Jethro Health System, LLC

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review, patient and staff interviews, the Home Health Agency (HHA) failed to meet the Condition of Participation related to Clinical Records. Findings include: 1.The HHA failed to ensure that clinical records contain information regarding assessment, medication administration, treatments, and services, and response to those interventions and that information was available to the physician issuing the orders as well as for the staff. Please refer to G1014. 2.The HHA failed to ensure that clinical documentation was complete and appropriately authenticated and dated. Please refer to G1024.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to electronically transmit completed Outcome and Assessment Information Set (OASIS) assessment data within 30 days of completion for 2 patients (#1and #5), out of a total of 7 sampled patients. Findings include: Review of the agency’s Home Health Agency Error Summary Report dated June 1, 2025 through December 31, 2025, indicated that 93 of 100 OASIS Assessments processed were submitted more than 30 days after completion. 1.Patient #1 was admitted to the agency in November 2025. Review of the clinical record indicated the HHA failed to transmit 1 of 1 OASIS assessments within 30 days of completion as required, including the following: *OASIS Start of Care Assessment completed 11/10/25 had not been transmitted as of 1/7/25, greater than 30 days. 2. Patient # 5 was admitted to the agency in May 2025. Review of the clinical record indicated the HHA failed to transmit 2 of 2 OASIS assessments within 30 days of completion as required, including the following: *OASIS Recertification Assessment completed 11/15/25 had not been transmitted as of 1/7/25, greater than 30 days. *OASIS Recertification Assessment completed 9/18/25 had not been transmitted as of 1/7/25, greater than 30 days. During an interview on 1/7/26 at 2:30 P.M., the Administrator said that the data on the Error Summary Report was correct, and those 93 OASIS Assessments were submitted late.”

“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 observations, interview and policy review the Home Health Agency (HHA) failed to adhere to hand hygiene and glove use practices to reduce the risk of infection, during 1 of 1 home health visit observations of patient care. Findings include: Review of the HHA policy, titled, Standard Precautions for All Health Care Workers, copyright 2017, included the following: -Gloves should be changed after each patient contact. On 1/7/26 from 8:20 A.M. to 9:30 A.M., the surveyor observed the Administrator, who is also a Registered Nurse, provide care during a home visit for Patient #2. The Administrator put on gloves and performed a patient assessment which included taking a temperature, oxygen saturation, heart rate and blood pressure. The Administrator then moved the patient’s clothing and linens to listen to lung sounds and bowel sounds. With the same gloves on the Administrator then went and prepared the patient’s medications for administration which included eye drops, a nasal spray, an inhaler and pills/tablets/capsules to be taken by mouth. When preparing the medications to be taken by mouth she reached her contaminated gloves into the pill containers to retrieve the medications two times, and three times opened packets containing pills and placed them into her contaminated gloves before placing them into the administration container. The Administrator then obtained a sample of blood from the patient’s finger and obtained a blood sugar level. With the same gloves she then administered an eye drop to the left eye, with the same gloves she then administered the inhaler, with the same gloves she then administered the nasal spray to both nares, with the same gloves she then administered another eye drop to the left eye and then with the same gloves administered the medications by mouth. She then brought the inhaler; eye drops and nasal spray back in their containers. She removed her gloves and performed hand hygiene. During an interview on 1/7/26 at 9:30 A.M., the Administrator said that her gloves were not clean after she performed the patient assessment and she should not have touched the medications. She said she should have changed her gloves between the assessment and preparing medications and each time she moved from taking a blood sample to eye drops to inhaler to nasal spray to by mouth medications.”

“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 Home Health Agency (HHA) failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 3 patients (#2, #6 and #7), out of a total sample of 7 patients. Findings include: Review of the HHA policy, titled, Submission of Clinical Record Visits, copyright 2017, included the following: -All nursing visit notes must be submitted with 7 days of providing services. 1.Patient #2 was admitted to the HHA in July 2024 with a diagnosis of Diabetes Mellitus Type II and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification 10/27/25 through 12/25/25 indicated the following: Skilled Nursing two times per day for 60 days. Review of the medical record indicated the following visit notes had been started, but had not been signed: 11/26/25, 11/29/25, 2 visits on 11/29/25, 2 visits on 11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/15, 12/12/25, 2 visits on 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, and 12/23/25. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that notes should be signed within 48 hours. During an interview on 1/6/25 at 1:50 P.M., the Administrator said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 2. Patient #6 was admitted to the HHA in September 2025 with an open wound and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification, dated 9/26/25 through 11/24/25, and 11/25/25 to 1/23/25 indicated the following: Skilled Nursing 7 visits a week for 9 weeks. Review of a physician order dated 11/30/25 indicated a decrease in frequency to 2 visits per week. Review of the medical record indicated that the following visit notes had been started but had not been signed: 11/30/25, 12/1/25 and 12/26/25. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that notes should be signed within 48 hours. During an interview on 1/6/25 at 1:50 P.M., the Administrator said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 3.Patient #7 was admitted to the HHA in August 2025 with a diagnosis of major depressive disorder and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification for 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26 included the following: -Skilled Nursing 7 times per week for 9 weeks Review of the medical record indicated that nursing visit notes had been started but not signed for the following: 11/11/25, 11/15/25, 11/19/25, 11/21/25, 11/29/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/9/25, 12/10/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/18/25, 12/21/25, 12/23/25, 12/24/25, and 12/25/25. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that notes should be signed within 48 hours. During an interview on 1/6/25 at 1:50 P.M., the Administrator said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure that services and treatments were administered only as ordered by a physician or allowed practitioner for 1 patient (#2), out of a total sample of 7 patients. Findings include: Patient #2 was admitted to the HHA in July 2024 with a diagnosis of Diabetes Mellitus Type II and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 10/27/25 through 12/25/25, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. -Physical Therapy (PT): 1 time for evaluation and initiation of PT plan of care. Review of the medical record indicated that a PT evaluation and treatment were provided twice a week for the week of 10/26/25-11/1/25, 11/2/25-11/8/25, 11/9/25-11/15/25, 11/16/25-11/22/25, 11/23/25-11/29/25, 11/30/35-12/6/25, 12/14/25-12/20/25 and 12/21/25-12/27/25. Further review of the medical record failed to include an order for PT treatment. Review of the physician ordered Home Health Plan of Care and Certification, dated 12/26/25 through 2/23/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. -Physical Therapy (PT): 1 time for evaluation and initiation of PT plan of care. Review of the medical record indicated that a PT evaluation and treatment was provided two times per week for the week of 12/28/25-1/3/26. PT treatment was also provided 1/6/26. Further review of the medical record failed to include an order for PT treatment. During an interview on 1/7/26 at 1:00 P.M., the Administrator said that the PT order was an oversight and should have been put in as twice a week.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on document review, and staff interview, the Home Health Agency failed to ensure that performance is tracked and that improvement is sustained. Findings include: Review of the agency policy, titled, Quality Assessment and Performance Improvement Program (QAPI) Program, copyright 2017, indicated the following: *The home health agency must take action aimed at performance improvement, and, after implementing those actions, the agency must measure its success and track performance to ensure that improvements are sustained. *Ongoing monitoring and evaluation of each indicator and analysis of logs will be performed to ensure effective resolution. If the problem is not resolved or improvement is not apparent, the action taken will be re assessed and further changes will be formulated. Review of the QAPI documents for June 5, 2025, included a performance improvement project (PIP), for Outcome and Assessment Information Set (OASIS) Review, OASIS submission. The PIP indicated a threshold is 100% of all OASIS data will be completed within the 5-day timeframe and 90% of submission to IQIES within 30 days of OASIS start of care/resumption of care/recertification/discharged/transfer. The PIP also indicated to complete audits on all admission and submit findings to QAPI. During the survey, the survey team identified issues with 2 of 7 patients with OASIS assessments that had not been transmitted despite being completed more than 30 days prior, and 93 of 100 OASIS assessments processed from June 1, 2025, through December 31, 2025, were submitted more than 30 days after the completion. During an interview on 1/7/26 at 2:50 P.M., the Administrator said that PIP was implemented but not sustained. She said that the agency is not meeting the goal. She said that audits for OASIS submissions were not done on time and acknowledged that it continues to be an ongoing issue. The Administrator failed to provide the surveyor any evidence of audits.”

“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 interview and document review, the Home Health Agency (HHA) failed to ensure that services were provided per the physician ordered plan of care for 2 patients (#7 and #5), out of a total sample of 7 patients. Findings include: 2.Patient #5 was admitted to the home health agency in May 2025 with a diagnosis of bipolar disorder and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/18/25 through 1/16/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to indicate that 2 nursing visits per day were provided as ordered for the following weeks: 11/23/25-11/29/25 - only 8 visits documented as provided. 11/30/25-12/6/25 – only 3 visits documented as provided. 12/7/25-12/13/25 - only 3 visits documented as provided. 12/14/25-12/20/25 - only 3 visits documented as provided. Patient #5 is in the hospital and was unavailable for interview. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that visits should be documented and signed within 48 hours, but it was hard to chase the nurses to do it. 1.Patient #7 was admitted to the home health agency in August 2025 with a diagnosis of major depressive disorder and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification for 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26 included the following: -Skilled Nursing 7 times per week for 9 weeks Review of the medical record failed to indicate that 7 nursing visits were provided as ordered for the following weeks: 11/9/25-11/15/25 - only 2 visits documented as provided. 11/16/25-11/22/25 - only 2 visits documented as provided. 11/23/25-11/29/25 - only 1 visit documented as provided. 11/30/25-12/6/25 - only 6 visits documented as provided. 12/7/25-12/13/25 - only 6 visits documented as provided. Patient #7 was unavailable for interview. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that visits should be documented and signed within 48 hours, but it was hard to chase the nurses to do it.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and document review, the Home Health Agency (HHA) failed to ensure that clinical notes were prepared for services provided for 4 patients (#2, #6, #1 and #5), out of a total sample of 7 patients. Findings include: 3.Patient #1 was admitted to the home health agency in November 2025 with a diagnosis of major depressive disorder and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/10/25 through 1/8/26, indicated the following: -Skilled Nurse Visit (SNVs): three times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided three times per day for the following days: 11/20/25, 11/30/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/24/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25 and 12/25/25, 12/26/25, 12/26/25, 12/27/25, 12/28/25, and 12/29/25. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. During an interview via telephone on 1/6/26 at 1:35 P.M., Patient #1 said that a nurse from the home health agency comes three times a day, 7 days a week to administer insulin. 4.Patient #5 was admitted to the home health agency in May 2025 with a diagnosis of bipolar disorder and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/18/25 through 1/16/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided two times per day for the following days: 11/22/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25 and 12/16/25, 12/17/25, 12/18/25, and 12/19/25. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. Patient #5 was unavailable for interview. Review of the home health agency policy titled Submission of Clinical Record Visits, copyright 2017, included the following: -All nursing visit notes must be submitted within 7 days of providing services. 1.Patient #2 was admitted to the home health agency in July 2024 with a diagnosis of Diabetes Mellitus Type II and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 10/27/25 through 12/25/25, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the physician ordered Home Health Plan of Care and Certification, dated 12/26/25 through 2/23/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided two times per day for the following days: 12/1/25, 12/3/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/10/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25 and 12/30/25. During an interview on 1/7/26 at 8:20 A.M., Patient #2 said that a nurse from the home health agency comes twice a day, 7 days a week. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. 2.Patient #6 was admitted to the home health agency in September 2025 with an open wound and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification, dated 9/26/25 through 11/24/25, and 11/25/25 to 1/23/25 indicated the following: Skilled Nursing 7 visits a week for 9 weeks. Review of a physician order dated 11/30/25 indicated a decrease in frequency to 2 visits per week. Review of the medical record failed to include nurses notes for visits 7 times per week for the following weeks: 11/9/25 to 11/15/25 and 11/16/25 to 11/22/25. The medical record failed to include nurses notes for visits 2 times per week for the following weeks: 12/7/25 to 12/13/25, 12/14/25 to 12/20/25, 12/21/25 to12/27/25 and 12/28/25 to 1/3/26. During an interview on 1/7/26 at 10:30 A.M., Patient #6 said that a nurse from the home health agency came 7 days a week when he/she was first admitted and then it changed to 2 times a week. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. Review of the HHA policy, titled, Submission of Clinical Record Visits, copyright 2017, included the following: -All nursing visit notes must be submitted within 7 days of providing services. 1.Patient #2 was admitted to the HHA in July 2024 with a diagnosis of Diabetes Mellitus Type II and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 10/27/25 through 12/25/25, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the physician ordered Home Health Plan of Care and Certification, dated 12/26/25 through 2/23/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided two times per day for the following days: 12/1/25, 12/3/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/10/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25 and 12/30/25. During an interview on 1/7/26 at 8:20 A.M., Patient #2 said that a nurse from the home health agency comes twice a day, 7 days a week.During an interview on 1/6/25 at 1:50 P.M., the Administrator said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 2.Patient #6 was admitted to the HHA in September 2025 with an open wound and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification, dated 9/26/25 through 11/24/25, and 11/25/25 to 1/23/25 indicated the following: Skilled Nursing 7 visits a week for 9 weeks. Review of a physician order dated 11/30/25 indicated a decrease in frequency to 2 visits per week. Review of the medical record failed to include nurses notes for visits 7 times per week for the following weeks: 11/9/25 to 11/15/25 and 11/16/25 to 11/22/25. The medical record failed to include nurses notes for visits 2 times per week for the following weeks: 12/7/25 to 12/13/25, 12/14/25 to 12/20/25, 12/21/25 to12/27/25 and 12/28/25 to 1/3/26. During an interview on 1/7/26 at 10:30 A.M., Patient #6 said that a nurse from the home health agency came 7 days a week when he/she was first admitted and then it changed to 2 times a week. During an interview on 1/6/25 at 1:50 P.M., the Administrator said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 3.Patient #1 was admitted to the HHA in November 2025 with a diagnosis of major depressive disorder, type 2 diabetes mellitus with diabetic neuropathy and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/10/25 through 1/8/26, indicated the following: -Skilled Nurse Visit (SNVs): three times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided three times per day for the following days: 11/20/25, 11/30/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/24/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25 and 12/25/25, 12/26/25, 12/26/25, 12/27/25, 12/28/25, and 12/29/25. During an interview via telephone on 1/6/26 at 1:35 P.M., Patient #1 said that a nurse from the home health agency comes three times a day, 7 days a week to administer insulin. During an interview on 1/6/25 at 1:50 P.M., the Administrator reviewed the medical record and said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 4.Patient #5 was admitted to the HHA in May 2025 with a diagnosis of bipolar disorder and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/18/25 through 1/16/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided two times per day for the following days: 11/22/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25 and 12/16/25, 12/17/25, 12/18/25, and 12/19/25. During an interview on 1/6/25 at 1:50 P.M., the Administrator reviewed the medical record and said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. Patient #5 was unavailable for interview.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that a Nurse Aide Registry background check for 4 of 4 employees reviewed (Administrator, Registered Nurse (RN) #1, RN #2, RN#3) was conducted prior to hire, as required. Findings include: Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry Section: 105CMR 155.010 (E)(3) included the following: -All home health agencies, homemaker agencies, and hospice programs shall contact the Registry prior to hiring an individual who will provide direct care to patients or have access to patients or their property to ascertain if there is any sanction, finding or adjudicated finding of patient or resident abuse, neglect, mistreatment, or misappropriation of patient or resident property against the prospective employee. The Administrator was hired on 3/20/2018.Review of the employee file indicated that a Nurse Aide registry check was not conducted until 1/7/26. 2.RN #1 was hired on 4/29/25. Review of the employee file indicated that a Nurse Aide registry check was not conducted until 1/7/26. 3.RN #2 was hired on 5/8/25. Review of the employee file indicated that a Nurse Aide registry check was not conducted until 1/7/26. 4.RN #3 was hired on 10/7/25. Review of the employee file indicated that a Nurse Aide registry check was not conducted until 1/7/26. During an interview on 1/7/26 at 3:05 P.M., the Administrator said that all employees Nurse Aide Registry background checks were conducted prior to hire. She said that Nurse Aide Registry background checks for the Administrator, RN #1, RN#2, and RN #3 were done prior to hire but she could not find the documents and that she requested new Nurse Aide Registry background checks on 1/7/26.”

“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 review and staff interview, the Home Health Agency (HHA) failed to ensure that clinical records contain information regarding assessment, medication administration, treatment, and services, and response to those interventions and that information was available to the physician issuing the orders as well as for the staff for 5 patients (#2, #6, #7, #1, and #5), out of a total sample of 7 patients. 4. Patient #1 was admitted to the HHA in November 2025 with a diagnosis of major depressive disorder, type 2 diabetes mellitus with diabetic neuropathy and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/10/25 through 1/8/26, indicated the following: -Skilled Nurse Visit (SNVs): three times per day for 60 days. -Check blood sugar before meals and administer insulin per sliding scale. *If blood sugar is 200 mg/dl (milligram per deciliter) - 250 mg/dl (give 2 units of insulin lispro.) *If blood sugar is 251 mg/ml – 300 mg/ml (give 4 units of insulin lispro). *If blood sugar is 301 mg/ml – 350 mg/ml (give 6 units of insulin lispro). *If blood sugar is greater than 400 mg/ml (give 10 units of insulin lispro). -Mounjarno solution pen-injector (helps manage diabetes) 5 mg (milligram)/0.5ml (milliliter), once every week on Wednesday. -Parameters to notify the physician: *Temperature: greater than 100 *F (Fahrenheit), or less than 96 *F. *Respiration: greater than 22/min, or less than 12/min. *Systolic Blood Pressure (pressure in the arteries when heart beats and pumps blood throughout the body: greater than 170 millimeters of mercury (mmHg), or less than 90 mmHg. *Diastolic Blood Pressure (measures the pressure in the arteries between heartbeats): greater than 90 mmHg, or less than 55 mmHg. *Heart Rate: greater than 120 bpm (beats per minute), or less than 60 bpm. *Oxygen Saturation (percentage of oxygen carried by red blood cells in the blood stream): less than 90 percent. *Pain level: greater than 8 out of 10. Review of the medical record failed to include nursing notes including (vital signs, blood sugar readings and insulin coverage) for visits provided three times per day for the following days: 11/20/25, 11/30/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/24/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, 12/21/25, 12/22/25, 12/23/25, 12/24/25 and 12/25/25, 12/26/25, 12/26/25, 12/27/25, 12/28/25, and 12/29/25. During an interview via telephone on 1/6/26 at 1:35 P.M., Patient #1 said that a nurse from the home health agency comes three times a day, 7 days a week to administer insulin. During an interview on 1/6/25 at 1:50 P.M., the Administrator reviewed the medical record and said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. 5.Patient #5 was admitted to the HHA in May 2025 with a diagnosis of bipolar disorder and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 11/18/25 through 1/16/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. -Skilled Nurse to assess every visit: bilateral extremities for edema (swelling caused by excess fluid trapped in body’s tissues) and report edema greater than 3 to the physician. -Skilled Nurse to assess every visit: bilateral lower extremities for any lesions, open areas, drainage, and sign and symptoms of infection related to cellulitis. -Parameters to notify the physician: *Temperature: greater than 100 *F (Fahrenheit), or less than 96 *F. *Respiration: greater than 22/min, or less than 12/min. *Systolic Blood Pressure (pressure in the arteries when heart beats and pumps blood throughout the body: greater than 170 millimeters of mercury (mmHg), or less than 90 mmHg. *Diastolic Blood Pressure (measures the pressure in the arteries between heartbeats): greater than 90 mmHg, or less than 55 mmHg. *Heart Rate: greater than 120 bpm (beats per minute), or less than 60 bpm. *Oxygen Saturation (percentage of oxygen carried by red blood cells in the blood stream): less than 90 percent. *Pain level: greater than 8 out of 10. Review of the medical record failed to include nursing notes including (vital signs, edema, skin assessment) for visits provided two times per day for the following days: 11/22/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25 and 12/16/25, 12/17/25, 12/18/25, and 12/19/25. During an interview on 1/6/25 at 1:50 P.M., the Administrator reviewed the medical record and said that nursing visit documentation was not done as required. She told the surveyor that she is the only full-time nurse and does majority of home visits and acknowledged that she does not document every visit. Patient #5 was unavailable for interview. 1.Patient #2 was admitted to the HHA in July 2024 with a diagnosis of Diabetes Mellitus Type II and required skilled home care services. Review of the physician ordered Home Health Plan of Care and Certification, dated 10/27/25 through 12/25/25, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Direct Care Skilled nurse to administer insulin per physician orders Patient is currently unable to administer insulin due to: partially impaired vision; hand tremors; poor hand-eye coordination; poor manual dexterity due to neuropathy and there is no trained caregiver available at this time to administer insulin to the patient. Observation and Assessment Nurse to report to MD if Blood Sugar greater than 350 or less than 70. Parameters to Notify Physician: Temperature greater than 100.9 or less than 96, Respirations greater than 22 or less than 12, Blood Pressure Systolic greater than 170 or less than 90, Blood Pressure Diastolic greater than 100 or less than 55, Pulse Rate greater than 120 or less than 60, Pulse Ox less than 90, Pain Levels greater than 8, Blood Sugar greater than 350 or less than 70. Skilled Nurse to flush and irrigate the suprapubic catheter daily with 60 to 180 milliliters of normal saline. Skilled Nurse to Assess and Provide catheter care. Skilled Nurse to change catheter bag weekly. Skilled Nurse to assess every visit: Bilateral extremities for edema and report edema greater than 3+ to MD. Skilled Nurse to instill eye drops every shift and assess both eyes for any signs/symptoms of eye infection. Review of the physician ordered Home Health Plan of Care and Certification, dated 12/26/25 through 2/23/26, indicated the following: -Skilled Nurse Visit (SNVs): two times per day for 60 days. Review of the medical record failed to include nursing notes for visits provided two times per day for the following days: 12/1/25, 12/3/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/10/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25 and 12/30/25. During an interview on 1/7/26 at 8:20 A.M., Patient #2 said that a nurse from the home health agency comes twice a day, 7 days a week. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. 2.Patient #6 was admitted to the HHA in September 2025 with an open wound and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification, dated 9/26/25 through 11/24/25, and 11/25/25 to 1/23/25 indicated the following: Skilled Nursing 7 visits a week for 9 weeks. Parameters To Notify Physician: Temperature greater than 100.9 or less than 96 Respirations greater than 22 or less than 12 Blood Pressure Systolic greater than 170 or less than 90, Blood Pressure Diastolic greater than 100 or less than 55, Pulse Rate greater than 120 or less than 60, Pulse Ox greater than 90 Pain Levels or less than 8. Review of a physician order dated 11/30/25 indicated a decrease in frequency to 2 visits per week. Review of the medical record failed to include nurses notes for visits 7 times per week for the following weeks: 11/9/25 to 11/15/25 and 11/16/25 to 11/22/25. The medical record failed to include nurses notes for visits 2 times per week for the following weeks: 12/7/25 to 12/13/25, 12/14/25 to 12/20/25, 12/21/25 to12/27/25 and 12/28/25 to 1/3/26. During an interview on 1/7/26 at 10:30 A.M., Patient #6 said that a nurse from the home health agency came 7 days a week when he/she was first admitted and then it changed to 2 times a week. During an interview on 1/6/25 at 1:15 P.M., the Administrator said clinical notes should be submitted and signed within 48 hours of the visit, but it is hard to chase the nurses to get this done. 3.Patient #7 was admitted to the HHA in August 2025 with a diagnosis of major depressive disorder and required skilled home health services. Review of the physician ordered Home Health Plan of Care and Certification for 10/12/25 to 12/10/25 and 12/11/25 to 2/8/26 included the following: -Skilled Nursing 7 times per week for 9 weeks. Parameters To Notify Physician: Temperature greater than 100.9 or less than 96, Respirations greater than 22 or less than 12, Blood Pressure Systolic greater than 170 or less than 90, Blood Pressure Diastolic greater than 100 or less than 55, Pulse Rate greater than 120 or less than 60, Pulse Ox less than 90, Pain level greater than 8. Review of the medical record failed to indicate that 7 nursing visits were provided as ordered for the following weeks: 11/9/25-11/15/25 - only 2 visits documented as provided. 11/16/25-11/22/25 - only 2 visits documented as provided. 11/23/25-11/29/25 - only 1 visit documented as provided. 11/30/25-12/6/25 - only 6 visits documented as provided. 12/7/25-12/13/25 - only 6 visits documented as provided. Patient #7 was unavailable for interview. During an interview on 1/6/26 at 1:15 P.M., the Administrator said that visits should be documented and signed within 48 hours, but it was hard to chase the nurses to do it.”