Rmg Home Care Inc.

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and no document available to review, the agency failed to complete a hazards risk assessment as part of the agency’s Emergency Preparedness (EP) Plan. Finding include: Review of the documents provided to the surveyor for the agency’s EP Plan failed to indicate that any hazards had been identified and a risk assessment had been completed. During an interview on 4/16/26 at 3:30 P.M., the Compliance Officer said she could not provide any documentation that a hazard risk assessment had been completed by the agency, as required.”

“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 document review and staff interview, the agency failed to electronically transmit completed Outcome and Assessment Information Set (OASIS-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the required 30 days of completing the assessments of the beneficiary. Findings include: Review of the agency policy entitled, Data Entry/Transmission of OASIS Information, undated, included the following: *The OASIS information must be electronically transmitted with accurate, complete, encoded and locked OASIS data for each patient to the State Agency at least monthly. Review of the Home Health Agency (HHA) Error Summary by Agency Report indicated the agency had 454 late OASIS Assessment submissions between 4/8/25 to 4/8/26, out of a total of 881, which equaled to a 51.53% error rate. During a phone interview on 4/16/26 at 2:50 P.M., the Interim Clinical Director said she is responsible for the OASIS submissions. She further said she was not aware of any late submissions and could not provide any additional information about the late submissions.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to follow standards of practice for infection control during wound care for one patient (#5), out of three total home visit observations. Findings Include: Review of the agency’s policy titled Hand Washing, undated, indicated but was not limited to the following: *Decontaminate hands after removing gloves. Review of the agency’s policy titled Contaminated Waste Disposal, undated, indicated but was not limited to the following: *Contaminated paper wastes (disposable gloves, gowns, masks, paper towels, tubing, dressings, etc.), should be placed in a plastic puncture resistant bag and secured. It should be double bagged and, if possible, placed in a plastic trash container with tight lid. Patient #5 was admitted to the agency in December 2021 with a diagnosis of chronic atrial fibrillation (common, often chronic arrhythmia characterized by a rapid, chaotic, and irregular heartbeat starting in the heart’s upper chambers). Review of the physician ordered Plan of Care (POC) for certification period 3/19/26 through 5/17/26 indicated the following: *Skilled Nurse Visits (SNV): once weekly plus medication administration visit once weekly x 9 weeks and 1 SNV visit as needed (prn) Review of a Wound Order, dated 4/16/26, indicated the following: Patient-Specific Orders for Discipline and Treatments: Per wound clinic visit on 4/10/26: -Skin tear Left Posterior LE (lower extremity): Cleanse with NS (normal saline), apply xeroform (sterile, non-adhering petrolatum-impregnated dressing designed to maintain a moist wound environment while preventing sticking), DCD (decellularized dermis dressing-enhances healing of skin tears), secure with Kling/tape 3 times a week -Left 2nd/3rd toes: Cleanse with NS, apply fibracol collagen dressing (designed to manage low-to-high exudate levels, maintain a moist wound environment, and support granulation tissue) On 4/15/26 at 2:08 P.M., the surveyor observed Nurse #1 provide wound care to Patient #5’s left posterior LE skin tear and left foot 2nd and 3rd toe wounds and observed the following: a. Nurse #1 doffed (removed) her gloves on three occasions while providing wound care and donned (put on) new gloves without performing hand hygiene first. b. Nurse #1 doffed her gloves on two occasions and placed them on top of the patient’s over the bed tray table located to the left of the patient’s chair. Nurse #1 then disposed of the soiled gloves in the patient’s trash and wiped the table in a single, one-directional motion with a disinfectant wipe. Nurse #1 did not place a barrier on the surface underneath the soiled gloves to help prevent potential contamination and did not properly disinfect the table afterward. c. Nurse #1 placed a clean barrier on the patient’s floor in his/her home to set up clean wound supplies. Nurse #1, after cleansing the patient’s left posterior LE wound with NS, placed the soiled gauze on the clean barrier. Nurse #1 then cleansed the 2nd and 3rd toes with NS and placed the soiled gauze on the clean barrier. Nurse #1 did not separate clean from dirty (soiled) items when providing wound care to help prevent cross-contamination. During an interview on 4/16/26 at 2:34 P.M., Nurse #1 said the expectation was to perform hand hygiene in between glove changes and said she should have separated clean wound supplies from soiled. Nurse #1 further said she should have placed a protective barrier on the patient’s table and adequately disinfect its surface after use but did not. During an interview on 4/16/26 at 1:28 P.M., the Compliance Officer said the expectation was to perform hand hygiene in between glove changes, separate clean wound supplies from dirty, utilize protective barriers, and properly disinfect surface areas.”

“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, policy review, and interview, the facility failed to ensure staff entries were legible, clear, complete, appropriately authenticated, dated, and timed, relative to a.) staff visit notes for 4 patients (#1, #2, #3, and #7), and b.) physician ordered Home Health Certification and Plan of Care (POC) for 2 patients (#1 and #2), out of a total sample of 7 patients. Findings included: Review of the agency policy entitled, Registered Nurses, undated, included the following: *Prepare documentation and clinical notes to be completed within 24-48 hours of regular visit and five days for OASIS assessments. Review of the agency policy entitled, Licensed Practical Nurse (LPN), undated, included the following: *Prepare documentation and clinical notes to be completed within 24-28 hours of visit. Review of the agency policy entitled, Certified Nursing Aide/Home Health Aide, (CNA/HHA), undated, included the following: *The certified nursing aide/home health aide shall have the following responsibilities: *Shall complete a clinical note for each visit, which must be completed within 24-48 hours of visit..... Review of the agency policy entitled. Physician Orders/Plan of Care (POC), undated, included the following: *If the agency does not receive a signed physician’s order within thirty (30) days of the date the order is sent to the physician for signature, the agency contacts the physician’s office to obtain the signed document or resends the order (s) to be signed. All follow-up contacts to obtain signed orders are documented. 1. Patient #1 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM) without complications (presence of high sugar due to insulin resistance without associated damage to nerves, eyes, kidneys or blood vessels). a. Review of the physician ordered Home Health POC & Certification, dated 2/17/26 through 4/17/26, indicated the following: -Skilled Nurse (SN) visit: 2 times a week for 9 weeks. -HHA visit: 2 hours, 5 times a week for 9 weeks. Review of the clinical record indicated the following: *2/19/26 LPN visit, note was signed on 3/8/26. *2/23/26 LPN visit, note was signed on 3/8/26. *3/2/26 LPN visit, note was signed on 3/8/26. *3/17/26 HHA visit, note was signed on 3/20/26. *3/20/26 HHA visit, note was signed on 4/12/26. *3/27/26 LPN visit, note was signed on 4/5/26. *4/2/26 LPN Supervisory visit, note was signed on 4/6/26. b. Review of the clinical record indicated the Home Health POC and Certification, dated 2/17/26 through 4/17/26, was signed by the physician on 4/15/26, and not within the 30 day required timeframe. 2. Patient #2 was admitted to the agency in June 2025 with a diagnosis of pancreatitis (inflammation of the pancreas). a. Review of the physician ordered Home Health POC & Certification, dated 2/22/26 through 4/22/26, indicated the following: -SN visit: 3 times a week for 9 weeks. Review of the clinical record indicated the following: *3/11/26 SN visit, note was signed on 3/26/26. *3/13/26 SN visit, note was signed on 3/26/26. *3/16/26 SN visit, note was signed on 3/26/26. *3/18/26 SN visit, note was signed on 3/26/26. *3/24/26 SN visit, note was signed on 3/27/26. b. Review of the clinical record indicated the Home Health POC & Certification, dated 6/27/25 through 8/25/25, was signed by the physician on 2/11/26, and the Home Health POC & Certification, dated 8/26/25 through 10/24/25, was signed by the physician on 10/1/25, and not within the 30 day required timeframe. 3. Patient #3 was admitted to the agency in July 2025 with a diagnosis of ventral hernia with obstruction (occurs when abdominal tissue, often intestine, pushes through a weak spot in the abdominal wall and becomes trapped, blocking normal flow of food and waste through the digestive system). Review of the clinical record indicated a Discharge OASIS (Outcome and Assessment Information-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) visit was provided on 11/18/25 and the note was signed and completed on 11/24/25. 4. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (long-term progressive loss of kidney function, preventing waste filtration from the blood). Review of the physician ordered POC for certification periods 2/10/26 through 4/10/26 and 4/11/26 through 6/9/26 indicated the following: -HHA visits: 7 times a week for 2 hours a day x 9 weeks. Review of the clinical record indicated the following: *2/15/26 HHA visit, note was signed on 2/24/26. *2/16/26 HHA visit, note was signed on 2/24/26. *2/17/26 HHA visit, note was signed on 2/24/26. *2/18/26 HHA visit, note was signed on 2/24/26. *2/19/26 HHA visit, note was signed on 2/24/26. *2/20/26 HHA visit, note was signed on 2/24/26. *2/21/26 HHA visit, note was signed on 2/24/26. *2/28/26 HHA visit, note was signed on 3/2/26. During an interview on 4/15/26 at 4:00 P.M., after reviewing the clinical records for patients #1, #2, #3, and #7, the Compliance Officer said the clinical notes were signed late and not within the required 48 hour timeframe. She further said the Home Health Certifications and POCs for patients #1 and #2 were signed by the physicians beyond the required 30 day timeframe. Review of the agency policy entitled, Registered Nurses, undated, included the following: *Prepare documentation and clinical notes to be completed within 24-48 hours of regular visit and five days for OASIS assessments. Review of the agency policy entitled, Licensed Practical Nurse (LPN), undated, included the following: *Prepare documentation and clinical notes to be completed within 24-28 hours of visit. Review of the agency policy entitled, Certified Nursing Aide/Home Health Aide, (CNA/HHA), undated, included the following: *The certified nursing aide/home health aide shall have the following responsibilities: *Shall complete a clinical note for each visit, which must be completed within 24-48 hours of visit..... Review of the agency policy entitled. Physician Orders/Plan of Care (POC), undated, included the following: *If the agency does not receive a signed physician’s order within thirty (30) days of the date the order is sent to the physician for signature, the agency contacts the physician’s office to obtain the signed document or resends the order (s) to be signed. All follow-up contacts to obtain signed orders are documented. 1. Patient #1 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM) without complications (presence of high sugar due to insulin resistance without associated damage to nerves, eyes, kidneys or blood vessels). a. Review of the physician ordered Home Health POC & Certification, dated 2/17/26 through 4/17/26, indicated the following: -Skilled Nurse (SN) visit: 2 times a week for 9 weeks. -HHA visit: 2 hours, 5 times a week for 9 weeks. Review of the clinical record indicated the following: *2/19/26 LPN visit, note was signed on 3/8/26. *2/23/26 LPN visit, note was signed on 3/8/26. *3/2/26 LPN visit, note was signed on 3/8/26. *3/17/26 HHA visit, note was signed on 3/20/26. *3/20/26 HHA visit, note was signed on 4/12/26. *3/27/26 LPN visit, note was signed on 4/5/26. *4/2/26 LPN Supervisory visit, note was signed on 4/6/26. b. Review of the clinical record indicated the Home Health POC and Certification, dated 2/17/26 through 4/17/26, was signed by the physician on 4/15/26, and not within the 30 day required timeframe. 2. Patient #2 was admitted to the agency in June 2025 with a diagnosis of pancreatitis (inflammation of the pancreas). a. Review of the physician ordered Home Health POC & Certification, dated 2/22/26 through 4/22/26, indicated the following: -SN visit: 3 times a week for 9 weeks. Review of the clinical record indicated the following: *3/11/26 SN visit, note was signed on 3/26/26. *3/13/26 SN visit, note was signed on 3/26/26. *3/16/26 SN visit, note was signed on 3/26/26. *3/18/26 SN visit, note was signed on 3/26/26. *3/24/26 SN visit, note was signed on 3/27/26. b. Review of the clinical record indicated the Home Health POC & Certification, dated 6/27/25 through 8/25/25, was signed by the physician on 2/11/26, and the Home Health POC & Certification, dated 8/26/25 through 10/24/25, was signed by the physician on 10/1/25, and not within the 30 day required timeframe. 3. Patient #3 was admitted to the agency in July 2025 with a diagnosis of ventral hernia with obstruction (occurs when abdominal tissue, often intestine, pushes through a weak spot in the abdominal wall and becomes trapped, blocking normal flow of food and waste through the digestive system). Review of the clinical record indicated a Discharge OASIS (Outcome and Assessment Information-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) visit was provided on 11/18/25 and the note was signed and completed on 11/24/25. 4. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (long-term progressive loss of kidney function, preventing waste filtration from the blood). Review of the physician ordered POC for certification periods 2/10/26 through 4/10/26 and 4/11/26 through 6/9/26 indicated the following: -HHA visits: 7 times a week for 2 hours a day x 9 weeks. Review of the clinical record indicated the following: *2/15/26 HHA visit, note was signed on 2/24/26. *2/16/26 HHA visit, note was signed on 2/24/26. *2/17/26 HHA visit, note was signed on 2/24/26. *2/18/26 HHA visit, note was signed on 2/24/26. *2/19/26 HHA visit, note was signed on 2/24/26. *2/20/26 HHA visit, note was signed on 2/24/26. *2/21/26 HHA visit, note was signed on 2/24/26. *2/28/26 HHA visit, note was signed on 3/2/26. During an interview on 4/15/26 at 4:00 P.M., after reviewing the clinical records for patients #1, #2, #3, and #7, the Compliance Officer said the clinical notes were signed late and not within the required 48 hour timeframe. She further said the Home Health Certifications and POCs for patients #1 and #2 were signed by the physicians beyond the required 30 day timeframe.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure a patient participate in, was informed about, and consented or refused care in advance of and during treatment, where appropriate, for 2 patients (#2 and #7), out of a total sample of 7 patients. Findings include: 2. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (long-term, progressive loss of kidney function, preventing waste filtration from the blood). Review of the physician ordered Plan of Care (POC) for certification periods 12/12/25 through 2/9/26, 2/10/26 through 4/10/26, and 4/11/26 through 6/9/26 indicated the following: *Home Health Aide (HHA): 7 visits daily for 2 hours a day x 9 weeks. Review of the clinical record indicated HHA visits were completed daily for 2 hours a day as physician ordered. Further review of the clinical record failed to include consent for HHA services and care provided. During an interview on 4/16/26 at 12:46 P.M., the Compliance Officer, after reviewing the clinical record, said Patient #7 was admitted with HHA services but there was no signed consent to receive HHA care and services provided. Review of the agency policy entitled, Patient Conduct, Responsibility and Rights, undated, indicated the following: *The agency staff will obtain written consent/Service Agreement that specifies the type of care and services that may be provided by the agency on every patient, either by patient or legal representative. The patient or legal representative must sign or mark the consent form. *The Service Agreement will contain a signature line for the Patient/Representative and agency staff indicating compliance with State and Federal regulatory mandates including Patient Rights and Advanced Directives. 1. Patient #2 was admitted to the agency in June 2025 with a diagnosis of pancreatitis (inflammation of the pancreas). Review of the clinical record indicated the initial start of care was completed on 6/27/25. Further review of the clinical record did not include any signed documents or consents that were provided and reviewed upon admission. During an interview on 4/16/26 at 11:45 A.M., the Operations Manager said she could not locate a signed admission consent for Patient #2, 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 that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care (POC), for 4 patients (#1, #2, #5 and #7), out of a total sample of 7 patients. Findings include: 3. Patient #5 was admitted to the agency in December 2021 with a diagnosis of chronic atrial fibrillation (common, often chronic arrhythmia characterized by a rapid, chaotic, and irregular heartbeat starting in the heart’s upper chambers). Review of the physician ordered POC for certification period 3/19/26 through 5/17/2026 indicated the following: -SN visits: once weekly plus once weekly medication administration visit x 9 weeks and 1 visit as needed (prn). Review of the clinical record indicated no documented evidence that a second SN visit was provided during the weeks of 2/15/26 through 2/21/26 and 3/29/26 through 4/4/26. Further review of the clinical record did not contain any documentation why the POC was not followed for SN visits. 4. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the physician ordered POC for certification periods 2/10/26 through 4/10/26 and 4/11/26 through 6/9/26 indicated the following: -HHA visits: 7 times a week for 2 hours a day x 9 weeks. Review of the clinical record indicated no documented evidence that a 7th HHA visit was provided during the weeks of 2/22/26 through 2/28/26, 3/15/26 through 3/21/26, and 4/5/26 through 4/11/26. During an interview on 4/16/26 at 1:28 P.M., the Compliance Officer, after reviewing the clinical records, said the SN and HHA visits were not provided to Patient #5 and Patient #7 per the physician ordered POC, as required. Review of the agency policy entitled, Physician Orders/Plan of Care, undated, included the following: *The physician sets up a plan of care, which includes the diagnosis, prognosis, medications, frequency and type of service, treatments, diet, goals to be accomplished, an order for each service, item of drugs and equipment to to be provided by the Agency. *Orders for all disciplines shall include amount, frequency, and duration. Review of the agency’s policy entitled Care Planning, undated, indicated but was not limited to the following: *The care planning process will include the following: -Implementation of the planned care or services by appropriate clinicians and/or the patient/family. 1. Patient #1 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM) without complications (presence of high sugar due to insulin resistance without associated damage to nerves, eyes, kidneys or blood vessels). Review of the physician ordered Home Health POC & Certification, dated 2/17/26 through 4/17/26, indicated the following: -Home Health Aide (HHA) visit: 2 hours 5 days a week for 9 weeks. Review of the clinical record indicated no HHA visits occurred for the weeks of 3/22/26, 3/29/26, and 4/5/26. Further review of the clinical record did not contain any documentation why the POC was not followed for HHA visits. During an interview on 4/15/26 at 2:45 P.M., the Compliance Officer said the HHA visits were not provided as per the physician ordered POC, as required. 2. Patient #2 was admitted to the agency in June 2025 with a diagnosis of pancreatitis (inflammation of the pancreas). Review of the physician ordered Home Health POC & Certification, dated 2/22/26 through 4/22/26, indicated the following: -Skilled Nurse (SN) visit: 3 times a week for 9 weeks. Review of the clinical record indicated 2 SN visits were provided for the week of 3/1/26-3/7/26, and not 3 visits, as ordered. Further review of the clinical record indicated 4 SN visits were provided for the week of 3/8/26-3/14/26 and not 3, as ordered. During an interview on 4/16/26 at 2:00 P.M., the Compliance Officer said the POC was not followed when a SN visit was missed the week of 3/1/26 and an extra visit was provided the week of 3/8/26.”

“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 (POC) and other health care practitioners (as appropriate) related to the current POC, for 4 patients (#1, #2, #5 and #7), out of total sample of 7 patients. Findings include: 3. Patient #5 was admitted to the agency in December 2021 with a diagnosis of chronic atrial fibrillation (common, often chronic arrhythmia characterized by a rapid, chaotic, and irregular heartbeat starting in the heart’s upper chambers). Review of the physician ordered POC for certification period 3/19/26 through 5/17/2026 indicated the following: -SN visits: once weekly plus once weekly medication administration visit x 9 weeks and 1 visit as needed (prn). Review of the clinical record indicated no documented evidence that a second SN visit was provided during the weeks of 2/15/26 through 2/21/26 and 3/29/26 through 4/4/26. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed SN visits. 4. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (long-term progressive loss of kidney function, preventing waste filtration from the blood). Review of the physician ordered POC for certification periods 2/10/26 through 4/10/26 indicated the following: -SN visits twice a week x 9 weeks. Review of the medical record indicated missed SN visit notes on 2/12/26, 2/24/26, 3/3/26, 3/26/26, 3/31/26, and 4/2/26. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed SN visits until 4/3/26. During an interview on 4/16/26 at 1:28 P.M., after reviewing Patient #5 and Patient #7’s clinical record, the Compliance Officer said the physician had not been notified timely of the missed SN visits, as required. Review of the agency policy entitled, Patient Identification and Missed Visit, undated, included the following: *The agency will establish the patient’s identity prior to performing treatments or providing services. The agency will notify the provider if patient has a missed visit. Notification may be done via fax, phone or call. Order will be created if frequency is out of range. 1. Patient #1 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM) without complications (presence of high sugar due to insulin resistance without associated damage to nerves, eyes, kidneys or blood vessels). Review of the physician ordered Home Health POC & Certification, dated 2/17/26 through 4/17/26, indicated the following: -Home Health Aide (HHA) visit: 2 hours 5 days a week for 9 weeks. Review of the clinical record indicated no HHA visits occurred for the weeks of 3/22/26, 3/29/26, and 4/5/26. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed HHA visits. During an interview on 4/15/26 at 2:45 P.M., after reviewing the clinical record, the Compliance Officer said the physician had not been notified of the missed HHA visits, as required. 2. Patient #2 was admitted to the agency in June 2025 with a diagnosis of pancreatitis (inflammation of the pancreas). Review of the physician ordered Home Health POC & Certification, dated 2/22/26 through 4/22/26, indicated the following: -Skilled Nurse (SN) visit: 3 times a week for 9 weeks. Review of the clinical record indicated 2 SN visits were provided for the week of 3/1/26-3/7/26, and not 3 visits, as ordered. Further review of the clinical record indicated 4 SN visits were provided for the week of 3/8/26-3/14/26 and not 3, as ordered. The clinical record did not contain any documentation that the physician had been notified that the POC for SN visits was not followed. During an interview on 4/16/26 at 2:00 P.M., after reviewing the clinical record, the Compliance Officer said the physician had not been notified that the POC for SN visits was not followed was for the week of 3/1/26 and the week of 3/8/26, as required.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to complete a supervisory assessment of the Home Health Aide (HHA) services being provided no less frequently than 14 days for one patient (#7), out of one receiving HHA services out of a total sample of 7 patients. Findings include: Review of the agency’s policy titled Nurse Supervision, undated, indicated but was not limited to the following: *If a patient receives skilled nursing care, a registered nurse shall make a supervisory visit to each patient’s residence at least every 2 weeks. The visit may be made when the home health aide is present or when the home health aide is absent. Patient #7 was admitted to the agency in December 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the physician ordered Plan of Care (POC) for certification periods 2/10/26 through 4/10/26 indicated the following: -HHA visits: 2 hours a day 7 days a week x 9 weeks Review of the clinical record indicated HHA visits were completed on 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/21/26, 2/22/26, 2/23/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/1/26, 3/2/26, 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/10/26, 3/11/26, 3/12/26, 3/13/26, 3/14/26, 3/16/26, 3/17/26, 3/18/26, 3/19/26, 3/20/26, 3/21/26, 3/22/26, 3/23/26, 3/24/26, 3/265/26, 3/26/26, 3/27/26, 3/28/26, 3/29/26, 3/30/26, 3/31/26, 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, and 4/8/26. Further review of the clinical record failed to include any documentation that HHA supervisory assessments of the aide services being provided were completed by a registered nurse (RN) or other appropriate skilled professional as required until 4/10/26. During an interview on 4/16/26 at 12:46 P.M., after reviewing the clinical record, the Compliance Officer said HHA supervisory visits were not completed every 14 days as required.”

“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 review, policy review, and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient’s discharge for 1 patient (#4), out of 2 discharge records reviewed, in a total sample of 7 patients. Findings include: Review of the agency policy entitled, Discharge/Transfer from Service, undated, included the following: *A completed discharge or transfer summary 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 agency (if any) within 5 business days of the patient’s discharge; or if the patient’s care will be immediately continued in a health care faciilty, a discharge or transfer summery is sent to the facility within 2 business days of the patient’s discharge or transfer..... Patient #4 was admitted to the agency in June 2024 with a diagnosis of cerebral infarction (a stroke). Review of the clinical record indicated the patient was discharged from the agency on 11/24/25. Further review of the clinical record did not contain any documentation to indicate a discharge summary was sent to the physician responsible for providing care to the patient after discharge. During an interview on 4/16/26 at 9:50 A.M., after reviewing the clinical record, the Compliance Officer showed the surveyor a Fax Documentation Log that indicated the discharge summary was attempted to be faxed to the physician on 11/26/25 but the fax failed and there was no other documentation to indicate that the discharge summary was provided to the physician, as required.”