Modern Home Health, Inc.

“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 reviews and interview, the agency failed to provide and maintain documentation of Emergency Preparedness (EP) training to staff and contract staff at least every two (2) years for 6 (S4PTA, S7PT, S8COTA, S9HHA, S11HHA, and S13HHA) of 10 personnel files reviewed for EP training. Findings: Review of S4PTA’s personnel record revealed a hire date of 04/25/2018. Further review revealed there was no documented evidence EP training was completed after 05/18/2023. Review of S7PT’s personnel record revealed a hire date of 03/23/2015. Further review revealed there was no documented evidence EP training was completed after 05/18/2023. Review of S8COTA’s personnel record revealed S8COTA was contract staff with a hire date of 02/11/2021. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S9HHA’s personnel record revealed a hire date of 08/07/2018. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S11HHA’s personnel record revealed a hire date of 03/08/2011. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S13HHA’s personnel record revealed a hire date of 07/27/2017. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. An interview was conducted with S1ADM on 05/15/2026 at 3:15 p.m. S1ADM confirmed the above staff and contract personnel files reviewed had no documented evidence EP training was completed every 2 years as required, and should have.”

“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 ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 318 patients according to the agency’s active census. Findings: Review of the agency’s undated policy titled “Encoding and Reporting OASIS Data” revealed, in part: Policy The agency will electronically report all OASIS data collected in accordance with federal regulations. Special Instructions 1. Agency will encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the client. Review of the agency’s OASIS Final Validation Report dated 04/01/2026 revealed 47 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/03/2026 revealed 21 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/10/2026 revealed 44 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/15/2026 revealed 74 total records were submitted with 3 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Error Detail Report dated 04/01/2026 to 05/07/2026 revealed on 04/17/2026 there were 2 records submitted greater than 30 days of the completion date. The agency’s OASIS Final Validation report dated 04/17/2026 was requested and unavailable for review. Review of the agency’s OASIS Final Validation Report dated 04/22/2026 revealed 55 total records were submitted with 4 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/27/2026 revealed 28 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/29/2026 revealed 77 total records were submitted with 4 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/06/2026 revealed 37 total records were submitted with 3 records submitted greater than 30 days of the completion date. An interview was conducted with S1ADM on 05/18/2026 at 12:35 p.m. S1ADM stated all OASIS assessments should be submitted within 30 days of the completion date. The above OASIS Final Validation Reports and the agency’s OASIS Error Detail Report were reviewed. S1ADM confirmed the above OASIS assessments were submitted greater than 30 days of the completion date. S1ADM confirmed the agency had no OASIS Final Validation report dated 04/17/2026 available for review. S1ADM further confirmed the above mentioned 2 records submitted on 04/17/2026 were submitted greater than 30 days of the completion date.”

“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 home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 2 (#15 and #16) of 6 patients reviewed for Pressure Ulcers. The agency failed to ensure the RN assessed Patient #15 and #16’s Pressure Ulcers, including size and stage, on a weekly basis. 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. 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 Care Policy & Procedure”, revealed the following, in part: The agency shall provide wound and pressure ulcer care according to physician/provider orders, current clinical standards, and applicable federal/state guidelines. Responsibilities Registered Nurse (RN) Performs comprehensive wound assessment Provides wound treatment Supervises LPN… Procedure: Upon admission and as needed thereafter, the clinician shall: To assess all pressure ulcer injuries on a weekly basis. Patient #15 Review of Patient #15’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/05/2022, had a certification period of 06/18/2025 to 08/16/2025, and was discharged from the agency on 07/11/2025. Patient #15 had diagnoses, which included Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Buttock, Stage 4 Pressure Ulcer of Right Heel, Stage 4 Pressure Ulcer of Left Ankle, and Stage 3 Pressure Ulcer of Other Site. Review of Patient #15’s Plan of Care for Certification Period 06/18/2025 to 08/16/2025 revealed the following, in part: Skilled Nursing Visits once weekly for nine weeks effective 06/18/2025. Skilled Nurse (SN) to perform wound care to Right Heel Pressure Ulcer, Left Foot Pressure Ulcer, Left Ischial Pressure Ulcer, Right Hip Pressure Ulcer, and Right Anterior Foot Pressure Ulcer once a week and as needed. Review of Patient #15’s Skilled Nursing Visit notes conducted for Certification Period 06/18/2025 to 08/16/2025 revealed Patient #15’s Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Buttock, Stage 4 Pressure Ulcer of Right Heel, Stage 4 Pressure Ulcer of Left Ankle, and Stage 3 Pressure Ulcer of Other Site was not assessed by a RN, to include measurements the weeks of 06/20/2025, 06/27/2025, 07/01/2025 and 07/11/2025. An interview was conducted with S1ADM on 05/14/2026 at 11:00 a.m. He reviewed Patient #15’s Clinical Record and confirmed Patient #15 had Pressure Ulcers on admission until discharge. He confirmed Patient #15’s Pressure Ulcers were not assessed by a RN on the above mentioned weeks. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 05/31/2025, had a certification period of 05/31/2025 to 07/29/2025, and was discharged from the agency on 07/18/2025. Patient #16 had diagnoses, which included Stage 2 Pressure Ulcer of Left Buttock and Stage 1 Pressure Ulcer of Sacral Region. Review of Patient #16’s Plan of Care for Certification Period 05/31/2025 to 07/29/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week, twice weekly for two weeks then once weekly for six weeks; and Skilled Nurse (SN) to perform/instruct caregiver on wound care to Left Buttock Pressure Ulcer and Sacral Pressure Ulcer three times a week and as needed. Review of Patient #16’s Physician Order dated 06/04/2025 revealed the following, in part: Increase Skilled Nursing Visits to three times weekly; and Skilled Nurse (SN) to perform wound care to Left Buttock Pressure Ulcer and Sacral Pressure Ulcer three times a week and as needed. Review of Patient #16’s Skilled Nursing Visit notes conducted for Certification Period 05/31/2025 to 07/29/2025 revealed Patient #16’s Stage 2 Left Buttock Pressure Ulcer and Stage 1 Sacral Pressure Ulcer was not assessed by a RN, to include measurements the weeks of 06/01/2025, 06/08/2025, 06/15/2025, 06/22/2025, and 07/06/2025. An interview was conducted with S1ADM on 05/14/2026 at 10:35 a.m. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had Pressure Ulcers on admission until discharge. He confirmed Patient #16’s Pressure Ulcers were not assessed by a RN on the above mentioned weeks. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the Registered Nurse or other appropriate skilled professional prepared written instructions for the Home Health Aide for 1 (#8) of 5 patients reviewed receiving home health aide services. Findings: Review of the agency’s undated policy titled, “Home Health Aide Policy” revealed the following, in part: Policy All home health aide services shall be provided according to a written patient-specific care plan developed and supervised by a registered nurse or qualified therapist. Home Health aides may only perform tasks assigned... Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 05/02/2026, and had a current Certification Period of 05/02/2026 through 06/30/2026. Review of Patient #8’s Physician Orders dated 05/08/2026 revealed Home Health Aide services were ordered for two (2) home health aide visits per week for 2 weeks, and one (1) home health aide visit per week for 4 weeks. Review of Patient #8’s Visit Calendar revealed he had received home health aide visits on 05/12/2026 and 05/14/2026. Further review revealed a written plan of care with instructions for the home health aide had not been completed. An interview was conducted with S2RN on 05/15/2026 at 10:26 a.m. S2RN stated she had not completed a Care Plan with written instructions for the home health aide to care for Patient #8. An interview was conducted with S1ADM on 05/15/2026 at 10:35 a.m. S1ADM reviewed Patient #8’s clinical record and confirmed the above Physician’s order dated 05/08/2026 for Patient #8 to receive home health aide services. S1ADM confirmed there was no documented evidence of a home health aide care plan completed prior to a home health aide visit completed, and should have been.”

“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 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, #6, and #7) of 7 patients with home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S4PTA on 05/12/2026 at 2:22 p.m. S4PTA reviewed Patient #1’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S7PT on 05/12/2026 at 2:00 p.m. S7PT reviewed Patient #2’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S10LPN on 05/13/2026 at 10:32 a.m. S10LPN reviewed Patient #6’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/2/2026. A home visit was conducted with Patient #7 on 05/13/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S15LPN on 05/13/2026 at 12:46 p.m. S15LPN reviewed Patient #7’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated office staff were responsible for placing a label with the Administrator’s name and contact information in the patient’s Home Health folder. He stated if the information was not there on admit, the clinician admitting the patient was responsible for writing the Administrator’s name and contact information in the patient’s Home Health folder. S1ADM was made aware of the above mentioned findings for Patient #1, #2, #6, and #7 and confirmed the name of the Administrator should have been documented on the patient’s Home Health folders. Findings:”

“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 each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 3 (#1, #2 and #5) of 7 patients reviewed with home visits. Findings: Review of the agency’s undated policy titled, “Medication Reconciliation Policy & Procedure” revealed the following, in part: Policy: It is the policy of this agency to perform medication reconciliation for all patients receiving home health services to ensure accurate and complete medication information is communicated consistently throughout the course of care. Medication reconciliation will be completed upon admission … and whenever medication changed occur. Procedure: 1. Medication Reconciliation Requirements Medication reconciliation shall be completed: At Start of Care When medications are discontinued or changed 2. Responsibilities of the Clinician The admitting or assigned clinician is responsible for: 1. Obtaining a complete and accurate medication list including: Prescription medication Over-the-counter medications… 2. Comparing: Physician orders Hospital discharge instructions Medication bottles/packages in the home 3. Identifying discrepancies including: Omitted medications Incorrect dosages… 5. Updating the medication profile in the clinical record. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/24/2026 and had a current Certification Period of 04/24/2026 through 06/22/2026. Further review revealed Patient #1 had diagnoses, which included Type 2 Diabetes Mellitus with Hyperglycemia, Anxiety Disorder and Long Term Current Use of Insulin. Review of Patient #1’s current orders revealed Patient #1 was to receive Skilled Nursing Visits once weekly for one week, three times weekly for one week, twice weekly for two weeks then once weekly for five weeks. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. with S4PTA present in the home. Patient #1’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Humulin N Kwikpen Subcutaneous (SC) 100 units/ml 8 units SC daily was on the medication profile and the patient was taking 30 units SC every morning; and Xanax 0.5 mg take one tablet by mouth twice daily was on the medication profile and the patient was a 1 mg tablet by mouth twice daily. An interview was conducted with Patient #1 during the home visit on 05/12/2026 at 2:00 p.m. Patient #1 stated she had taken 30 units of Humulin N insulin daily for years. Patient #1 stated she took Xanax 1 mg tablets every morning and night. An interview was conducted with S4PTA on 05/12/2026 at 2:22 p.m. S4PTA confirmed the medications Patient #1 was taking and the medication profile should match and did not. An interview was conducted with S5LPN on 05/13/2026 at 2:41 p.m. S5LPN stated the nurses were responsible for reconciling patient medications each visit. S5LPN was made aware of the above mentioned medication discrepancies for Patient #1. S5LPN confirmed the medications Patient #1 was taking and the agency’s medication profile should match and did not. Patient #2 Review of Patient #2’s Clinical Record revealed she began receiving services from the Home Health Agency on 02/12/2026 and had a current Certification Period of 02/12/2026 through 06/11/2026. Further review revealed Patient #2 had diagnoses, which included Essential Hypertension and Depression, Unspecified. Review of Patient #2’s current orders revealed Patient #2 was ordered to receive Skilled Nursing Visits once weekly for nine weeks. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. with S7PT and her family member present. Patient #2’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Rexulti 0.5mg 1 tablet by mouth daily was not on the medication profile and the patient was taking a 0.5mg tablet by mouth daily. An interview was conducted with Patient #2’s family member during the home visit on 05/12/2026 at 2:00 p.m. She stated Patient #2 had taken Rexulti 0.5mg daily since 02/12/2026. An interview was conducted with S7PT on 05/12/2026 at 2:20 p.m. S7PT confirmed the medications Patient #2 was taking and the medication profile should match and did not. An interview was conducted with S6RN on 05/13/2026 at 2:55 p.m. S6RN stated the nurses should reconcile patient medications each visit. S6RN was made aware of the above mentioned medication discrepancies for Patient #2. S6RN confirmed the medications Patient #2 was taking and the agency’s medication profile should match and did not. Patient #5 Review of Patient #5’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/23/2026 and had a current Certification Period of 03/23/2026 through 05/21/2026. Patient #5 had diagnoses, which included Age-Related Osteoporosis with Current Pathological Fracture, Left Pelvis, Age-Related Osteoporosis with Current Pathological Fracture, Vertebrae, Unspecified Fall, and Subsequent Encounter, and Bilateral Primary Osteoarthritis of Hip. Review of Patient #5’s current orders revealed Patient #5 was to receive Skilled Nursing Visits twice weekly for two weeks, then once weekly for seven weeks as of 03/24/2026. A home visit was conducted with Patient #5 on 05/12/2026 at 8:35 a.m. with S9HHA present. Patient #5’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Stool Softener 1 tablet by mouth daily was not on the medication profile and the patient was taking 1 tablet daily. Probiotic 1 soft gel every evening was not on the medication profile and the patient was taking 1 soft gel every evening. An interview was conducted with Patient #5 during the home visit on 05/12/2026 at 9:00 a.m. She stated she has taken the Stool Softener daily and Probiotic soft gel every evening since 04/23/2026. An interview was conducted with S3RN on 05/13/2026 at 3:45 p.m. S3RN stated nurses were responsible for reconciling patient’s medications each visit. S3RN was made aware of the above mentioned medication discrepancies for Patient #5. S3RN confirmed the medications Patient #5 was taking and the agency’s medication profile should match and did not. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated patient medications should be reconciled during each home visit by the agency’s nurses. He was made aware of Patient #1, #2 and #5’s medication discrepancies identified during their home visits. S1ADM confirmed the medications each patient were currently taking should have matched the patient’s current medication profile.”

“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 reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 2 (#15 and #17) of 17 sampled patients reviewed. Findings: Review of the agency’s undated policy titled, “MD (Medical Doctor) Order Policy and Procedures” revealed in part: Policy The agency shall ensure that all patient care is provided according to a physician/provider approved Plan of Care (POC) and authorized physician/provider orders. Services shall be coordinated, documented, and periodically reviewed to ensure patient needs are met safely and effectively. Procedure 4. Plan of Care Review and Updates 1. The POC shall be reviewed: at least every 60 days. Patient #17 Review of Patient #17’s clinical record revealed a SOC date of 07/11/2025. Review of Patient #17’s POC for certification period 07/11/2025 through 09/08/2025 revealed Patient #17’s physician reviewed and signed the POC on 10/02/2025, which was not within the 60 day timeframe. Review of Patient #17’s POC for certification period 11/08/2025 through 01/06/2026 revealed Patient #17’s physician reviewed and signed the POC on 02/25/2026, which was not within the 60 day timeframe. An interview was conducted with S1ADM on 05/14/2026 at 3:07 p.m. The above mentioned POCs for Patients #15 and #17 were reviewed. S1ADM confirmed Patients #15 and #17’s POC orders were not reviewed and signed by the physician within the 60 day timeframe, and should have been. Findings: Patient #15 Review of Patient #15’s clinical record revealed a Start of Care (SOC) date or 01/05/2022. Review of Patient #15’s POC for certification period 04/29/2025 through 06/17/2025 revealed Patient #15’s physician reviewed and signed the POC on 07/17/2025, which was not within the 60 day timeframe. Review of Patient #15’s POC for certification period 06/18/2025 through 08/16/2025 revealed Patient #15’s physician reviewed and signed the POC on 09/15/2025, which was not within the 60 day timeframe.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record reviews, the agency failed to provide the patient and/or caregiver with a copy of written instructions of the Home Health outlining the visit schedule, including frequencies of visits consistent with the current plan of care for 7 (#1, #2, #3, #4, #5, #6, and #7) of 7 patient home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions outlining Patient #1’s Home Health visit schedule, including the frequency of visits. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions outlining Patient #2’s Home Health visit schedule, including the frequency of visits. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions outlining Patient #3’s Home Health visit schedule, including the frequency of visits. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/29/2026, and had a current Certification Period of 04/24/2026 through 06/22/2026. A home visit was conducted with Patient #4 on 05/13/2026 at 11:30 p.m. Review of Patient #4’s Home Health folder revealed no documentation of written instructions outlining Patient #4’s Home Health visit schedule, including the frequency of visits. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions outlining Patient #5’s Home Health visit schedule, including the frequency of visits. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of written instructions outlining Patient #6’s Home Health visit schedule, including the frequency of visits. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/29/2026. A home visit was conducted with Patient #7 on 05/13/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of written instructions outlining Patient #7’s Home Health visit schedule, including the frequency of visits. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated the admitting clinicians gave the patient and/or caregiver a verbal visit schedule. He was made aware of the above mentioned findings during the home visits for Patient’s #1, #2, #3, #4, #5, #6 and #7. S1ADM confirmed he was unaware of the requirement a written visit schedule including the frequency of visits was required to be provided to the patients and/or caregivers. Findings: Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions outlining Patient #2’s Home Health visit schedule, including the frequency of visits. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions outlining Patient #3’s Home Health visit schedule, including the frequency of visits. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions outlining Patient #5’s Home Health visit schedule, including the frequency of visits.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to provide the patient and/or caregiver with a copy of written instructions of the patient’s medication regimen for 7 (#1, #2, #3, #4, #5, #6, and #7) of 7 patient home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions for Patient #1’s medication regimen. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions for Patient #2’s medication regimen. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions for Patient #3’s medication regimen. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/29/2025, and had a current Certification Period of 04/24/2026 through 06/22/2026. A home visit was conducted with Patient #4 on 05/13/2026 at 11:30 a.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions for Patient #4’s medication regimen. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions for Patient #5’s medication regimen. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of written instructions for Patient #6’s medication regimen. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/29/2026. A home visit was conducted with Patient #7 on 05/12/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of written instructions for Patient #7’s medication regimen. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. S1ADM was made aware of the above mentioned findings during the home visits for Patient’s #1, #2, #3, #4, #5, #6 and #7. S1ADM confirmed each patient should have been provided written instructions of the medication regimen. Findings:”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to have completed clinical documentation of skilled nursing services provided according to the Plan of Care (POC) for 1 (#9) of 17 patient records reviewed. Findings: Review of the agency’s undated policy titled “Policy and Procedures for Clinical Documentation” revealed, in part: Procedures Completion TimelineRoutine visit notes: Completed and submitted with 48 hours of the visit. Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 01/05/2026 with a current Certification Period of 05/05/2026 through 07/03/2026. The patient’s diagnoses included, in part: Pressure Ulcer of Right Buttock, Stage 2, Pressure Ulcer of Other Site, Stage 2, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Acquired Absence of Right Leg, Below Knee. Review of the Plan of Care (POC) orders for Patient #9 for Certification Period 05/05/2026 through 07/03/2026 revealed, in part: Skilled Nurse visits one time a week for one week, then two times a week for 8 weeks. Skilled Nurse to perform wound care to Right Buttock twice a week and as needed. Skilled Nurse to perform wound care to Sacral wound twice a week and as needed. Skilled Nurse to perform wound care to Right Lower Extremity, Below Knee Amputation weekly. Review of Patient #9’s Visit Calendar revealed Patient #9 was seen by S3RN on 05/07/2026 for labs and 05/11/2026 for wound care. Further review revealed clinical note documentation for the above dates were not available for review as of 05/15/2026 at 10:51 a.m. An interview was conducted with S3RN on 05/15/2026 at 11:26 a.m. S3RN confirmed Patient #9 was seen for skilled nursing services on 05/07/2026 and 05/11/2026. S3RN confirmed all visit notes should be completed timely per agency policy. S3RN confirmed Patient #9’s skilled nurse visit documentation for 05/07/2026 and 05/11/2026 should have been completed per agency policy, and were not. An interview was conducted with S1ADM on 05/15/2026 at 11:38 a.m. S1ADM stated the agency’s policy for clinical documentation required all clinical staff to turn in visit documentation within 48 hours of their visit. Patient #9’s skilled nursing visit calendar was reviewed. S1ADM confirmed Patient #9’s skilled nurse visits on 05/07/2026 and 05/11/2026 should have been documented and available for review within 48 hours of the visit completion date, and were not.”

“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 or other health care professional responsible for providing care and services to the patient after discharge within 5 business days of the patients’ discharge from the agency for 6 (#4, #13, #14, #15, #16 and #17) of 6 patients reviewed for discharge. Review of the agency’s undated policy titled, “Discharge Planning Policy & Procedure” revealed the following, in part: Policy: It is the policy of this agency to ensure all patients receiving home health services are discharged in a safe, timely, and coordinated manner based on achievements of goals, physician orders, patient choice, transfer to a higher or alternate level of care, inability to safely continue services, or when home health eligibility criteria are no longer met. Procedure: 7. Quality Assurance The agency will monitor discharge planning processes through periodic chart audits, OASIS review, and QAPI activities to ensure: Appropriate coordination of care… Compliance with state and federal regulations. Patient #4 Review of Patient #4’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/21/2025, had a certification period of 2/21/2025 to 04/21/2025, and was discharged from the agency on 04/21/2025. Review of Patient #4’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #4’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 10:45 a.m. He reviewed Patient #4’s Clinical Record and verified the patient was discharged from the agency on 04/21/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #13 Review of Patient #13’s Clinical Record revealed he began receiving services from the Home Health Agency on 12/12/2025, had a certification period of 12/12/2025 to 02/09/2026, and was discharged from the agency on 01/02/2026. Review of Patient #13’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #13’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 11:45 a.m. He reviewed Patient #13’s Clinical Record and verified the patient was discharged from the agency on 01/02/2026. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #14 Review of Patient #14’s Clinical Record revealed he began receiving services from the Home Health Agency on 09/16/2025, had a certification period of 11/15/2025 to 01/13/2026, and was discharged from the agency on 12/11/2025. Review of Patient #14’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #14’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 3:40 p.m. He reviewed Patient #14’s Clinical Record and verified the patient was discharged from the agency on 12/11/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #15 Review of Patient #15’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/05/2022, had a certification period of 06/18/2025 to 08/16/2025, and was discharged from the agency on 07/11/2025. Review of Patient #15’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #15’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 11:00 a.m. He reviewed Patient #15’s clinical record and verified the patient was discharged from the agency on 07/11/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 05/31/2025, had a certification period of 05/31/2025 to 07/29/2025, and was discharged from the agency on 07/18/2025. Review of Patient #16’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #16’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 10:35 a.m. He reviewed Patient #16’s clinical record and verified the patient was discharged from the agency on 07/18/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #17 Review of Patient #17’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/11/2025, had a certification period of 01/07/2026 to 03/07/2026, and was discharged from the agency on 01/31/2026. Review of Patient #17’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #17’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 3:07 p.m. He reviewed Patient #17’s clinical record and verified the patient was discharged from the agency on 01/31/2026. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Findings:”