Majestic Home Health LLC

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included strategies for addressing emergency events identified by the risk assessment (See E0006); failed to ensure the EP Plan addressed patient population, including, but not limited to, the type of services the home health agency has the ability to provide in an emergency (See E0007); failed to ensure the EP Plan included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation (See E0009); failed to ensure each patient had an individualized EP plan and failed to ensure the individualized EP plans were complete and accurate (See E0017); failed to ensure policies or procedures were implemented to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency (See E0024); agency failed to ensure the EP Plan included names and contact information of agency staff (See E0030); failed to ensure the EP Plan included contact information for local EP staff for all counties the agency served (See E0031); failed to ensure the EP Plan included both primary and alternate means of contacting Federal, State, regional, and local emergency staff (See E0032); failed to the ensure the EP Plan included a means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee (See E0034); and failed to ensure all staff received training upon hire and at least every two years (See E0037). Findings include: The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR §484.102 Emergency preparedness, with the likelihood to affect all 15 current patients receiving Home Health services from this provider.”

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the Patient with a copy of the OASIS privacy notice (See G416); failed to obtain power of attorney paperwork (See G418); failed to ensure the Patient was informed about the delay in the initial OT evaluation assessment (See G434); failed to ensure the patient received the ST evaluation as ordered on the POC (See G436); failed to ensure patients were notified of the State hotline hours of operation (See G444); failed to ensure patients received a copy of the agency’s discharge and transfer policies (See G452); and failed to ensure collaboration with the physician prior to discharge (See G458). Findings include: The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.50 Patient rights, with the likelihood to affect all 15 current patients receiving Home Health services from this provider.”

“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 POC was established with the physician or allowed practitioner (See G572); failed to ensure all required information was included in the POC and failed to ensure all information included in the POC was correct (See G574); failed to ensure physician or allowed practitioner orders were received prior to services and treatments being provided (See G580); failed to ensure the POC was reviewed by the physician or allowed practitioner at least every 60 days (See G588); failed to notify the physician regarding the need to alter/change the POC (See G590); failed to ensure collaboration with outside entities also providing care for the patient (See G608); failed to ensure the caregiver was provided wound care education (See G610); and failed to provide the current CM’s name and contact information to patients (See G622). A deficient practice citation was also evidenced at this standard as follows: Based on record review and interview, the home health agency failed to meet the patient’s needs for 1 of 1 record reviewed with a referral for ST services (Patient #1) and 1 of 1 record reviewed with a referral for HHA services (Patient #6). Findings include: 2. Patient #6’s clinical record evidenced a referral for PT, OT and HHA services was received from Physician I on 1/30/26. The record included a comprehensive assessment completed by PT 2 on 2/04/26 and a POC for the certification period of 2/04/26 to 4/04/26 with orders for PT and OT services only. The record failed to evidence Patient #6 was offered HHA services as indicated in the referral to home health. During an interview on 5/28/26 at 3:20 PM, the Administrator relayed she was unsure if Patient #6 was offered HHA services and was unsure if Physician I had been notified of not offering HHA services. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed they were unsure if Patient #6 was offered HHA services at SOC and were also unsure if the Physician was notified of not receiving HHA services. 1.Patient #1’s clinical record included a referral dated 7/03/24 which included but was not limited to orders for a ST evaluation. The record failed to evidence a ST evaluation was offered or completed for Patient #1.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on QAPI document review, governing body document review, policy review and interview, the home health agency failed to show measurable improvement in indicators which will improve health outcomes, patient safety, and quality of care (See G642); failed to ensure the governing body approved the frequency and data of QAPI (See (G644); and failed to document performance improvement projects (See G658) for 1 of 1 agency. Findings include: The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR §484.65 Condition: Quality Assessment/Performance Improvement.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Alternate Administrator was authorized in writing (See G954); failed to ensure the Clinical Manager was involved in daily activities of the agency (See G958); failed to ensure the Clinical Manager coordinated patient and personnel assignments (See G960); failed to ensure the Clinical Manager coordinated patient care (See G962); and failed to ensure the Clinical Manager was involved in coordinating referrals (See G964). Findings include: The cumulative effect of these problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.105 Organization and Administration of Services.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included strategies for addressing emergency events identified by the risk assessment for 1 of 1 EP Plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… Strategies should be developed based on events identified during the development of the HVA [hazard vulnerability analysis] such as staffing strategy for staff shortages and a surge capacity strategy in the event the organization accepts additional patients during an emergency… Specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities will be developed for each priority emergency…” 2. The EP plan included a hazard vulnerability assessment updated with data as of 11/01/25 which identified the following hazards as moderate, moderate to high, or high probability: Fire/ Wildfire/ Extreme Heat, Severe Thunderstorms, Tornado, Flooding/ Flash Flooding, Winter Storms (Snow Storm, Ice Storm, Extreme Cold), Hazardous Materials Incidents, Utility Failures, Transportation Interruptions, Active Shooter/ Hostage Situation/ Explosives Attack, Cyber Security Attack, and Emerging Infectious Disease Pandemics. The EP Plan failed to include strategies to address Fire/ Wildfire, Hazardous Materials Incident, Utility Failures, Transportation Interruptions, Active Shooter, and/ or Pandemic. 3. During an interview on 6/02/26 at 1:34 PM, the Administrator relayed the EP Plan should include strategies to address hazards identified in the hazard vulnerability assessment. 4. During an interview on 6/02/26 at 1:35 PM, the CM relayed the EP Plan did not include strategies for addressing Fire/ Wildfire, Hazardous Materials Incident, Utility Failures, Transportation Interruptions, Active Shooter, and/ or Pandemic.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan addressed patient population, including, but not limited to, the type of services the home health agency has the ability to provide in an emergency for 1 of 1 EP Plan. Findings include: 1. The EP plan failed to address the types of services the home health agency has the ability to provide in an emergency. 2. During an interview on 6/02/26 at 1:35 PM, the CM relayed she did not see anything in the EP Plan that addressed the type of services the home health agency has the ability to provide in an emergency.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation for 1 of 1 EP Plan. Findings include: 1. The EP plan failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. 2. During an interview on 6/02/26 at 1:35 PM, the CM indicated she saw contact information for emergency officials in the EP Plan but did not see a process for cooperation and collaboration with emergency officials.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure each patient had an individualized EP plan for 1 of 6 patient records reviewed (Patient #6) and failed to ensure the individualized EP plans were complete and accurate for 4 of 5 patient records reviewed who had an individualized EP plan (Patient #1, 2, 3, and 5). 5. Patient #5’s clinical record included an individualized EP plan completed on 4/17/26 which evidenced an EP triage level of 1. The record also included a POC for certification period 4/17/26 to 6/15/26 which evidenced an EP triage level of 3. During an interview on 5/29/26 at 1:50 PM, PT 1 relayed the EP triage level should have been the same on the individual EP plan and the POC. the Administrator relayed she could not say why Patient #2’s EP triage levels were inconsistent between the individualized EP plan and the POC. 6. Patient #6’s clinical record evidenced a SOC on 2/4/26 and included copies of the signed admission documents. The record failed to evidence an individual EP plan had been created. 7. During an interview on 5/29/26 at 3:09 PM, the CM indicated the individual emergency plan should be completed at SOC and the EP triage levels should be the same on the individual EP plan and the POC. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… Individualized plans for patients during a natural or man-made disaster will be included as part of the comprehensive patient assessment… During the comprehensive assessment, the patient will be placed in one of three categories for triaging patient care in the even the emergency management plan (operations) is implemented… The agency maintains a hard-copy of a current patient list including contact information and categories identified for each patient…” 2. Patient #1’s clinical record evidenced an individualized EP Plan which included incorrect telephone numbers for Patient #1’s emergency contact person. During an interview on 6/01/26 at 2:33 PM, the CM indicated Patient #1’s clinical record and the patient list in the EP Plan binder did not include a correct emergency contact phone number and relayed they needed to get that updated. 3. Patient #2’s clinical record included an individualized EP plan completed on 4/09/26 which had an EP triage level of 1. The record also included a POC for certification period 4/09/26 to 6/07/26 which included an EP triage level of 3. During an interview on 6/01/26 at 2:42 PM, the Administrator relayed she could not say why Patient #2’s EP triage levels were inconsistent between the individualized EP plan and the POC. 4. Patient #3’s clinical record included an individualized EP plan completed on 5/01/26 which had an EP triage level of 1, The record also included a POC for certification period 5/01/26 to 6/29/26 which included an EP triage level of 2. During an interview on 6/01/26 at 2:51 PM, the Administrator relayed she did not know why Patient #3’s EP triage levels were inconsistent between the individualized EP plan and the POC. 8. During an interview on 6/01/26 at 2:19 PM, the Administrator indicated the EP triage level on the individualized EP plan and the triage level on the POC should be the same.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure policies or procedures were implemented to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for 1 of 1 EP plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… Staff will work with regional or county emergency management planning agencies, where available, in… Defining organization’s role in relation to the community-wide emergency management program, use of volunteers, other emergency staff, including state or federally-designated healthcare professionals to address the organization’s surge needs…” 2. The EP plan failed to include implementation of policies and procedures to address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs 3. During an interview on 6/02/26 at 1:35 PM, the CM relayed she did not see anything in the EP Plan about the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included names and contact information of agency staff for 1 of 1 EP Plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… The plan includes the following… Names and contact information for the following… Staff…” 2. The EP plan failed to include names and contact information for agency staff. 3. During an interview on 6/02/26 at 1:35 PM, the CM relayed the EP Plan did not include an agency staff contact list.”

“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 record review and interview, the home health agency failed to ensure the EP Plan included contact information for local EP staff for all counties the agency served for 1 of 1 EP Plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… The plan includes the following… Contact information for the following… local emergency preparedness staff…” 2. The Geographic Area form (a form used to indicate which counties the agency served) that had been filled out by the Administrator on 5/27/26 included but was not limited to the following counties: Adams, Allen, Bartholemew, Blackford, Brown, Carroll, Cass, Clay, Clinton, Decatur, Delaware, Elkhart, Fayette, Franklin, Grant, Henry, Huntington, Jay, Kosciusko, Miami, Monroe, Montgomery, Owen, Parke, Putnam, Randolph, Rush, Tippecanoe, Union, Vermillion, Vigo, Wabash, Warren, Wayne, Wells, and Whitley. 3. The EP plan failed to include local EP staff contact information for the above counties. 4. During an interview on 6/02/26 at 1:35 PM, the CM relayed the EP Plan did not include contact information for EP staff in all counties listed as served by the agency.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included both primary and alternate means of contacting Federal, State, regional, and local emergency staff for 1 of 1 EP Plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… The plan includes the following… Primary and alternate means for communicating with the staff, federal, State, tribal, regional, and local emergency management agencies…” 2. The EP plan failed to include both primary and alternate means of contacting Federal, State, regional, and local emergency staff. 3. During an interview on 6/02/26 at 1:35 PM, the CM relayed she did not see an alternate means for contacting EP officials in the EP Plan.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the EP Plan included a means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee for 1 of 1 EP Plan. Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… The plan includes the following… A means of providing information about the organization’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee…” 2. The EP plan failed to include a means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. 3. During an interview on 6/02/26 at 1:35 PM, the CM relayed the EP Plan did not include a means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

“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 staff received training upon hire and at least every two years for 4 of 13 active staff (Communication Liaison, RN 2, RN 3, and PT 1). Findings include: 1. The Emergency Management Plan policy, revised December 2025, indicated “… The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff… The training is provided at least every two (2) years and demonstrates staff knowledge of emergency procedures…” 2. The Communications Liaison’s personnel record included a hire date of 6/19/23. Her record included EP training in 2023 and 2026. The record failed to evidence EP training at least every two years. During an interview on 6/02/26 at 2:00 PM, the Business Office Manager relayed she could not find EP training for the Communication Liaison for 2024 or 2025. 3. RN 2’s personnel record included a hire date of 8/05/24. The record failed to evidence any EP Plan training. During an interview on 6/02/26 at 2:00 PM, the Business Office Manager relayed RN 2 had not completed any EP training with the agency. 4. RN 3’s personnel record included a hire date of 5/28/25. The record included EP training in 2026. The record failed to evidence initial EP training at hire. During an interview on 6/02/26 at 2:00 PM, the Business Office Manager relayed RN 3 did not receive EP training upon hire. 5. PT 1’s personnel record included a hire date of 11/29/21. The record included EP training in 2021 and 2026. The record failed to evidence PT 1 received EP training at least every two years. During an interview on 6/02/26 at 2:00 PM, the Business Office Manager relayed she could not find EP training for PT 1 other than in 2021 and 2026.”

“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 agency failed to submit OASIS assessments within 30 days for 1 of 1 agency surveyed. Findings include: 1. The “OASIS Error Summary by Agency Report” evidenced a 19.21% late submission rate for the period 1/01/25 through 12/31/25 and a 23.76% late submission rate for the period of 1/01/26 through 5/29/26. 2. The “OASIS Error Detail Report” indicated there were 165 late OASIS submissions for the period 1/01/25 through 12/31/25 and 67 late OASIS submissions for the period 1/01/26 through 5/29/26. 3. During an interview on 6/01/26 at 2:03 PM, the Administrator relayed she was responsible for OASIS submissions and the information should have been submitted within 30 days of the assessment. 4. During an interview on 6/02/26 at 1:13 PM, the Administrator was unsure why the OASIS submissions were submitted late in 2025 or 2026.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients received a copy of the agency’s discharge and transfer policies at SOC for 1 of 1 agency. 6. Patient #4’s clinical record failed to evidence receipt of the agency’s discharge and transfer policies. 7. Patient #5’s clinical record failed to evidence receipt of the agency’s discharge and transfer policies. 8. Patient #6’s clinical record failed to evidence receipt of the agency’s discharge and transfer policies. 9. During an interview on 5/29/26 at 2:05 PM, RN 1 relayed the home health agency did not give the Patient a copy of the discharge and transfer policy during SOC. Findings include: 1. The Patient Bill of Rights policy, revised December 2025, indicated “… The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights… The Patient Bill of Rights statement defines the right of the patient to… The organization’s transfer and discharge policies…” 2. Review of the agency’s admission packet failed to evidence the agency’s discharge and transfer policies. 3. During an interview on 6/01/26 at 2:19 PM, the Administrator relayed the agency’s discharge and transfer policy should be in the admission packet. 4. During an interview on 6/01/26 at 2:19 PM, the CM relayed she didn’t see the discharge and transfer policy in the admission packet.”

“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 home health agency failed to ensure the POC was established with the physician or allowed practitioner for 6 of 6 patient records reviewed (Patient #1, 2, 3, 4, 5, and 6). 5. Patient #4’s clinical record evidenced a SOC comprehensive assessment completed on 1/12/26 by RN 1 and included a POC for the certification period 1/12/26 to 3/12/26. The clinical record failed to evidence collaboration with the physician for POC orders on 1/12/26. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed they call the physician and notify them of SOC. When queried as to where this is documented, RN 1 stated this must have been missed. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed they created the PT POC and the Administrator sent the POC to the physician for review. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed they created the OT POC and it was faxed to the physician for review. 6. Patient #5’s clinical record evidenced a SOC comprehensive assessment completed on 4/17/26 by PT 1 and included a POC for the certification period 4/17/26 to 6/15/26. The clinical record failed to evidence collaboration with the physician for POC orders on 4/17/26. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed the office staff was responsible for notifying the physician of SOC and was also responsible for sending the POC to the physician for signature. During an interview on 5/28/26 at 1:49 PM, OT 1 stated they couldn’t remember if they collaborated with the physician for POC orders. 7. Patient #6’s clinical record evidenced a SOC comprehensive assessment completed on 2/04/26 by PT 2 and included a POC for the certification period 2/04/26 to 4/04/26. The clinical record failed to evidence collaboration with the physician for POC orders on 4/17/26. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed the CM is responsible for calling the physician and obtaining orders. 8. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed the clinicians are responsible for obtaining verbal physician orders. Findings include: 1. The Physician Participation in Plan of Care policy, Revised December 2025, indicated “… The attending physician (or allowed practitioner) will participate in the care planning process by initiating, reviewing, and revising the plan of care (therapeutic and diagnostic orders) …” 2. Patient #1’s clinical record included a POC for certification period 4/29/26 to 6/27/26 signed by PT 1. The record failed to evidence collaboration with the physician when developing the POC. During an interview on 5/28/26 at 12:37 PM, PT 1 relayed he did not collaborate with the physician regarding Patient #1’s POC and relayed it was his understanding that the CM would call the physician about anything except emergencies like falls. 3. Patient #2’s clinical record included a POC for certification period 4/09/26 to 6/27/26. The record failed to evidence collaboration with the physician when developing the POC. During an interview on 6/01/26 at 2:42 PM, the Administrator relayed there was no documentation of collaboration with the physician when Patient #2’s POC was developed. During an interview on 6/02/26 at 10:24 AM, PT 1 relayed he had only collaborated with Patient #2, their spouse, and the agency’s CM regarding Patient #2’s POC. 4. Patient #3’s clinical record included a POC for certification period 5/01/26 to 6/29/26. The record failed to evidence collaboration with the physician when developing the POC. During an interview on 5/28/26 at 2:40 PM, the Administrator relayed the clinicians should be calling the provider to confirm the POC. During an interview on 6/02/26 at 10:32 AM, PT 1 relayed he collaborated with the agency’s CM regarding the POC, and the CM would take it from there.”

“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 document review, governing body document review, and interview, the home health agency failed to show measurable improvement in indicators which will improve health outcomes, patient safety, and quality of care for 1 of 1 agency. Findings include: 1. The 12/2025 agency policy “Improving Organizational Performance” indicated monitor indicators related to improved outcomes including the use of emergent care services, hospital admissions and re-admissions, and takes actions that address performance across the spectrum of care, including the prevention and reduction of medical errors. 2. Review of the 7/24/25, 10/15/25 and 1/13/26 QAPI meetings failed to include monitoring indicators for emergent care services, hospital admissions and re-admissions, infections, etc. 3. During an interview on 6/02/26 at 1:13 PM, the Administrator relayed the QAPI documentation for the 7/24/25, 10/15/25 and 1/13/26 meeting did not include indicators for emergent care services, hospital admissions and re-admissions, infections, etc.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on QAPI document review, governing body document review, and interview, the home health agency failed to ensure the governing body approved the frequency and data of QAPI for 1 of 1 agency. Findings include: 1. The 12/2025 agency policy “Improving Organizational Performance” indicated the Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually. 2. Review of the agency’s QAPI program documentation provided failed to evidence the governing body approved the detail of the data collection in 2024 and 2025. The agency failed to provide governing body minutes for 2024 and 2025. 3. During an interview on 6/02/26 at 1:10 PM, the Alternate Administrator relayed the agency did not have any governing body minutes to review for 2024 or 2025.”

“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 document review, governing body document review, and interview, the home health agency failed to document performance improvement projects for 1 of 1 agency. Findings include: 1. The 12/2025 agency policy “Improving Organizational Performance” indicated performance improvement projects are conducted that reflect the following standards: The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization’s services and operations and the organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. 2. Review of the 7/24/25, 10/15/25 and 1/13/26 QAPI meetings failed to include documentation regarding performance improvement projects. 3. During an interview on 6/02/26 at 1:13 PM, the Administrator relayed the QAPI documentation for the 7/24/25, 10/15/25 and 1/13/26 meeting did not include performance improvement project documentation.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure the Clinical Manager was involved in daily activities of the agency for 1 of 1 home health agency surveyed. Findings include: 1. During the entrance conference on 5/27/26 at 10:00 AM, the Administrator relayed she was responsible for clinical supervision, in-service training, home health aide supervision, personnel records and the EMR system and the Administrator listed Admin 2 as the Clinical Manager of the home health agency. 2. Review of CMS provider details, last updated on 1/26/26, evidenced Admin 3 as the Clinical Manager of the agency. 3. Review of the home health agency organizational chart evidenced Admin 2 as the Clinical Manager of the agency. 4. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed Admin 1 was the CM of the agency. 5. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed Admin 1 was the CM of the agency. 6. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed Admin 1 was the CM of the agency. 7. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed Admin 2 was the CM of the agency. 8. During an interview on 5/29/26 at 1:10 PM, Admin 2 relayed the Administrator was the CM of the agency. 9. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed Admin 1 was the CM of the agency. 10. During an interview on 5/29/26 at 3:09 PM, Admin 2 relayed they “were getting their feet wet as the Alternate Administrator of the agency.” 11. During an interview on 6/02/26 at 8:29 AM, ST 1 relayed Admin 1 was the CM of the agency. 12. During an interview on 6/02/26 at 9:00 AM, RN 2 relayed Admin 1 was the CM of the agency.”

“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 home health agency failed to ensure all clinical record entries were appropriately authenticated, dated and timed for 1 of 1 discharge record reviewed (Patient #4). Findings include: 1. Patient #4’s clinical record was reviewed on 5/28/26 and evidenced the following: The 1/19/26 LPN visit note included a Verified Visit Log. The Verified Visit Log failed to include GPS coordinates; failed to include time in and time out and failed to include the Patient’s signature. The 1/22/26 LPN visit note included a Verified Visit Log. The Verified Visit Log failed to include GPS coordinates; failed to include time in and time out and failed to include the Patient’s signature. The 2/13/26 LPN visit note included a Verified Visit Log. The Verified Visit Log failed to include GPS coordinates; failed to include time in and time out and failed to include the Patient’s signature. The 2/27/26 LPN visit note included a Verified Visit Log. The Verified Visit Log failed to include GPS coordinates; failed to include time in and time out and failed to include the Patient’s signature. 2. During an interview on 5/29/26 at 11:53 AM, Person A relayed they had complained to the agency regarding missed nurse visits and stated they “didn’t think LPN 1 ever provided wound care three times a week.” During this conversation, Patient #4 relayed the caregiver always signed the tablet confirming the visits when they were made. 3. During an interview on 6/01/26 at 3:50 PM, the CM relayed the LPN visits on 1/19/26, 1/22/26, 2/13/26 and 2/27/26 were missing times, missing the patient or caregiver signature and missing the GPS coordinates to identify if the visit was completed.”

“Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient’s clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to provide patients with accurate information on their right to receive a copy of their clinical record for 1 of 1 agency. Findings include: 1. The Patient Requests for Access to PHI policy, revised December 2025, indicated “… If the patient requests access to only their clinical record, the clinical record will be made available to the patient, free of charge, upon requests at the next home visit, or within 4 business days (whichever comes first) …” 2. The Patient Bill of Rights policy, revised December 2025, indicated “… The Patient Bill of Rights statement defines the right of the patient to… Confidentiality of the clinical records maintained by the organization and the policies and procedures for disclosure…” 3. The Privacy Notice included in the agency’s admission packet indicated “… You may inspect and obtain a copy of your PHI [protected health information] that we have created or received as we provide your treatment or obtain payment for your treatment. To inspect and copy your PHI, you must submit a written request to the Privacy Officer with Majestic Home Health… We may charge you a fee for the reasonable costs that we incur in processing your request…” The agency failed to notify patients of the agency’s policy regarding patient requests for a copy of their clinical records, including but not limited to the timeframe for patient receipt of the clinical record copies and that the copies would be free of charge. 4. During an interview on 6/01/26 at 2:19 PM, the Administrator relayed information regarding a patient’s right to copies of their clinical record should be included in the admission packet and should be consistent with the agency’s policy. 5. During an interview on 6/01/26 at 2:25 PM, the CM relayed the information in the admission packet did not indicate copies would be provided at the next visit or within four business and did not indicate the copies would be free of charge.”

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on admission packet review, record review and interview, the home health agency failed to provide the Patient with a copy of the OASIS privacy notice for 1 of 1 agency. Findings include: 1. Review of the home health agency admission folder and forms failed to include a copy of the OASIS privacy notice. 2. The admission folder included a document titled “Home Health Informed Consent Form.” This form failed to include information regarding the OASIS privacy notice. 3. During an interview on 5/29/26 at 2:05 PM, RN 1 verified the home health agency did not give the Patient a copy of the OASIS privacy notice during SOC. 4. During an interview on 6/01/26 at 2:04 PM, the Administrator thought the agency was giving the Patient a copy of the OASIS privacy notice. When queried as to why it was not in the admission packet, she was unsure.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to obtain POA paperwork for 1 of 1 patient record reviewed with POA signed admission consents (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a SOC on 1/12/26. The record included admission documents and consents signed by Person G on 1/12/26 and an OASIS comprehensive assessment that indicated Person H was the legal representative of Patient #4. The clinical record failed to include proof of POA documentation. 2. During an interview on 6/01/26 at 2:04 PM, the Administrator was unsure who Patient #4’s POA was and was unsure why Person G signed the admission documents.”

“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 the Patient was informed about the delay in the initial ST or OT evaluation assessment for 4 of 6 patient records reviewed with ST or OT services ordered on the referral (Patient #1, 4, 5 and 6) and failed to ensure the patient was notified of discharge prior to the discharge for 1 of 1 discharge record reviewed with wounds (Patient #4). Findings include: 2. Patient #4’s clinical record evidenced a SOC date of 1/12/26 and included an OT evaluation completed on 1/21/26, nine days after SOC. The record failed to evidence Patient #4 was notified of the delay in the OT evaluation. The record included a POC for the certification period 1/12/26 to 3/12/26 with orders for SN three times a week to provide wound care. The record evidenced a discharge from SN services on 3/04/26. The record failed to evidence Patient #4 was notified of the discharge prior to discharge. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed they sent an email to the therapy clinicians after SOC informing them of the initial therapy evaluation needed. RN 1 also relayed they were unsure if the patient and/or physician were notified in the delay of the initial OT evaluation. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed Patient #4 should have been given a notice of discharge prior to the discharge visit and she verified the clinical record did not include any documentation of collaboration with the Patient or Physician prior to discharge. 3. Patient #5’s clinical record evidenced a SOC date of 4/17/26 and included an OT evaluation completed on 4/27/26, 10 days after SOC. The record failed to evidence Patient #5 was notified of the delay in the OT evaluation. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed they were unsure if Patient #5 had been notified of the delay in the OT evaluation as they were only responsible for doing the PT SOC visit. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed Patient #5’s clinical record did not include any documentation of Patient or Physician notified of the delay in starting OT services. 4. Patient #6’s clinical record evidenced a SOC date of 2/04/26 and included an OT evaluation completed on 2/16/26, 12 days after SOC. The record failed to evidence Patient #6 was notified of the delay in the OT evaluation. During an interview on 5/28/26 at 3:20 PM, the Administrator relayed Patient #6’s clinical record did not include any documentation of Patient or Physician notified of the delay in starting OT services. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed they were unsure if Patient #6 was notified of the delay in the OT evaluation as the Administrator was responsible for scheduling the OT evaluation. 5. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed when the OT evaluation was included in the referral, it should have been scheduled by the office scheduler. 6. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed the initial OT evaluation should have been completed within a day or two of when it is ordered. 7. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed the initial OT evaluations should have been completed within five days of SOC. X. Patient #1’s clinical record included a referral dated 7/03/24 which indicated Patient #1 needed ST services. The record included an initial assessment dated 7/08/24. The record failed to evidence Patient #1 received an initial assessment within 48 hours and failed to evidence Patient #1 had received a ST evaluation. The record failed to evidence Patient #1 had been notified of the delay in the initial assessment or that Patient #1 would not receive an ST evaluation. During an interview on 5/28/26 at 3:26 PM, the Administrator relayed Patient #1 had not been notified of the delay in the initial assessment or that Patient #1 would not receive a ST 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 the ST evaluation as ordered on the POC for 1 of 1 discharged record reviewed with ST ordered (Patient #6). Findings include: 1. Patient #6’s clinical record included a POC for the certification period 2/04/26 to 4/04/26. The POC indicated the patient was to receive a ST evaluation. The clinical record failed to evidence Patient #6 received the ST evaluation and failed to evidence documentation that Patient #6 and Physician F were notified of not receiving the ST evaluation as ordered on the POC. 2. During an interview on 5/28/26 at 3:20 PM, the Administrator verified Patient #6 did not receive a ST evaluation and confirmed the clinical record failed to evidence documentation of Patient #6 or Physician F notified.”

“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 notified of the State hotline hours of operation for 1 of 1 agency. Findings include: 1. The Patient Bill of Rights policy, revised December 2025, indicated “… The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights… The Patient Bill of Rights statement defines the right of the patient to… Receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline and the ACHC Hotline, including hours of operation…” 2. The agency’s admission packet failed to evidence the State hotline number’s hours of operation. 3. During an interview on 6/01/26 at 2:22 PM the Administrator relayed the State hotline hours of operation should be included in the admission packet, but they were not there.”

“Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure collaboration with the physician prior to discharge for 1 of 1 discharged record reviewed for goals met (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a SOC date of 1/12/26 and included a POC for the certification period 1/12/26 to 3/12/26 with orders for SN three times a week to provide wound care and PT visits two times a week. The record evidenced a discharge on 3/12/26. The record failed to evidence collaboration with the physician prior to discharge. 2. During an interview on 5/29/26 at 2:05 PM, RN 1 relayed she was unaware of any collaboration with the physician prior to discharge. 3. During an interview on 5/28/26 at 2:53 PM, the Administrator verified the clinical record did not evidence any collaboration with the Physician prior to discharge.”

“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 2 of 6 patient records reviewed (Patient #1 and 5). Findings include: 2. Patient #5’s clinical record evidenced a referral was received on 4/10/26 and an initial assessment/SOC visit was conducted on 4/17/26. The record failed to evidence documentation of the reason for delay in conducting an initial assessment within 48 hours of the referral. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed the SOC visit was assigned by the Administrator and they tried to do the SOC visit the next day. Findings include: 2. Patient #5’s clinical record evidenced a referral was received on 4/10/26 and an initial assessment/SOC visit was conducted on 4/17/26. The record failed to evidence documentation of the reason for delay in conducting an initial assessment within 48 hours of the referral. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed the SOC visit was assigned by the Administrator and they tried to do the SOC visit the next day. X. During an interview on 5/28/26 at 2:40 PM, the Administrator relayed the initial assessment should be completed within 48 hours of referral.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct a comprehensive assessment which included an evaluation for all referred services within five days of the SOC for 3 of 3 discharged records reviewed with therapy services (Patient #4, 5 and 6). Findings include: 1. Patient #4’s clinical record evidenced a referral was received for OT services on 1/07/26 and SOC was initiated on 1/12/26. The record evidenced the OT comprehensive assessment evaluation was completed on 1/21/25, eight days after SOC. The OT evaluation was not completed within five days of SOC. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed they sent an email to the therapy clinicians after SOC informing them of the initial therapy evaluation needed. 2. Patient #5’s clinical record evidenced a referral for OT services was received on 4/10/26 and SOC was initiated on 4/17/26 by PT 1. The record evidenced the OT comprehensive assessment evaluation was completed on 4/27/26, 10 days after SOC. The OT evaluation was not completed within five days of SOC. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed when the OT evaluation was included in the referral, it should have been scheduled by the office scheduler. 3. Patient #6’s clinical record evidenced a referral for OT services on 1/30/26 and SOC was initiated on 2/04/26 b y PT 2. The record evidenced the OT comprehensive assessment evaluation was completed on 2/16/26, 12 days after SOC. The OT evaluation was not completed within five days of SOC. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed the Administrator was responsible for scheduling the OT evaluation. 4. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed the initial OT evaluation should have been completed within a day or two of when it is ordered. 5. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed the initial OT evaluations should have been completed within five days of SOC.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all required information was included in the POC and/or failed to ensure all information included in the POC was correct for 6 of 6 patient records reviewed (Patient #1, 2, 3, 4, 5, and 6). 5. Patient #4’s clinical record included a POC for the certification period 1/12/26 to 4/12/26. The POC failed to include all diagnosis, medication indications, and target dates for goals. During an interview on 5/28/26 at 2:05 PM, RN 1 relayed she only included the referral diagnosis on the POC and verified all medications should have an indication for use. She was unsure why they didn’t flow to the POC. RN 1 relayed POC goals were imported from a template and she was unable to edit the template. She thought the POC goals were in place until discharge or the end of the episode period. 6. Patient #5’s clinical record included a POC for the certification period 4/17/26 to 6/15/26. The POC included interventions to notify the physician of fasting blood sugar greater than 180 milligram (mg)/deciliter (dL) and less than 70 mg/dL; and Random blood sugars greater than 200 mg/dL and less than 70 mg/dL. Review of Patient #5’s diagnosis and medication lists failed to include Diabetes. Patient #5’s POC included interventions not appropriate for Patient and failed to be patient specific. During an interview on 5/29/26 at 1:50 PM, PT 1 verified Patient #5 did not have Diabetes and relayed they were unsure how the interventions were placed on the POC. PT 1 then stated, “it is supposed to be specific to what the patient needed and I don’t know how they got on there.” 7. Patient #6’s clinical record included a POC for the certification period 2/04/26 to 4/04/26. Review of the 2/04/26 OASIS comprehensive assessment completed by PT 2 evidenced medications had been reconciled and Patient #6 was taking an anticoagulant. The POC failed to include prescribed medications and failed to include bleeding safety precautions. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed medications were reconciled during the comprehensive assessment and they were unsure why they were not listed on the POC. PT 2 also relayed bleeding safety precautions should have been listed on the POC. Findings include: 1. The Care Planning Process policy, revised December 2025, indicated “… Based on the assessment and conclusions, the plan of care will include, but will not be limited to… Patient specific interventions and education… Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient… Specific services and treatments to be provided… All pertinent diagnoses… All medications… Safety measures to protect against injury… 2. Patient #1’s clinical record included a POC for certification period 4/29/26 to 6/27/26. The POC failed to include bleeding precautions due to the Patient taking Eliquis (a blood thinner) and failed to include measurable timeframes for OT goals. During an interview on 6/02/26 at 10:23 AM, PT 1 relayed he must have missed putting bleeding precautions on Patient #1’s POC. During an interview on 6/01/26 at 4:38 PM, OT 1 relayed she marked goals as short-term or long-term but did not get more specific than that. 3. Patient #2’s clinical record included a POC for certification period 4/09/26 to 6/07/26. The POC failed to include bleeding precautions due to Patient #2 taking aspirin (a blood thinner) according to the POC medication list. The POC also failed to include a diagnosis of hypothyroidism (low thyroid hormone levels) related to Patient #2 taking levothyroxine (a medication used to treat hypothyroidism) according to the POC medication list. The POC also failed to include measurable OT goals due to the lack of measurable timeframes for the goals. During an interview on 6/01/26 at 2:42 PM, the Administrator relayed Patient #2’s POC should include bleeding precautions, but she did not see it. The Administrator also relayed she believed Patient #2 was taking levothyroxine for hypothyroidism but did not see that diagnosis on the POC. During an interview on 6/01/26 at 4:39 PM, OT 1 relayed she did not give a more specific timeframe for Patient #2’s OT goals than long-term and short-term. 4. Patient #3’s clinical record included a POC for certification period 5/01/26 to 6/29/26. The POC failed to include The POC failed to include bleeding precautions due to Patient #2 taking Apixaban (a blood thinner) according to the POC medication list. The POC also failed to include measurable OT goals due to the lack of measurable timeframes for the goals. During an interview on 6/01/26 at 2:51 PM, the Administrator relayed Patient #3’s POC did not include bleeding precautions. During an interview on 6/02/26 at 4:40 PM, OT 1 relayed she did not give a more specific timeframe for Patient #3’s OT goals than long-term and short-term.”

“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 physician or allowed practitioner orders were received prior to services and treatments being provided for 5 of 6 patient records reviewed (Patient #1, 2, 3, 4, and 6). 5. Patient #4’s clinical record evidenced a SOC completed on 1/12/26. The record included a POC for the certification period 1/12/26 to 3/12/26. The clinical record failed to evidence collaboration with the physician for POC orders on 1/12/26. The record evidenced SN visits were completed on 1/12/26, 1/17/26, 1/19/26, 1/22/26, 1/23/26, 1/27/26, 1/28/26, 1/30/26, 2/02/26 and 2/04/26; PT visits were completed on 1/15/26, 1/20/26, 1/23/26, 1/27/26, 1/29/26 and 2/02/26 and OT visits were completed on 1/21/26, 1/28/26, 2/04/26, 2/11/26 and 2/19/26. The clinical record failed to evidence a verbal or signed order for SN and PT services that were provided from 1/12/26 to 2/05/26 and failed to evidence a verbal or signed order for OT services that were provided from 1/21/26 to 2/19/26 . During an interview on 5/28/26 at 12:43 PM, RN 1 relayed they call the physician and notify them of SOC. When queried as to where this is documented, RN 1 stated this must have been missed. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed they created the PT POC and the Administrator sent the POC to the physician for review. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed they created the OT POC and it was faxed to the physician for review. 6. Patient #6’s clinical record evidenced a SOC completed on 2/04/26. The record included a POC for the certification period 2/04/26 to 4/04/26. The clinical record failed to evidence collaboration with the physician for POC orders on 2/04/26. The record evidenced PT visits were completed on 2/04, 2/06/26, 2/10/26, 2/13/26, 2/18/26, 2/20/26, 2/25/26 and 2/27/26 and OT visits were completed on 2/16/26 and 2/25/26. The clinical record failed to evidence a verbal or signed order for PT and OT services that were provided from 2/04/26 to 2/27/26. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed the POC is sent to the physician for signature by and was unsure if they had any orders. OT 1 was not aware if anyone got any verbal POC orders and was unsure of the delay in getting the signed POC. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed the CM is responsible for calling the physician and obtaining orders. 7. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed the clinicians are responsible for obtaining verbal physician orders. Findings include: 1. The Verification of Physician Orders policy, revised December 2025, indicated “… Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients…” 2. Patient #1’s clinical record included a POC for certification period 4/29/26 to 6/27/26 which was returned signed by the provider on 5/14/26. The record also included OT visit notes dated 5/04/26 and 5/11/26. The record failed to evidence provider orders were obtained prior to these visits. During an interview on 5/28/26 at 12:37 PM, PT 1 relayed he did not collaborate with the physician regarding Patient #1’s POC and relayed it was his understanding that the CM would call the physician about anything except emergencies like falls. During an interview on 5/28/26 at 2:40 PM, the Administrator relayed the clinicians should be calling the provider for verbal orders to cover orders for services until the POC was returned signed by the provider. During an interview on 6/01/26 at 2:05 PM, OT 1 relayed she did not know if there were verbal orders for Patient #1’s OT visits on 5/04/26 and 5/11/26. OT 1 further indicated the PT did the recertifications, so upon the PT’s recertification the OT would get notified to continue services. 3. Patient #2’s clinical record included a POC for certification period 4/09/26 to 6/07/26 which was returned signed by the provider on 4/23/26. The record also included an OT evaluation with orders which was returned signed by the physician on 4/22/26. The record also included PT visit notes dated 4/14/26 and 4/16/26 and an OT visit note dated 4/20/26. The record failed to evidence provider orders were obtained prior to these visits. During an interview on 6/01/26 at 2:42 PM, the Administrator relayed there was no documentation that provider orders had been received prior to Patient #2 receiving PT services on 4/14/26 and 4/16/26 and OT services on 4/20/26. 4. Patient #3’s clinical record included a POC for certification period 5/01/26 to 6/29/26 which was returned signed by the provider on 5/12/26. The record also included PT visit notes dated 5/05/26 and 5/07/26. The record failed to evidence provider orders were obtained prior to these visits. During an interview on 6/01/26 at 2:51 PM, the Administrator relayed Patient #3’s record did not include orders for the PT services on 5/05/26 and 5/07/26.”

“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 by the physician or allowed practitioner at least every 60 days for 1 of 1 patient record reviewed where the patient had been on service with the agency for more than 60 days (Patient #1). Findings include: 1. Patient #1’s clinical record included a SOC date of 7/08/24. The record included POCs for certification periods 10/31/25 to 12/29/25, 12/30/25 to 2/27/26, and 2/28/26 to 4/28/26, which were not returned signed by the physician. The record included a POC for certification period 4/29/26 to 6/27/26 which was returned signed by the physician on 5/11/26. The record failed to evidence the physician reviewed the POC at least every 60 days. 2. During an interview on 6/01/26 at 2:33 PM, the CM relayed the POC for Patient #1 for certification periods 10/31/25 to 12/29/25, 12/30/25 to 2/27/26, and 2/28/26 to 4/28/26 were not returned signed by the physician.”

“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 notify the physician regarding the need to alter/change the POC for 1 of 1 patient record reviewed with SN interventions to administer insulin (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a POC for the certification period 1/12/26 to 3/12/26 with orders for the SN to perform intramuscular [sic] injection of Lantus Insulin 22 units every evening and Aspart insulin 15 units every morning. The clinical record failed to evidence the SN completed a visit every morning and evening to administer prescribed Insulin and the SN visit notes completed on 1/12/26, 1/17/26, 1/19/26, 1/22/26, 1/23/26, 1/27/26, 1/28/26, 1/30/26, 2/02/26, 2/04/26, 2/09/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, 2/27/26, 3/02/26 and 3/04/26 failed to include documentation of Insulin administered by the SN. 2. During an interview on 5/28/26 at 12:43 PM, RN 1 reported they were unsure who added the SN intervention to administer Insulin on the POC and verified the home health agency did not administer any Insulin to Patient #4. RN 1 was also unsure if the Administrator had notified the physician of the need to change the POC. 3. During an interview on 5/28/26 at 3:07 PM, the Administrator relayed RN 1 created Patient #4’s POC and verified the clinical record failed to include collaboration with the physician to change the POC.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure collaboration with outside entities also providing care for the patient for 4 of 4 patient records reviewed in which the patient was also receiving services from an outside entity (Patient #2, 3, 4, and 5). 3. Patient #4’s clinical record evidenced a SOC date of 1/12/26 and included a POC for the certification period 1/12/26 to 3/12/26. The 1/12/26 OASIS comprehensive assessment included documentation of Patient #4 receiving HHA services from Entity K. The POC failed to evidence collaboration of care documentation with Entity K. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed Patient #4’s niece owned the PSA company so she was aware of home health and she verified the clinical record did not include any collaboration documentation with Entity K. 4. Patient #5’s clinical record evidenced a SOC date of 4/17/26 and included a POC for the certification period 4/17/26 to 6/15/26. The POC failed to evidence collaboration of care documentation with Entity J at SOC. During an interview on 5/29/26 at 1:50 PM, PT 1 relayed Patient #5 lived independently in their room and Entity J was aware of Patient #5 being on home health as “they saw us coming so they knew what we were doing there.” Findings include: 1. Patient #2’s clinical record failed to evidence collaboration with the Patient’s assisted living facility. During an interview on 6/02/26 at 10:24 AM, PT 1 relayed he would sometimes tell assisted living facility staff about a patient’s progress but didn’t think it was necessary to document that. PT 1 further relayed he would notify the assisted living facility and document it if the patient had a fall, increased pain, weakness, or a high blood pressure because the assisted living facility had better access to the physician and would notify them. During an interview on 6/02/26 at 1:32 PM, the Administrator relayed she did not find any evidence of collaboration between the agency and Patient #2’s assisted living facility. 2. Patient #3’s clinical record failed to evidence collaboration with the Patient’s assisted living facility. During an interview on 5/27/26 at 3:45 PM, Person M, a relative of Patient #3, relayed Patient #3 resided in an assisted living facility. During an interview on 6/02/26 at 10:32 AM, PT 1 relayed he did not collaborate with Patient #3’s assisted living facility about routine things but would notify them if there was a problem. PT 1 further relayed he had not notified the assisted living facility about Patient #3.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the caregiver was provided wound care education for 1 of 1 discharged record with wounds (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a SOC date of 1/12/26 and included a POC for the certification period 1/12/26 to 3/12/26 with orders for SN three times a week to provide wound care. The record evidenced a discharge from SN services on 3/04/26. The record failed to evidence wound care education had been provided to the caregiver prior to discharge. 2. During an interview on 5/28/26 at 3:07 PM, the Administrator relayed Patient #4’s caregiver should have been educated on proper wound care prior to discharge. 3. During an interview on 5/29/26 at 11:53 AM, Person A, family member of Patient #4, relayed the home health agency did not educate or teach wound care. They also relayed they were not given any discharge instructions by the home health agency.”

“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 record review and interview, the home health agency failed to provide the current CM’s name and contact information to patients for 1 of 1 agency. Findings include: 1. The Care Planning Process policy, revised December 2025, indicated “… The organization shall provide the patient and caregiver with a copy of written instructions outlining… Name and contact information of the organization’s clinical manager…” 2. The agency’s admission packet failed to include the name and contact information for the CM. 3. During an interview on 6/01/26 at 2:19 PM, the Administrator relayed the CM’s name and contact information should be included in the agency’s admission packet.”

“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 record review and interview, the SN failed to measure wounds at least weekly for 1 of 1 discharged record reviewed with wounds (Patient #4). Findings include: 1. Patient #4’s clinical record evidenced a SOC date of 1/12/26 and included a POC for the certification period 1/12/26 to 3/12/26 with orders for SN visits three times a week to provide wound care. The record failed to evidence wound measurements had been obtained during the weeks of 1/18/26 and 2/01/26. 2. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed wounds should have been measured at least weekly and verified the SN visits for the weeks of 1/19/26 and 2/01/26 did not include wound measurements.”

“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 SN visit note documentation was completed the day of service for 1 of 1 discharge record reviewed with wounds (Patient #4). Findings include: 1. The 12/2025 agency policy “Clinical/Service Data Collection” indicated entries into the clinical/service record will be made on the day care/service is provided to the patient. 2. Patient #4’s clinical record was reviewed on 5/28/26 and evidenced the following: The 1/19/26 LPN visit note was completed on 1/26/16, seven days later. LPN 1 failed to document the SN visit note on the day care was provided. The 1/22/26 LPN visit note was completed on 1/26/16, four days later. LPN 1 failed to document the SN visit note on the day care was provided. The 2/13/26 LPN visit note was completed on 2/17/16, four days later. LPN 1 failed to document the SN visit note on the day care was provided. The 2/27/26 LPN visit note was completed on 3/02/16, three days later. LPN 1 failed to document the SN visit note on the day care was provided. 3. During an interview on 6/02/26 at 1:10 PM, the CM verified the above LPN visit notes were not completed on the day care was provided.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure the Alternate Administrator was authorized in writing for 1 of 1 agency. Findings include: 1. Review of the agency 1/20/26 Governing Body meeting minutes evidenced Admin 1 appointed Administrator. The meeting minutes failed to evidence a qualified Alternate Administrator had been named to oversee the home health agency in the Admonistrator’s absence. 2. During an interview on 6/01/26 at 2:04 PM, the Administrator relayed she thought Admin 2 had been named the Alternate Administrator in writing. The agency was unable to provide this documentation.”

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure the Clinical Manager coordinated patient and personnel assignments for 1 of 1 home health agency surveyed. Findings include: 1. Review of the home health agency organizational chart evidenced Admin 2 as the Clinical Manager of the agency. 2. During the entrance conference on 5/27/26 at 10:00 AM, the Administrator relayed she was responsible for clinical supervision, in-service training, home health aide supervision, personnel records and the EMR system and the Administrator listed Admin 2 as the Clinical Manager of the home health agency. 3. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed Admin 1 was the CM of the agency and stated Admin 1 and Admin 4 were responsible for assigning/scheduling patients. 4. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed Admin 1 was the CM of the agency and was responsible for assigning patients. 5. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed Admin 1 was the CM of the agency and relayed Admin 1 and Admin were responsible for scheduling patients. 6. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed she was responsible for coordinating/scheduling patient SOC visits. 7. During an interview on 5/29/26 at 2:04 PM, Admin 2 relayed the Administrator was responsible for making personnel assignments/coordinating patient care.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure the Clinical Manager coordinated patient care for 1 of 1 home health agency surveyed. Findings include: 1. Review of the home health agency organizational chart evidenced Admin 2 as the Clinical Manager of the agency. 2. During the entrance conference on 5/27/26 at 10:00 AM, the Administrator relayed she was responsible for clinical supervision, in-service training, home health aide supervision, personnel records and the EMR system and the Administrator listed Admin 2 as the Clinical Manager of the home health agency. 3. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed she was responsible for coordinating/scheduling patient SOC visits. 4. During an interview on 5/29/26 at 1:10 PM, Admin 2 relayed the Administrator was the CM of the agency and at 3:09 PM, Admin 2 relayed they “were getting their feet wet as the Alternate Administrator of the agency.” 5. During an interview on 5/29/26 at 2:04 PM, Admin 2 relayed the Administrator was responsible for making personnel assignments/coordinating patient care.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interviews, the home health agency failed to ensure the Clinical Manager was involved in coordinating referrals for 1 of 1 home health agency surveyed. Findings include: 1. Review of the home health agency organizational chart evidenced Admin 2 as the Clinical Manager of the agency. 2. During an interview on 5/28/26 at 12:21 PM, PT 1 relayed Admin 1 was responsible for reviewing referrals. 3. During an interview on 5/28/26 at 12:43 PM, RN 1 relayed Admin 1 or Admin 4 were responsible for reviewing referrals. 4. During an interview on 5/28/26 at 1:49 PM, OT 1 relayed Admin 1 was responsible for reviewing referrals. 5. During an interview on 5/28/26 at 2:53 PM, the Administrator relayed she was responsible for reviewing referrals. 6. During an interview on 5/29/26 at 1:32 PM, PT 2 relayed Admin 1 or Admin 4 were responsible for reviewing referrals.”

“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 a transfer summary within two days for 2 of 3 discharge records reviewed (Patient #5 and 6). Findings include: 1. Patient #5’s clinical record included a PT visit completed on 5/12/26 by PT 1. The PT visit note included documentation of Patient #5 admitted to an outside hospice agency and evidenced a discharge from home health completed on 5/13/26. The record failed to evidence a transfer summary had been submitted to the hospice agency within two days. During an interview on 4/28/26 at 2:04 PM, the Administrator relayed the agency did not create a transfer summary for Patient #5. 2. Patient #6’s clinical record evidenced a transfer completed on 3/02/26 and included a transfer summary sent on 3/05/26, three days after the transfer. The agency failed to send the transfer summary within two days of transfer. During an interview on 4/28/26 at 2:04 PM, the Administrator relayed the transfer summary should have been sent within two days of transfer and verified Patient #6’s transfer summary was not sent within two days.”