Superior Home Health Care Inc.

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record reviews and interviews, the Home Health Agency failed to meet the Condition of Participation for Skilled Professional Services. The Home Health Agency failed to ensure the Registered Nurse (RN) provided Skilled Professional Services in accordance with current clinical practice guidelines as set forth by the LSBN (Louisiana State Board of Nursing) Declaratory Statement for Scope of Practice for Registered Nurses - Wound Care Management and accepted professional standards as set forth by National Pressure Ulcer Advisory Panel for Prevention and Treatment of Pressure Ulcers. This deficient practice was evidenced by failure of the agency to ensure: 1. The RN assessed Patient #1, #12 and #13’s Pressure Ulcers, including size and stage, on a weekly basis (See Findings in G702); and 2. The RN assessed Patient #1, #12 and #13’s Pressure Ulcers prior to delegating wound care to the Licensed Practical Nurse (LPN). (See Findings in G702) See Findings in G702.”

“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 reviews and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Center for Medicare and Medicaid Services (CMS) system within 30 days of completion. Findings: Review of the agency’s OASIS Agency Final Validation Report with a submission date of 04/18/2025 revealed 19 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 04/23/2025 revealed 29 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 04/28/2025 revealed 90 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 05/01/2025 revealed 99 records were processed with 6 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted on 07/21/2025 at 9:12 a.m. with S3RN. S3RN confirmed she was responsible for the agency’s OASIS Agency Final Validation Reports. S3RNreviewed the above OASIS validation reports and confirmed 10 of the records were submitted late, more than 30 days after completion, and OASIS Assessments should have been submitted within 30 days of completion.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the OASIS (Outcome and Assessment Information Set) data accurately reflected the patient’s status at the time of assessment. The agency inaccurately documented a patient’s discharge status for 1 (#13) of 6 (#5, #13, #14, #15, #16 and #17) discharged patient records reviewed. Findings: Review of Patient #13’s Clinical Record revealed she began receiving services from the Home Health Agency on 07/11/2023, had a Certification Period of 01/01/2025 to 03/01/2025, and was discharged from the agency on 01/09/2025. Review of Patient #13’s Physician Order dated 01/09/2025 and signed by S3RN, revealed the following, in part: Patient is requesting and has declined to the extent of needing to transition to hospice care/services. Ok to discharge from the agency as of 01/09/2025, Patient to be admitted to hospice services. Review of Patient #13’s Communication Note dated 01/09/2025 and signed by S3RN, revealed the following, in part: Received a call from a local hospice agency that patient has signed consents to begin hospice services. Review of Patient #13’s Discharge OASIS dated 01/09/2025 revealed the following, in part: Discharge Disposition: Where is the patient after discharge from your agency? 1-Patient remained in the community (without skilled services from a Medicare certified Home Health Agency or non-institutional hospice) On 07/21/2025 at 11:50 a.m., an interview was conducted with S2DON. She reviewed Patient #13’s Physician Order and Discharge OASIS dated 01/09/2025. She stated the patient was discharged from the agency to hospice services. She confirmed the Discharge OASIS was not accurately coded and should have been. On 07/21/2025 at 12:32 p.m., an interview was conducted with S3RN. She stated the agency knew Patient #13 was discharging to hospice services. She confirmed the Discharge OASIS was not accurately coded. On 07/21/2025 at 12:05 p.m., an interview was conducted with S1ADM. She reviewed Patient #13’s Physician Order and Discharge OASIS dated 01/09/2025. She confirmed the patient was discharged from the agency to hospice services. She confirmed the Discharge OASIS was not accurately coded and should have been.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the Registered Nurse (RN) provided Skilled Professional Services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing (LSBN) Declaratory Statement for Scope of Practice for Registered Nurses - Wound Care Management and accepted professional standards as set forth by National Pressure Ulcer Advisory Panel for Prevention and Treatment of Pressure Ulcers for 3 of 3 (#1, #12 and #13) sampled patients reviewed for Pressure Ulcers. This deficient practice was evidenced by failure of the agency to ensure: a. The RN assessed Patient #1, #12 and #13’s Pressure Ulcers, including size and stage, on a weekly basis; and b. The RN assessed Patient #1, #12 and #13’s Pressure Ulcers prior to delegating wound care to the Licensed Practical Nurse (LPN). Findings: Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. The Registered Nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation - In accord with the Law Governing the Practice of Nursing (RS 37:913(14) the Registered Nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the Board’s rules on delegation (LAC 46:XLVII.3703.). The Registered Nurse retains the accountability for the total nursing care of the individual. The Registered Nurse may delegate to a Licensed Practical Nurse wound care interventions in any situation when the Registered Nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient’s clinical condition are predictable. Furthermore, the patient’s medical and nursing orders are not subject to continuous change or complex modification, and appropriate RN supervision is available. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcers initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agency’s undated policy titled “Wound Assessment”, revealed the following, in part: Policy: The Agency utilizes industry best practice for assessment and reassessment of wounds. Procedure: Continued/Ongoing Treatment: 3. A Skilled Nurse visit (SNV) will occur at least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present. Review of S1ADM and S2DON’s personnel files on 07/17/2025 revealed they were both Registered Nurses with current active licenses. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/26/2025, and had a current Certification Period of 06/26/2025 to 08/24/2025. Patient #1 had diagnoses, which included a Stage 3 Pressure Ulcer of Right Buttock. Review of Patient #1’s Plan of Care for Certification Period 06/26/2025 to 08/24/2025 revealed the following, in part: SNV once weekly for one week then three times weekly for eight weeks; and Skilled Nurse (SN) to perform wound care to Right Buttock Pressure Ulcers as follows: Cleanse the wound with wound cleanser and pat dry. Apply medical grade honey product and cover with foam border dressing. Wound care to be performed three times a week and as needed for dislodgement or soilage. Review of Patient #1’s SNV notes conducted for Certification Period 06/26/2025 to 08/24/2025 revealed Patient #1’s Right Buttock Pressure Ulcer, Stage 3 was not assessed by a RN, to include measurements the weeks of 06/29/2025 and 07/06/2025. On 07/14/2025 at 11:45 a.m., an interview was conducted with S11LPN. She verified she had seen Patient #1 for wound care three times a week since her admission to the agency. She confirmed no RN had made a wound care visit to assess Patient #1’s Right Buttock Pressure Ulcers since admit and should have. She confirmed a RN visit should be made weekly for a patient with a Pressure Ulcer. On 07/15/2025 at 3:30 p.m., an interview was conducted with S3RN. She verified Pressure Ulcers should be assessed and measured by a RN at least weekly. She stated at times the LPN had to make all wound care visits for the week due to RN staffing. She stated when a RN was unable to make a weekly wound care visit the agency had the LPN make the visits until the RN could see the patient. She reviewed Patient #1’s Clinical Record and confirmed a RN had not assessed or measured Patient #1’s Pressure Ulcer listed above weekly for two weeks. On 07/15/2025 at 3:32 p.m., an interview was conducted with S2DON. She stated it was best practice for a RN to assess and measure a patient’s Pressure Ulcers weekly. She reviewed Patient #1’s Clinical Record and confirmed a RN had not assessed or measured Patient #1’s Pressure Ulcer listed above weekly for two weeks. On 07/15/2025 at 3:35 p.m., an interview was conducted with S1ADM. She stated it was best practice for a RN to assess and measure a patient’s Pressure Ulcers weekly. She reviewed Patient #1’s Clinical Record and confirmed a RN had not assessed or measured Patient #1’s Pressure Ulcer listed above weekly for two weeks. Patient #12 Review of Patient #12’s Clinical Record revealed he began receiving services with the Home Health Agency on 08/10/2023, had a previous Certification Period of 04/01/2025 to 05/30/2025, and a current Certification Period of 05/31/2025 to 07/29/2025. Patient #12 had diagnoses, which included Unstageable Pressure Ulcer of Sacral Region and Stage 4 Pressure Ulcer of Left Buttock. Review of Patient #12’s Plan of Care for Certification Period 04/01/2025 to 05/30/2025 revealed the following, in part: SNV’s three times weekly for one week, four times weekly for three weeks, and three times weekly for five weeks; and Wound care orders to Left Buttock and Sacral Pressure Ulcers. SN to assess and perform wound vac dressing change three times weekly and as needed for dislodgement or soilage per protocol. SN to assess/teach patient and caregiver that the vac unit should be on 125 mm/hg continuous therapy. Review of Patient #12’s SNV notes conducted for Certification Period 04/01/2025 to 05/30/2025 revealed Patient #12’s Unstageable Pressure Ulcer of Sacral Region and Stage 4 Pressure Ulcer of Left Buttock were not assessed by a RN, to include measurements the weeks of 04/27/2025, 05/04/2025, 05/11/2025, 05/18/2025, and 05/25/2025. Review of Patient #12’s Plan of Care for Certification Period 05/31/2025 to 07/29/2025 revealed the following, in part: SNV’s zero day one, then effective week of 06/01/2025, three times weekly for eight weeks and one time weekly for one week; and Wound care orders to Left Buttock and Sacral Pressure Ulcers. SN to assess and perform wound vac dressing change three times weekly and as needed for dislodgement or soilage per protocol. SN to assess/teach patient and caregiver that the vac unit should be on 125 mm/hg continuous therapy. Review of Patient #12’s SNV notes conducted for Certification Period 05/31/2025 to 07/29/2025 revealed Patient #12’s Unstageable Pressure Ulcer of Sacral Region and Stage 4 Pressure Ulcer of Left Buttock were not assessed by a RN, to include measurements the weeks of 06/08/2025, 06/15/2025, 06/22/2025, 06/29/2025, and 07/06/2025. Further review of Patient #12’s Clinical Record revealed no documented evidence of Patient #12 refusing RN weekly wound care visits for the above mentioned Certification Periods for ten weeks. On 07/17/2025 at 11:00 a.m., an interview was conducted with S4LPN. She stated she saw Patient #12 three times weekly and as needed for wound care to his Left Ischial and Right Ischial Pressure Ulcers. She stated Patient #12 preferred she change his wound vac three times a week as it was a difficult dressing change due to the patient’s anatomy and wound locations. She stated it was best practice for the RN to see a patient with Pressure Ulcers weekly. She stated in her area, it was rural and hard to staff a RN. She confirmed a RN had not seen Patient #12 weekly for a total of ten weeks to assess and measure his pressure ulcers. On 07/17/2025 at 12:40 p.m., an interview was conducted with S3RN. She stated it had been difficult to find RN coverage in the area where Patient #12 lived. She stated Patient #12 would not allow a RN to make the wound care visits and only wanted S4LPN to perform his wound care. She stated Patient #12’s physician had been notified previously he was refusing RN wound care visits, but not recently. She reviewed the above mentioned Certification Periods and confirmed there was no documentation of Patient #12 refusing RN visits for wound care. She reviewed Patient #12’s Clinical Record and confirmed a RN had not assessed or measured Patient #12’s Pressure Ulcers listed above weekly for ten weeks and should have. On 07/17/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated Patient #12 had chronic Pressure Ulcers and his wound care was difficult due to his anatomy and wound locations. She stated Patient #12 only wanted S4LPN to perform his wound care. She stated at this point the agency no longer scheduled weekly RN visits for wound care because of the patient’s preference and previous refusals. She stated it had been difficult to find RN coverage in the area where Patient #12 lived. She reviewed the above mentioned Certification Periods and confirmed there was no documentation of Patient #12 refusing RN visits for wound care. She reviewed Patient #12’s Clinical Record and confirmed a RN had not assessed or measured Patient #12’s Pressure Ulcers listed above weekly for ten weeks and should have. On 07/17/2025 at 1:35 p.m., an interview was conducted with S1ADM. She reviewed Patient #12’s Clinical Record and verified the patient had Pressure Ulcers. She stated it was best practice for a RN to assess and measure a patient’s Pressure Ulcers weekly. She reviewed the above mentioned Certification Periods and confirmed a RN had not assessed or measured Patient #12’s Pressure Ulcers listed above weekly for ten weeks and should have. She stated it had been a struggle to find RN coverage in the area where Patient #12 lived. She stated she was not aware of Patient #12 refusing RN wound care visits. Patient #13 Review of Patient #13’s Clinical Record revealed she began receiving services from the Home Health Agency on 07/11/2023, had previous Certification Periods of 11/02/2024 to 12/31/2024 and 01/01/2025 to 03/01/2025, and was discharged from the agency on 01/09/2025. Patient #13 had diagnoses, which included a Stage 2 Pressure Ulcer of Right Buttock. Review of Patient #13’s Plan of Care for Certification Period 11/02/2024 to 12/31/2024 revealed the following, in part: SNV zero day one, then once weekly for nine weeks effective 11/03/2024; New order dated 12/03/2024- Right Buttock wound: 3.2 x 2.0 x 0.1 cm. Wound bed pink and moist with fatty tissue exposed. Scant serosanguineous drainage noted. Treatment - using aseptic technique SN cleansed wound with wound cleanser on gauze, and patted dry with gauze. Applied an antimicrobial silver dressing to wound bed, covered with dry dressing. Wound care is to be performed two times a week and as needed as indicated by soiled dressing. SN to perform two times a week. SN frequency effective 12/03/2024 two times weekly times four weeks then once weekly times one week. Review of Patient #13’s SNV notes conducted for Certification Period 11/02/2024 to 12/31/2024 revealed the following, in part: SNV dated 12/03/2024 and signed by S13LPN, Location: Right Buttock, Onset Date: 12/03/2024, Size: 3.2 x 2.0 x 0.1 cm, Etiology: Pressure. Further review revealed Patient #13’s Stage 2 Pressure Ulcer of Right Buttock was not assessed by a RN, to include staging and measurements the weeks of 12/01/2024 and 12/08/2024. On 07/21/2025 at 11:50 a.m., an interview was conducted with S2DON. She stated when a new wound was identified the RN should assess the new wound within a week. She reviewed Patient #13’s Clinical Record including the Physician Order and SNV note dated 12/03/2024 by S13LPN. She confirmed Patient #13 had a new Pressure Ulcer to her Right Buttocks. She confirmed the RN did not make a SNV to assess, stage and measure the wound until 12/17/2024. She confirmed a RN had not assessed or measured Patient #12’s Pressure Ulcer listed above weekly for two weeks and should have. On 07/21/2025 at 12:05 p.m., an interview was conducted with S1ADM. She stated when a new wound was identified the RN should be sent on the next SNV to assess, measure and stage the new wound. She reviewed Patient #13’s Clinical Record including the Physician Order and SNV noted dated 12/03/2024 by S13LPN. She confirmed Patient #13 had a new Pressure Ulcer to her Right Buttocks. She confirmed the RN did not make a SNV to assess, stage and measure the wound until 12/17/2024. She confirmed a RN had not assessed or measured Patient #12’s Pressure Ulcers listed above weekly for two weeks and should have.”

“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 reviews and interviews, the agency failed to ensure Skilled Nurse entries were completed for 3 (#5, #10, and #12) of 17 (#1-#17) patient records reviewed. Findings: Review of the agency’s undated policy titled, “Clinical Documentation” revealed the following, in part: Policy: Agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care. Special Instructions: 5. Documentation of services ordered on the plan of care will be completed within 48 hours of the day service is rendered and incorporated into the clinical record within seven days after the care has been provided. Patient #5 Review of Patient #5’s Clinical Record revealed he began receiving services from the Home Health Agency on 04/11/2025, had a Certification Period of 04/11/2025 through 05/31/2025, and was discharged from the agency on 05/31/2025. Further review revealed he was readmitted for services on 06/12/2025 and discharged on 06/30/2025, and readmitted again on 07/03/2025 with a current Certification Period of 07/03/2025 through 08/31/2025. Review of Patient #5’s Skilled Nursing visits on 07/15/2025 revealed the Outcome and Assessment Information Set (OASIS) Discharge (Non-Billable) note dated 06/30/2025 was not completed or signed by S17RN. On 07/15/2025 at 3:20 p.m., an interview was conducted with S3RN. S3RN confirmed all visit notes should be completed within at least 48 hours of the visit made. She reviewed Patient #5’s Clinical Record and confirmed his OASIS Discharge note dated 06/30/2025 was not completed within 48 hours of the visit. On 07/15/2025 at 3:36 p.m., an interview was conducted with S1ADM. S1ADM confirmed visit notes should be completed within 48 hours, and Patient #5’s OASIS Discharge note was not. Patient #10 Review of Patient #10’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/04/2025, and had a current Certification Period of 06/04/2025 through 08/02/2025. Review of Patient #10’s Skilled Nursing visits on 07/16/2025 revealed the Licensed Practical Nurse (LPN) Skilled Nursing visit notes dated 06/18/2025 and 06/25/2025 were not completed by S18LPN. On 07/16/2025 at 2:45 p.m., an interview was conducted with S2DON. She reviewed Patient #10’s Clinical Record and confirmed S18LPN had incomplete Skilled Nurse visit notes dated 06/18/2025 and 06/25/2025. She stated visit notes should be documented within 48 hours of the visit and at the latest within a week of the visit. Patient #12 Review of Patient #12’s Clinical Record revealed he began receiving services from the Home Health Agency on 08/10/2023, and had a current Certification Period of 05/31/2025 through 07/29/2025. Review of Patient #12’s Skilled Nursing visits on 07/17/2025 revealed the LPN Skilled Nursing visit notes dated 07/02/2025, 07/04/2025, 07/07/2025, 07/09/2025, and 07/10/2025 were not completed by S4LPN. On 07/17/2025 at 11:00 a.m., an interview was conducted with S4LPN. She stated the agency’s expected time frame for completing Skilled Nursing visits notes was 48 hours. She confirmed she had not completed her Skilled Nursing visits notes dated 07/02/2025, 07/04/2025, 07/07/2025, 07/09/2025, and 07/10/2025 and should have. On 07/17/2025 at 12:40 p.m., an interview was conducted with S3RN. She reviewed Patient #12’s Clinical Record and confirmed S4LPN had not completed her Skilled Nursing visits notes for the above-mentioned dates and should have. On 07/17/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated visit notes should be documented within 48 hours of the visit and at the latest within a week of the visit. She reviewed Patient #12’s Clinical Record and confirmed S4LPN had not completed her Skilled Nursing visits notes for the above mentioned dates and should have. On 07/17/2025 at 1:35 p.m., an interview was conducted with S1ADM. She stated visit notes should be documented within 48 hours of the visit. She reviewed Patient #12’s Clinical Record and confirmed S4LPN had not completed her Skilled Nursing visits notes for the above-mentioned dates and should have.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to provide the patient and/or legal representative with the Administrator’s name in order to file complaints for 4 (#1, #2, #3, and #6) of 6 (#1, #2, #3, #4, #5, and #6) home visits conducted. Findings: Review of the agency’s undated policy titled, “Client Admission Process” revealed the following, in part: Special Instructions: 10. The admission professional will: c. Provide the client/caregiver/representative with a copy and an explanation of the Home Care Bill of Rights and Responsibilities, and the procedures for filing a complaint. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 06/26/2025, and had a current Certification Period of 06/26/2025 through 08/24/2025. A home visit was conducted for Patient #1 on 07/14/2025 at 11:00 a.m. with S11LPN present. A review of Patient #1’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. On 07/14/2025 at 11:45 a.m., an interview was conducted with S11LPN during Patient #1’s home visit. She reviewed Patient #1’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator and there should have been. She stated the RN who completed the patient’s admission assessment was responsible for writing the name of the Administrator in their Home Health folder and they did not. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 03/28/2025, and had a current Certification Period of 05/27/2025 through 07/25/2025. A home visit was conducted for Patient #2 on 07/14/2025 at 1:30 p.m. with S5RN present. A review of Patient #2’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. On 07/14/2025 at 1:30 p.m., an interview was conducted with S5RN during Patient #2’s home visit. She reviewed Patient #2’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator and there should have been. She confirmed the RN who completed the patient’s admission assessment was responsible for writing the name of the Administrator in their Home Health folder and they did not. Patient #3 Review of Patient 3’s Clinical Record revealed he was admitted to the agency on 07/07/2025, and had a current Certification Period of 07/07/2025 to 09/04/2025. A home visit was conducted for Patient #3 on 07/14/2025 at 3:10 p.m. with S12PT present. A review of Patient #3’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. On 07/14/2025 at 3:50 p.m., an interview was conducted with S12PT during Patient #3’s home visit. He reviewed Patient #3’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator and there should have been. Patient #6 Review of Patient 6’s Clinical Record revealed she was admitted to the agency on 07/01/2025, and had a current Certification Period of 07/01/2025 through 08/29/2025. A home visit was conducted for Patient #6 on 07/15/2025 at 9:30 a.m. with S4LPN present. A review of Patient #6’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. On 07/15/2025 at 9:30 a.m., an interview was conducted with S4LPN during Patient #6’s home visit. She reviewed Patient #6’s home health folder and confirmed there was no documentation of the name for the agency’s Administrator, and there should have been. On 07/15/2025 at 3:26 p.m., an interview was conducted with S1ADM. S1ADM confirmed the RN performing the patient’s admission assessment was responsible for writing the Administrator’s name and contact information in the patient’s Home Health folder, and they had not for Patient #1, #2, #3, and #6.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure a patient’s comprehensive assessment included a review of all medications currently in use. This deficient practice was evidenced by failure to ensure nursing and therapy staff reconciled the patient’s medications during their visits for 4 (#1, #2, #3 and #4) of 6 (#1, #2, #3, #4, #5 and #6) home visits conducted. Findings: Review of the agency’s undated policy titled, “Medication Reconciliation” revealed the following, in part: Special Instructions: 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter, prescribed, and PRN (as needed) medications. Documentation of these medications will be listed on the Medication Profile and include name, dose, route of administration, frequency, and when last dose was taken. 9. Medications will be reviewed with the client on each home visit to determine if other prescriptions or non-prescription drugs are being taken. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/26/2025 and had a current Certification Period of 06/26/2025 to 08/24/2025. Further review revealed Patient #1 had diagnoses which included a Stage 3 Pressure Ulcer of Right Buttock, Esophagitis, Gastritis, and Chronic Obstructive Pulmonary Disease. Patient #1 was ordered to receive Skilled Nursing Visits once weekly for one week then three times weekly for eight weeks, Physical Therapy Visits twice weekly for three weeks and once weekly for one week, and Occupational Therapy Visits twice weekly for three weeks. On 07/14/2025 at 11:00 a.m., a home visit was conducted with Patient #1 with S11LPN present. The following medications were present in Patient #1’s home: Albuterol Sulfate Ventolin 90 mcg inhaler - Take 2 puffs inhalation every 6 hours PRN; Loperamide Hydrochloride 2 mg tablets - Take PRN for loose stools; and Amoxicillin-Pot Clavulanate 875-125 mg - Take one tablet twice daily for 14 days (Discontinued on 07/10/2025). Review of Patient #1’s Medication Profile, dated 06/26/2025 through 08/24/2025, as of 07/14/2025, revealed, in part, no documented evidence of an order for the following medications: Albuterol Sulfate Ventolin 90 mcg inhaler - Take 2 puffs inhalation every 6 hours PRN; Loperamide Hydrochloride 2 mg tablets - Take PRN for loose stools; and Amoxicillin-Pot Clavulanate 875-125 mg - Take one tablet twice daily for 14 days (Discontinued on 07/10/2025). On 07/14/2025 at 11:05 a.m., an interview was conducted with Patient #1. She stated she had been taking Loperamide Hydrochloride for one week and took one tablet the morning of 07/14/2025. She stated she used her Albuterol Sulfate Ventolin inhaler twice daily and was still taking the Amoxicillin-Pot Clavulanate. On 07/14/2025 at 11:45 a.m., an interview was conducted with S11LPN. She stated a patient’s medications should be reconciled during each visit to ensure the patient’s medication profile was accurate. She reviewed Patient #1’s current Medication Profile and confirmed it did not match the medications she was currently taking and should. Patient #2 Review of Patient #2’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/28/2025 and had a current Certification Period of 05/27/2025 to 07/25/2025. Further review revealed Patient #2 had diagnoses which included Infection/ Inflammation due to Cardiovascular Device Implant, Malignant Neoplasm of the Appendix, Complications of Enterostomy, Anxiety, and Encounter for Adjustment and Management of Vascular Access Device. Patient #2 was ordered to receive Skilled Nursing Visits once weekly for eight weeks, and Physical Therapy Visits once weekly for four weeks. On 07/14/2025 at 1:30 p.m., a home visit was conducted with Patient #2 and S5RN present. The following information was obtained during Patient #2’s medication reconciliation: Review of Patient #2’s current Medication Profile, dated 05/27/2025 through 07/25/2025, as of 07/14/2025, revealed the following current medication orders: Diphenoxylate/Atropine 2.5-0.025mg - Take two tablets every 6 hours; Lomotil Oral 2.5-0.025mg - Take two tablets four times daily; Clonazepam Oral 0.5mg - Take one tablet 2 times daily PRN for anxiety; Scopolamine Transdermal 1mg/3days – Apply one patch every 3 days; Olanzapine Oral 5mg - Take one tablet by mouth every night; and Fibercon 625mg - Take two tablets daily. On 07/14/2025 at 1:30 p.m., an interview was conducted with Patient #2. She confirmed she was no longer taking Diphenoxylate/Atropine, Scopolamine, Olanzapine, or Fibercon. She further confirmed she was taking Clonazepam 1mg by mouth at bed time as needed for anxiety, Loperamide 2mg by mouth four times daily as needed for diarrhea, and Vitamin D3 2,000IU one tablet weekly on Mondays. Further review revealed no documented evidence of current orders for the following medications present in the home Patient #2 was currently taking: Loperamide 2mg – Take one tablet by mouth four times daily PRN for diarrhea; Vitamin D3 2,000 IU - Take one tablet by mouth every Monday: and Total Parenteral Nutrition (TPN) Solution – Administer 1800mL/12 hours (150mL/hr) via Right Upper Extremity (RUE) Peripherally Inserted Central Catheter (PICC) line with no documented evidence of orders for the additives to the TPN Solution; Multivitamin and Famotadine. Review of Patient #2’s current TPN order from her local infusion clinic, written on 05/20/2025, revealed the following: Administer the following TPN Solution at 1800mL/day over 12 hours with a 1 hour taper up and a 1 hour taper down rate. TPN Solution to include the following Additives: Amino Acids: 40gm/day (Clinisol, 15%); Dextrose: 130gm/day; Lipids: 25gm/day; 7days/week; Sodium chloride: 60mEq/day; Sodium acetate: 70 mEq/day; Potassium chloride: 10 mEq/day; Magnesium sulfate: 4 mEq/day; Calcium gluconate: 5 mEq/day; and Trace Element Solution: 1 mL/day. Patient Additives: Multivitamin: Infuvite Adult, 10 mL/day; and Famotidine 40mg/day. On 07/15/2025 at 1:30 p.m., an interview was conducted with Patient #2. She stated her husband prepared her medications and TPN infusion. She confirmed she was not aware what the TPN Solution included. On 07/21/2025 at 1:11 p.m., an interview was conducted with Patient #2’s husband. He confirmed he managed her medications and her TPN solution. He confirmed the aforementioned information given by Patient #2 regarding her mediation regimen and confirmed her regimen had not changed since she was discharged from the hospital at the end of May 2025. He confirmed he added a Multivitamin and Famotidine to her TPN Solution daily. He confirmed he administered the TPN Solution through her RUE PICC line over 12 hours at 150mL/ hour for a total of 1800mL TPN Solution per day, and the infusion pump was pre-set with the rate. On 07/15/2025 at 2:04p.m., an interview was conducted with S5RN. She reviewed Patient #2’s current Medication Profile and confirmed it did not match the medications she currently received and should. She confirmed Patient #2’s current TPN order did not reflect the aforementioned order written by her infusion clinic and should. She confirmed she was unaware of what Patient #2 currently received via the TPN prepared by her husband and the orders should have been reflected in her Clinical Record. She further confirmed Patient #2’s PICC line was in the Right Upper Arm, and the Physician Orders were incorrect stating it was in the Left Upper Arm. Patient #3 Review of Patient #3’s Clinical Record revealed he began receiving services from the Home Health Agency on 0707/2025 and had a current Certification Period of 07/07/2025 to 09/04/2025. Further review revealed Patient #3 had diagnoses which included Encounter for Other Orthopedic Aftercare, Spinal Stenosis Cervical Region, Polyneuropathy, and Gastro-esophageal Reflux Disease without Esophagitis. Patient #3 was ordered to receive Skilled Nursing Visits once weekly for nine weeks, Physical Therapy Visits twice weekly for three weeks and Occupational Therapy Visits twice weekly for two weeks. On 07/14/2025 at 3:10 p.m., a home visit and interview was conducted with Patient #3 with S12PT present. Patient #3 confirmed he managed his own medications. The following information was obtained during Patient #3’s medication reconciliation: Allopurinol 300 mg - Patient #3 confirmed he took one and a half tablets once a day; Protonix 40 mg – Patient #3 confirmed he took one tablet twice a day; Gabapentin 400 mg - Patient #3 confirmed he took one 300 mg capsule three times a day; and Hydrocodone 7.5/325 mg – Patient #3 confirmed he took one tablet daily as needed for severe pain. He further confirmed he recently took a dose on 07/11/2025 for pain. Review of Patient #3’s current Medication Profile, dated 07/07/2025 through 09/04/2025, as of 07/14/2025, revealed the following current medication orders: Allopurinol 300 mg – Take one tablet daily; Protonix 40 mg – Take one tablet daily; and Gabapentin 400 mg - Take one capsule three times daily. Further review revealed no documented evidence of a current order for Hydrocodone 7.5/325 mg. On 07/14/2025 at 3:50 p.m., an interview was conducted with S12PT. He reviewed Patient #3’s current Medication Profile and confirmed it did not match the medications he was currently taking and should. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/12/2025 and had a current Certification Period of 06/12/2025 to 08/10/2025. Patient #4 had diagnoses, which included Hypertensive Heart disease With Heart Failure, Chronic Systolic Congestive Heart Failure, Polyneuropathy, and Ventricular Fibrillation. Patient #4 was ordered to receive Skilled Nursing Visits once weekly for nine weeks and Physical Therapy Visits once weekly for one week, twice weekly for two weeks and once weekly for one week. On 07/15/2025 at 12:00 p.m., a home visit and interview was conducted with Patient #4 with S13LPN present. Patient #4 confirmed she managed her own medications and filled her own pill planner with the assistance of her family members. The following information was obtained during Patient #4’s medication reconciliation: Entresto 49-51 mg – Patient #4 confirmed she had taken half a tablet twice daily since the dose was decreased three weeks ago; Digoxin – Patient #4 confirmed she had taken 0.125 mg half a tablet daily since her hospitalization on 06/21/2025; Spironolactone 25 mg – Patient #4 confirmed she had taken one tablet a day since her hospitalization on 06/21/2025; Trelegy Ellipta Inhaler – Patient #4 confirmed she stopped taking this medication prior to 06/21/2025; and Tylenol Extra Strength 500mg – Patient #4 confirmed she took two tablets almost every night to manager her bilateral foot pain with the most recent dose taken on 07/14/2025. Review of Patient #4’s current Medication Profile, dated 06/12/2025 through 08/10/2025, as of 07/15/2025, revealed the following current medication orders: Entresto 24-26 mg – Take one tablet twice daily; Digoxin 62.5 mcg – Take one tablet daily; Spironolactone 25 mg - Take one tablet twice daily; and Trelegy Ellipta Inhalation 100-62.5-25 mcg/ACT - Take one inhalation daily. Further review revealed no documented evidence of a current order for Tylenol Extra Strength 500 mg. On 07/15/2025 at 12:55 p.m., an interview was conducted with S13LPN. She stated a patient’s medications should be reconciled during each visit to ensure the patient’s medication profile was accurate. She reviewed Patient #4’s current Medication Profile and confirmed it did not match the medications she was currently taking and should. On 07/15/2025 at 3:26 p.m., an interview was conducted with S2DON. She confirmed patient medications should be reconciled by both nursing and therapy during every visit they conduct and anytime there were medication changes. She was made aware of the medication discrepancies identified during Patient #1, #2, #3 and #4’s home visits. She confirmed Patient #1, #2, #3 and #4’s medication profiles should have matched the medications they were currently taking and they did not. On 07/15/2025 at 3:30 p.m., an interview was conducted with S1ADM. She confirmed patient medications should be reconciled by both nursing and therapy during every visit they conduct and anytime there were medication changes. She was made aware of the medication discrepancies identified during Patient #1, #2, #3 and #4’s home visits. She confirmed Patient #1, #2, #3 and #4’s medication profiles should have matched the medications they were currently taking and they did not.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the comprehensive assessment was updated within the last 5 days of every 60-day episode for 1 (#12) of 17 (#1-#17) patient records reviewed. Findings: Review of the agency’s undated policy titled, “Comprehensive Client Assessment”, revealed the following, in part: Policy: The depth and frequency of ongoing assessments will depend on client needs, goals, and the care, treatment and services provided, but will be done at least once in every sixty (60) day period. Special Instructions: 13. Reassessments are conducted based on… OASIS (Outcome and Assessment Information Set) or other regulatory requirement… Review of Patient #12’s Clinical Record revealed he began receiving services with the Home Health Agency on 08/10/2023, had a previous Certification Period of 04/01/2025 through 05/30/2025, and a current Certification Period of 05/31/2025 through 07/29/2025. Review of Patient #12’s OASIS Recertification Missed Visit Note, dated 05/30/2025 and signed by S16RN revealed the following: Reason: Blank Comments: Blank Review of Patient #12’s OASIS Recertification visit dated 06/02/2025 revealed the comprehensive assessment was completed by S2DON in the Certification Period of 05/31/2025 through 07/29/2025. On 07/17/2025 at 11:00 a.m., an interview was conducted with S4LPN. She stated on 05/30/2025, S16RN was scheduled for Patient #12’s Recertification visit. She stated S16RN missed the visit and Patient #12 did not refuse the RN visit. She stated an OASIS Recertification visit should be completed within 5 days prior to the end of the episode. She confirmed Patient #12’s OASIS Recertification visit was not completed in the 5-day window prior to the end of the episode and should have been. On 07/17/2025 at 11:28 a.m., an interview was conducted with S16RN. She stated she did not recall Patient #12, was not aware she had an OASIS Recertification visit scheduled for him on 05/30/2025 and did not contact the patient. She stated an OASIS Recertification visit should be completed within 5 days prior to the end of the episode. On 07/17/2025 at 12:40 p.m., an interview was conducted with S3RN. She reviewed Patient #12’s Clinical Record and confirmed the OASIS Recertification visit on 05/30/2025 was scheduled to S16RN and was a missed visit. She stated she spoke with S16RN about why she did not make the Recertification visit on 05/30/2025. She stated S16RN stated she did not know the visit was on her schedule. She stated the Recertification visit was not completed within the 5-day window prior to the end of the episode and should have been. On 07/17/2025 at 1:15 p.m., an interview was conducted with S2DON. She reviewed Patient #12’s Clinical Record and confirmed the OASIS Recertification visit on 05/30/2025 was scheduled to S16RN and was a missed visit. She stated she was not sure exactly why the Recertification visit was missed. She confirmed she completed Patient #12’s Recertification visit on 06/02/2025. She confirmed the Recertification visit was not completed within the 5-day window at the end of episode and should have been. On 07/17/2025 at 1:35 p.m., an interview was conducted with S1ADM. She reviewed Patient #12’s Clinical Record and confirmed the OASIS Recertification visit on 05/30/2025 was scheduled to S16RN and was a missed visit. She stated she did not know why the Recertification visit was not made. She confirmed the Recertification visit was not completed within the 5-day window at the end of episode and should have been.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure orders from the Provider for Home Health Aide Services were integrated into the Plan of Care (POC) to ensure all services and interventions were provided to the patient for 2 (#4 and #10) of 3 (#4, #9, and #10) patients reviewed with orders for Home Health Aide Services. Findings: Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/12/2025 and had a current Certification Period of 06/12/2025 to 08/10/2025. Patient #4 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Polyneuropathy, and Ventricular Fibrillation. Further review revealed a Physician’s Order dated 06/10/2025 for admit to Home Health, which included to evaluate for Home Health Aide Services. Review of Patient #4’s POC dated 06/12/2025 to 08/10/2025 revealed no evidence the agency implemented Home Health Aide Services as ordered. Review of Patient #4’s Client Calendar Report revealed no documentation of a Home Health Aide visit for the Certification Period of 06/12/2025 to 08/10/2025. Review of Patient #4’s Physician Orders and Communication Notes for Certification Period 06/12/2025 to 08/10/2025 revealed no documented evidence the Provider was notified Home Health Aide Services were not provided as ordered. On 07/16/2025 at 10:10 a.m., an interview was conducted with S2DON. She reviewed Patient #4’s Clinical Record and Home Health referral dated 06/10/2025. She confirmed the Provider ordered Home Health Aide Services. She stated the agency had no Home Health Aide Services available in Patient #4’s area and the Provider should have been notified by S19CLM. She confirmed there was no documented evidence the Provider was notified Home Health Aide Services were not provided as ordered. On 07/16/2025 at 12:30 p.m., an interview was conducted with S19CLM. She stated she notified one of the nurses, but not sure who, at Patient #4’s referring Providers’ office the agency was unable to provide the Home Health Aide Services. She stated she did not have access to the patient’s Clinical Records and did not document any notes in their charts when she notified the Provider a discipline could not be provided. She stated if it was nursing or a therapy discipline the agency could not provide she would have the Provider redo and resend the order, but not for the Home Health Aide. On 07/16/2025 at 1:00 p.m., an interview was conducted with S3RN. She stated the Marketers notified the ordering Providers if a discipline was unable to be provided upon referral. She stated the agency’s policy was to include on the POC if they were unable to provide a discipline. She stated S19CLM would have notified the Home Health ordering Provider the Home Health Aide Services were not able to be provided for Patient #4. She reviewed Patient #4’s Clinical Record and confirmed there was no documented evidence the Provider was notified Home Health Aide Services were not provided as ordered and there should have been. On 07/16/2025 at 1:45 p.m., an interview was conducted with S1ADM. She stated when a referral was received and the agency was unable to staff any discipline, the field nurse, the Marketer or someone in the agency’s office was responsible for notifying the Provider. She reviewed Patient #4’s Clinical Record and confirmed there was no documented evidence the Provider was notified Home Health Aide Services were not provided as ordered and there should have been. Patient #10 Review of Patient #10’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/04/2025 and had a current Certification Period of 06/04/2025 to 08/02/2025. Patient #10 had diagnoses, which included Other Nondisplaced Fracture of Sixth Cervical Vertebrae, Other Malaise, and Chronic Pain. Review of Patient #10’s POC dated 06/04/2025 to 08/02/2025 revealed the following Physician Orders: Home Health Aide Services zero week one, then once weekly for six weeks. Review of Patient #10’s Aide Care Plan dated 06/04/2025 revealed the following, in part: Aide Frequency: zero week one, then once weekly for six weeks. Review of Patient #10’s Home Health Aide Missed Visit Note, dated 06/13/2025 and signed by S20HHA revealed the following: Reason: Other (Specify) Comments: Patient asked me to come Monday, due to bad weather. Review of Patient #10’s Client Calendar Report revealed no documentation a Home Health Aide visit was made for the Certification Period 06/04/2025 to 08/02/2025. Review of Patient #10’s Physician Orders and Communication Notes for Certification Period 06/04/2025 to 08/02/2025 revealed no documented evidence as to why the Home Health Aide Services were not provided or the Provider was notified Home Health Aide Services were not provided as ordered and there should have been. On 07/16/2025 at 2:45 p.m., an interview was conducted with S2DON. She reviewed Patient #10’s Clinical Record and confirmed the Home Health Aide was ordered once weekly for six weeks. She stated an Aide Care Plan was completed and one Home Health Aide missed visit for patient refusal due to bad weather was documented. She confirmed there was no documented evidence as to why the Home Health Aide Services were not provided or the Provider was notified Home Health Aide Services were not provided as ordered and there should have been. On 07/16/2025 at 2:55 p.m., an interview was conducted with S1ADM. She reviewed Patient #10’s Clinical Record and confirmed the Home Health Aide was ordered once weekly for six weeks. She confirmed there was no documented evidence as to why the Home Health Aide Services were not provided or the Provider was notified Home Health Aide Services were not provided as ordered and there should have been.”

“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 observations, interviews, and record reviews, the agency failed to provide the patient and caregiver with the Clinical Managers name in order to discuss their services for 4 (#1, #2, #3, and #6) of 6 (#1, #2, #3, #4, #5, and #6) home visits conducted. Findings: Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 06/26/2025, and had a current Certification Period of 06/26/2025 through 08/24/2025. A home visit was conducted for Patient #1 on 07/14/2025 at 11:00 a.m. with S11LPN present. A review of Patient #1’s Home Health folder revealed no documentation of the name of the Clinical Manager to be used to discuss patient’s services. On 07/14/2025 at 11:45 a.m., an interview was conducted with S11LPN during Patient #1’s home visit. She reviewed Patient #1’s Home Health folder and confirmed there was no documentation of the name of the agency’s Clinical Manager and there should have been. She stated the Registered Nurse (RN) who completed the patient’s admission assessment was responsible for writing the name of the Clinical Manager in their Home Health folder and they did not. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 03/28/2025, and had a current Certification Period of 05/27/2025 through 07/25/2025. A home visit was conducted for Patient #2 on 07/14/2025 at 1:30 p.m. with S5RN present. A review of Patient #2’s Home Health folder revealed no documentation of the name of the Clinical Manager to be used to discuss patient’s services. On 07/14/2025 at 1:30 p.m., an interview was conducted with S5RN during Patient #2’s home visit. She reviewed Patient #2’s Home Health folder and confirmed there was no documentation of the name of the agency’s Clinical Manager and there should have been. She confirmed the RN who completed the patient’s admission assessment was responsible for writing the name of the Clinical Manager in their Home Health folder and they did not. Patient #3 Review of Patient 3’s Clinical Record revealed he was admitted to the agency on 07/07/2025, and had a current Certification Period of 07/07/2025 to 09/04/2025. A home visit was conducted for Patient #3 on 07/14/2025 at 3:10 p.m. with S12PT present. A review of Patient #3’s Home Health folder revealed no documentation of the name of the Clinical Manager to be used to discuss patient’s services. On 07/14/2025 at 3:50 p.m., an interview was conducted with S12PT during Patient #3’s home visit. He reviewed Patient #3’s Home Health folder and confirmed there was no documentation of the name of the agency’s Clinical Manager and there should have been. Patient #6 Review of Patient 6’s Clinical Record revealed she was admitted to the agency on 07/01/2025, and had a current Certification Period of 07/01/2025 through 08/29/2025. A home visit was conducted for Patient #6 on 07/15/2025 at 9:30 a.m. with S4LPN present. A review of Patient #6’s Home Health folder revealed no documentation of the name of the Clinical Manager to be used to discuss patient’s services. On 07/15/2025 at 9:30 a.m., an interview was conducted with S4LPN during Patient #6’s home visit. She reviewed Patient #6’s Home Health folder and confirmed there was no documentation of the name for the agency’s Clinical Manager, and there should have been. On 07/15/2025 at 3:26 p.m., an interview was conducted with S1ADM. S1ADM confirmed the RN performing the patient’s admission assessment was responsible for writing the Clinical Manager’s name and in the patient’s Home Health folder, and they had not for Patient #1, #2, #3, and #6.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, record reviews, and interviews, the agency failed to provide services as ordered by the physician in the Plan of Care (POC) for 2 (#2 and #4) of 17 (#1-#17) patient records reviewed. The agency failed to ensure: 1. The Skilled Nurse changed the injection caps on Resident #2’s Peripherally Inserted Central Catheter (PICC line), and measured Patient #2’s Right Mid-Arm Circumference (MAC) as per the POC; and 2. The Skilled Nurse obtained and documented respirations and oxygen saturations for Patient #4 on each visit. Findings: 1. Review of agency’s undated policy, titled “PICC Line Dressing Change” revealed the following, in part: Purpose: To prevent infection Special considerations: Dressing changes will be done weekly per agency protocol Procedure: 19. Replace injection cap to end of the primed extension tubing and secure connection. Review of Patient #2’s Clinical Record revealed she began receiving services form the Home Health Agency on 03/28/2025 with a current Certification Period of 05/27/2025 through 07/25/2025. Patient #2 had diagnoses, which included Infection/ Inflammation due to Cardiovascular Device, Malignant Neoplasm of the Appendix, Encounter for Adjustment and Management of Vascular Access Device. Further review of Patient #2’s Clinical Record revealed no documented evidence of a Mid Arm Circumference being obtained or charted. Review of Patient #2’s POC for Certification Period 05/27/2025 through 07/25/2025 revealed she was to receive Skilled Nursing services once weekly for eight weeks, and Physical Therapy once weekly for four weeks. Further review of Patient #2’s POC revealed the following, in part: Skilled Nurse to perform arm circumference each visit and caps should be changed ever Monday per agency policy. On 07/14/2025 at 1:30 p.m., an observation was conducted of S5RN during Patient #2’s home visit. S5RN was observed changing Patient #2’s Right Upper Arm PICC Line dressing using sterile technique. S5RN was not observed changing the PICC line injection caps or measuring Patient #2’s Mid Arm Circumference. On 07/14/2025 at 2:04 p.m., an interview was conducted with S5RN. She confirmed she did not change the caps on the PICC Line and reported that she forgot, and the caps should be changed weekly. She further confirmed she did not measure Patient #2’s Mid Arm Circumference. She stated that she had only measured the Mid Arm Circumference if there were signs or symptoms of Edema, pain or complications related to the PICC line. On 07/15/2025 at 3:26 p.m., an interview was conducted with S2DON. She was informed of the observations during the home visit. S2DON confirmed the agency’s policy stated the PICC line caps should be changed weekly on Mondays, and Patient #2’s Mid Arm Circumference should be measured weekly per her POC, but was not. On 07/15/2025 at 3:26 p.m., an interview was conducted with S1ADM. She was informed of observations during the home visit. S1ADM confirmed the agency’s policy stated the PICC line caps should be changed weekly, and Patient #2’s Mid Arm Circumference should be measured weekly per her POC, but was not. 2. Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 06/12/2025 and had a current Certification Period of 06/12/2025 to 08/10/2025. Patient #4 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, and Ventricular Fibrillation. Review of Patient #4’s POC for Certification Period 06/12/2025 through 08/10/2025 revealed she was to receive Skilled Nursing services once weekly for nine weeks. Further review revealed, in part: Skilled Nurse to assess oxygen saturation on room air every Skilled Nurse visit; and Notify physician of: Respirations greater than 24 or less than 14 and oxygen saturations less than 90%. Review of Patient #4’s Skilled Nurse Visit Note dated 07/08/2025 completed by S17RN revealed no documentation of respirations or oxygen saturations. On 07/16/2025 at 10:10 a.m., an interview was conducted with S2DON. She reviewed Patient #4’s Clinical Record and Skilled Nurse visit completed by S17RN on 07/08/2025. She stated the expectation were for vital signs to be obtained and documented each patient visit. She confirmed there were no documented respirations or oxygen saturation for Patient #4 and there should have been.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the physician was notified of a patient’s vital signs outside of the established parameters per the Plan of Care (POC) for 2 (#2 and #8) of 17 (#1-#17) patients reviewed for care and services provided per the POC. Findings: Review of the agency’s undated policy titled, “Reporting to physician,” revealed the following, in part: Purpose: To provide the physician with information necessary to make informed decisions about the patient’s medical status. Policy: 1. The nurse will notify the physician of significant changes in the patient’s condition… or other pertinent information that may require physician intervention. 3. The nurse will document the following in the medical record communication… a. Date and time of call b. Reason for call c. Name of physician contacted 7. The nurse will follow the agency policy for documentation and physician notification. Patient #2 Review of Patient #2’s Clinical Record revealed she began receiving services with the Home Health Agency on 03/28/2025, and had a current Certification Period of 05/27/2025 through 07/25/2025. Patient #2 had diagnoses, which included Infection/ Inflammation due to Cardiovascular Device Implant and Malignant Neoplasm of Appendix. Review of Patient #2’s POC dated 03/28/2025 through 05/26/2025 revealed the following physician orders: Vital sign parameters: Notify physician of: Diastolic Blood Pressure less than 60. Review of Patient #2’s Skilled Nurses’ Visit Notes revealed the following, in part: 03/31/2025- Blood Pressure 100/58, signed by S5RN. Further review revealed no documented evidence Patient #2’s physician was notified of her Diastolic Blood Pressure being outside of the established parameters per her POC. An interview was conducted on 07/15/2025 at 12:40 p.m. with S5RN. She confirmed Patient #2’s Diastolic Blood Pressure parameter was to notify the physician if less than 60. She reviewed Patient #2’s Clinical Record and confirmed she conducted a Skilled Nurse Visit on 03/31/2025 and Patient #2’s Blood Pressure was 100/58 which was outside of the parameters on the POC. She further confirmed she did not contact the physician, and should have. Patient #8 Review of Patient #8’s Clinical Record revealed he began receiving services with the Home Health Agency on 05/31/2025, and had a current Certification Period of 05/31/2025 through 07/29/2025. Patient #8 had diagnoses, which included Moderate Laceration of Spleen, Acute Post Hemorrhagic Anemia, and Laceration with Foreign Body Right Foot. Review of Patient #8’s POC dated 05/31/2025 through 07/29/2025 revealed the following physician Orders: Skilled Nurse twice a week for seven weeks and once a week for one week; and Vital sign Parameters: Notify physician of: Pulse greater than 100 or less than 50 and Diastolic Blood Pressure greater than 90 or less than 60. Review of Patient #8’s Skilled Nurses’ Visit Notes revealed the following, in part: 07/03/2025-Pulse 120, Blood Pressure 150/100, signed by S15RN. Further review revealed no documented evidence Patient #8’s physician was notified of his blood pressure and heart rate being outside of the established parameters per his POC. An interview was conducted on 07/15/2025 at 9:38 a.m. with S15RN. She reviewed Patient #8’s Clinical Record and confirmed she conducted a Skilled Nurse Visit on 07/03/2025. She stated Patient #8’s pulse was 120 bpm and his Blood Pressure was documented as 150/100. She confirmed she did not notify a physician of Patient #8’s vital signs outside of parameters and should have. An interview was conducted on 07/15/2025 at 3:26 p.m. with S1ADM. She stated staff were expected to notify the physician for vital signs outside of ordered parameters, and document the communication in the patient’s Clinical Record. She was made aware of Patient #2 and Patient #8’s vital signs outside of parameters per the POC and stated staff should have contacted the patients’ physicians.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interviews, the agency failed to provide nursing services under the supervision of a Registered Nurse (RN) for 1 (S4LPN) of 1 Licensed Practical Nurses (LPN) personnel file reviewed for supervisory visits. This deficient practice had the potential to affect any of the 1,741 unduplicated admissions during the past 12 months, a current census of 416 patients, and any future admissions to the agency. Findings: Review of the state’s Minimum Standards for Home Health Agencies, last revised February, 2022 revealed, in part, the following: 9103K,2.j. Responsibilities. The Registered Nurse shall: j. conduct on-site supervisory evaluations at least every six months for each licensed practical nurse while he/she is providing care and document such supervision in the LPN’s personnel file. Review of S4LPN’s personnel file revealed she was hired by the Home Health Agency on 07/03/2017. On 07/21/2025 at 2:00 p.m., S2DON provided documentation of supervisory visits made on S4LPN on the following dates 06/02/2025, 06/03/2025, and 06/23/2025. Further review revealed no evidence the supervisory visit was conducted on-site by a RN. On 07/21/2025 at 2:20 p.m., an interview was conducted with S2DON. She confirmed she was an RN and responsible for LPN supervisory documentation for S4LPN. She confirmed for the supervisory visits dated 06/02/2025, 06/03/2025, and 06/23/2025 the RN was not present in the home. She further confirmed the agency does not have RNs perform on-site supervisory evaluations for LPNs, and was unaware the on-site evaluations for LPNs should be completed every six months. On 07/21/2025 at 3:30 p.m., an interview was conducted with S1ADM. S1ADM stated the agency was unable to provide documentation of any on-site supervisory visits for S4LPN. She confirmed she was unaware on-site LPN supervisory visits should have been completed every six months.”

“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 reviews and interviews, the agency failed to ensure a completed discharge summary was sent to the patients primary care practitioner (PCP) or other health care professional responsible for providing care and services to the patient after discharge within 5 business days of the patient’s discharge from the agency for 6 of 6 (#5, #13, #14, #15, #16 and #17) discharged patients reviewed. Findings: Patient #5 Review of Patient #5’s Clinical Record revealed he began receiving services from the Home Health Agency on 04/11/2025, had a Certification Period of 04/11/2025 through 05/31/2025, and was discharged from the agency on 05/31/2025. Further review revealed he was readmitted for services on 06/12/2025 and discharged on 06/30/2025, then readmitted again on 07/03/2025 for a current Certification Period of 07/03/2025 through 08/31/2025. Review of Patient #5’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #5’s care and services upon their discharge from the agency. Patient #13 Review of Patient #13’s Clinical Record revealed she began receiving services from the Home Health Agency on 07/11/2023, had a Certification Period of 01/01/2025 to 03/01/2025, and was discharged from the agency on 01/09/2025. Review of Patient #13’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #13’s care and services upon their discharge from the agency. Patient #14 Review of Patient #14’s Clinical Record revealed he began receiving services from the Home Health Agency on 10/07/2023, had a Certification Period of 04/04/2024 to 06/02/2024, and was discharged from the agency on 04/17/2024. Review of Patient #14’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #14’s care and services upon their discharge from the agency. Patient #15 Review of Patient #15’s Clinical Record revealed she began receiving services from the Home Health Agency on 12/10/2024, had a Certification Period of 04/09/2025 to 06/07/2025, and was discharged from the agency on 05/08/2025. Review of Patient #15’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #15’s care and services upon their discharge from the agency. Patient #16 Review of Patient #16’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/14/2025, had a Certification Period of 01/14/2025 through 03/10/2025, and was discharged from the agency on 03/10/2025. Review of Patient #16’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #16’s care and services upon their discharge from the agency. Patient #17 Review of Patient #17’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/04/2025, had a Certification Period of 01/04/2025 through 01/28/2025, and was discharged from the agency on 01/28/2025. Review of Patient #17’s Clinical Record revealed no documented evidence of a completed discharge summary being sent to the health care provider who would be assuming responsibility for Patient #17’s care and services upon their discharge from the agency. On 07/21/2025 at 10:34 a.m., an interview was conducted with S14CL. She stated she was responsible for sending a patient’s discharge summary to the health care provider who would be accepting responsibility for the patient’s care upon their discharge from the agency. She confirmed she was unaware a complete discharge summary should include the patient’s required nursing services and should be sent to the patient’s accepting provider within 5 days of their discharge from the agency. She confirmed a complete discharge summary was not faxed to the accepting provider for Patient #5, #13, #14, #15, #16 and #17 and should have been. On 07/21/2025 at 10:40 a.m., an interview was conducted with S3RN. She stated it was the agency’s process to fax therapy discharge summaries to the patient’s physicians. She stated nursing discharge summaries were not faxed to the patient’s physicians and she was unaware they were required to be sent to the patient’s physicians. She reviewed Patient #5, #13, #14, #15, #16 and #17’s discharge summaries and verified they would not have been sent to the patient’s providers if they were nursing discharges. On 07/21/2025 at 12:00 p.m., an interview was conducted with S1ADM. She stated S14CL was responsible for sending therapy discharge summaries to the patient’s home health providers. She reviewed Patient #5, #13, #14, #15, #16 and #17’s discharge orders and discharge summaries. She confirmed the skilled nursing discharge summaries were not sent to the patient’s primary care physicians or home health ordering providers and should have been.”