Home Health Care 2000-Baton Rouge

“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 observations, interviews, and record reviews the Home Health agency failed to meet the Condition of Participation for Skilled Professional Services. This deficient practice was evidenced by the agency’s failure to ensure: 1. The RN performed weekly assessments and measurements for Patient #2’s Stage 2 and Stage 3 Pressure Ulcers and Patient #5’s three Stage 4 Pressure Ulcers (See Findings in G702); 2. The RN performed an assessment of Patient #2 and #5’s Pressure Ulcers prior to delegating wound care to an LPN (See Findings in G702); Findings: 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 policy titled, “Oasis Data Transmission,” dated May 2024, revealed the following, in part: Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information 42 CFR 484.45. OASIS data will be reported electronically in accordance with 42 CFR 484.55. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 09/05/2025 revealed 5 records were processed with 5 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 09/19/2025 revealed 1 record was 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 09/26/2025 revealed 3 records were processed with 3 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 10/10/2025 revealed 7 records were processed with 7 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 10/17/2025 revealed 4 records were processed with 4 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 10/24/2025 revealed 3 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 11/06/2025 revealed 3 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 11/06/2025 revealed 6 records were processed with 5 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 11/12/2025 revealed 2 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. On 12/04/2025 at 12:05 p.m., an interview was conducted with S4QM. S4QM confirmed she was responsible for the agency’s OASIS submissions. S4QM confirmed the above records were submitted late and the OASIS Assessments should have been submitted within 30 days of completion.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the patient’s written individualized Plan of Care (POC) was followed as evidenced by Skilled Nursing Visits (SNV) were not conducted as ordered, not attempted to be rescheduled, and the physician was not notified of the missed visits for 2 (#1 and #2) of 7 sampled patients. Findings: Patient #1 Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024. Further review revealed a current Certification Period of 11/21/2025 through 01/19/2026, with diagnoses, which included Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Asthma, Heart Failure Unspecified, and Dependence on Supplemental Oxygen. Review of Patient #1’s POC for Certification Period 01/25/2025 through 03/25/2025 revealed Patient #1 was ordered to receive Skilled Nursing (SN) visits once weekly for nine weeks. Review of Patient #1’s SNV notes revealed a missed SNV on 02/04/2025, and the clinical record revealed no evidence of a charted missed visit note, attempt to further reschedule the SNV, and no evidence the physician was notified of the missed visit. Review of Patient #1’s POC for Certification Period 05/25/2025 through 07/23/2025 revealed Patient #1 was ordered to receive Skilled Nursing Visits once weekly for nine weeks. Review of Patient #1’s SNV notes revealed a missed SNV the weeks of 06/01/2025 and 06/08/2025, with no evidence of a charted missed visit note, attempt to further reschedule the SNV, and no evidence the physician was notified of the missed visit. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. S2AA stated a visit was not considered missed until end of the week on Saturday. She stated she investigated any missed visits and notified the physician of the missed visit by phone or faxed a communication note. S2AA reviewed Patient #1’s clinical record for the SN missed visit dated 02/04/2025 and the patient’s scheduled visits for the weeks of 06/01/2025 and 06/08/2025. S2AA confirmed there was no documented reason for the SN missed visits and there was no documented evidence the physician was notified of the SN missed visits and there should have been. On 12/03/2025 at 12:45 p.m., an interview was conducted with S1ADM. She stated for any patient missed visits there should be documentation in the patient’s clinical record as to why the visit was missed, attempts to reschedule the visit, and the physician should be notified. Patient #2 Review of Patient #2’s clinical record revealed she began services from the Home Health Agency on 10/29/2024. Further review revealed a current Certification Period of 10/24/2025 through 12/22/2025, with diagnosis which included Pressure Ulcer of Right Buttock Stage 3. Review of Patient #2’s POC for the Certification Period of 10/29/2024 through 12/27/2024 revealed Patient #2 was ordered to receive Skilled Nursing Visits twice weekly for two weeks then once weekly for seven weeks. Review of Patient #2’s SNV notes revealed a missed SNV on 12/13/2024, and the clinical record revealed no evidence of a charted missed visit, attempt to further rescheduled the SNV, and no evidence the physician was notified of the missed visit. Review of Patient #2’s POC for the Certification Period 12/28/2024 through 02/25/2025 revealed Patient #2 was ordered to receive Skilled Nursing Visits twice weekly for eight weeks beginning 12/30/2024. Review of Patient #2’s SNV notes revealed she did not have a SNV the week of 01/19/2025 through 01/25/2025, and a missed visit with physician notification was documented on 01/22/2025. Further review of the clinical record revealed no further attempts to see Patient #2 the week of 01/19/2025 through 01/25/2025 were documented, and the physician was not notified. Further review of the SNV notes revealed Patient #2 was seen only once the week of 02/02/2025 through 02/08/2025, and the physician was not notified of the missed SNV. Review of Patient #2’s POC for the Certification Period 02/26/2025 through 04/26/2025 revealed Patient #2 was ordered to receive Skilled Nursing Visits twice weekly for nine weeks. Review of Patient #2’s SNV notes revealed Patient #2 was only seen once the week of 03/09/2025 through 03/15/2025, and the clinical record revealed no evidence of a charted missed visit, no evidence to further reschedule the missed SNV, and no evidence the physician was notified of the missed visit. On 12/03/2025 at 11:27 a.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #2’s clinical record and confirmed the above missed visits. She confirmed the Plan of Care was not followed as ordered by the physician, the clinical record revealed no documented attempts to reschedule the missed visits, and the agency should have notified the physician for any missed visits and did not.”

“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 interviews, and record reviews, the agency failed to ensure the RN provided home health agency services in accordance with current clinical practice guidelines as set forth by the Louisiana State Board of Nursing’s (LSBN) Declaratory Statement for Scope of Practice for RN’s - Wound Care Management and accepted professional standards as set forth by the 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 performed weekly assessments and measurements for Patient #2’s Stage 2 and Stage 3 Pressure Ulcers and Patient #5’s three Stage 4 Pressure Ulcers; and 2. The RN assessed Patient #2 and #5’s Pressure Ulcers prior to delegating wound care to the Licensed Practical Nurse (LPN). This deficient practice affected 100% of the agency’s two patients with current Pressure Ulcers. Findings: Review of the Louisiana State Board of Nursing’s Declaratory Statement Scope of Practice for RNs - Wound Care Management revealed, in part, the following: RNs render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The State’s Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse who 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 RN 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 RN may delegate select nursing interventions to qualified nursing personnel as set forth in the Board’s rules on delegation (LAC 46:XLVII.3703.). The RN retains the accountability for the total nursing care of the individual. The RN may delegate to a LPN wound care interventions in any situation when the RN 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. 1. RN’s weekly assessment and measurement of pressure ulcers. Patient #2 Review of the clinical record for Patient #2 revealed she began receiving services from the agency on 10/29/2024 with diagnoses, which included a Stage 3 Pressure Ulcer of Right Buttock. Review of Patient #2’s Plan of Care for Certification Period dated 4/27/2025 through 6/25/2025 revealed the following, in part: Skilled Nursing Visits (SNV) twice weekly for eight weeks then once weekly for one week; and Skilled Nurse (SN) to perform wound care to the Stage 2 Pressure Ulcer to Right Distal Medial Buttock and Stage 3 Pressure Ulcer to the Right Buttock. Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 04/27/2025 through 06/25/2025, revealed there were 2 missed weekly assessments with measurements for her Pressure Ulcers: 05/25/2025 through 05/31/2025 – No documented wound assessment and measurements by RN; and 06/08/2025 through 06/14/2025 - No documented wound assessment and measurements by RN. Review of Patient #2’s Plan of Care for Certification Period dated 06/26/2025 through 08/24/2025 revealed the following, in part: SNV twice weekly for nine weeks; and SN to perform wound care to Stage 2 Right Distal Medial Buttock and Stage 3 Pressure Ulcers to the Right Buttock. Review of Patient #2’s Skilled Nurse Visit Notes, Physician’s Orders, and Communication Notes for the Certification Period of 06/26/2025 through 08/24/2025, revealed there were 2 missed weekly assessments with measurements for her Pressure Ulcers: 07/20/2025 through 07/26/2025 – No documented wound assessment and measurements by RN; and 07/27/2025 through 08/02/2025 - No documented wound assessment and measurements by RN. Review of Patient #2’s Plan of Care for Certification Period dated 08/25/2025 through 10/23/2025 revealed the following, in part: SNV twice weekly for eight weeks; SNV once weekly for one week and SN to perform wound care to Stage 4 Pressure Ulcer to Right Distal Buttock and Stage 3 Sacral Pressure Ulcer twice weekly. Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 8/25/2025 through 10/23/2025, revealed there were 3 missed weekly assessments with measurements for Pressure Ulcers: 08/27/2025 through 09/02/2025 – No documented wound assessment and measurements by RN; 09/14/2025 through 09/20/2025 – No documented wound assessment and measurements by RN; and 09/21/2025 through 09/27/2025 - No documented wound assessment and measurements by RN. On 12/03/2025 at 11:27 a.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #2’s clinical record and confirmed her Pressure Ulcers were not assessed or measured by an RN on the weeks of 05/25/2025, 06/08/2025, 07/20/2025, 07/27/2025, 08/31/2025, 09/14/2025, and 09/21/2025 for a total of 7 missed opportunities. S1ADM stated she thought the RN should assess and measure wounds every two weeks instead of weekly. Patient #5 Review of the clinical record for Patient #5 revealed she began receiving services from the agency on 04/12/2024 with diagnoses including a Stage 4 Pressure Ulcer of Right Buttock, Stage 4 Pressure Ulcer of Sacral Region, and Stage 4 Pressure Ulcer of Left Buttock. Review of Patient #5’s Plan of Care for Certification Period dated 08/05/2025 through 10/03/2025 revealed the following, in part: SNV once weekly for one week, twice weekly for eight weeks, and two as needed visits for wound care complications. Further review revealed SN to perform wound care to the Stage 4 Pressure Ulcer of Right Buttock, Stage 4 Pressure Ulcer of Sacral Region, and Stage 4 Pressure Ulcer of Left Buttock. Review of Patient #5’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 08/05/2025 through 10/03/2025, revealed there were 2 missed weekly assessments with measurements for her Pressure Ulcers: 08/24/2025 through 08/30/2025 - No documented wound assessment and measurements by RN; and 09/07/2025 through 09/13/2025 - No documented wound assessment and measurements by RN. Review of Patient #5’s Plan of Care for Certification Period dated 10/04/2025 through 12/02/2025 revealed the following, in part: SNV twice weekly for eight weeks, once weekly for one week and two as needed visits for wound care complications. Further review revealed SN to perform wound care to the Stage 4 Pressure Ulcer to Medial Coccyx, Stage 4 Pressure Ulcer to Right Perineum, and Stage 4 Pressure Ulcer Right Medial Perineum. Review of Patient #5’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 10/04/2025 through 12/02/2025, revealed there were 2 missed weekly assessments with measurements for her Pressure Ulcers: 10/05/2025 through 10/11/2025 - No documented wound assessment and measurements by RN; and 11/02/2025 through 11/08/2025 - No documented wound assessment and measurements by RN. On 12/03/2025 at 4:13 p.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #5’s clinical record and confirmed her Pressure Ulcers were not assessed or measured by an RN on the weeks of 08/24/2025, 09/07/2025, 10/05/2025, and 11/02/2025 for a total of 4 missed opportunities. S1ADM confirmed Patient #5’s Pressure Ulcers should have been measured weekly and were not. 2. RN’s delegation of Wound Care to an LPN. Patient #2 Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 04/27/2025 through 06/25/2025 revealed the following 2 LPN visits were conducted without an RN SNV conducted to assess the wounds prior to the LPN performing wound care: 06/06/2025 – LPN SNV conducted; and 06/13/2025 – LPN SNV conducted. Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 06/26/2025 through 08/24/2025 revealed the following 3 LPN visits were conducted without an RN SNV conducted to assess the wounds prior to the LPN performing wound care: 07/18/2025 - LPN SNV conducted; 07/25/2025 - LPN SNV conducted; and 08/01/2025 - LPN SNV conducted. Review of Patient #2’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 08/25/2025 through 10/23/2025 revealed the following 3 LPN visits were conducted without an RN SNV conducted to assess the wounds prior to the LPN performing wound care: 09/05/2025 - LPN SNV conducted; 09/24/2025 - LPN SNV conducted; and 09/26/2025 - LPN SNV conducted. Patient #5 Review of Patient #5’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for the Certification Period of 08/05/2025 through 10/03/2025, revealed the following 6 LPN visits were conducted without an RN SNV conducted to assess the wounds prior to the LPN performing wound care: 08/25/2025 - LPN SNV conducted; 08/29/2025 - LPN SNV conducted; 09/01/2025 - LPN SNV conducted; 09/08/2025 - LPN SNV conducted; 09/12/2025 - LPN SNV conducted; and 09/15/2025- LPN SNV conducted; Review of Patient #5’s Skilled Nurse Visit Notes, Physician Orders and Communication Notes for the Certification Period of 10/04/2025 through 12/02/2025 revealed the following 6 LPN visits were conducted without an RN SNV conducted to assess the wounds prior to the LPN performing wound care: 10/06/2025 - LPN SNV conducted; 10/10/2025 - LPN SNV conducted; 10/13/2025 - LPN SNV conducted; 11/03/2025 – LPN SNV conducted; 11/07/2025 - LPN SNV conducted; and 11/10/2025 - LPN SNV conducted. On 12/03/2025 at 4:13 p.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #2 and #5’s clinical records and confirmed their Pressure Ulcers were not assessed or measured by an RN prior to the LPN’s aforementioned visits to perform their wound care.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to maintain documentation of the efforts made to resolve problems prior to discharging a patient for 2 of 2 (#6 and #7) discharged patients reviewed. Findings: Review of the agency’s policy titled, “Discharge Criteria and Process,” with a revision date of May 2024, revealed the following, in part: Policy: When the patient’s plan of care changes and this change results in discharge from or reduction of services, the patient or his/her representative, as well as his/her primary physician (or other allowed practitioner), will be notified and involved in planning decisions. Discharge/Reduction of Services Criteria: Services will be terminated when the patient meets one (1) or more of the following discharge criteria: 4. The patient or family/caregiver refuses or discontinues care. 7. The patient and/or family displays disruptive, abusive, and uncooperative behavior. Procedure: 5. The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the patient, the responsible family/caregiver or representative, and the patient’s physician. Efforts to resolve problems prior to discharge will also be documented in the patient’s record. If the decision to terminate services is due to the patient’s behavior or situation, the clinical record must reflect the following: A. Identification of the problems encountered. B. Assessment of the situation. C. Communication with organization management and the physician responsible for the plan of care. D.A plan to resolve the issues. E. Results of the plan implementation. Patient #6 Review of the clinical record for Patient #6 revealed she began receiving services from the agency on 04/01/2020, with a Certification Period dated 02/27/2025 through 04/27/2025, and was discharged on 04/24/2025. Further review of Patient #6’s Skilled Nurse Visits Notes, Physician Orders and Communication Notes for Certification Period dated 02/27/2025 through 04/27/2025 revealed: Communication note dated 04/10/2025 per S2AA: Patient #6 contacted the agency office regarding her wound care. Patient #6 stated she would like the nurse to apply the compression bandage over her skin to secure it from falling. Patient #6 stated if the nurse is not ok with that then she understands. She would still like to keep services and is ok with the current nurse that is coming out to make the visit. Communication note dated 04/18/2025 per S3LPN: Upon arrival to patient’s house skilled nurse observed patients sitting in chair with a frown upon her face, S3LPN asked what was wrong, She stated that she had a conversation with S2AA last week and it was established that S3LPN was not supposed to come back to her house because S3LPN did not perform her wound care the way that she wanted to. S3LPN explained to her that we have a care plan that we go by that comes from the Doctor. She stated that she only wanted her wound care performed her way. S3LPN performed wound care aseptic technique used patient tolerated well, but continued to state that she wanted her legs wrapped her way and that she would probably remove the bandage and redo it. Communication noted dated 04/22/2025 per S2AA: Skilled nurse contacted office regarding visit to Patient #6. Patient #6 was very rude to skilled nurse and did not want skilled nurse in the home. Patient #6 was informed on 04/11/2025 that was the only nurse available to make the visit. Patient stated she was ok with the skilled nurse and he could make the visit. Patient will have to be discharged due to no other available nurse. Review of Physician Order dated 04/24/2025 revealed the following: Discharge patient from home health services due to patient refusing services from nurse scheduled to see her. On 12/03/2025 at 9:10 a.m., an interview was conducted with S2AA. S2AA reported she verbally communicated Patient #6’s discharge with her physician and did not have documented evidence in the clinical record of the communication, but should have. She reported the agency attempted to find another agency to transfer Patient #6 to, but did not have any documented evidence in the clinical record of attempting transfer. She reported Patient #6’s physician verbally informed her to discharge Patient #6 if they did not have another nurse to send. On 12/03/2025 at 9:40 a.m., an interview was conducted with Patient #6’s physician. Patient #6’s physician stated Patient #6 was discharged due to having issues with a nurse going out to see her, but was unsure what the issues were with the nurse, and she could not recall the issues being communicated to her. On 12/03/2025 at 9:15 a.m., 9:27 a.m., 9:56 a.m., and 12:50 p.m. four unsuccessful attempts were made to interview Patient #6. On 12/03/2025 at 4:22 p.m., an interview was conducted with S1ADM. S1ADM confirmed she did not attempt to make a home visit or telephone contact with Patient #6 after the she called a complaint into the office on 04/10/2025. S1ADM further confirmed the agency did not have documented evidence in the clinical record of communication with Patient #6’s physician prior to discharge or communication regarding any attempts to transfer Patient #6 to another home health agency, and should have. S1ADM confirmed the reason Patient #6 was discharged was due to not having an available nurse to send for the visit. Patient #7 Review of the clinical record for Patient #7 revealed she began receiving services from the Home Health Agency on 03/05/2024, with a Certification Period dated 04/29/2025 through 06/27/2025, and was discharged on 06/27/2025. Review of Physician Order dated 06/27/2025 and signed by S1ADM for Patient #7 revealed the following: Discharge patient from the agency due to patient being unavailable at recertification time. Further review of Patient #7’s Skilled Nurse Visit Notes, Physician Orders, and Communication Notes for Certification Period 04/29/2025 through 06/27/2025 revealed no documented evidence of the agency’s efforts made to resolve problems prior to discharging Patient #7. On 12/03/2025 at 4:10 p.m., and on 12/04/2025 at 10:15a.m., unsuccessful attempts were made to interview Patient #7. On 12/04/2025 at 10:25 a.m., an interview was conducted with S1ADM. S1ADM reviewed the clinical record for Patient #7 and stated she discharged the patient on 06/27/2025 on the last day of the episode. S1ADM stated she tried multiple times the last week of the end of the certification period to see Patient #7 for the recertification visit and Patient #7 refused the visit each time. S1ADM stated she told Patient #7 over the phone if she did not allow the recertification visit she would be discharged from the agency, and the patient told her she was not available. S1ADM confirmed she did not document any of the communications or efforts to make the visit prior to the patient’s discharge and should have.”

“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 (#2 and #3) of 3 patients reviewed during home visits. Findings: Review of the Agency’s Policy titled, “Medication Profile”, with a revision date of November 2024, revealed the following, in part: Purpose: To define the use of medication profile in evaluating a patient’s medication regimen. Policy: Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/ or discontinued medications. Patient #2 Review of the clinical record for Patient #2 revealed she began receiving services from the Home Health Agency on 10/29/2024. Further review revealed a current Certification Period of 10/24/2025 through 12/22/2025, with diagnoses, which included Pressure Ulcer of Right Buttock Stage 3, Hypertensive Chronic Kidney Disease, Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Kidney Disease Stage 4, and Vitamin D Deficiency. A home visit was conducted with Patient #2 on 12/02/2025 at 12:30 p.m. with S1ADM and the patient’s caregiver present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #2’s current medication profile provided by the Home Health Agency: Vitamin D3 1,000 IU (International Unit) take one tablet by mouth daily was present in the home, and not on the medication profile; Losartan Potassium 50 mg one tablet by mouth in the morning was on the medication profile, but the patient was taking one tablet by mouth twice daily; Meloxicam 7.5 mg one tablet by mouth daily was on the medication profile, but the patient was not taking this medication; Sodium Bicarbonate 650mg two tablets by mouth in the morning and one tablet at night, but the patient was taking two tablets in the morning; and Trajenta 5 mg one tablet by mouth daily in the morning was on the medication profile, but the patient was not taking this medication. On 12/02/2025 during the home visit. Patient #2’s caregiver confirmed she was responsible for administering Patient #2’s medications. She further confirmed the current medication profile in the home was not accurate with the medications Patient #2 was currently taking. On 12/02/2025 at 1:00 p.m. an interview was conducted with S1ADM. She confirmed the above medication discrepancies identified during the home visit. S1ADM further confirmed the current medication profile should accurately reflect the medications Patient #2 was currently taking. Patient #3 Review of the clinical record for Patient #3 revealed she began receiving services from the Home Health Agency on 01/11/2024. Further review revealed a current Certification Period of 11/01/2025 through 12/30/2025, with diagnoses, which included Essential Hypertension, Rheumatoid Arthritis, Major Depressive Disorder, Unilateral Primary Osteoarthritis Right Knee, Age-related Osteoporosis without Current Pathological Fracture, and Unspecified Anemia. A home visit was conducted with Patient #3 on 12/02/2025 at 10:35 a.m. with S6CNA and the patient’s caregiver present in the home. Patient #3’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #3’s current medication profile provided by the Home Health Agency: B-12 1000 mcg tablets one tablet by mouth daily was present in the home and not on the medication profile; Iron 65 mg tablet one tablet by mouth on Monday, Wednesday and Friday was present in the home and not on the medication profile; Folic acid 1 mg tablet one tablet by mouth once a day was present in the home and not on the medication profile; Chlorhexidine Gluconate oral rinse 0.12% swish 5 ml for 30 seconds twice daily for 2 weeks was present in the home and not on the medication profile; Atenolol 25 mg tablet one tablet by mouth daily was present in the home and not on the medication profile; Zyrtec allergy 10 mg one tablet by mouth daily was on the medication profile and the patient was taking Claritin 10 mg one tablet by mouth daily; Fluoxetine HCL 40 mg one capsule by mouth twice daily was on the medication profile and patient was taking Fluoxetine HCL 20 mg one capsule by mouth daily; Lopressor 50 mg 0.25 tablet by mouth twice daily was on the medication profile and the patient was not taking this medication; Prednisone 2.5 mg two tablets by mouth daily was on the medication profile and the patient was taking Prednisone 5 mg one tablet by mouth daily; Celebrex 200 mg one capsule by mouth daily was on the medication profile and the patient was not taking this medication; and Alprazolam 0.25 mg one tablet by mouth daily as needed for anxiety or sleep was on the medication profile and the patient was not taking this medication. On 12/02/2025 at 11:15 a.m., an interview was conducted with Patient #3’s caregiver. She stated she managed and administered Patient #3’s medications. She stated Patient #3 had been taking B-12, Folic Acid, and Iron “for years”. She stated Patient #3 had dental work in September 2025 and had been using the Chlorhexidine Gluconate twice daily since then. She stated Patient #3 had been taking Atenolol and Prednisone 5 mg tablets for “a while”. She stated Patient #3 had been taking Claritin not Zyrtec for “a while”. She stated Patient #3 had been taking Fluoxetine 20 mg daily for “one year”. She stated she did not know what Lopressor was for and she was not sure the patient ever had this medication. She stated Patient #3 stopped taking Celebrex and Alprazolam “years ago”. On 12/02/2025 at 2:00 p.m. an interview was conducted with S1ADM. She stated the agency’s policy for medication reconciliation was for nurses to review each patient’s medications, including the medication bottles every visit. S1ADM confirmed the above medication discrepancies identified during the home visit. S1ADM confirmed the medication’s the patient was taking and the medication profile should match and did not.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure each patient’s Plan of Care (POC) included patient-specific interventions. The agency failed to ensure a nursing intervention to administer an injectable medication was included on the patient’s POC for 1 of 1 (#1) patient records reviewed for medication administration. Findings: Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024 with diagnoses, which included in part: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Asthma, and Dependence on Supplemental Oxygen. Review of Patient #1’s Plan of Care (POC) for Certification Period 11/26/2024 through 01/24/2025 revealed she was to receive skilled nursing services once weekly for three weeks then every other week for six weeks. Medications: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Further review revealed no documented nursing intervention to administer the Dupixent. Review of Patient #1’s Skilled Nurse Visit Notes for Certification Period 11/26/2024 through 01/24/2025 revealed Dupixent was administered to Patient #1 on 12/02/2024 and 12/19/2024. Review of Patient #1’s Plan of Care for Certification Period 11/21/2025 through 01/19/2026 revealed she was to receive skilled nursing services once weekly for eight weeks, beginning 11/24/2025. Medications: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Further review revealed no documented nursing intervention to administer the Dupixent. Review of Patient #1’s Communication Notes signed by S1ADM for Certification Period 11/21/2025 to 01/19/2026 revealed the following, in part: 12/01/2025: Patient’s Dupixent injection has not come in yet. Per pharmacy medication will arrive on 12/02/2025. SN will administer once medication has been delivered. On 12/03/2025 at 12:45 p.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #1’s clinical record. S1ADM stated Patient #1 was ordered Dupixent to be administered by the home health nurse every 2 weeks. S1ADM confirmed the intervention for the home health nurse to administer Patient #1’s Dupixent should have been included on the Patient #1’s POCs for Certification Periods dated 11/26/2024 through 01/24/2025 and 11/21/2025 through 01/19/2026 an was not.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure the Plan of Care (POC) was signed by the authorized healthcare provider within 60 days for 1 (#3) of 7 sampled patients reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The POC for each patient shall be individualized to address the patient’s problems, goals, and required services. 1. The POC, telephone and/or verbal orders shall be signed by the authorized healthcare provider within a timely manner, not to exceed 60 days. Findings: Review of the agency’s policy titled, “Verification of Physician Orders” with a revision date of April 2021 revealed the following, in part: Policy: Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients. Procedure: 11. Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. Review of Patient #3’s clinical record revealed she was admitted to the agency on 01/11/2024, and had a current Certification Period of 11/01/2025 through 12/30/2025. Review of Patient #3’s POC for Certification Period of 09/02/2025 through 10/31/2025 revealed it was not signed by the authorized healthcare provider until 11/25/2025, not within the 60 day requirement. On 12/02/2025 at 4:20 p.m., an interview was conducted with S2AA. She stated she was responsible for the agency’s orders. S2AA reviewed Patient #3’s clinical record and confirmed the POC dated 09/02/2025 was not signed within 60 days as required.”

“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 reviews 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 Dupixent, an injectable medication for reducing inflammation related to respiratory diseases for a patient with diagnoses of Asthma and Chronic Obstructive Pulmonary Disease (COPD), was not administered as ordered for 1 (#1) of 7 patient records reviewed for medication administration. Findings: Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024 with diagnoses, which included in part: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Asthma, and Dependence on Supplemental Oxygen. Review of Patient #1’s Plan of Care (POC) for Certification Period 11/26/2024 to 01/24/2025 revealed she was to receive skilled nursing services once weekly for three weeks then every other week for six weeks. Treatments: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Review of Patient #1’s Skilled Nurse Visit Notes for Certification Period 11/26/2024 to 01/24/2025 revealed no documented evidence Dupixent was administered to Patient #1 after 12/19/2024. Patient #1 was ordered to receive 4 doses and missed 2 of the doses of Dupixent for Certification Period 11/26/2024 to 01/24/2025. Further review of Patient #1’s Skilled Nurse Visit Notes, Physician Orders and Communication Notes for Certification Period 11/26/2024 to 01/24/2025 revealed no documented evidence the physician was notified Patient #1 was not administered Dupixent every 2 weeks as ordered. Review of Patient #1’s Plan of Care for Certification Period 01/25/2025 to 03/25/2025 revealed she was to receive skilled nursing services once weekly for nine weeks. Treatments: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Review of Patient #1’s Skilled Nurse Visit Notes for Certification Period 01/25/2025 to 03/25/2025 revealed no documented evidence Dupixent was administered to Patient #1. Patient #1 was ordered to receive 4 doses and missed the 4 doses of Dupixent for Certification Period 01/25/2025 to 03/25/2025. Further review of Patient #1’s Skilled Nurse Visit Notes, Physician Orders and Communication Notes for Certification Period 01/25/2025 to 03/25/2025 revealed no documented evidence the physician was notified Patient #1 was not administered Dupixent every 2 weeks as ordered. Review of Patient #1’s Plan of Care for Certification Period 07/24/2025 to 09/21/2025 revealed she was to receive skilled nursing services once weekly for nine weeks. Treatments: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Skilled Nurse to inject Dupixent 300 mg/2ml subcutaneous every 2 weeks. Review of Patient #1’s Skilled Nurse Visit Notes for Certification Period 07/24/2025 to 09/21/2025 revealed no documented evidence Dupixent was administered to Patient #1 before or after 08/22/2025. Patient #1 was ordered to receive 4 doses and missed 3 of the doses of Dupixent for Certification Period 07/24/2025 to 09/21/2025. Further review of Patient #1’s Skilled Nurse Visit Notes, Physician Orders and Communication Notes for Certification Period 07/24/2025 to 09/21/2025 revealed no documented evidence the physician was notified Patient #1 was not administered Dupixent every 2 weeks as ordered. Review of Patient #1’s Plan of Care for Certification Period 11/21/2025 to 01/19/2026 revealed she was to receive skilled nursing services once weekly for eight weeks, beginning 11/24/2025. Treatments: Dupixent Subcutaneous 300 mg/2 ml every 2 weeks. Review of Patient #1’s Skilled Nurse Visit Notes for Certification Period 11/21/2025 to 01/19/2026 revealed no documented evidence Dupixent was administered to Patient #1. Patient #1 was ordered to receive 4 doses and missed 1 of the doses of Dupixent for Certification Period 11/21/2025 to 01/19/2026. Review of Patient #1’s Communicates Notes signed by S1ADM for Certification Period 11/21/2025 to 01/19/2026 revealed the following, in part: 12/01/2025: Patient Dupixent injection has not come in yet. Per pharmacy, medication will arrive on 12/02/2025. SN will administer once medication has been delivered. 12/03/2025: Called Patient #1’s Specialty Pharmacy, medication was delivered yesterday 12/02/2025 at 1:30 pm. Patient called and stating she has not received her medication. Tracking number given... Package picture shows delivery at patient front door. Further review of Patient #1’s Skilled Nurse Visit Notes, Physician Orders and Communication Notes for Certification Period 11/21/2025 to 01/19/2026 revealed no documented evidence the physician was notified Patient #1 was not administered Dupixent every 2 weeks as ordered. On 12/02/2025 at 9:08 a.m., an interview was conducted with Patient #1. She stated the home health nurses gave her a shot (injection) of the medication Dupixent twice a month. She stated the medication was for her lungs. She stated the pharmacy delivered the medication to her home. She stated sometimes the pharmacy was late delivering the medication, when this happened she called the pharmacy and the home health nurse. She stated she was not sure why the medication deliveries were late and did not notify her doctors if she missed any doses. On 12/03/2025 at 10:07 a.m., an interview was conducted with S3LPN. He stated Patient #1 was ordered a Dupixent injection to be administered by the home health nurse every 2 weeks. He stated when the medication was not delivered on time and not administered as ordered he notified S1ADM or S2AA, but he did not notify the doctor. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. She reviewed Patient #1’s clinical record for the above mentioned Certification Periods. She stated Patient #1 was ordered a Dupixent injection 300 mg/2ml to be administered every 2 weeks by the home health nurse. She confirmed Patient #1 was not administered the Dupixent injection as ordered. S2AA confirmed there was no documented evidence the physician was notified Patient #1 did not receive the Dupixent as ordered for the above mentioned Certification Periods and should have been. On 12/03/2025 at 12:45 p.m., an interview was conducted with S1ADM. She stated Patient #1 was ordered to be administered Dupixent by the home health nurse every 2 weeks. S1ADM stated she expected there should have been documentation as to why Patient #1’s Dupixent was not administered as ordered and the physician should have been notified. On 12/04/2025 at 8:52 a.m., an interview was conducted with S5NP. She stated Patient #1 was prescribed Dupixent for her diagnoses of COPD and Asthma. She stated Patient #1’s Dupixent 300 mg/2 ml was ordered to be administered every 14 days by the home health agency. She reviewed Patient #1’s clinical record and stated the last time she spoke with the home health agency was in April 2025, when refills of the Dupixent were sent to Patient #1’s pharmacy. She stated there were no communications in Patient #1’s record for 2025 prior to April. She stated in April 2025, the Dupixent order was sent in to Patient #1’s pharmacy with the understanding the home health agency would assist Patient #1 to refill the medication and administer it. She stated she had not been made aware of Patient #1 not receiving her Dupixent as ordered. She stated she would have expected the home health agency to notify the physician or nurse practitioner if the Dupixent was not administered to Patient #1 as ordered. She stated Patient #1 not receiving the Dupixent as ordered had potential effects and increased her risk for exacerbations and hospitalizations.”

“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 Occupational Therapy and Home Health Aide Services were integrated into the Plan of Care (POC) to ensure all services and interventions were provided to the patient for 1 (#7) of 7 sampled patients reviewed. Findings: Review of Patient #7’s clinical record revealed she began receiving services from the Home Health Agency on 03/05/2024 and was discharged on 06/27/2025. Patient #7 had diagnoses, which included Chronic Obstructive Pulmonary Disease, Anxiety disorder Unspecified, Diverticulosis of both Small and Large Intestine without Perforation or Abscess, and Encounter for Attention to Colostomy. Review of Patient #7’s Physician’s Order dated 02/22/2024 for admission to home health revealed to evaluate for Occupational Therapy and Home Health Aide Services. Review of Patient #7’s POC dated 03/05/2024 through 05/03/2024 revealed no evidence the agency implemented Occupational Therapy or Home Health Aide Services as ordered. Review of Patient #7’s client Calendar Report revealed no documentation of an Occupational Therapy or Home Health Aide visit for the Certification Period of 03/05/2024 through 05/03/2024. Review of Patient #7’s Physician Orders and Communication Notes for Certification Period 03/05/2024 through 05/03/2024 revealed no documented evidence the Provider was notified Occupational Therapy and Home Health Aide Services were not provided as ordered. On 12/03/2025 and 12/04/2025 attempts were made to interview Patient #7. On 12/04/2025 at 10:25 a.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #7’s clinical record and home health referral dated 02/22/2024. S1ADM confirmed the provider ordered Occupational Therapy and Home Health Aide Services. S1ADM confirmed there was no documented evidence why the services were not provided. S1ADM further confirmed there was no documented evidence the provider was notified Occupational Therapy and Home Health Aide Services were not provided as ordered and there should have been.”

“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 3 (#1, #4, and #7) of 7 patient records reviewed. The agency failed to ensure: 1. The Skilled Nurse obtained and documented oxygen saturations for Patient #1, Patient #4 and Patient #7 on each visit, and 2. The Skilled Nurse obtained and documented a Capillary Blood Glucose (CBG) for Patient #1 during the home visit. Findings: 1. Patient #1 Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024, with diagnoses, which included Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Asthma, Heart Failure Unspecified, and Dependence on Supplemental Oxygen. Review of Patient #1’s POC for Certification Period 01/25/2025 through 03/25/2025 revealed Patient #1 was ordered to receive Skilled Nursing Visits once weekly for nine weeks. Further review revealed, in part: Nurse to obtain oxygen saturation each visit. Report all abnormal vitals to physician and Registered Nurse (RN) case manager; and Notify physician of: Oxygen saturations less than 90%. Review of Patient #1’s Skilled Nurse Visit (SNV) Note dated 03/05/2025, 03/12/2025, and 03/20/2025, completed by S3LPN, revealed no documentation of oxygen saturations. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. S2AA reviewed Patient #1’s clinical record and POC for the Certification Period 01/25/2025 through 03/25/2025 and confirmed an oxygen saturation was ordered to be obtained each nursing visit. S2AA reviewed the SNV notes dated 03/05/2025, 03/12/2025, and 03/20/2025, and confirmed no oxygen saturation was documented per physician orders and should have been. Patient #4 Review of Patient #4’s clinical record revealed she began receiving services from the agency on 09/16/2024, with a current Certification Period dated 11/10/2025 through 01/08/2026, and diagnoses, which included Hypertensive Heart and Chronic Kidney Disease and Mild Intermittent Asthma. Review of Patient #4’s POC for Certification Period dated 09/11/2025 through 11/09/2025 revealed Patient #4 was ordered to receive Skilled Nursing Visits once weekly for eight weeks, beginning 09/15/2025. Further review revealed, in part: Nurse to obtain oxygen saturation each visit. Report all abnormal vitals to physician and RN case manager; and Notify physician of: Oxygen saturations less than 90%. Review of Patient #4’s Skilled Nurse Visit Note dated 09/26/2025 completed by S1ADM revealed no documentation of oxygen saturations. On 12/03/2025 at 3:05 p.m., an interview was conducted with S1ADM. S1ADM stated nursing staff were expected to obtain vital signs with documentation completed on each patient visit as ordered. S1ADM stated she was the nurse assigned to and made the above visit for Patient #4. S1ADM confirmed there was no documented oxygen saturation for Patient #4 on 09/26/2025 and there should have been. Patient #7 Review of Patient #7’s clinical record revealed she began receiving services from the Home Health Agency on 03/05/2024 with diagnoses, which included Chronic Obstructive Pulmonary Disease and Wheezing, and was discharged on 06/27/2025. Review of Patient #7’s POC for Certification Period dated 04/29/2025 through 06/27/2025 revealed Patient #7 was ordered to receive Skilled Nursing Visits every other week for eight weeks, then once per week for one week, beginning 05/05/2025. Further review revealed, in part: Nurse to obtain oxygen saturation each visit. Report all abnormal vitals to physician and RN case manager; and Notify physician of: Oxygen saturations less than 90%. Review of Patient #7’s Skilled Nurse Visit Note dated 06/19/2025 completed by S3LPN revealed no documentation of oxygen saturations. On 12/04/2025 at 10:25 a.m., an interview was conducted with S1ADM. S1ADM reviewed Patient #7’s POC for Certification Period dated 04/29/2025 through 06/27/2025 and verified the physician order to obtain an oxygen saturation each nurse visit with physician notification parameters. S1ADM reviewed the SNV dated 06/19/2025 and confirmed no oxygen saturation was documented and should have been. 2. Review of Patient #1’s POC for Certification Period 11/21/2025 through 01/19/2026 revealed Patient #1 was ordered to receive Skilled Nursing Visits once weekly for eight weeks, beginning 11/24/2025. Further review revealed, in part: Nurse to obtain CBG each visit. Report all abnormal vitals to physician and RN case manager; and Notify physician of: Fasting blood sugar greater than 250 or less than 60, and Random blood sugar greater than 350 or less than 70. On 12/02/2025 at 9:23 a.m., a home visit was conducted with Patient #1 with S2AA present. S2AA did not obtain Patient #1’s CBG or ask the patient if she had obtained a CBG during the home visit. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. S2AA reviewed Patient #1’s POC for Certification Period 11/21/2025 through 01/19/2026 and confirmed the physician ordered a CBG to be obtained every nurse visit with physician notification parameters. S2AA confirmed she did not obtain Patient #1’s CBG during the home visit on 12/02/2025. On 12/03/2025 at 12:45 p.m., an interview was conducted with S1ADM. S1ADM confirmed physician ordered services in each patient’s plan of care should be obtained completed and documented each skilled nurse visit as ordered.”

“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 reviews and interviews, the agency failed to ensure a physician was notified regarding a change in patient’s status as evidenced by the agency failing to: 1. Ensure a patient’s change in condition was communicated to the physician for 1 (#1) of 7 patient records reviewed; and 2. Ensure a patient’s vital signs outside of the established parameters per the Plan of Care (POC) were reported to the physician for 2 (#1 and #4) of 7 patient records reviewed for care and services provided per the POC. Findings: Patient #1 Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024, with current Certification Period dated 11/21/2025 through 01/19/2026 and diagnoses, which included Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Asthma, Heart Failure Unspecified, and Dependence on Supplemental Oxygen. Review of Patient #1’s POC for Certification Period 11/26/2024 through 01/24/2025 revealed Patient #1 was ordered to receive Skilled Nursing Visits once weekly for three weeks then every other week for six weeks. Further review revealed, in part: Nurse to obtain oxygen saturation each visit. Report all abnormal vitals to physician and Registered Nurse (RN) case manager; and Notify physician of: Oxygen saturations less than 90%. Review of Patient #1’s Skilled Nurse Visit Note signed by S7LPN revealed the following, in part: 01/13/2025: Oxygen saturation 82% on oxygen at 2 liter per minute via nasal cannula; Comments: Oxygen saturation with oxygen noted via nasal cannula at 82%, patient has increased shortness of breath. Patient states she has been like this times two days. 911 called, Emergency Medical Services arrived, patient requested to go to a local hospital for evaluation. Office notified spoke with S2AA. Further review revealed no documented evidence Patient #1’s physician was notified of her change in condition and oxygen saturation being outside of the established parameters per her POC and requiring Emergency Medical Services. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. S2AA reviewed Patient #1’s clinical record and POC for Certification Period 11/26/2024 through 01/24/2025. S2AA reviewed the Skilled Nurse visit dated 01/13/2025 and confirmed Patient #1 had an oxygen saturation of 82% on oxygen, S7LPN called Emergency Medical Services, and Patient #1 was transported to the hospital. S2AA confirmed there was no documented evidence the physician was notified of Patient #1’s change in condition and vital signs out of ordered parameters and there should have been. On 12/03/2025 at 12:45 p.m., an interview was conducted 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 #1’s change in condition and vital signs outside of parameters per the POC. S1ADM confirmed staff should have contacted the patients’ physicians for Patient #1’s change in condition. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the agency on 09/16/2024, with current Certification Period dated 11/10/2025 through 01/08/2026, and diagnoses, which included Hypertensive Heart and Chronic Kidney Disease and Mild Intermittent Asthma. Review of Patient #4’s POC for Certification Period 09/11/2025 through 11/09/2025 revealed Patient #4 was ordered to receive Skilled Nursing Visits once weekly for eight weeks, beginning 09/15/2025. Further review revealed, in part: Nurse to obtain blood pressure each visit. Report all abnormal vitals to physician and RN case manager; and Notify physician of: Diastolic BP greater than 90 or less than 60. Review of Patient #4’s Skilled Nurse Visit Notes signed by S1ADM revealed the following, in part: 09/16/2025: Blood Pressure Left Arm 140/100 Diastolic. 09/26/2025: Blood Pressure Left Arm 150/94 Diastolic. Further review revealed no documented evidence Patient #4’s physician was notified of her Diastolic blood pressure being outside of the established parameters per her POC. On 12/03/2025 at 3:05 p.m., an interview was conducted 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. S1ADM stated she was the nurse assigned to Patient #4 and made the above visits. S1ADM confirmed she did not notify the physician of Patient #4’s Diastolic Blood Pressure out of ordered parameters on 09/16/2025 and 09/26/2025 and should have.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure each patient’s clinical record contained all services and interventions provided and responses to those interventions for 1 (#1) of 7 sampled patients reviewed. The provider failed to ensure documentation of Patient #1’s capillary blood glucose (CBG) each skilled nurse visit were maintained in the clinical record. Findings: Review of Patient #1’s clinical record revealed she began receiving services from the agency on 01/31/2024, with current Certification Period dated 11/21/2025 through 01/19/2026, and diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Long Term Use of Oral Hypoglycemic Drugs. Review of Patient #1’s Plan of Care for Certification Period 07/24/2025 to 09/21/2025 revealed she was to receive skilled nursing services once weekly for nine weeks. Further review revealed, in part: Nurse to obtain CBG each visit. Report all abnormal vitals to physician and Registered Nurse (RN) case manager; and Notify physician of: Fasting blood sugar greater than 250 or less than 60, and Random blood sugar greater than 350 or less than 70. Review of Patient #1’s Skilled Nurse Visit Notes dated 07/25/2025, 07/30/2025, 08/06/2025, 08/14/2025, 08/29/2025, 09/04/2025, and 09/11/2025 completed by S3LPN revealed no documentation of a CBG as ordered. Review of Patient #1’s Plan of Care for Certification Period 09/22/2025 to 11/20/2025 revealed she was to receive skilled nursing services once weekly for nine weeks. Further review revealed, in part: Nurse to obtain CBG each visit. Report all abnormal vitals to physician and RN case manager; and Notify physician of: Fasting blood sugar greater than 250 or less than 60, and Random blood sugar greater than 350 or less than 70. Review of Patient #1’s Skilled Nurse Visit Notes dated 09/26/2025, 10/03/2025, 10/10/2025, 10/17/2025, 10/24/2025, 10/31/2025, 11/07/2025, and 11/14/2025 completed by S3LPN revealed no documentation of a CBG as ordered. On 12/02/2025 at 9:08 a.m., a home visit was conducted with Patient #1. She stated the nurses checked her blood sugar each visit. On 12/03/2025 at 10:07 a.m., an interview was conducted with S3LPN. He stated Patient #1 was Diabetic and on an oral hypoglycemic medication. S3LPN stated he used Patient #1’s CBG machine and checked her blood sugar each visit. S3LPN confirmed he should have documented the CBG results in his skilled nurse note for each visit and did not. On 12/03/2025 at 11:20 a.m., an interview was conducted with S2AA. S2AA reviewed Patient #1’s POC and Skilled Nurse Visit notes for the above mentioned certification periods. S2AA confirmed the physician ordered a CBG to be obtained every nurse visit with physician notification parameters. S2AA confirmed there were no documented CBG’s for Patient #1 on the above mentioned skilled nurse visits and there should have been. On 12/03/2025 at 12:45 p.m., an interview was conducted with S1ADM. S1ADM confirmed physician ordered services, including a CBG in each patient’s plan of care, should be obtained and documented each skilled nurse visit as ordered.”

“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 1(#6) of 2 discharged patients reviewed. Findings: Review of the agency’s policy titled, “Discharge Summary,” revised May 2024, revealed the following, in part: Policy: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. Review of the clinical record for Patient #6 revealed she began receiving services from the agency on 04/01/2020, with a Certification Period dated 02/27/2025 through 04/27/2025, and was discharged on 04/24/2025. Further review revealed no Discharge Summary was completed. On 12/03/2025 at 9:10 a.m., an interview was conducted with S2AA. S2AA confirmed she was responsible for sending Discharge Summaries to a patient’s provider upon discharge. S2AA confirmed a discharge summary was not completed in the clinical record or sent to Patient #6’s provider upon discharge, and should have been. On 12/03/2025 at 11:46 a.m., an interview was conducted with S1ADM. S1ADM confirmed a discharge summary was not completed in the clinical record or sent to Patient #6’s provider upon discharge, and should have been.”