Greater Boston Home Health Care, LLC

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness (EP) Plan and interview, the agency failed to develop an emergency plan that included a process for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials. Findings include: Review of the agency’s EP plan, updated December 2024, indicated the following: *Our agency will be in contact with local/state emergency personnel/agencies in an effort to coordinate emergency services for which we are capable of handling within our agency. *Our agency will document any and all efforts to contact emergency officials and collaboration and cooperative planning efforts on a Communication Note. During an interview on 7/2/25 at 12:50 P.M., the Administrator said the agency had not been in contact with any local, regional, tribal, State or Federal EP officials since before the last recertification survey. She said in the past she had reached out to them without being able to obtain a successful collaboration plan, but she had not re-attempted to reach out to them as required.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness (EP) Plan, and interview, the agency failed to conduct exercises to test the emergency plan at least annually by doing the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. Findings include: During an interview on 7/2/25 at 12:50 P.M., the Administrator said the agency has not done an EP drill, nor have they had to implement their EP plan which would allow them the opportunity to analyze the agency’s response. She said she is only providing annual in-service education training each fall, which was last done in October 2024.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure 1 patient (#13) received 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, from a total sample of 13 patients. Findings include: Review of the agency’s policy entitled Plan of Care, dated March 2020, indicated the following: *Each patient will receive 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 physician. *If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Patient #13 was admitted to the agency in May 2025 with a diagnosis of spinal stenosis (narrowing of one or more spaces within the spinal canal), requiring skilled care. Review of the physician ordered Home Health Certification and Plan of Care, dated 5/16/25 through 7/14/25, included the following: *Skilled nursing visit (SNV): 1 time a week for 1 week, 2 times a week for 8 weeks and 2 as needed (PRN). Review of the clinical record indicated a Physical Therapy (PT) evaluation was completed on 6/11/125, and the patient received additional PT visits on 6/17/25, 6/18/5, 6/24/25 and 6/30/25. Further review of the clinical record did not indicate the physician was notified to obtain approval and an order for PT services, which was not included in the original plan of care. During an interview on 7/2/25 at 11:40 A.M., the Administrator said that she thought the referral given to the agency for skilled care was all that was needed to provide the PT services. She said there was no additional order for PT to do the evaluation and provide services, as required. She said the plan of care was not updated.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, and interview, the agency failed to ensure patient and staff signed consents were legible and clear relative to the date, for 1 patient (#13) out of total sample of 13 patients. Findings include: Review of the agency’s policy entitled, Clinical, dated March 2020, indicated the following: *Clinical Record Documentation: Documentation errors will be handled by crossing out the incorrect words with one line ink. Write the word “ERROR” above the the incorrect word and write in correct word. Patient #13 was admitted to the agency in May 2025 with a diagnosis of spinal stenosis (narrowing of one or more spaces in the spinal canal), requiring skilled services. Review of the following consent signed by the Patient #13 and nursing indicated the dates signed were illegible. *Authorization for Use/Disclosure of Health Information *Patient Financial Authorization *Lock Box Agreement During an interview on 7/2/25 at 11:42 A.M., after reviewing the consents with the surveyor, the Administrator said the dates signed were difficult to read and appeared written over. She said staff should not have written over the dates, and instead crossed them out, noted error, and documented the correct date.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review, and staff interview, the Agency failed to ensure that the patient’s signature was obtained confirming that he/she had received a copy service agreement and patient rights and responsibilities prior to the start of treatment for 1 of 13 (#1) applicable patients. Findings include: Review of the Agency policy titled “Admission Documentation/Patient Education”, dated 3/2020, indicated the following: -Upon admission to the agency, certain documentation will be provided to, explained and reviewed with, and signed by the patient, by the admitting clinician. -At the start of services, the agency will establish a written agreement with the patient, which will be signed and dated by the patient and the agency. The agreement will contain: *Services to be provided *Rates/charges for services paid with private funds *Charges for services that may not be covered by Medicare, Medicaid, or any other Federally funded. *Charges the individual may have to pay before care is initiated. The Patient Rights and Responsibilities will be verbally reviewed with the patient/representative, in the individual’s primary or preferred language and in a manner the individual understands, by the 2nd professional visit free of charge, with the use of competent interpreter, if necessary. A copy must be given to the patient representative by the 4th visit and signed that it was received. Patient #1 was admitted to the agency in May 2025 with a diagnosis of Paroxysmal Vertigo (a sudden feeling of spinning or of the world spinning). Review of the physician’s order for certification period of 5/15/25-7/13/25 indicated an order for Skilled Nursing Services 1 times a week for one week, then 2 times a week for 8 weeks, and an order for Home Health Aide service 2 times a week for 9 weeks. Review of the admission notes indicated that on 5/15/25, the clinician reviewed “Admission Consents” documents which include written service agreement and patient rights and responsibilities with Patient #1. Further record review indicated that Patient #1 did not have a signed Admission Consent in his/her medical chart. During an interview on 7/2/25 at 12:00 P.M., the Administrator said that she reviewed Patient #1’s medical chart and was unable to locate a signed copy of Admission Consents which included a written service agreement and Patient Rights and Responsibilities.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for one Patient (#2), out of a total sample of 13 patients. Findings include: Review of the facility’s policy titled Plan of Care, dated March 2020, indicated but was not limited to the following: *Each patient will receive 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 physician *The Plan of Care (POC) is developed by the Registered Nurse (RN), Physical Therapist (PT), Speech Therapist (ST), Occupational Therapist (OT), acting as the PSM, from the comprehensive Outcome and Assessment Information Set (OASIS-a core set of items used to track the status of patients receiving home healthcare services) assessment. *The POC is updated/revised as new orders are received. *All patient care orders, including verbal orders, must be recorded in the plan of care. Patient #2 was admitted to the agency in March 2022 with a diagnosis of type 2 diabetes mellitus. Review of the medical record indicated a Med Work Sheet document, dated 2/28/25, which included but was not limited to the following documentation by Nurse #1: *New - Right shin open wound. 1- Dry protective dressing every other day, change dressing until healed. *New - Wound of left arm. Apply wet to dry dressing, f/b Mepilex border dressing every other day until healed. *A verbal order was obtained from the physician by Nurse #1 for the wound treatments. Review of the physician ordered Home Health Certifications and Plans of Care, for certification period of 1/11/25-3/11/25, 3/12/25-5/10/25, and 5/11/25-7/9/25, failed to include the physician’s verbal order obtained by Nurse #1 on 2/28/25 for wound treatments. Review of the clinical record and skilled nursing visit notes indicated wound treatments were being provided to Patient #2 as verbally ordered on 2/28/25. During an interview on 7/1/25 at 12:08 P.M., the surveyor reviewed the medical record with the Administrator who said all treatments should be included in the patient’s plan of care. During an interview on 7/1/25 at 4:15 P.M., Nurse #1 said she obtained a verbal order from the physician on 2/28/25 and provided the wound treatments to Patient #2 but did not update the plan of care to reflect the wound treatments being provided, as required.”

“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 record review, policy review and interview, the agency failed to ensure services that were ordered by the physician or allowed practitioner as indicated in the plan of care for 4 patients (#7, #8, #11 and #4), out of a total sample of 13 patients. Findings include: 4.Patient #4 was admitted to the agency in May 2025 with a diagnosis of food in the respiratory tract, part unspecified causing asphyxiation (condition where the body is deprived of oxygen, leading to unconsciousness or even death) requiring skilled care. The physician ordered Home Health Certification and Plan of Care (POC), dated 5/7/25-7/5/25, indicated the following: *effective 5/7/25, physical therapy (PT) visits - two times a week for eight weeks Review of the medical record failed to indicate documentation of PT services performed as ordered by the physician and as indicated in the POC from 5/7/25 through 6/3/25 or an explanation of why PT services were not performed. Review of the PT Evaluation Refused document, dated 6/4/25, indicated Patient #4 refused PT services. PT services were discontinued at that time. During an interview on 7/2/25 at 9:06 A.M., the Administrator said Patient #4 refused PT services, so the evaluation was never done, and the only PT note she had was from 6/4/25 discontinuing the service. She said there was no documentation in the medical record explaining the missed PT visits to provide the service per the plan of care from 5/7/25 through 6/3/25 but should have been. Review of the agency’s policy entitled Plan of Care, dated March 2020, indicated the following: *Each patient will receive 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 physician. *Promptly alert the physician who is responsible for the agency plan of care to any changes in the patient’s condition or needs that would suggest that measurable outcomes are not being achieved and/or that the agency should alter the plan of care. 1.Patient #7 was admitted to the agency in November 2024 with a diagnosis of wedge compression fracture of thoracic vertebrae, requiring skilled services. Review of the physician ordered Home Health Certification and Plan of Care, dated 1/10/25 through 3/10/25, indicated the following: *Skilled nursing visit (SNV): 1 time a week for 1 week, 2 times a week for 8 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated a SNV was provided on 1/12/25. Further review of the record included missed SNV notes for 1/16/25, 1/20/25, 1/23/25. 1/27/25, 1/30/25 and 2/3/25. The notes indicated the reason for the missed visit was “patient traveled”. The record did not include any additional documentation of SNVs as ordered, and/or missed SNVs. Review of a discharge summary, dated 3/10/25, indicated Patient #7 was discharged from the agency’s home health services, with a reason for discharge as “moved from service area”. 2. Patient #8 was admitted to the agency March 2025 with a diagnosis of severe protein-calorie malnutrition, requiring skilled care. Review of the physician ordered Home Health Certification and Plan of Care, dated 3/29/25 through 5/27/25, indicated the following: *SNV: 1 time a week for 1 week, 3 times a week for 1 week, 7 times a week for 7 weeks and 2 PRN visits. *Home Health Aide visits (HHAVs): 2 times a week for 8 weeks. Review of the clinical record indicated no HHAVs were provided as ordered before the patient was discharged on 4/10/25, and no documentation to indicate why HHAVs were not provided. 3. Patient # 11 was admitted to the agency in May 2025 with a diagnosis of encounter for aftercare following surgery, requiring skilled care. Review of the physician ordered Home Health Certification and Plan of Care, dated 5/8/25 through 7/6/25, indicated the following: *SNV: 1 time a week for 1 week, 2 times a week for 8 weeks, 2 PRNs. *HHAVs: 2 times a week for 8 weeks. Review of the clinical record indicated no HHAVs were provided as ordered before the patient was transferred to the hospital on 5/15/25, and no documentation to indicate why HHAVs were provided. During an interview on 7/2/25 at 10:45 A.M., after reviewing the clinical records of Patients #7, #8 and #11, the Administrator said skilled services were not provided as ordered in the plan of care, and there was no documentation that indicated why they were not provided.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure staff communicated with all physicians involved in the plan of care, other health care practitioners (as appropriate) related to the current plan of care for 2 patients (#7 and #8), out of a total sample of 13 patients. Findings include: Review of the agency’s policy entitled Plan of Care, dated March 2020, indicated the following: *Each patient will receive 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 physician. *Promptly alert the physician who is responsible for the agency plan of care to any changes in the patient’s condition or needs that would suggest that measurable outcomes are not being achieved and/or that the agency should alter the plan of care. 1.Patient #7 was admitted to the agency in November 2024 with a diagnosis of wedge compression fracture of thoracic vertebrae, requiring skilled services. Review of the physician ordered Home Health Certification and Plan of Care, dated 1/10/25 through 3/10/25, indicated the following: *Skilled nursing visit (SNV): 1 time a week for 1 week, 2 times a week for 8 weeks and 2 as needed (PRN) visits. Review of the clinical record indicated a SNV was provided on 1/12/25. Further review of the record included missed SNV notes for 1/16/25, 1/20/25, 1/23/25. 1/27/25, 1/30/25 and 2/3/25. The notes indicated the reason for the missed visit was “patient traveled”. The record did not include any additional documentation of SNVs as ordered, and/or missed SNVs. Review of a discharge summary, dated 3/10/25, indicated Patient #7 was discharged from the agency’s home health services, with a reason for discharge as “moved from service area”. During an interview on 7/1/25 at 2:40 P.M., the Administrator said that nursing should have communicated with the physician when SNVs could not be provided as ordered. She said there was no documentation by nursing after 2/3/25 that visits were not provided as ordered. She said the physician was not notified of missed visits after 2/3/25, and was only notified of the patient’s discharge on 3/10/25. 2. Patient #8 was admitted to the agency March 2025 with a diagnosis of severe protein-calorie malnutrition, requiring skilled care. Review of the physician ordered Home Health Certification and Plan of Care, dated 3/29/25 through 5/27/25, indicated the following: *SNV: 1 time a week for 1 week, 3 times a week for 1 week, 7 times a week for 7 weeks and 2 PRN visits. *Home Health Aide visits (HHAVs): 2 times a week for 8 weeks. Review of the clinical record indicated no HHAVs were provided as ordered before the patient was discharged on 4/10/25, and there was no documentation to indicate why HHAVs were not provided. During an interview on 7/1/25 at 3:10 P.M., the Administrator said staff did not provide HHAVs because he/she had a private aide. She said this information was not documented in the clinical record. She also said there was no documentation to indicate the physician was notified of this, thereby allowing physician to updated the plan of care.”