and signed by RN 2. c. An order to begin PT visits and for the PT portion of the POC, dated 4/24/2025 and signed by PT 2. d. An order to begin OT visits, dated 4/28/2028 and signed by OT 6. The record failed to evidence the ordering physician authenticated and signed the verbal orders within 30 days. During an interview on 6/18/2025 beginning at 1:32 PM, Alternate Administrator reported the agency had no signed verbal orders for Patient. 4. Patient #10’s clinical record evidenced a SOC of 5/12/2025. The record evidenced the following verbal orders were obtained: a. An order to delay SOC, dated 5/13/2025 by RN 4. b. An order to begin home health services, including SN and HHA frequencies and a PT, OT, and MSW evaluation, dated 5/13/2025 by RN 4. The record failed to evidence the ordering physician authenticated and signed the verbal orders within 30 days. During an interview on 6/18/2025 beginning at 1:32 PM, Alternate Administrator reported the agency had no signed verbal orders for Patient. 5. During an interview on 6/19/2025 beginning at 1:42 PM, Administrator reported verbal orders were to be authenticated and signed by the ordering physician within “30 – 60 days.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the POC was reviewed with the physician or attending practitioner no less frequently than once every 60 days, for 4 of 6 active records reviewed with a recertification (Patient #1, 2, 7 and 9). Findings include: 1. The undated agency policy “Plan of Care-CMS #485 and Physician/ Practitioner Orders” indicated recertification of the Plan of Care is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode and the individualized plan of care must be reviewed and revised by the physician/practitioner who is responsible for the home health plan of care and the agency as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. 2. Patient #2’s clinical record was reviewed on 6/12/25 and evidenced a SOC on 4/03/25 and a current certification period of 6/02/25 to 7/31/25. The record failed to include a recertification POC had been created for the certification period beginning 6/02/25. Additional record review on 6/16/25 evidenced a POC had been created for the certification period 6/02/25 to 7/31/25. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/13/25 at 2:45 PM, RN 2 relayed she completed an updated comprehensive assessment on 5/29/25 and she failed to create the recertification POC as she was waiting to hear back from the physician’s office. She relayed that she created the POC on 6/12/25 in the evening and she was unsure if she received orders from the physician. 3. Patient #4’s clinical record evidenced a SOC on 3/26/25 and a POC for the certification period of 5/25/25 to 7/23/25. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed he thought he collaborated with the physician but was unsure if he documented the collaboration. 4. Patient #7’s clinical record evidenced a SOC on 5/19/25 and included a ROC POC effective 6/03/25. The ROC indicated the patient was to receive an OT evaluation and treat visit and a PT evaluation and treat visit. The clinical record evidenced the OT evaluation was completed by OT 3 on 6/12/25 and the PT evaluation was completed by PT 2 on 6/12/25. The record failed to evidence collaboration with the physician after the OT and PT evaluations for the POC. During an interview on 6/13/25 at 2:42 PM, OT 3 confirmed that she did not collaborate with the physician for the ROC POC and relayed she writes up the evaluation and physician orders and it is sent to the physician via the computer. She was unsure if any orders had been received back from the physician’s office. During an interview on 6/13/25 at 2:30 PM, PT 2 confirmed he did not collaborate with the physician for the PT POC. He relayed he created the PT POC and it was sent to the physician. 5. Patient #9’s clinical record evidenced a SOC on 11/07/24 and a POC for the certification period of 5/06/25 to 7/04/25. The record failed to include collaboration with the physician for the recertification POC and failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 6/17/25 at 4:25 PM, RN 1 relayed she was unsure if she spoke with the physician for the recertification POC.”

“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 record review and interview, the home health agency failed to promptly alert the physician for a change in the patient condition and/or need to alter the POC for 1 of 1 record reviewed which evidenced a patient fall (Patient #15) and 2 of 4 records reviewed which evidenced missed visits (Patient #4, #15). Findings include: 1. The agency policy “Notification of Physician Regarding Missed Visits,” dated 02/2024, indicated a missed visit which could not be rescheduled was to be communicated to the physician. Staff were to document the “time faxed, the time and person communicated with, or the date notice was mailed.” 3. Patient #15’s clinical record evidenced a SOC date of 5/12/2025. Patient’s POC included service orders for SN visits three times a week, HHA visits three times a week, and PT, OT, and MSW evaluations. The record indicated a SN missed visit was documented on 5/15/2025, Patient did not receive a SN visit between 5/12/2025 – 5/22/2025, and a HHA missed visit was documented on 5/19/2025 and 5/21/2025. The record failed to evidence Patient’s physician was notified of the missed visits. During an interview on 6/17/2025 beginning at 11:17 AM, LPN 1 reported when she arrived for Patient’s SN visit on 5/22/2025, Patient was found on the floor and reported they have fallen. The record indicated on 5/22/2025, LPN 1 documented she was present at Patient’s home for a visit. The record failed to evidence the nurse notified Patient’s physician of the fall. During an interview on 6/19/2025 beginning at 10:02 AM, LPN 1 reported she did not report the missed SN visits to Patient’s physician. During an interview on 6/18/2025 beginning at 12:42 PM, HHA 2 stated she reported the missed aide visits to staff at the agency, but could not recall to whom. 2. Patient #4’s clinical record evidenced a SOC date of 3/26/25 and included a POC for the certification period 5/25/25 to 7/23/25 with orders for SN visits three times a week for two weeks and then two times a week for two weeks effective 5/26/25. The record indicated SN missed visits were documented on 5/27/25 and 5/28/25. The record failed to evidence Patient #4’s physician was notified of the missed visits. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed he did collaborate with the physician regarding the missed visits. During an interview on 6/18/25 at 1:37 PM, Patient #4 relayed he was not notified in advance of the missed visits. He was frustrated with the home health agency due to several missed visits and not receiving wound care when needed and he requested to be transferred to another home health agency.”

“Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide a plan of care to the patient in a timely manner for 2 of 6 home visit observations (Patients #10, #13). Findings include: 1. Patient #10’s clinical record evidenced a SOC date of 4/23/2025. RN 2 conducted a comprehensive assessment on 4/23/2025. A POC for the initial certification period of 4/23/2025 – 6/21/2025 evidenced Patient was to receive PT and OT services. During a home visit observation on 6/16/2025 beginning at 1:38 PM, Patient #10 had a manilla folder laying on their kitchen table, which included a POC for the certification period of 4/23/2025 – 6/21/2025. During an interview on 6/16/2025 beginning at 2:32 PM, Patient reported approximately half an hour prior to the start of the home visit observation, an unknown female employee of the agency came to Patient’s home and gave Patient the file folder with the POC. Patient reported the employee told him/her that the papers within the folder would be needed for the home visit observation. Patient stated the agency had not previously provided a POC. During an interview on 6/19/2025 beginning at 2:27 PM, RN 2 reported it was the office staff’s responsibility to provide the POC to Patient. 2. Patient #13’s clinical record evidenced a SOC date of 6/10/25 and included a POC for the certification period 6/10/25 to 8/08/25. The record evidenced Patient #13 received SN and OT visits on 6/13/25. During an interview with Patient #13 on 6/16/25 beginning at 1:45 PM, Patient #13 relayed an unidentified person from the home health agency came in to her home unannounced and dropped off a copy of the POC a few minutes before the home visit was scheduled. She was able to show the POC to Surveyor during the home visit observation and was questioning what the document was.”

“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 observation, document review and interview, the home health agency failed to provide the patient and/or caregiver with accurate clinical manager information for 9 of 9 active patients reviewed with SOC in the past 90 days (Patient #1, 2, 3, 4, 5, 7, 10, 12 and 13). Findings include: 1. During a home visit observation with Patient #1 on 6/13/24 at 9:27 AM, the home health agency’s folder was reviewed and included a copy of a document titled “Admission Instructions to Patient” which was signed by Patient #1 on 5/13/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 2. Patient #2’s clinical record included a document titled “Admission Instructions to Patient” which was signed by Patient #2 on 4/03/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 3. Patient #3’s clinical record included a document titled “Admission Instructions to Patient” which was signed by Patient #3 on 5/06/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 4. Patient #4’s clinical record included a document titled “Admission Instructions to Patient” which was signed by Patient #4 on 3/26/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 6. Patient #7’s clinical record included a document titled “Admission Instructions to Patient” which was signed by Patient #7 on 5/19/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 7. Patient #3’s clinical record included a document titled “Admission Instructions to Patient” which was signed by Patient #3 on 5/06/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 10. During a home visit observation with Patient #13 on 6/16/24 at 1:45 PM, the home health agency’s folder was reviewed and included a copy of a document titled “Admission Instructions to Patient” which was signed by Patient #13 on 6/10/25 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 11. During an interview on 6/12/25 at 11:25 AM, the Alternate Administrator verified the current clinical manager. She also confirmed the patient handbook had incorrect CM information. 12. During an interview on 6/13/25 at 1:27 PM, the CM verified the clinical manager listed in the patient’s home binder was inaccurate and indicated the patients should have been given the correct information to include the current clinical manager’s name and contact information. 7. Patient #10’s clinical record included a document titled “Admission Instructions to Patient,” which was signed by Patient #10 on 4/23/2025 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. During a home visit observation on 6/16/2025 beginning at 1:38 PM, the home health agency’s folder was reviewed. The handbook evidenced Former Clinical Manager 3 was listed as the agency’s clinical manager. 10. Patient #15’s clinical record included a document titled “Admission Instructions to Patient,” which was signed by Patient #10 on 5/12/2025 during the SOC visit. The document failed to evidence the correct name and contact information of the clinical manager. 5. Patient #5’s medical record evidenced an undated document titled “Admission Instructions to Patient.” The document signed by Patient #5 on 03/14/2025 included the contact information for the former Clinical Manager. The current Clinical Manager took the position on 03/10/2025. The agency failed to notify patients of the contact information of the current clinical manager. 8. Patient #12’s medical record evidenced an undated document titled “Admission Instructions to Patient.” The document, signed by Patient #12 on 05/19/2025, included the contact information for the former Clinical Manager. The current Clinical Manager took the position on 03/10/2025. The agency failed to notify patients of the contact information of the current clinical manager.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, policy review, and interview, the PTA failed to conduct a pain assessment for 1 of 1 home visit observation with a PTA (Patient #10), and the SN failed to measure wounds for 1 of 1 discharged wound patient with RN 1 (Patient #16). Findings include: 1. The undated agency policy “Pain Assessment and Reassessment” indicated patients receiving therapy services, including physical therapy, would have their pain assessed and reassessed “as appropriate and relevant to the care provided by the therapist … Each therapist will use the same established criteria for assessing and reassessing pain ….” 2. Patient #10’s clinical record evidenced a POC for the initial certification period of 4/23/2025 – 6/21/2025. The POC indicated PT interventions included to “assess functional status … pain management ….” During a home visit observation on 6/16/2025 beginning at 1:38 PM, PTA 5 was observed assisting Patient #10 with physical therapy exercises. During the visit, Patient began to complain of pain to the lower back and had to pause the therapy exercises. Patient also reported pain to the right knee which began approximately one week prior. PTA 5 failed to assess Patient’s pain, including severity, description, interventions which make the pain better or worse, etc. During an interview on 6/16/2025 beginning at 2:28 PM, PTA 5 reported she “always” asked patients what their pain severity was, however she did not assess this during Patient’s visit. 3. Patient #16’s medical record evidenced a POC for certification period 12/14/2025 – 02/11/2025, completed by RN 1. The POC evidenced diagnoses of stage 2 pressure ulcers (shallow open ulcers due to prolonged pressure) of the right and left buttocks. The POC evidenced wound care orders for “SN to perform wound care to sacral area. Cleanse wound with soap and water, apply A & D ointment, cover and secure with Duoderm [a type of wound dressing], using aseptic technique.” The POC included a statement that it was a “… taxing effort to leave home due to pressure ulcer wound.” Patient #16’s medical record evidenced SN visits performed by RN 1 on 12/30/2024, 01/01/2025, 01/06/2025, 01/08/2025, and 01/15/2025. All SN visit notes indicated RN 1failed to complete wound measurements. The documented reason there were no wound measurements was “No measurement tools.” During an interview on 06/18/2025 beginning at 12:30 PM, RN 1 indicated wound measurements were due weekly. RN 1 indicated they did not believe the wounds were pressure ulcers and did not require measurements. RN 1 indicated the visit note template required an answer to the reason no measurements were taken, so they used “no measurement tools.” RN 1 confirmed they did not measure the wound.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all visit note documentation was completed within 14 days for 3 of 7 active patient records reviewed with wounds (Patient #2, 5 and 7) and 4 of 5 discharged records reviewed (Patient’s #3, 4, 14 and 15). 7. Patient #15’s clinical record included a POC for the initial certification period of 5/12/2025 – 7/10/2025. Patient was ordered to receive skilled nurse visits three times a week, with interventions to include “SN to perform complete physical assessment each visit … notify physician immediately of any potential problems ….” The SN was also to perform wound care to wounds on both heels. On 5/22/2025, LPN 1 documented a communication note stating she was at Patient’s home “for assessment visit.” The record failed to evidence any further documentation regarding the visit, including the SN assessment, wound care performed, and physician notification of Patient’s fall. During an interview on 6/17/2025 beginning at 11:17 AM, LPN 1 reported she conducted one visit with Patient but could not recall the date of the visit. The nurse stated she found Patient lying on the floor and Patient reported they had fallen. LPN 1 stated she conducted an assessment, including “vital signs and stuff,” but was unsure if she had documented this assessment. LPN 1 reported she notified Patient’s physician of the fall, however there was no documentation of this report. Findings include: 1. The agency policy “Timely Submission of Patient Documentation”, last updated 11/22/23, indicated visit itineraries, with all visit notes, must be submitted within fourteen (14) calendar days and upon discharge from services, the patient discharge summary must be submitted within five (5) business days. 2. Patient #2’s clinical record was reviewed on 6/12/25. The record failed to evidence any SN visits performed after 5/22/25. Additional record review on 6/16/25 evidenced a SN visit was completed on 5/27/25. This visit note was completed 6/14/25, 18 days after the visit. A SN recertification visit was completed on 5/29/25. This visit note was completed on 6/13/25, 15 days after the visit. The RN failed to complete SN visit notes within 14 days of the visit. During an interview on 6/13/25 at 2:45 PM, RN 2 relayed she had seven to fourteen days to complete visit notes in the EMR. 3. Patient #3’s clinical record evidenced a discharge date on 5/21/25 and included a discharge summary that was completed on 6/17/25 by the CM. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/17/25 at 12:35 PM, the CM relayed the discharge summary should be sent to the physician as soon as possible once the discharge has been completed. 4. Patient #4’s clinical record evidenced a discharge date on 6/06/25 and included a discharge summary that was completed on 6/17/25 by RN 3. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed the discharge summary had not been sent to the physician because he had not completed the discharge note yet. 6. Patient #7’s clinical record was reviewed on 6/13/25 and evidenced a SOC on 5/19/25 and a ROC on 5/28/25. The record failed to include a ROC SN visit note had been completed for 5/28/25. During an interview on 6/17/25 at 4:00 PM, RN 2 confirmed she did not create a SN visit note for the 5/28/25 ROC visit. She relayed she created this late. 7. Patient #14’s clinical record evidenced a discharge date on 5/27/25. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/18/25 at 11:35 AM, the Alternate Administrator verified the discharge summary for Patient #14 had not been sent to the physician yet. 5. Patient #5’s medical record evidenced documentation of the Recertification assessment dated 05/09/2025, completed by RN 2. The document activity detail report, which identified when a clinician completed a document, indicated RN 2 completed the document on 05/30/2025. During an interview on 06/12/2025 during the entrance conference, the Alternate Administrator indicated clinicians often completed documentation late. Patient #11’s medical record evidenced documentation of a nursing visit on 06/03/2025 completed by LPN 2. The note indicated Patient #11 had a new wound care order. The documentation in the “Wound Care Performed” section of the note indicated LPN 2 performed wound care inconsistent with the new wound care order. During an interview on 06/19/2025 at 12:50 PM, LPN 2 indicated they performed the wound care as the new order instructed. LPN 2 indicated the “Wound Care Performed” section of the note automatically pulled the most recent wound care instructions entered in the EMR. LPN 2 indicated the new wound orders were not entered in the EMR at the time of the visit with Patient #11. LPN 2 indicated they could not change the “Wound Care Performed” section of the note. LPN 2 confirmed they should have documented the actual care performed in the comments section of the note. During an interview on 06/19/2025 at 03:10 PM, the Administrator indicated the nurse should have documented the wound care they performed.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the RN supervised the LPN every 30 days on-site for 1 of 1 active clinical record reviewed of patients receiving skilled wound care services with an LPN (Patient #9). Findings include: 1. The undated agency policy Supervision of Licensed Practical/Licensed Vocational Nurse” indicated services furnished by a Licensed Practical/Licensed Vocational Nurse will be furnished under the supervision of a qualified registered nurse and supervisory visits will occur every 30 days. 2. Patient #9’s clinical record included a POC for the certification period 5/06/25 to 7/04/25 and included orders for SN, PT, OT and HHA services. The record evidenced the LPN performed visits on 5/07/25, 5/09/25, 5/12/25, 5/14/25, 5/16/25, 5/19/25, 5/23/25, 5/24/25, 5/26/25, 5/28/25, 5/30/25, 6/03/25, 6/05/25, 6/07/25, 6/09/25, 6/11/25, 6/13/25 and 6/16/25 and RN 1 documented LPN supervisory visits on 4/04/25, 5/06/25 and 5/30/25. The clinical record failed to evidence RN 1 performed on-site LPN supervisory visits every 30 days with Patient #9. 3. During an interview on 6/17/25 at 2:26 PM, Patient #9 relayed RN 1 visited him every couple of months. 4. During an interview on 6/18/25 at 1:49 PM, RN 1 relayed LPN supervisory visits should be done every month and she relayed she didn’t always do the supervisory visits in person, she sometimes called Patient #9 to check-in.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on personnel file review and interview, the home health agency failed to ensure the HHA was qualified to provide home health services for 1 of 2 HHA personnel files reviewed who have been employed more than one year (HHA 2). Findings include: 1. The undated agency policy “Home Health Aide Services and Training Program” indicated a qualified Home Health Aide is a person who has successfully completed: a nurse aide training and competency evaluation program approved by the state as meeting the requirements and is currently listed in good standing on the state nurse aide registry. 2. HHA 2’s personnel file indicated a hire date of 6/20/24. The file included a certificate issued by Entity E on 6/13/24. The file failed to evidence a qualified training and competency evaluation program. 3. Review of the State of Indiana’s license and certification verification website, www.mylicense.IN.gov, on 6/19/25 failed to evidence an active HHA license for HHA 2. 4. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator confirmed HHA 2 was not listed on the State of Indiana’s license and certification verification website. She also relayed that the Administrator initiated the HHA training from Entity E.”

“Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This Element is not met as evidenced by: Based on personnel file review and interview, the home health agency failed to ensure the HHA obtained the appropriate HHA training for 1 of 1 unlicensed HHA who was hired in the past year (HHA 2). Findings include: 1. The undated agency policy “Home Health Aide Services and Training Program” indicated a qualified Home Health Aide is a person who has successfully completed: a nurse aide training and competency evaluation program approved by the state as meeting the requirements and is currently listed in good standing on the state nurse aide registry and home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or licensed practical nurse who is under the direct supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. 2. HHA 2’s personnel file indicated a hire date of 6/20/24. The file included a certificate titled “National Caregiver Certification as a Home Health Aide” issued by Entity E on 6/13/24. The file failed to evidence HHA 2 participated in a qualified training and competency evaluation program which included classroom and practical training. 3. During an interview on 6/19/25 at 2:00 PM, the Alternate Administrator relayed the only training HHA 2 received was the online certification course through Entity E and she was unsure if Entity E’s course was an approved training course.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the RN supervised the HHA every 14 days for 1 of 1 active clinical record reviewed of patients receiving skilled wound care services and HHA services (Patient #9). Findings include: 1. The undated agency policy “Home Health Aide Supervision” indicated if home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care and the written patient care instructions must make an onsite visit to the patient’s home no less frequently than every 14 days. 2. Patient #9’s clinical record included a POC for the certification period 5/06/25 to 7/04/25 and included orders for SN, PT, OT and HHA services. The record evidenced the RN performed HHA supervisory visits on 4/30/25, 5/16/25, 5/30/25 and 6/11/25. The clinical record failed to evidence RN 1 performed HHA supervisory visits every 14 days. 3. During an interview on 6/17/25 at 2:26 PM, Patient #9 relayed RN 1 visited him every couple of months. 4. During an interview on 6/17/25 at 4:25 PM, RN 1 relayed HHA supervisory visits should be done every 30 days and when queued, she stated she did not perform HHA supervisory visits for Patient #9 every 14 days.”

“If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the RN completed an on-site HHA supervisory visit every 14 days for 2 of 2 active clinical record reviewed of patients receiving HHA services (Patient #9 and 12). Patient #12’s medical record evidenced documentation of a supervisory visit for HHA 2 dated 05/28/2025. The note failed to evidence RN 1 met with Patient #12 in person to review HHA 2’s performance. During an interview on 06/18/2025 beginning at 12:30 PM, RN 1 indicated they called Patient #12 to review HHA’s performance and did not make a visit with Patient #12. During an interview on 06/19/2025 beginning at 04:37 PM, the Administrator indicated RN’s need to do supervisory visits in the patients’ homes. Findings include: 1. The undated agency policy “Home Health Aide Supervision” indicated if home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care and the written patient care instructions must make an onsite visit to the patient’s home no less frequently than every 14 days. 2. Patient #9’s clinical record included a POC for the certification period 5/06/25 to 7/04/25 and included orders for SN, PT, OT and HHA services. The record evidenced the RN performed HHA supervisory visits on 4/30/25, 5/16/25, 5/30/25 and 6/11/25. The clinical record failed to evidence RN 1 performed HHA supervisory visits every on-site14 days. During an interview on 6/17/25 at 2:26 PM, Patient #9 relayed RN 1 visited him every couple of months. During an interview on 6/17/25 at 4:25 PM, RN 1 relayed HHA supervisory visits should be done every 30 days and when queued, she stated she did not perform HHA supervisory visits for Patient #9 every 14 days in person. She relayed she sometimes called Patient #9 to check-in.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient address was in the medical record for 1 of 1 home visit observations scheduled on 06/13/2025 with RN 2 (Patient #5). Findings include: On 06/12/2025 at 4:05 PM, the Alternate Administrator provided Patient #5’s POC document, which included the address of Patient, for a home visit scheduled for 06/13/2025 at 10 AM. On 06/13/2025, the surveyor arrived at the address listed on the POC at 09:30 AM. At 10:10 AM, the surveyor knocked on the identified address. There was no answer. At 10:20 AM the surveyor called RN 2 to enquire about the nurse’s estimated time of arrival. When the surveyor gave the address, RN 2 indicated this was the patient’s old address.”

“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 record review and interview, the home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 5 of 5 discharged records reviewed (Patient #3, 4, 14, 15 and 16). 5. Patient #15’s clinical record evidenced a discharge date of 5/22/2025. A discharge summary was completed on 5/22/2025, however the record failed to evidence the discharge summary was sent to Patient’s physician within 5 days of discharge. During an interview on 6/19/2025 beginning at 10:50 AM, Alternate Administrator reported the agency had no record of Patient’s discharge summary being sent to the physician within 5 days of discharge. Findings include: 1. The agency policy “Discharge Summary”, last revised 02/2021 indicated a discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. 2. The agency policy “Timely Submission of Patient Documentation”, last updated 11/22/23, indicated visit itineraries, with all visit notes, must be submitted within fourteen (14) calendar days and upon discharge from services, the patient discharge summary must be submitted within five (5) business days. 3. Patient #3’s clinical record evidenced a discharge date on 5/21/25 and included a discharge summary that was completed on 6/17/25 by the CM. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/17/25 at 12:35 PM, the CM relayed the discharge summary should be sent to the physician as soon as possible once the discharge has been completed. 4. Patient #4’s clinical record evidenced a discharge date on 6/06/25 and included a discharge summary that was completed on 6/17/25 by RN 3. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/16/25 at 4:53 PM, RN 3 relayed the discharge summary had not been sent to the physician because he had not completed the discharge note yet. 5. Patient #14’s clinical record evidenced a discharge date on 5/27/25. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 6/18/25 at 11:35 AM, the Alternate Administrator verified the discharge summary for Patient #14 had not been sent to the physician yet. 6. Patient #13’s medical record evidenced a SOC of 12/14/2024 and a discharge date of 01/17/2025. The Secure Messaging application B evidenced a note by the Alternate Administrator on 02/25/2025, which indicated Patient #16 was discharged. During an interview on 06/17/2025 beginning at 4 PM, the Alternate Administrator indicated there was no record of the discharge summary being sent to Patient #13’s primary care provider.”