Up Health System Home Care and Hospice

“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 and interview, the agency failed to ensure the patient was informed of, consented to, or refused care prior to treatment in 4 (P-5, P-7, P-8 and P-12) of 13 records reviewed, resulting in the potential for the violation of patient rights. Findings include: Patient #12 (P-12): Patient was admitted to the agency 11/14/25 with a diagnosis of osteomyelitis and gangrenous wound to the left ankle, with skilled nursing services to manage the care of the wound. During the review of records on 6/24/26 at 11:42 AM, it revealed no evidence that the patient was informed or consented to the care, services, or frequency of visits to be provided by the agency. This is evidenced by the void of a signed consent form in the patient’s record. The Administrator (Staff A) reviewed and acknowledged the findings during an interview on 6/25/26 at 10:00 AM. Patient #5 (P-5): During record review on 6/23/26, it was noted that the initial referral to start home care dated 6/11/26 ordered services from physical therapy. Upon review of the start of care visit dated 6/16/26, it was noted the physical therapist documented, “AGREEABLE TO OT DUE TO FALLS IN BATHROOM AND NEEDING ASSISTANCE FOR DRESSING AND BATHING” and “AGREEABLE TO SN EVAL FOR MED MANAGEMENT AND ASSESSMENT OF SKIN.” [sic] It was also determined that orders for skilled nursing and occupational therapy were obtained following the initial assessment. Upon further review of the record, it was determined the consent form signed by P-5 on 6/16/26 indicated he would only receive services from physical therapy. The sections under skilled nursing and occupational therapy were left blank, indicating P-5 did not consent to skilled nursing or occupational therapy. However, it was determined occupational therapy saw P-5 on 6/23/26 and skilled nursing was scheduled to start on 6/24/26. Patient #7 (P-7): During record review on 6/24/26, it was noted that the initial referral to start home care dated 2/15/26 ordered services from physical therapy, occupational therapy, and skilled nursing. Upon further review of the record, it was determined the consent form signed by P-7 on 2/19/26 marked a “0” under occupational therapy, indicating P-7 did not consent to occupational therapy. However, occupational therapy saw P-5 for an evaluation on 3/2/25. Patient #8 (P-8): During record review on 6/23/26, it was noted that the initial referral to start home care dated 4/22/26 ordered services from physical therapy, occupational therapy, and skilled nursing. Upon further review of the record, it was determined the consent form signed by P-8 on 4/30/26 marked a “0” under occupational therapy, indicating P-8 did not consent to occupational therapy. However, occupational therapy saw P-8 on 5/11/26. Additionally, frequencies were marked as “weekly” for skilled nursing and physical therapy, so it was unclear on how often P-8 would receive services from these disciplines. A review of agency policy titled “Coordination of Care, from Admit through Discharge” (revised 12/1/25) revealed, “7. Coordination of care with patient and caregiver: Written information obtained from the plan of care will be provided to the patient and caregiver outlining: a. Visit schedule including frequency of visits by agency staff and contract workers.” The administrator (Staff A) reviewed and acknowledged the findings during an interview on 6/25/26 at 9:30 AM.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment, to determine immediate care needs of the patient, was conducted within 48 hours in 4 (P-1, P-5, P-10, and P-11) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #5 (P-5): During record review on 6/23/26, it was noted the initial referral to start home care services was dated 6/11/26. Upon further review of the record, it was determined the initial assessment visit was not conducted until 6/16/26 – 5 days after it was initially ordered. A review of agency policy titled “Patient Assessment, Initial and Reassessment” (revised 12/1/25) revealed that the admission visit will occur, “…within 48 hours from referral or physician ordered start of care date.” A review of agency policy titled “Coordination of Care, from Admit through Discharge” (revised 12/1/25) revealed, “3. During time of referral, transfer, or discharge from the agency: a. Patients are referred to alternative agencies when the patient requires services that are unable to be met by the agency and/or for continuing are needs.” During an interview with the administrator (Staff A) on 6/25/26 at 9:30 AM, Staff A stated staffing issues have been a significant issue with the agency that they are working to resolve. Staff A acknowledged the findings at the time of interview. Patient # 10 (P-10): During the record review on 6/23/26 at 3:21 PM, it was noted that the patient was discharged from a senior living facility (SNF) on 5/21/26 with an initial referral for home care services dated 5/21/26. Upon further review of the record, it was determined that the initial assessment visit was on 5/25/26 – 4 days after it was initially ordered. Patient #11 (P-11): During the record review on 6/24/26 at 10:39 AM, it was noted that the initial referral for “home nursing/care” was on 2/18/26. Upon further review it was determined that the initial assessment visit was on 2/23/26 – 5 days after it was initially ordered. The Administrator (Staff A) reviewed and acknowledged the findings during an interview on 6/25/26 at 10:00 AM.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 calendars days after the start of care in 4 (P-6, P-7, P-8, and P-10) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient # 10 (P-10): During the record review on 6/23/26 at 3:21 PM, it was noted that the initial referral for skilled nursing (SN) and Physical Therapy (PT) home care services dated 5/21/26. SN completed the initial start of care (SOC) visit on 5/25/26. Noted in the review of the plan of care, SN, PT and occupational therapy (OT) services were ordered. Upon further review of the record, it was determined that the OT’s initial assessment visit was on 6/1/26 – 7 days after the SOC; and the PT initial assessment visit was 6/17/26 – 23 days after the SOC. The record was void of documented evidence that the patient was informed of or requested the delay in OT and PT services. The Administrator (Staff A) reviewed and acknowledged the findings during an interview on 6/25/26 at 10:00 AM. Patient #6 (P-6): During record review on 6/23/26, it was determined services were ordered from physical therapy, occupational therapy, and skilled nursing. Upon further review of the record, it was determined skilled nursing completed the start of care visit on 5/25/26, however, physical therapy did not evaluate P-6 until 6/17/26 – 23 days after the start of care. Patient #7 (P-7): During record review on 6/24/26, it was determined services were ordered from physical therapy, occupational therapy, and skilled nursing. Upon further review of the record, it was determined skilled nursing completed the start of care visit on 2/19/26, however, physical therapy did not evaluate P-7 until 6/27/26 – 8 days after the start of care. Additionally, occupational therapy did not evaluate P-7 until 3/2/26 – 11 days after the start of care. Patient #8 (P-8): During record review on 6/24/26, it was determined services were ordered from physical therapy, occupational therapy, and skilled nursing. Upon further review of the record, it was determined skilled nursing completed the start of care visit on 4/30/26, however, occupational therapy did not evaluate P-8 until 5/11/26 – 11 days after the start of care. Additionally, physical therapy did not evaluate P-8 until 5/14/26 – 14 days after the start of care. A review of agency policy titled “Patient Assessment, Initial and Reassessment” (revised 12/1/25) revealed, “Physical Therapist, Speech Therapist, Occupational Therapist, Medical Social Worker, and Dietician may make initial evaluation of the patient status to determine the need for specific therapies. The initial discipline specific evaluation(s) will occur within 5 days from the Start of care (SOC) date or order date or sooner…”. A review of agency policy titled “Coordination of Care, from Admit through Discharge” (revised 12/1/25) revealed, “3. During time of referral, transfer, or discharge from the agency: a. Patients are referred to alternative agencies when the patient requires services that are unable to be met by the agency and/or for continuing are needs.” During an interview with the administrator (Staff A) on 6/25/26 at 9:30 AM, Staff A stated staffing issues have been a significant issue with the agency that they are working to resolve. Staff A acknowledged the findings at the time of interview.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-5 and P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #5 (P-5): During record review on 6/23/26, it was noted the comprehensive assessment dated 6/16/26 documented, “This patient lives with spouse in a two story home) that has steps does not have steps for entry…The patient does does not have an available able, and willing caregiver, has family or friends that help intermittently)…”. [sic] The information is conflicting and does provide a clear picture of the patient’s current or potential status. Patient #8 (P-8): During record review on 6/23/26, it was noted the comprehensive assessment dated 4/30/26 listed a primary diagnosis of a closed fracture of the right femur (thigh bone). Additionally, the integumentary (skin) assessment indicated “No” next to the question that asked, “Does this patient have a surgical wound?” However, upon review of the occupational therapy evaluation dated 5/11/26, it was noted the occupational therapist documented, “PATIENT REFERRED FOR HOME HEALTH OCCUPATIONAL THERAPY SERVICES DUE TO DECLINE IN FUNCTION RESULTING FROM GROUNDLEVEL FALL, SUSTAINING RIGHT FEMUR FRACTURE REQUIRING HOSPITALIZATION AND SURGICAL INTERVENTION.” The information is conflicting as it was unclear if or when the patient had surgery and if there were any resultant precautions to follow. The administrator (Staff A) reviewed and acknowledged the findings during an interview on 6/25/26 at 9:30 AM.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medication reconciliation was accurate and up to date for 2 (P-5 and P-8) of 13 records reviewed, resulting in the potential for harmful medication interactions. Findings include: Patient #5 (P-5): During a joint home visit with the occupational therapist (Staff C) on 6/23/26 at 10:00 AM, the medications listed on the plan of care dated 6/16/26 were reviewed with P-5’s wife. Upon review of the list, P-5’s wife stated P-5 no longer took Metformin (a medication used to treat diabetes) and hasn’t for some time per doctor’s orders. Additionally, P-5’s wife reviewed the insulin (another medication used to treat diabetes) dosage and stated in addition to the 22 units on the list, P-5 took 10 units in the evening as well. Patient #8 (P-8): During a joint home visit with the physical therapist (Staff D) on 6/24/26 at 1:30 PM, the medication list from the facility where P-8 resided was reviewed with what was listed in the agency’s electronic medical record (EMR) system. Upon review of the medications, it was determined an order for “PEG 3350 POW” (last updated 5/4/26) was on the facility medication list, however, it was not listed in the agency’s EMR system. Staff D acknowledged the findings and updated the agency’s medication list. A review of agency policy titled “Monitoring Medications” (revised4/1/26) revealed, “1. The discipline responsible for the drug regiment review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking.” Staff A reviewed and acknowledged the findings during an interview on 6/26/26 at 9:30 AM”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to develop an individualized Plan of Care (POC) that included objective measurable goals specific to the needs of the patient in 8 (P-1, P-2, P-3, P-5, P-9, P-10, P-12, P-13) of 13 records reviewed. Findings include: Patient #9 (P-9): During record review on 6/23/26 at 2:15 PM it revealed that the POC for episode 6/8/20 through 8/6/26 identified that 11 out of 11 goals were written in terms that that were not patient specific or measurable. For example, “Patient/caregiver will verbalize/demonstrate understanding of recommended safety and fall risk reduction strategies by 8/7/26.” Another stated, “Signs and symptoms of constipation will be identified promptly and interventions initiated quickly to minimize associated risk and prevent hospitalization.” Patient #10 (P-10): During record review on 6/23/26 at 3:21 PM it revealed that the POC for episode period 5/25/26 through 7/23/26 identified 17 out of 18 goals were written in terms that were not patient specific or measurable. For example, “Patient/caregiver will understand and demonstrate compliance with treatment regimen for chronic obstructive Pulmonary disease within 4 weeks.” Another stated, “Patient’s complications will resolve promptly with implementation of prescribed interventions through the end of Episode.” Patient #12 (P-12): During record review on 6/24/26 at 11:42 AM it revealed that the POC for episode period 11/14/25 through 1/12/26 identified 19 out of 19 goals were written in terms that were not patient specific or measurable. For example, “Patient / caregiver will be able to verbalize the reason and importance for necessary lifestyle changes by 1/9/26.” Another stated, “Patient/caregiver will understand and demonstrate compliance with treatment regimen for heart failure by 1/9/25.” Patient #13 (P-13): During record review on 6/24/26 at 2:52 PM, it revealed that the POC for episode period 5/12/26 through 7/10/26 identified 18 out of 19 goals were written in terms that were not patient specific or measurable. For example, “Patient will maintain a stable weight by 7/7/26.” Another stated, “Patient’s complications will resolve promptly with implementation of prescribed interventions through the end of episode.” The Administrator (Staff A) reviewed and acknowledged findings during an interview on 6/25/26 at 10:00 AM, which did not meet the agency’s expectations or their policy referenced below. A review of agency policy on 6/25/26 at 8:42 AM, titled, “Plan of Care (POC), (revised 3/1/26), revealed that the POC includes: “Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient.” Patient #5 (P-5): During record review on 6/23/26, it was noted the plan of care dated 6/16/26 identified the primary diagnosis as “type 2 diabetes mellitus with diabetic polyneuropathy” with an exacerbation date of 6/11/26. Additionally, “type 2 diabetes” was listed as 3 other diagnoses on the plan of care (out of 11 total). Upon further review, it was noted the plan of care failed to include blood sugar parameters to monitor and report for patient safety. During review of the comprehensive assessment, it was documented that P-5 no longer checked his blood sugar, so there were no parameters to report/monitor. However, during an interview with the administrator (Staff A) on 6/25/26 at 9:30 AM, Staff A acknowledged there should be safety measures/parameters in place if diabetes was the primary diagnosis noted with a recent exacerbation. Staff A acknowledged the findings at the time of interview. Patient #1 (P-1): The patient’s start of care (SOC) was 6/16/26, with diagnoses that included venous hypertension with ulcer and inflammation of lower ext., wound care. The Plan of Care (POC) ordered Skilled nursing (SN) at a visit frequency of 1 visit a week for 9 weeks. During record review on 6/23/26 it was discovered that only 1 of 6 goals on the POC were measurable, for example, one goal stated, “Patient/caregiver will demonstrate proper use and administration of prescribed medications by week 3.” Another stated, “Patient’s complications will resolve promptly with implementation of prescribed interventions throughout the end of the episode.” Patient #2 (P-2): The patient’s start of care SOC was 10/9/25, with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, oxygen dependance, and indwelling catheter. The POC ordered Physical Therapy (PT) at a visit frequency of 1 visit a week for 9 weeks. During record review on 6/23/26 it was discovered that 0 of 10 goals on the POC were measurable, for example, one goal stated, “Patient/caregiver will verbalize/demonstrate understanding of home safety and fall prevention by 12/4/25.” Another stated, “Patient/caregiver will verbalize/demonstrate understanding of oxygen precautions and care of equipment by 12/4/25.” Patient #3 (P-3): The patient’s SOC was 4/29/26, with diagnoses that included encounter for change or removal of surgical wound dressing, hypertensive heart disease with heart failure, and encounter for surgical aftercare. The POC ordered SN at a frequency of 1 visit a week for 1 week, 2 visits a week for 2 weeks, and 1 visit a week for 6 weeks. PT was ordered at a visit frequency of 1 visit a week for 8 weeks. During record review on 6/24/26 it was discovered that only 1 of 21 goals on the POC were measurable, for example, one goal stated, “Patient/caregiver will verbalize/demonstrate understanding of possible mood changes, and the reason and importance of necessary lifestyle changes by 6/24/26.” Another stated, “Patient/caregiver will maintain a stable weight by 6/10/26.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 6/25/26 at 9:35 a.m.”

“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 and interview, the agency failed to ensure skilled professionals provided services, as ordered by the physician, in the plan of care for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #8 (P-8): During record review on 6/23/26, it was noted the plan of care dated 4/30/26 listed an order for, “SKILLED NURSE TO OBTAIN WEIGHT EVERY VISIT AND NOTIFY RN/PHYSICIAN OF WEIGHT GAIN OF 3 LBS WITHIN 1 DAY OR 5 LBS WITHIN ONE WEEK.” [sic] It was also noted P-8’s weight was listed as 110 pounds under the vitals section, however, a later section indicated P-8’s weight was 124 pounds upon admission. Upon further review of the record, it was determined the skilled nursing note dated 5/13/26 listed P-8’s weight as 110 pounds and the next skilled nursing note dated 5/28/26 listed P-8’s weight as 122 pounds – a weight gain of 12 pounds. Additionally, it was noted the skilled nursing note dated 5/28/26 (following the documented weight gain) marked “No” next to the question that stated, “HAS THE PATIENT EXPERIENCED UNWANTED WEIGHT GAIN/LOSS OF MORE THAN 2 POUNDS SINCE THE LAST VISIT OR 5 POUNDS IN THE LAST WEEK OR AN INCREASE IN ANKLE CIRCUMFERENCE/ABD GIRTH OF 2CM?” There was no indication that the weight gain was acknowledged by the clinician or reported to the physician as ordered in the plan of care. A review of agency policy titled “Vital Signs” (revised 9/1/24) revealed, “4. The clinician shall collaborate with the other clinicians and/or Patient Care Manager/Case Manager and notify the physician or authorized practitioner for deviations per the plan of care orders.” During an interview with the administrator (Staff A) on 6/25/26 at 9:30 AM, Staff A reviewed the findings above. Staff A stated there was likely a documentation error due to the 2 weights listed in the comprehensive assessment. However, Staff A acknowledged the system should have flagged the documented weight increase so the error could be corrected, or the findings could be reported, if needed. Staff A acknowledged the findings at the time of interview.”