North Woods Home Nursing

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure that Skilled Nursing (SN) assumed responsibility for the appropriate management of acute congestive heart failure in 1 (P-13) 3 records reviewed with congestive heart failure (See G 704); failed to ensure services were provided as ordered in the plan of care for 4 (P-5, P-6, P-8, and P-13) of 13 records reviewed (See G 710); failed to ensure skilled professionals prepared clinical notes per agency expectation for 1 (P-8) of 13 records reviewed (See G 716); and failed to ensure SN notified the physician of significant weight gain in 1 (P-13) of 1 record reviewed with a resumption of care after hospitalization (See G 718). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.75 Skilled Professional Services.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure 2 (2025 and 2026) of 2 Emergency Preparedness (EP) drills included all required documentation, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) drills were requested for review on 08/05/2026 at 2:30 PM. During review of the drills dated 12/28/2025 and 03/15/2026, it was determined the agency activated their emergency response due to severe weather. During review of the documentation for the “actual” drills, it was determined that both drills contained generic descriptions of what occurred during the emergency. However, both drills failed to include specific details on who was involved, what occurred, who did what, what should have occurred, and how patients were affected by the emergency. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:15 AM.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the ordered skilled nurse visit frequency was honored for 1 (P-6) of 1 patient, resulting in the potential for unidentified health concerns and unmet care needs. Findings include: Patient #6 (P-6)’s start of care was 02/04/2026 with diagnoses that included Osteoporosis, Left Femur Fracture and Pulmonary Embolism. The Plan of Care ordered Skilled Nursing (SN) at a frequency of 1x/wk. x 8 wks.; 3 prn (as needed) visits and Physical Therapy (PT) services at a frequency of 1x/wk. x 1 wk. (02/10/2026), 2x/wk. x 3 wks., 1x/wk. x 4 wks. During the record review on 08/05/2026 at 11:15 AM, it was noted that the SN missed a home visit on 03/18/2026. There were no SN visits made during this week. Additionally, PT only made one of the 2 visits ordered each week. Upon further review, there were no documented attempts to reschedule the visits in order to honor the ordered visit frequency, and there was no Physician’s order to change the frequency of PT services. Additionally, there was no documented evidence of patient refusal of visits or that the Physician had been notified of the altered plan of care. The agency failed to ensure services were provided in accordance with the Physician’s orders and Plan of Care. The Clinical Manager (Staff-B) reviewed and acknowledged these findings during an interview on 08/06/2026 at 9:23 AM.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that Skilled Nursing (SN) assumed responsibility for the appropriate management of acute CHF (congestive heart failure) in 1 (P-13) 3 records reviewed with CHF, resulting in unmonitored exacerbation of CHF symptoms, hospitalization and poor clinical outcomes. Findings include: Patient #13 (P-13)’s start of care (SOC) was 10/20/25, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/04/2026, the referral for home care noted documentation of P-13’s hospital admission (10/07/2025) had a weight of 250.4 lbs. and the hospital discharge on 10/18/2025 that documented, “(P-13) also had issues with hyponatremia in the setting of notable volume overload. (P-13) was placed on a 1200 mL fluid restriction and was diuresed (extra bodily fluid removed through increased urination).” P-13’s Plan of Care (POC) effective on 10/20/2025, ordered SN a visit frequency of 1W1 (once a week times one week), 2W1, 1W7 and 3 PRN (as needed) visits for symptom management. The POC further ordered SN to “monitor weight and notify MD if gain of 3+ lbs. in 24 hrs. or 5+ lbs. in 1 week. Base weight: 227.9 lbs.” Further review of the SN visits performed had the following documentation: 10/23/2025 had a documented weight of 227.3 lbs. 10/27/2025 had a documented weight of 227.6 lbs. 10/30/2025 had a documented weight of 233 lbs. (gain of 5.4 lbs. in 3 days) and SN documented MD aware but no physician response was found. 11/05/2025 was a missed visit due to no answer at the door. 11/11/2025 had no weight obtained after a missed visit which followed a 5.4 lb. weight gain on 10/30/25. Further, SN documented P-13’s “LS (lung sounds) with rales noted in bilateral lower lobes, has SOB (shortness of breath) on exertion and an intermittent non-productive cough.” No evidence was found of any physician communication in P-13’s record. 11/15/2025 had no weight obtained due to P-13 being transferred to the hospital for “Bilateral lower extremity edema thought to have acute on chronic CHF...” The hospital discharged P-13 on 11/20/2025 with a documented weight of 207.3 lbs. after being diuresed again. SN performed a ROC (resumption of care) visit on 11/22/2025 with a recorded weight of 225 lbs. (17.7 lb. gain in 2 days) with no physician communication evidenced in the medical record. Further, SN visits performed on 11/25/2025, 11/28/2025 and 12/05/2025 failed to obtain a weight recording. In addition, P-13 had 4 consecutive missed visits from 12/8/2025 through 12/18/2025 (when P-13 was discharged from the home care agency). SN failed to manage and monitor P-13’s acute CHF diagnosis that was one of the primary concerns leading up to home care admission which then contributed to another hospital admission on 11/20/2025 for CHF symptoms again. The mismanagement continued after the ROC visit up until discharge from the agency without verifying P-13 was in stable condition. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 08/06/2026 at 10:54 AM. Both further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “Coordination of Care-Home Health & Private Duty” (revised 01/2026) stated, “Integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician (COP 484.60 (d) 1).””

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the aide care plan included patient specific care instructions for 1 (P-7) of 3 records reviewed of patients who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #7 (P-7): During record review on 08/04/2026, it was determined P-7 had an open wound on her right upper arm that was covered by gauze and tape due to continued drainage. It was also noted that the dressing would be changed during nursing visits. However, during review of the aide care plan, it was determined there were no instructions on what the aide should do with the dressing/wound during or after a shower. During a joint home visit with the home health aide on 08/05/2026 at 10:00 AM, it was observed that the home health aide (Staff-E) was unsure what to do with the dressing when P-7’s caregiver asked if he was going to remove it prior to the shower. Staff-E consulted the aide care plan and confirmed there were no instructions. Additionally, it was determined the interventions on the aide care plan were generalized (e.g., “foot care” and “nail care”) and failed to include patient specific information (e.g., assist level needed or that the shower was located downstairs) to assist in providing the best and safest care for this patient. A review of agency policy titled “SN or PT Instructions for Completing ADL’s/IADL’s – HHA Care Plan for Home Health”(Revised 01/2026) [sic] revealed, “It is the policy of the agency to provide adequate instruction to the home health aide (HHA) and ensure continuity of care by assuring communication between all providers of care in the home.” The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM.”

“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 observation, interview and record review, the agency failed to ensure that 2 (P-4 and P-5) of 2 patients were included in the overall planning of care; and failed to ensure patients consented to services provided in 1 (P-9) of 1 record, resulting in the lack of inclusion in planning, the potential for missed visits, and unmet care needs. Findings include: Patient #9 (P-9): During record review on 08/05/2026, it was noted the initial referral for home care dated 03/31/2026 ordered services from skilled nursing, physical therapy, and occupational therapy. Upon review of the consent form signed by the patient at the start of care on 04/06/2026, it was determined the space next to occupational therapy was left blank. Additionally, it was determined that occupational therapy services started on 04/16/2026. There was no evidence P-9 consented to receiving services from occupational therapy. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM. Patient #4 (P-4)’s start of care (SOC) was 07/29/2026 with diagnoses that included Post surgical neoplasm of cheek mucosa, HTN and CHF. During the clinical record review on 08/04/2026 at 8:20 AM, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 08/04/2026 at 11:00 AM, a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, the patient’s admission packet was reviewed. The calendar of proposed was noted to be blank. There was no indication of which disciplines would be providing care in addition to their frequencies. Upon completion of the visit, Staff-C informed the patient, “You should have another visit. I won’t confirm because the scheduler could change it.” The agency failed to ensure the patient was included in the planning of his care. The Administrator (Staff-A) and the Clinical Manager (Staff-B) reviewed and acknowledged these findings during an interview on 08/05/2026 at 12:00 PM. P-5’s SOC was 07/25/2026 with diagnoses that included Sepsis with resultant Right Above the Knee Amputation. On 08/04/2026 at 9:20 AM, it was noted that the POC ordered SN and PT services to be provided. On 08/04/2026 at 1:00 PM, a scheduled survey home visit was conducted with the Registered Nurse (Staff-D). During the visit, it was noted that the calendar to be completed with proposed visits was blank. There was no indication of which disciplines would be providing care in addition to their ordered frequencies. Upon completion of the visit, the patient inquired, “Who else is supposed to be coming out?” The patient’s husband responded, “I’m not sure. I think PT is supposed to be coming today.” The agency failed to ensure the patient and caregiver was including in the overall planning of care. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 08/05/2026 at 12:40 PM.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received written Notice of Medicare Non-Coverage (NOMNC) in advance of terminating ongoing home care services for 2 (P-6, P-13) of 4 discharged patients, resulting in patients not having the right or opportunity to dispute the termination of Medicare covered services. Findings include: Patient #13 (P-13): The start of care was dated 10/20/25, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/05/2026, no evidence was found in the medical record that indicated P-13 was given the opportunity to object to the termination of home care services prior to being discharged from the agency on 12/18/2025. During an interview on 08/05/2026 at 1:33 PM, the Administrator (Staff-A) and Clinical Manager (Staff-B) both reviewed and acknowledged that there was no evidence in the medical record that an NONMC form was provided to P-13 as required prior to discharge from the home care agency. Patient #6 (P-6)’s start of care was 02/04/2026 with diagnoses that included Osteoporosis, Left Femur Fracture and Pulmonary Embolism. The Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the record review on 08/05/2026 at 11:15 AM, it was noted that the patient was discharged from the agency’s services on 03/25/2026. The “Notice of Medicare Provider Non-Coverage” documented, “The effective date coverage of your current: Home Health services will end: 3/25/26.” The notice was signed by the patient and dated on the same date of notification (3/25/26). The agency failed to provide advanced notice of discharge prior to the termination of ongoing services. The Clinical Manager reviewed and acknowledged these findings during an interview on 08/06/2026 at 9:23 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 Registered Nurse conducted the initial assessment visit within 48 hours of referral for 2 (P-4 and P-9) of 2 patients, resulting in the delay of needed services and the potential for decline in health status. Findings include: Patient #9 (P-9): During record review on 08/05/2026, it was determined the initial referral to start home care was dated 03/31/2026. Upon further review of the record, it was determined the initial assessment wasn’t performed until 04/06/2026 - 6 days after the referral. A note on the plan of care dated 04/06/2026 indicated the physician was notified and agreed to a late start for all disciplines, however, there was no documentation regarding the reason for the delay. During an interview with the clinical manager (Staff-B) on 08/06/2026 at 9:50 AM, Staff-B was asked about the reason for the late start. Staff-B reported poor staff availability due to a high census was the reason for the delay in care. Staff-B also stated the doctor and patient still wanted to be admitted to the agency - even when notified that the care would be delayed and offered other agencies. However, Staff-B acknowledged this was not expressed in the documentation and that it also does not meet the requirements of the regulation. Staff-B acknowledged the findings at the time of interview. Patient #4 (P-4)’s start of care was 07/29/2026 with diagnoses that included Post surgical Neoplasm of Cheek Mucosa, HTN and CHF. During the record review on 08/04/2026 at 8:20 AM, it was noted that the referral for home care was dated 7/23/26 and ordered Skilled Nursing and Physical Therapy services to be provided. The start of care was conducted 6 days after the date of the referral. Upon further review, there was no documented rationale for the delay in needed services. Additionally, there was no evidence to support that the Physician had been notified of the delay in needed services. The Administrator and Clinical Manager reviewed and acknowledged these findings during an interview on 08/05/2026 at 12:00 PM.”

“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 observation, record review, and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history in 5 (P-2, P-3, P-7, P-8, and P-9) of 13 records reviewed, resulting in incomplete clinical information to assist in determining the needs of the patient. Findings included: Patient #7 (P-7): During record review on 08/04/2026, it was determined the Outcome and Assessment Information Set (OASIS) completed during the comprehensive assessment on 07/17/2026 indicated there were no medication interactions found. Upon further review of the record, it was determined there were 4 “severe” drug-to-drug interactions listed on the medication profile. Additionally, it was noted the comprehensive assessment indicated P-7 did not use oxygen. However, the physical therapy evaluation dated 07/22/2026 indicated the patient was on 2 liters of oxygen. It was also confirmed during a joint home visit on 08/05/2026 at 10:00 AM that P-7 used oxygen as needed at home and was observed using it before and after her shower. The information is conflicting; therefore, it does not provide a clear picture of the patient’s current or potential status. Additionally, it was noted that 23 of 23 diagnoses listed in the comprehensive assessment had an onset date of 07/17/2026 – the same date as the start of care. The diagnoses included a humerus (upper arm) fracture, which occurred in May 2026 according to the record. The diagnoses also included several conditions listed as “chronic”; therefore, the onset dates are inaccurate. Patient #8 (P-8): During record review on 08/04/2026, it was determined that 13 of 13 diagnoses listed on the comprehensive assessment had an onset date of 08/06/2025 – the same date as the start of care. The diagnoses included 2 diagnoses that were listed as “long term”; therefore, the onset dates are inaccurate. Patient #9 (P-9): During record review on 08/05/2026, it was determined that 27 of 27 diagnoses had an onset date of 04/06/2026 – the same date as the start of care. The diagnoses included an abdominal surgery, which occurred on 03/27/2026 according to the referral notes. The diagnoses also included several conditions listed as “long term”; therefore, the onset dates are inaccurate. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 07/24/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Congestive Heart Failure, and Anemia. During record review on 08/04/2026 at 8:15 AM, it was noted that the POC documented under “Primary Diagnosis and Other Pertinent Diagnoses”, all 20 diagnoses had an onset date of 07/24/2026. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. Patient #3’s (P-3) Start of Care (SOC) was dated 06/23/2026. The Plan of Care (POC) identified diagnoses of Abscess of Groin and Abscess of Buttock. During record review on 08/05/2026 at 12:30 PM, it was noted that the POC documented under “Primary Diagnosis and Other Pertinent Diagnoses”, all 10 diagnoses had an onset date of 06/23/2026. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 07/24/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Congestive Heart Failure, and Anemia. During record review on 08/04/2026 at 8:15 AM, it was noted that the POC documented under “Primary Diagnosis and Other Pertinent Diagnoses”, all 20 diagnoses had an onset date of 07/24/2026. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. Patient #3’s (P-3) Start of Care (SOC) was dated 06/23/2026. The Plan of Care (POC) identified diagnoses of Abscess of Groin and Abscess of Buttock. During record review on 08/05/2026 at 12:30 PM, it was noted that the POC documented under “Primary Diagnosis and Other Pertinent Diagnoses”, all 10 diagnoses had an onset date of 06/23/2026. No exacerbation, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM. Patient #7 (P-7): During record review on 08/04/2026, it was determined the Outcome and Assessment Information Set (OASIS) completed during the comprehensive assessment on 07/17/2026 indicated there were no medication interactions found. Upon further review of the record, it was determined there were 4 “severe” drug-to-drug interactions listed on the medication profile. Additionally, it was noted the comprehensive assessment indicated P-7 did not use oxygen. However, the physical therapy evaluation dated 07/22/2026 indicated the patient was on 2 liters of oxygen. It was also confirmed, during a joint home visit on 08/05/2026 at 10:00 AM, that P-7 used oxygen as needed at home and was observed using it before and after their shower. The information is conflicting; therefore, it does not provide a clear picture of the patient’s current or potential status. Additionally, it was noted that 23 of 23 diagnoses listed in the comprehensive assessment had an onset date of 07/17/2026 – the same date as the start of care. The diagnoses included a humerus (upper arm) fracture, which occurred in May 2026 according to the record. The diagnoses also included several conditions listed as “chronic”; therefore, the onset dates are inaccurate. Patient #8 (P-8): During record review on 08/04/2026, it was determined that 13 of 13 diagnoses listed on the comprehensive assessment had an onset date of 08/06/2025 – the same date as the start of care. The diagnoses included 2 diagnoses that were listed as “long term”; therefore, the onset dates are inaccurate. Patient #9 (P-9): During record review on 08/05/2026, it was determined that 27 of 27 diagnoses had an onset date of 04/06/2026 – the same date as the start of care. The diagnoses included an abdominal surgery, which occurred on 03/27/2026 according to the referral notes. The diagnoses also included several conditions listed as “long term”; therefore, the onset dates are inaccurate. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 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 observation, record review, and interview, the agency failed to ensure skilled nursing performed an updated medication reconciliation following an in-patient hospital discharge in 1 (P-13) of 1 record; and failed to ensure the patient’s clinical record documented all medications and documented evidence that the physician was notified of identified drug interactions in 5 (P-1, P-2, P-4, P-5, and P-7) of 5 records. These deficient practices resulted in an incomplete medication list and the potential for unrecognized side effects and drug interactions that could jeopardize patient safety. Findings included: Patient #13 (P-13): The start of care was dated 10/20/2025, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/04/2026, it was noted P-13 was hospitalized on 11/15/2025 for “bilateral lower extremity edema (swelling) thought to have acute on chronic CHF ...” Several medication changes were found in the hospital discharge summary resultant to clinical findings during the hospital admission. P-13 was discharged home on 11/20/2025 with a ROC (resumption of care) visit performed by skilled nursing (SN) services on 11/22/2025. Further record review found no evidence that SN had performed the required medication reconciliation review. The following are hospital discharge medications to be started 10/20/2025 at 12:02 PM: Keflex 500 mg. every 6 hours times 16 doses (ending on 10/24/2025), Claritin 10 mg. daily starting on 11/21/2025, Bactroban 2% ointment to be applied to affected areas, Nicotine 7 mg/24 HR patch-change daily, Nystatin 100,000 unit/gram powder-apply to affected areas under breast, Potassium Chloride 20 milliequivalents-2 tablets by mouth 2 times a day with meals, and Senokot-S 1 tablet twice daily. None of the 7 listed hospital medications were found in P-13’s medical record. The above findings were reviewed and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 08/05/2026 at 1:38 PM. Both Staff-A and B were noted that this did not meet agency expectations when asked. Patient #7 (P-7): During record review on 08/04/2026, it was noted the medication profile completed during the comprehensive assessment on 07/17/2026 identified 4 “severe” drug-to-drug interactions. Upon further review of the record, it was determined orders were sent to the physician regarding the interactions, however, there was no evidence the physician received the information or what the recommendation was. During an interview with the clinical manager on 08/06/2026 at 9:50 AM, the clinical manager (Staff-B) was asked about the process for notifying the physician of severe medication interactions. Staff-B stated orders were sent as noted in the record above, however, there should be a return signature once it was reviewed and acknowledged by the physician. Staff-B confirmed there was no physician signature on the orders sent for this patient; therefore, there was no evidence the physician was notified. Staff-B acknowledged the findings at the time of interview. Additionally, during a joint home visit on 08/05/2026 at 10:00 AM, P-7’s medications were reviewed with P-7’s daughter-in-law. Upon review of the medications in the home, it was determined the agency’s medication profile failed to include “fluticasone propionate” (a medication used to treat allergies). Lastly, it was determined P-7 was on 2 liters of oxygen as needed, however, oxygen was also not listed on the medication profile. During the interview with Staff-B on 08/06/2026 at 9:50 AM, Staff-B also reviewed and confirmed that fluticasone propionate and oxygen were not listed on the medication profile. Staff-B acknowledged the findings at the time of interview. Patient #4 (P-4)’s start of care (SOC) was 07/29/2026 with diagnoses that included Post surgical Neoplasm of Cheek Mucosa, HTN and CHF. During the clinical record review on 08/04/2026 at 8:20 AM, it was noted that the agency’s Drug Interaction Report identified severe drug to drug interactions between Morphine and Gabapentin. Upon further review, there was no clear evidence to support that the Physician had been promptly notified of these untoward findings. The Administrator (Staff-A) and the Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 08/05/2026 at 12:00 PM. P-5’s SOC was 07/25/2026 with diagnoses that included Sepsis with resultant Above the Knee Amputation. During the clinical record review on 08/04/2026 at 9:20 AM and again on 08/05/2026 at 9:15 AM, it was noted that the agency’s Drug Interaction Report identified severe drug to drug interactions between Primidone and Amlodipine and between Primidone and Hydrocodone. A “Patient Care Order” dated 07/25/2026 documented “Severe interactions: promising/amlodipine, promising/norco Please contact (Agency name) for more information if needed.” [sic] Upon further review, there was/is no drug known as “promising.” It would appear that this was incorrectly documented information. There was no documented evidence to support that the Physician had been notified of the accurate untoward findings. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 08/05/2026 at 12:40 PM. Patient #1’s (P-1) Start of Care (SOC) was dated 04/02/2026. The Plan of Care (POC) identified diagnoses of Sepsis, Chronic Obstructive Pulmonary Disease, and Emphysema. During record review on 08/04/2026 at 3:45 PM, it was noted that the POC stated, “Additional Services: …Patient was prescribed continuous Oxygen via NC (Nasal Canula) …Patient is using continuous Oxygen via NC @ 2LPM…” The medication profile failed to document Oxygen. Furthermore, the medication profile stated, “Dupixent Pre-filled Pen 300mg/2 mL Subcutaneous solution; Inject 2 milliliter(s) subcutaneously every 2 week, and Prednisone 20 mg oral tablet; Take 1 tab(s) orally once a day for 7 day(s). The in home hand written “Medication Schedule/Instruction Sheet” failed to document the above medications. Patient #2’s (P-2) Start of Care (SOC) was dated 07/24/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Congestive Heart Failure, and Anemia. During record review on 08/04/2026 at 8:15 AM, it was noted that the EMR (Electronic Medical Record) documented the following severe medication interactions: Albuterol and Carvedilol, and Carvedilol and Vilanterol. The EMR contained no documented evidence of the physician being notified of the severe medication interactions. A review of the agency policy occurred on 08/06/2026 titled “Medication Administration, Review, Validation and Documentation” (Revised 1/26). The policy states, “Procedure: 1. Patients’ drug regimen review/medication regimen – COP 484.55(c)(5) – will be assess by RN/PT at every visit… The RN/PT will notify the physician of any non-compliance, adverse effects or side effects related to the patients’ medications… 4. The RN/PT will then validate the medications within 1 calendar day, using the computer documentation system. The RN/PT will review validation report at the time of validation noting any allergies, duplicate drug therapies, and/or drug interactions…” The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to update the comprehensive assessment after a significant change in condition 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 08/04/2026, it was determined P-8’s husband took her to the emergency room on 08/22/2025 due to caregiver strain and no longer being able to take care of her at home. As a result, the hospital assisted P-8 to a temporary respite care location until long-term placement could be made. P-8 was then moved to a memory care unit at another assisted living facility. This was a significant change in condition. Upon further review of the record, it was determined the comprehensive assessment was not updated to determine P-8’s new needs following the change in condition, change in living situation, and the change in caregiver assistance. Additionally, it was determined the next visit made by agency staff to see P-8 was made by a home health aide (non-skilled staff) who had never seen the patient nor was qualified to assess a significant change in status. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 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 observation, interview, and record review, the agency failed to ensure the Plan of Care (POC) was complete and included safety parameters to protect against injury/harm in all 13 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-12, P-13) of 13 records reviewed, resulting in the potential for unreported clinical results and poor patient outcomes. Findings include: Patient #7 (P-7): During a joint home visit on 08/05/2026 at 10:00 AM, it was determined P-7 was on 2 liters of oxygen as needed. During review of the record, it was determined the plan of care failed to list oxygen precautions as a safety measure, The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM. Patient numbers #’s 1-13 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10, P-11, P-12, P-13): Record review on 08/03/2026 through 08/06/2026 noted all 13 records failed to incorporate safety parameters concerning temperature, pule, respirations, blood pressure and pain levels. These safety parameters would be needed in the event a patient would go outside of baseline and need physician notification/guidance for potential orders/treatments. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 08/06/2026 at 10:54 AM.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its disciplines promptly reported changes in patient’s conditions for 3 (P-2, P-4, P-5) of 3 patients with vital signs outside of the reportable parameters, resulting in the potential for unidentified, untreated health concerns. Findings include: Patient #4 (P-4)’s start of care (SOC) was 07/29/2626 with diagnoses that included Post surgical Neoplasm of Cheek Mucosa, HTN and CHF. During the record review on 8/4/26 at 8:20 AM, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 08/04/2026 at 11:00 AM, a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, Staff-C checked the patient’s blood pressure and obtained a reading of 141/83. (The reportable blood pressure parameters were set as 95/60 - 140/90). Staff-C then stated, “Your blood pressure is outside of the reportable parameters. I’ll recheck it again before I leave.” Staff-C proceeded with the visit but did not notify the Physician to ensure the patient was stable to continue on with the therapy session. On 08/05/2026 at 9:00 AM, during a continued review of the record, there was no documented evidence that Staff-C had promptly notified the Physician of the patient’s elevated blood pressure. The Administrator (Staff-A) and the Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 8/5/26 at 12:00 PM. P-5’s SOC was 70/25/2026 with diagnoses that included Sepsis with resultant right Above the Knee Amputation and Chronic Kidney Disease. During the record review on 08/04/2026 at 9:20 AM, it was noted that the POC ordered SN and PT services to be provided. It was further noted that there were no reportable parameters identified in which to notify the Physician. On 08/04/2026 at 12:00 PM, an onsite visit was made to the agency’s additional location in Munising, Michigan. During the visit, the Registered Nurse (Staff-D) was queried regarding the reportable parameters not being present on the POC. Staff-D stated there was an internal flow sheet in the computer and when the vital signs are outside of the reportable parameters, the results will be displayed in red. Staff-D then showed this writer how the untoward parameters would be illuminated and stated that on 07/29/2026 this patient’s heart rate was 48 bpm (beats per minute). The established reportable parameters were set at 60 - 100 bpm. On 08/05/2026 at 9:15 AM, during the continued review of the record, a “Patient Care Order” dated 08/04/2026 documented, “1: FYI: 7/29 patient HR (heart rate) low at 48 BPM (beats per minute). Patient asymptomatic…” There was no indication that the nurse promptly notified the Physician on 07/29/2026, when the incident occurred, that the patient’s heart rate was low. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 08/05/2026 at 12:40 PM. Patient #2’s (P-2) Start of Care (SOC) was dated 07/24/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Congestive Heart Failure, and Anemia. During record review on 08/4/26 at 8:15 AM, it was noted that on 7/28/2026, the Skilled Nurse (SN) stated, “Pain Assessment: Pain scale current: 6 – Intense, With Activity: 10 – Unbearable …Contacted “physician’s” office concerning patient’s pain, hoping that “physician” might be willing to prescribe the oxycodone again, message left for his nurse, awaiting return call…” The Electronic Medical Record failed to contain evidence of the physician’s follow-up or the SN’s continued efforts to contact the physician. A review of the agency policy occurred on 08/06/2026 titled “Coordination of Care-Home Health & Private Duty” (Revised 1/26). The policy states, “Purpose: 4. Integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician.” The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals provided ongoing assessments to meet the needs of the patient 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 08/04/2026, it was noted P-8 was taken to the emergency room by her husband on 08/22/2025 due to a change/progression in her condition that he was unable to take care of her anymore. Upon discharge from the emergency room to a temporary respite care location, the doctor at the emergency room requested social work re-evaluate P-8 early the following week to assist in addressing new needs and obtaining long-term placement. Upon further review of the record, it was determined social work did not see P-8 until 08/29/2025 – 1 week after her discharge from the emergency room. By this time, P-8 had been transferred from respite care to a memory care unit at another assisted living. There was no evidence of efforts made by social work or the agency to provide on-going assessment to meet the changing needs of the patient. Additionally, it was noted the home health aide, physical therapist, and skilled nurse all saw P-8 prior to the social worker (all also after the transfer to the memory care unit). There was no evidence of communication between the disciplines to meet the patient’s new and changing needs. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure services were provided as ordered in the plan of care for 3 (P-5, P-6, and P-8) of 3 patients, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #8 (P-8): During record review on 08/04/2026, it was noted that physical therapy was ordered 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 3 weeks. Upon further review of the record, it was determined the physical therapist documented a missed visit on 08/14/2025 and P-8 only received 1 physical therapy visit that week (instead of 2). There was no evidence of an attempt to reschedule the missed visit to meet the frequency ordered in the plan of care. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM. P-5’s SOC was 07/25/2026 with diagnoses that included Sepsis with resultant Right Above the Knee Amputation. On 08/04/2026 at 9:20 AM, it was noted that the POC ordered SN and PT services to be provided. On 08/04/2025 at 1:00 PM, a scheduled survey home visit was conducted with the Registered Nurse (Staff-D). During the visit, a document titled “Discipline Frequency and Liability for Payment” was observed and read, “SN; weekly x 4 then q (every) other week; PT: eval: SW (Social Work) Will get an order for eval..., By signing for form, I attest that I have been notified of my visit frequencies and payment liability and have received a written copy.” This document was signed and dated by the patient’s representative (husband) at the time of admission on 07/25/2026. At the time of this review, Social Work Services had not been provided as agreed upon. The agency failed to ensure services were provided based on the patient’s signed agreement and identified needs. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged these findings during an interview on 08/05/2026 at 12:40 PM. During the interview, Staff-B reported, “It doesn’t look like an order for Social Work was ever created.” Patient #6 (P-6)’s start of care was 02/04/2026 with diagnoses that included Osteoporosis, Left Femur Fracture and Pulmonary Embolism. The Plan of Care ordered Skilled Nursing (SN) at a frequency of 1x/wk. x 8 wks.; 3 prn (as needed) visits and Physical Therapy (PT) services at a frequency of 1x/wk. x 1 wk. (02/10/2026), 2x/wk. x 3 wks., 1x/wk. x 4 wks. During the record review on 08/05/2026 at 11:15 AM, it was noted that the SN missed a home visit on 03/18/2026. There were no SN visits made during this week. Additionally, PT only made one of the 2 visits ordered each week. Upon further review, there were no documented attempts to reschedule the visits in order to honor the ordered visit frequency. Additionally, there was no documented evidence of patient refusal of visits or that the Physician had been notified of the missed SN visit, the PT altered plan of care or gave approval to end PT services prior to completion of the ordered visit frequency. The agency failed to ensure services were provided in accordance with the Physician’s orders and Plan of Care. The Clinical Manager reviewed and acknowledged these findings during an interview on 08/06/2026 at 9:23 AM.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals prepared clinical notes per agency expectation for 1 (P-8) of 13 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #8 (P-8): During record review on 08/04/2026, it was noted the social work evaluation was performed on 08/11/2025, however, it was not completed and signed until 08/18/2025 – 1 week later. Additionally, it was noted a social work visit was made on 08/28/2025 and the documentation was not signed until 09/04/2025 – 1 week later. During the entrance interview on 08/03/2026 at 1:45 PM, the administrator (Staff-A) was asked about the agency expectation for clinical documentation completion. Staff-A stated the expectation was that all documentation was completed within 48 hours of the visit. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM.”

“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 and interview, the agency failed to ensure Skilled Nursing (SN) notified the physician of significant weight gain in 1 (P-13) of 1 record reviewed with a resumption of care after hospitalization. Findings include: Patient #13 (P-13)’s start of care (SOC) was 10/20/25, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/05/2026, noted P-13 was transferred to the hospital on 11/15/2025 for “Bilateral lower extremity edema thought to have acute on chronic CHF...” The hospital discharged P-13 on 11/20/2025 with a documented weight of 207.3 lbs. after being diuresed (extra bodily fluid removed through increased urination). The Plan of Care (POC) effective on 10/20/25, ordered a SN visit frequency of 1W1 (once a week times one week), 2W1, 1W7 and 3 PRN (as needed) visits for symptom management. The POC further ordered SN to “monitor weight and notify MD if gain of 3+ lbs. in 24 hrs. or 5+ lbs. in 1 week. After P-13 was discharged from the hospital, SN performed a ROC (resumption of care) visit on 11/22/2025 that recorded a weight of 225 lbs. (17.7 lb. gain in 2 days) with no physician communication evidenced in the medical record. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 08/06/2026 at 10:54 AM. Both further acknowledged that nursing should have notified the physician of the significant weight gain and receive potential interventions/treatments.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review an interview, the agency failed to ensure home health aides provided services as ordered in the plan of care for 1 (P-9) of 3 records reviewed of patients who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #9 (P-9): During record review on 08/05/2026, it was determined that home health aide services were ordered 1 time a week for 4 weeks. Upon further review of the record, it was determined that missed visits were documented by the home health aide on 04/11/2026, 04/14/2026, 04/24/2026, and 05/02/2026. Although the visits scheduled on 04/11/2026 and 05/02/2026 were on Saturdays and could not be rescheduled to meet the frequency in the plan of care, it was noted there was no evidence of attempts to reschedule the visits from 04/14/2026 or 04/24/2026. P-9 did not receive any visits from a home health aide and there was no documentation regarding a need to extend the order or the reason for discontinuing home health aide services as ordered in the plan of care. The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the clinical record was complete and contained accurate documentation for 3 (P-2, P-4, P-13) of 3 patients, resulting in the potential for unidentified, untreated health concerns, lack of continuity of care and unmet patient care needs. Findings include: Patient #13 (P-13)’s start of care was 10/20/25, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/04/2026, it was noted Skilled Nursing (SN) documented missed visits (due to P-13 not answering the door and phone) on 12/01/2025, 12/08/2025, 12/12/2025, 12/15/2025, and 12/18/2025 (discharge from agency). The lone SN visit was on 12/05/2025 with SN notifying the physician of an elevated systolic blood pressure (158/90) that was “outside of acceptable range (for P-13) 140/90. Action taken: (left blank).” The discharge OASIS (Outcome and Assessment Information Set) which is based on the initial comprehensive assessment, was performed by SN (Staff-F) on 12/18/2025. Staff-F documented no visit was made (no answer at the door). However, instead of a blank assessment, Staff F documented as if portions of a complete discharge assessment were performed on 12/18/2025 (12:45 PM through 1:26 PM). The Clinical Manager (Staff-B) reviewed P-13’s discharge OASIS and could not offer an explanation as to how the findings on 12/18/2025 could exist if the visit had never occurred. Under the discharge “Narrative Notes” section, Staff-F documented incomplete and inaccurate information that “Patient (P-13) had a fall in her home (11/15/2025) and was transferred back to (Hospital) where she stayed until 11/22/2025.” No other information was found concerning the P-13’s hospitalization of one week. Review of the hospital discharge summary under “Hospital Course” had no documentation regarding a fall but instead documented P-13 came into the hospital “with bilateral lower extremity edema (swelling) thought to have acute on-chronic CHF (congestive heart failure), she had stopped taking her home meds because of cost.” Several other concerns of hypokalemia (low potassium levels in the blood), cellulitis requiring antibiotic every 6 hours, and ongoing weakness-none of which were acknowledged by the agency’s SN services in the medical record. In addition, Staff F documented on the discharge OASIS that the “Patient agreed on 12/18/2025” to being discharged despite not seeing the patient since 12/05/2026 after four consecutive missed visits. Further, under “Status of Patient Goals at Discharge” Staff-F documented “Goals Met” when they were not. Staff-F also documented under “Patient needs post discharge: None at this time” when there was no evidence in the medical record that the agency had verified what P-13’s health status was since 12/05/2025 and two recent hospitalizations since 10/07/2025. The above findings were reviewed and acknowledged by the Administrator (Staff-A) and Clinical Manager (Staff-B) during an interview on 08/05/2026 at 1:47 PM. Both Staff-A and B were noted that this did not meet agency expectations when queried. Patient #4 (P-4)’s start of care (SOC) was 07/29/2026 with diagnoses that included Post surgical Neoplasm of Cheek Mucosa, HTN and CHF. During the record review on 08/04/2026 at 8:20 AM, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 08/04/2026 at 11:00 AM, a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, Staff-C checked the patient’s blood pressure and obtained a reading of 141/83. (The reportable blood pressure parameters were set as 95/60 - 140/90). Staff-C then stated, “Your blood pressure is outside of the reportable parameters. I’ll recheck it again before I leave.” Upon conclusion of the visit, Staff-C rechecked the patient’s blood pressure and got a reading of 132/76, which was within the reportable parameters. On 08/05/2026 at 9:00 AM, during the continued review of the record, it was noted that Staff-C only recording the post therapy blood pressure reading of 132/76. Staff-C failed to ensure the clinical record was complete and accurate. The Administrator and the Clinical Manager reviewed and acknowledged the above findings during an interview on 08/05/2026 at 12:00 PM. Patient #2’s (P-2) Start of Care (SOC) was dated 07/24/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Congestive Heart Failure, and Anemia. During record review on 08/04/2026 at 8:15 AM, it was noted that the POC stated, “SN (Skilled Nurse): Assess wound measurements weekly.” The POC ordered SN at a frequency of 2w8 (2 times a week for 8 weeks). On 0/28/2026 the Registered Nurse (RN) stated, “Assessment: Wound Measurements Completed: No.” On 07/30/2026, the Licensed Practical Nurse (LPN) stated, “Assessment: Wound Measurements Completed: No.” The wound measurements were not completed this week as ordered. Additionally, the POC stated, “Monitor weight and notify MD if gain of 3+ lbs in 24 hrs or 5+ lbs in 1 week.” The Electronic Medical Record (EMR) has no documented evidence of a weight recording for the RN visit on 07/28/2026. A review of the agency policy occurred on 08/06/2026 titled “Plan of Care Treatment Orders” (Revised 1/26). The policy states, “Policy: …. Patient care will be provided in accordance with this established individualized written Plan of Care approved by the physician. The Plan of Care, written, and Verbal Orders (VO) represent the prescribed orders and has many roles including orders, assessment and care planning…” The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM.”

“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 and interview, the agency failed to ensure the transfer/discharge summaries were complete, provided the patient’s current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 4 (P-3, P-6, P-8, and P-13) of 4 records in which the patient was discharged/transferred from the agency’s services, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #13 (P-13)’s start of care was 10/20/2025, with diagnoses which included CHF (congestive heart failure), Clostridium difficile, and COPD (chronic obstructive pulmonary disease). During record review on 08/04/2026, it was noted Skilled Nurse (SN) services discharged P-13 from the home care agency on 12/18/2025. Further review found no evidence that a discharge summary was ever sent to the physician within 5 business days of discharge. The Clinical Manager (Staff-B) reviewed and verified the above finding during an interview on 08/05/2026 at 2:02 PM. Staff-B further acknowledged that this did not meet agency expectations when queried. Patient #8 (P-8): During record review on 08/04/2026, it was determined the last physical therapy note dated 09/08/2025 indicated P-8 could transfer independently and could walk 400 feet without assistance. During review of the discharge comprehensive assessment completed by skilled nursing on 09/09/2025, it was determined it noted that P-8 needed “partial/moderate” assistance for transfers and to walk 150 feet. The information is conflicting; therefore, it does not provide a clear or complete picture of the patient’s status at discharge. A review of agency policy titled “Patient Discharge – Home Health” revealed the purpose of the discharge assessment was, “To assure that an accurate summary of services provided exists for future reference if needed.” The clinical manager (Staff-B) reviewed and acknowledged the findings during an interview on 08/06/2026 at 9:50 AM. Patient #6 (P-6)’s start of care was 02/04/2026 with diagnoses that included Osteoporosis, Left Femur Fracture and Pulmonary Embolism. The Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the record review on 08/05/2026 at 11:15 AM, it was noted that the patient was discharged from the agency’s services on 03/25/2026. The Skilled Nurse “Discharge Summary” dated 03/26/2026 was void of a summary that detailed the course of care provided, responses to treatment, overall health status at the time of discharge and any referrals as appropriate. The Clinical Manager reviewed and acknowledged these findings during an interview on 08/06/2026 at 9:23 AM. Patient #3’s (P-3) Start of Care (SOC) was dated 06/23/2026. The Plan of Care (POC) identified diagnoses of Abscess of Groin and Abscess of Buttock. During record review on 08/05/2026 at 12:30 PM, it was noted that the Skilled Nurse (SN) completed a transfer on 07/02/2026. The Electronic Medical Record contained no evidence that the transfer summary was sent within 2 business days of the patient’s known transfer. The Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 08/06/2026 at 8:35 AM.”