Pinnacle Home Health of Baton Rouge

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure skilled professionals accurately prepared clinical notes. The agency failed to ensure the skilled nurse documented changes in Patient #1’s wound assessment for 1 (#1) of 3 patients reviewed with wounds. Findings: Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/28/2026, had a certification period of 03/29/2026 to 05/27/2026, and was discharged from the agency on 04/20/2026. Patient #1 had diagnoses, which included Unspecified Open Wound Left Ankle and Stage 2 Pressure Ulcer of Left Heel. Review of Patient #1’s Plan of Care for Certification Period 03/29/2026 to 05/27/2026 revealed the following, in part: Skilled Nursing Visits twice weekly for four weeks effective 03/29/2026. Skilled Nurse to perform wound care to Left Heel Pressure Ulcer and Left Dorsal Ankle twice a week and as needed. Review of Patient #1’s Skilled Nursing Visit note dated 04/13/2026 by S3LPN revealed the following, in part: Site Location: Left Dorsal Ankle Type: Trauma Healing: Healing by secondary intent Wound Measurement: 5.0 cm x 2.5 cm x 0.3 cm Wound Tissue Observed: Slough 10% Surrounding Tissue: Intact Drainage: Serosanguineous Drainage Amount: Small Review of Patient #1’s Clinical Notes for Certification Period 03/29/2026 to 05/27/2026 revealed the following, in part: 04/13/2026- Skilled Nurse reports the patient’s wife will be sending him to the Emergency Room for evaluation of lower extremity wound. Further review revealed no documented evidence of Patient #1’s change in wound condition on 04/13/2026. An interview was conducted with S3LPN on 07/07/2026 at 9:20 a.m. She stated Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound. She stated on 04/13/2026, she unwrapped Patient #1’s left lower leg dressing to provide wound care. She stated the Left Dorsal Ankle wound was open, looked like bone or cartilage was exposed, and there was a lot of serosanguinous drainage with clear pus. She confirmed this was a significant change in Patient #1’s Left Dorsal Ankle wound. She confirmed she did not document the change in Patient #1’s Left Dorsal Ankle wound assessment, including the cartilage or tendons being exposed, change in size and change in drainage and should have. An interview was conducted with S2DON on 07/07/2026 at 12:03 p.m. He reviewed Patient #1’s clinical record and verified Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound. He stated there was a change in Patient #1’s Left Dorsal Ankle wound on the 04/13/2026 skilled nurse visit made by S3LPN. He stated S3LPN should have documented the worsening of the wound on the wound assessment or in a clinical note. He confirmed the Left Dorsal Ankle wound assessment by S3LPN on 04/13/2026 was not accurately documented and should have been. An interview was conducted with S1ADM on 07/08/2026 at 2:30 p.m. He stated he expected the nurses to document changes in a patient’s wound in the wound assessment section of the visit note. He stated he expected the nurses to document significant wound changes in the wound assessment and in a clinical note. He reviewed Patient #1’s clinical record and confirmed Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound until discharge. He confirmed on 04/13/2026, Patient #1’s Left Dorsal Ankle wound had a change in condition. He confirmed there was no clinical note documented by S3LPN for the significant change in Patient #1’s Left Dorsal Ankle wound. He confirmed the Left Dorsal Ankle wound assessment by S3LPN on 04/13/2026 was not accurately documented and should have been.”

“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 interview and record review, the agency failed to ensure a patient’s OASIS assessments accurately reflected the patient’s wound status at the time of the assessments for 1 (#16) of 12 patients reviewed with wounds. Findings: Review of Patient #16’s Clinical Record revealed he began receiving services from the home health agency on 11/13/2024 and continued to receive services through his discharge certification period of 05/12/2025 to 07/10/2025. Patient #16 had a diagnosis of a Stage 3 Pressure Ulcer of Sacral Region. Further review revealed Patient #16 had no additional Pressure Ulcers. Review of Patient #16’s OASIS Assessments dated 01/08/2025, 03/12/2025, and 05/09/2025 revealed assessment of Patient #16’s Sacral Wound type was listed as “Other: nursing addressing.” Further review revealed the Sacral Wound was not listed as a Pressure Ulcer. Review of Patient #16’s Discharge OASIS Assessment dated 07/10/2025 revealed the following: Current number of unhealed Pressure Ulcers/Injuries at each stage/Stage 2: 10. An interview was conducted with S1ADM on 04/30/2026 at 2:30 p.m. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had a Sacral Pressure Ulcer on admission until discharge. He explained that when a wound was documented as one type, it populated to the next assessment as that type. He stated, on 12/27/2024, a Certified Occupational Therapy Assistant documented Patient #16’s Sacral wound as: “Other: Nursing addressing.” He stated none of the nurses following her updated the wound type on the OASIS assessments. S1ADM confirmed Patient #16’s OASIS assessments dated 01/08/2025, 03/12/2025, and 05/09/2025 did not accurately reflect Patient #16’s Sacral Pressure Ulcer and should have. He further confirmed Patient #16 had one Stage 3 Pressure Ulcer and not 10 Stage 2 Pressure Ulcers, which was inaccurate on his discharge OASIS dated 07/10/2026.”

“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 (#14 and #16) of 12 patients reviewed for Pressure Ulcers. The agency failed to ensure the RN assessed Patient #14 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 policy titled “Wound Care Policy & Procedure”, with a revision date of 03/2023, revealed the following, in part: Policy: The objective of establishing wound care guidelines is to be able to administer appropriate/effective wound care in the home. Personnel: The Registered Nurse is responsible for dressing change, assessment and measurement of all complex/complicated wound at least weekly. Patient #14 Review of Patient #14’s Clinical Record revealed he began receiving services from the Home Health Agency on 10/10/2025, had a Certification Period of 10/10/2025 to 12/08/2025 and 12/09/2025 to 02/06/2026, and was discharged from the agency on 12/15/2025. Patient #14 had diagnoses, which included Stage 3 Pressure Ulcer of Right Heel. Review of Patient #14’s Plan of Care for Certification Period of 10/10/2025 to 12/08/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week then three times weekly for eight weeks; and Skilled Nurse to perform wound care to Right Heel Pressure Ulcer three times a week and as needed. Review of Patient #14’s Plan of Care for Certification Period of 12/09/2025 to 02/06/2026 revealed the following, in part: Skilled Nursing Visits twice weekly times for four weeks; and Skilled Nurse to perform wound care to Right Heel Pressure Ulcer on skilled nursing visits and as needed. Review of Patient #14’s Skilled Nursing Visit notes conducted for Certification Periods of 10/10/2025 to 12/08/2025 and 12/09/2025 to 02/06/2026 revealed Patient #14’s Stage 3 Right Heel Pressure Ulcer was not assessed by a RN, to include measurements, the weeks of 10/26/2025, 11/09/2025, 11/23/2025, and 12/07/2025. An interview was conducted on 04/30/2026 at 11:30 a.m. with S1ADM. He reviewed Patient #14’s Clinical Record and confirmed a Registered Nurse had not assessed or measured Patient #14’s Pressure Ulcer on the weeks of 10/26/2025, 11/09/2025, 11/23/2025, and 12/07/2025. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 11/13/2024, had a discharge Certification Period of 05/12/2025 to 07/10/2025, and had diagnoses, which included Stage 3 Pressure Ulcer of Sacral Region. Review of Patient #16’s Plan of Care for Certification Period of 05/12/2025 to 07/10/2025 revealed the following, in part: Skilled Nursing Visits once weekly for four weeks then twice weekly for four weeks; Measure wound first Registered Nurse visit of week; and Skilled Nurse to perform wound care to Sacrum on skilled nursing visits. Review of Patient #16’s Skilled Nursing Visit notes conducted for Certification Period 05/12/2025 to 07/10/2025 revealed Patient #16’s Stage 3 Sacral Pressure Ulcer was not assessed by a RN, to include measurements, the weeks of 06/15/2025, 06/22/2025, and 06/29/2025. An interview was conducted on 04/30/2026 at 2:30 p.m. with S1ADM. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had a Sacral Pressure Ulcer on admission until discharge. He confirmed Patient #16’s Sacral Pressure Ulcer was not assessed by a RN on the weeks of 06/15/2026, 06/22/2026, and/or 06/29/2026. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse.”

“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 Physical Therapy vital sign entries were completed for 2 (#3 and #10) of 17 patient records reviewed. Findings: Review of the agency’s policy titled “Start of Care Assessment (SOC),” with a revision date of 12/01/2025, revealed the following, in part: Policy: The initial assessment will consist of the OASIS data set for Start of Care Assessments integrated with a patient specific comprehensive physical assessment. Procedure: During the initial patient assessment, all baseline data and other relevant information is documented in the patient’s clinical record, including at least the following information: Patient specific physical assessment information including at least the following: 1. Vital signs, including blood pressure, temperature, pulse, respirations… Vital signs are a key component of the home health visit and should be monitored accordingly. At minimum, blood pressure, heart and respiratory rate should be obtained at every visit. Patient #3 Review of Patient #3’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/20/2026, had a Certification Period of 01/20/2026 through 03/20/2026, and a current Certification Period of 03/21/2026 through 05/19/2026. Patient #3 had diagnoses, which included Parkinsonism, Corticobasal Degeneration, Essential Hypertension and Weakness. Review of Patient #3’s OASIS Start of Care Assessment signed by S8PT dated 01/20/2026 revealed no documented evidence of a temperature or respirations. Review of Patient #3’s Physical Therapy visits for Certification Period of 01/20/2026 through 03/20/2026 revealed the following, in part: 01/24/2026- no documented blood pressure, signed by S9PTA 01/28/2026- no documented blood pressure, signed by S9PTA 02/03/2026- no documented pulse or respirations, signed by S8PT 02/24/2026- no documented pulse or respirations, signed by S8PT 03/12/2026- no documented pulse or respirations, signed by S8PT Review of Patient #3’s in home document titled, “Home Care Vital Signs/Assessment/60 day Summarization” log revealed the following, in part: 01/24/2026- no documented blood pressure; 01/28/2026- no documented blood pressure; 02/03/2026- no documented respirations; 02/24/2026- no documented vital signs; and 03/12/2026- no documented vital signs. An interview was conducted with S9PTA on 04/30/2026 at 8:31 a.m. She stated at the start of each patient visit she obtained the patient’s blood pressure, pulse and respirations. She stated she documented the vital signs on the in home vital sign log and in the patient’s electronic clinical record. She was made aware of Patient #3’s therapy visit notes dated 01/24/2026 and 01/28/2026 with no blood pressure documented. She stated she obtained the blood pressure, but must have forgot to document it. She confirmed without the blood pressures documented the patient’s clinical record was not complete and accurate. Patient #10 Review of Patient #10’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/05/2026, and had a current Certification Period of 03/05/2026 through 05/03/2026. Patient #10 had diagnoses, which included Essential Hypertension and Unspecified Dementia. Review of Patient #10’s OASIS Start of Care Assessment signed by S8PT dated 03/05/2026 revealed no documented evidence of a temperature, pulse or respirations. An interview was conducted with S8PT on 04/30/2026 at 9:40 a.m. He stated, during a patient’s comprehensive assessment, he obtained the patient’s blood pressure, pulse, oxygen saturation, respirations, height, and weight. He stated on a physical therapy visit he obtained the patient’s blood pressure, pulse and respirations. He was made aware of the above listed physical therapy visits with no documentation of a blood pressure, pulse, and/or respirations for Patient #3 and Patient #10. He stated he obtained the patient’s vital signs, but did not document them and he should have. He confirmed without the vital signs documented in the patient’s clinical record, it was not complete and accurate. An interview was conducted with S1ADM on 04/30/2026 at 11:30 a.m. He stated, on a start of care assessment, the clinicians should obtain and document the patient’s blood pressure, pulse, respirations, temperature, height and weight. He stated on each discipline visit, the patient’s blood pressure, pulse and respirations should be obtained and documented. He reviewed the clinical record for Patient #3 and #10 and confirmed the above listed therapy visits were missing documentation of vital signs. He confirmed without a complete set of vitals documented, the patient’s clinical record was not complete and accurate.”

“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 2 (#3 and #5) of 7 patients reviewed with home visits. Findings: Review of the agency’s policy titled, “Medication Reconciliation” with a last review date of 04/21/2026, revealed the following, in part: Purpose: Medication Reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient is taking. Policy: The agency utilizes this medication reconciliation process and approach to ensure shared responsibility of health care providers in collaboration with patients and families. Procedure: 2. The clinician is to determine what medications the patient is actually taking. 6. The clinician is to review medications at each visit. 7. If there is a new medication, the medication should be documented … in the Electronic Medical Record. 8. If the medication has changed… In the Electronic Medical Record, discontinue the “old” dosage, and add the new dosage as if it were a new medication. 9. If a medication has been completed or discontinued by the Medical Doctor … discontinue in the Electronic Medical Record. Patient #3 Review of Patient #3’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/20/2026 and had a current Certification Period of 03/21/2026 through 05/19/2026. Patient #3 had diagnoses, which included Parkinsonism, Corticobasal Degeneration, and Weakness. Patient #3 was ordered to receive Speech Therapy Visits twice weekly for six weeks. A home visit was conducted with Patient #3 on 04/27/2026 at 2:00 p.m. with S6ST present in the home. Patient #3’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: Carbidopa-Levodopa 25-100 mg take two tablets by mouth twice a day was on the medication profile and the patient was taking two tablets three times a day; Nabumetone 750 mg take one tablet by mouth at bedtime was on the medication profile and the medication was prescribed as needed for pain; and Tylenol Arthritis 8 hour 650 mg take two caplets every night as needed for pain was present in the home and not on the medication profile. An interview was conducted with Patient #3’s spouse during the home visit. She stated she managed Patient #3’s medications and filled his pill planner weekly. She stated Patient #3 was prescribed and had taken Nabumetone as needed every night for pain since 03/30/2026. She stated Patient #3 had taken Tylenol Arthritis two caplets every night for pain since December 2025. She stated Patient #3 had been taking Carbidopa-Levodopa two tablets three times a day for months. An interview was conducted with S6ST on 04/27/2026 at 3:45 p.m. S6ST confirmed the above medication discrepancies during the home visit. S6ST stated medications should be reconciled during every home visit. Patient #5 Review of Patient #5’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/25/2026 and had a current Certification Period of 02/25/2026 through 04/25/2026. Patient #5 had diagnoses, which included Essential Hypertension and Unspecified Atrial Flutter. Patient #5 was ordered to receive the following discipline visit frequency: Skilled Nursing Visits- 02/25/2026 once weekly for four weeks; 03/15/2026 three times a week for one week then twice weekly for three weeks; and 03/26/2026 twice weekly for one week then three times weekly for four weeks. Physical Therapy Visits- 02/25/2026 twice weekly for three weeks; and 03/26/2026 once weekly for one week then twice weekly for three weeks. Occupational Therapy Visits - 02/25/2026 once weekly for one week then twice weekly for three weeks; and 04/15/2026 twice weekly for one week then twice weekly for three weeks. A home visit was conducted with Patient #5 on 04/28/2026 at 3:50 p.m. with S7OT present in the home. 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: Isosorbide Mononitrate Extended Release 30 mg take one tablet by mouth every other day was on the medication profile and the patient was no longer taking; Digoxin 0.125 mg take half a tablet by mouth in the morning was present in the home and not on the medication profile; Atorvastatin Calcium 80 mg take one tablet by mouth daily was on the medication profile and the patient was no longer taking; and Doxycycline Hyclate 100 mg take one tablet twice a day for 10 days was on the medication profile and the patient was no longer taking. An interview was conducted with Patient #5’s sister on 04/28/2026 at 4:20 p.m. She stated she managed Patient #5’s medications and filled his pill planner weekly. She stated Patient #5’s Atorvastatin Calcium was discontinued sometime in March 2026. She stated Patient #5’s Isosorbide Mononitrate was discontinued and the Digoxin was started on 04/15/2026. She stated Patient #5 completed the Doxycycline sometime in March 2026. An interview was conducted with S7OT on 04/28/2026 at 4:25 p.m. S7OT stated patient’s medications should be reconciled each visit. S7OT confirmed the medications Patient #5 was taking and the medication profile should match and did not. An interview was conducted with S1ADM on 04/29/2026 at 8:10 a.m. He stated medications should be reconciled during each home visit by the clinicians. He stated medication reconciliation should have been completed by comparing the medications in the home to the patient’s current medication profile. He was made aware of Patient #3 and #5’s medication discrepancies identified during their home visits. He confirmed the medications each patient were currently taking should have matched the patient’s current medication profile.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to assure communication with all physicians involved in the Plan of Care. The agency failed to ensure the physician was notified Physical Therapy services were not provided as ordered for 1 (#6) of 11 patients reviewed with orders for Home Health Therapy services. Findings: Review of Patient #6’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/10/2026 and had a current Certification Period of 04/10/2026 through 06/08/2026. Further review revealed a physician’s order dated 04/08/2026 for admission to home health, which included Physical Therapy to evaluate and treat. Review of Patient #6’s Coordination Note signed by S8PT dated 04/13/2026 revealed the following, in part: Physical Therapy missed visit. Refused Physical Therapy eval. Review of Patient #6’s Physician Orders and Coordination Notes for Certification Period 04/10/2026 through 06/08/2026 revealed no documented evidence the provider was notified Physical Therapy services were not provided as ordered. An interview was conducted with S8PT on 04/30/2026 at 9:40 a.m. He stated Patient #6 was ordered to receive Physical Therapy services. He stated Patient #6 refused Physical Therapy services on 04/13/2026. He stated when therapy services were refused he would document a note in the patient’s records per the agency’s policy. He stated agency staff would send the notification to the patient’s physician, but he was unsure which staff were responsible for the notifications. He confirmed he did not notify Patient #6’s physician the physical therapy services were not provided as ordered. An interview was conducted with S1ADM on 04/30/2026 at 11:30 a.m. He stated if a patient refused an ordered therapy service, he or the therapy coordinator contacted the physician’s office. He stated then a note was entered into the patient’s clinical record documenting the physician was made aware the ordered services were not provided. He confirmed there was no documented evidence the physician was notified Physical Therapy services were not provided as ordered for Patient #6.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation during a home visit, interviews, and record reviews, the agency failed to ensure patients received home health aide services included in the plan of care for 2 (#7 and #13) of 3 patients reviewed with home health aide services. Findings: Patient #7 Review of Patient #7’s Clinical Record revealed he began receiving services from the agency on 03/26/2026, had a current certification period of 03/26/2026 through 05/24/2026, and had a diagnosis of Parkinson’s Disease with Dyskinesia. Further review of the Clinical Record revealed Patient #7 was ordered to receive home health aide services twice weekly for three weeks then twice weekly for four weeks. Review of Patient #7’s Home Health Aide Care Plan for the certification period of 03/26/2026 through 05/24/2026 revealed interventions, which included change bed linens and make bed. Review of Patient #7’s Home Health Aide Visit Notes by S4CNA dated 03/31/2026, 04/02/2026, 04/09/2026, 04/14/2026, 04/16/2026, 04/21/2026, and 04/23/2026 revealed documentation of not applicable for the interventions of change bed linens and make bed. Further review of the Home Health Aide Visit Notes revealed no additional documentation to indicate why the bed linen changes and making of the bed was not applicable. An interview was conducted with S4CNA on 04/29/2026 at 8:40 a.m. She confirmed she provided home health aide services for Patient #7. She stated she had not made Patient #7’s bed or changed his linens during any of her visits. A home visit was conducted with Patient #7 on 04/28/2026 at 2:00 p.m. with S3CNA present. S3CNA did not provide linen changes or make the bed during the visit. Patient #7’s wife was present in the home, and an interview was conducted with Patient #7’s wife during the home visit. Patient #7’s wife stated the home health aides had never offered to change bed linens or make Patient #7’s bed. She stated she did not know changing bed linens or making the bed were services offered by the agency. She stated if the aides had offered to change the linens or make the bed, she would have allowed them. An interview was conducted with S3CNA on 04/28/2026 at 3:13 p.m. She stated home health aide services should have been provided for the patients for each visit based on the aide care plan. She confirmed bed making and linen changes were interventions on Patient #7’s aide care plan. She confirmed she did not provide a linen change or make Patient #7’s during the visit on 04/28/2026. Patient #13 Review of Patient #13’s Clinical Record revealed he began receiving services from the agency on 12/04/2025, had a discharge certification period of 12/04/2025 through 02/01/2026, and had diagnoses of Osteoarthritis of Left Knee and Paraplegia. Further review of the Clinical Record revealed Patient #13 was ordered to receive home health aide services twice weekly for three weeks. Review of Patient #13’s Home Health Aide Care Plan for the certification period of 12/04/2025 through 02/01/2026 revealed interventions, which included temperature, blood pressure, pulse, and respirations every visit. Review of Patient #13’s Home Health Aide Visit Notes by S5CNA dated 12/16/2025, 12/18/2025, 12/23/2025, and 12/25/2026 revealed the following aide interventions were documented as not applicable on the following dates: 12/16/2025: Blood pressure every visit; Pulse every visit; and Respirations every visit. 12/18/2025: Temperature every visit; Blood pressure every visit; Pulse every visit; and Respirations every visit. 12/23/2025: Blood pressure every visit; and Pulse every visit. 12/25/2025: Blood pressure every visit; Pulse every visit; and Respirations every visit. An interview was conducted with S5CNA on 04/30/2026 at 11:03 a.m. She stated not applicable documented on her visit notes meant the intervention was not provided during that visit. An interview was conducted with S1ADM on 04/30/2026 at 11:25 a.m. He stated the home health aide visit notes’ interventions populated directly from the home health aide care plan. He stated all interventions on the aide care plan should have been provided during each home health aide visit. He stated not applicable was not an acceptable response to a home health aide intervention. He reviewed the aforementioned home health aide visit notes and confirmed the interventions on the care plan were not provided and should have been.”