Personalize Home Care Service

“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 its disciplines followed the visit frequency as ordered by the Physician and in the Plan of Care for 1 (P-2) of 7 sampled records reviewed, resulting in the patients not receiving care according to their identified needs, the potential for worsening of health condition and unmet care needs. Findings include: A review of the agency policy on 7/17/25 titled “Plan of Care – C-580” (undated). The policy states, “Special Instructions: 2. The Plan of Care shall be completed in full to include: c. Type, Frequency, and duration of all visits/services...” Patient #2’s (P-2) Start of Care (SOC) was dated 3/26/25. The Plan of Care (POC) identified diagnoses of Leukemia, Anemia and Hypertension. During record review on 7/15/25, it was noted that the POC had Skilled Nursing (SN) frequency of 1w5 (1 time per week for 5 weeks). The visits scheduled for 4/18/25 was documented a “Skilled Nurse Missed Visit”, stating, “Reason for Missed Visit: Blank under Patient Request, Physician appointment, and Other… Comments: Blank…Physician Notified: Blank. How was Physician Notified? Blank. Agency notified: Blank…” There was no attempt to complete the frequency as ordered and the physician was not notified of the missed visit. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:45 pm.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure staff followed accepted standards of practice for infection control for 1 (P-6) of 3 patients with home visits, resulting in the potential for spread of infectious disease to all 52 patients currently receiving services from this agency. Findings include: Patient #6 (P-6) was admitted to this home care agency on 6/13/25 with the diagnosis of bilateral knee osteoarthritis. During a joint home visit with the physical therapist (PT #1) and P-6 on 7/15/25 at 1:00 PM, PT #1 was observed putting on a pair of gloves at the start of treatment. During the treatment, PT #1 was observed touching the patient with gloved hands while assessing her blood pressure. After he was finished, PT #1 used his gloved (dirty) hands to remove a pen and a folder from inside his bag to record the blood pressure. PT #1 then returned the folder and pen to the bag without disinfecting them first. PT #1 was observed using the pen 2 other times during treatment and returning it to the bag without disinfecting it. The same pair of gloves remained on PT #1 throughout the entire treatment. At the conclusion of treatment, PT #1 got a bottle of hand sanitizer out of the bag with his gloved (dirty) hands. He used the hand sanitizer on the gloves and then proceeded to put the bottle back into the bag. Additionally, PT #1 was also observed putting an exercise band the patient used back into his bag without disinfecting it first. PT #1 continued to wear his gloves when he left house and did not remove them until he got to his car. PT #1 did not disinfect his hands after removing his gloves before touching his car and the other equipment he was returning to the car. A review of agency policy titled “Handwashing/Hand Hygiene” (not dated) revealed, “3. Indications for handwashing and hand antisepsis:…d. Between tasks on the same client…f. After removing gloves, g. After touching objects that are potentially contaminated…q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client, r. Decontaminate hands after removing gloves.” A review of agency policy titled “Bag Technique” (not dated), revealed, “1. Observed the principles of Standard Precautions at all times. The inside of the nursing bag should be regarded and maintained as a clean area.” The policy also revealed, “8....If additional equipment or supplies are needed form the bag during the home visit, the handwashing procedure must be repeated.” Additionally, the policy stated, “After provided care, clean all equipment with soap and water or a home health agency-approved disinfectant before returning it to the bag.” The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documented evidence of infection control education for 3 of 7 sampled staff members including those employed through an arranged contract which has the potential to negatively impact on the safety and well-being of all 215 patients serviced by the agency in the past 12 months. Findings include: A review of the agency policy on 7/17/25 titled “Contract Personnel – D-460” (undated). The policy states, “Special Instructions: 3. Prior to rendering services to agency clients, all contract personnel shall receive an orientation to the agency’s client care policies and procedures and applicable personnel requirements. 4. Professional personnel under contract with eh agency to provide professional services shall have complete personnel files available for the agency upon request. Individuals who contract individually with the agency will have a complete personnel file in the agency which includes references, licenses/certifications, Mantoux/Health screening, and other documentation required by the agency…” A review of the agency policy on 7/17/25 titled “Infection Control Plan – B-401” (undated). The policy states, “Orientation and continuing education of personnel: All new employees of the agency shall complete an education session that covers Blood Borne Pathogen Exposure Control Plan, Tuberculosis Plan, COVID-19 Plan, CDC’s Hand Hygiene Guidelines and basic infection control. Ongoing education will also be provided to employees, clients, and visitors, utilizing a variety of formats and modalities, and the most current CDC, and OSHA guidelines, state regulations and requirements of accrediting bodies…” On 7/15/25, 7 personnel files for varied skilled staff including 5 employed directly by the agency, and 2 employed through arranged contracts were reviewed. During review, it was noted that no orientation Infection Control (IC) education and no ongoing annual IC education were found in the contracted personnel files reviewed. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:30 pm.”

“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 observation, interview and record review, the agency failed to ensure its skilled discipline utilized professional standards of practice during the provision of care for 1 (P-1) of 1 patient observed during a Physical Therapy home visit, from a total of 7 sampled records reviewed, resulting in the potential for worsening of health condition and unmet care needs. findings include: Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Acute Kidney Failure. On 7/16/25 at 9:35 a.m., during the clinical record review, it was noted that the Plan of Care ordered Skilled Nursing (SN), Occupational Therapy (OT) and Physical Therapy (PT) services to be provided. On 7/16/25 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #2). During the visit, PT #2 checked the patient’s blood pressure (BP) and got a reading of 158/100 (normal range is 120/80). PT #2 stated, “Oh, that’s really high. Let’s begin your exercises.” PT #2 did not recheck the patient’s BP to ensure it was safe to continue on. PT #2 then proceeded with the therapy session. Upon completion of the visit, PT #2 was queried. When asked why she chose to proceed with the therapy session in light of the patient’s elevated BP, PT #2 responded, “Because we’re just here for the exercises. I should have stopped earlier.” When asked why she did not recheck the patient’s BP after getting a high reading, PT #2 offered no response. The Administrator, Alternate Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 12:50 p.m.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: During a review of the agency’s contracts on 7/16/25 at 2:10 p.m., it was noted that all disciplines, including Skilled Nursing, Physical therapy, Occupational Therapy, Medical social work, Speech Therapy and Home Health Aide services were listed as an option to utilize their services. The agency failed to ensure that at least one qualifying service was directly provided by the agency. The Administrator, Alternate Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 1:11 p.m.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical record entries were appropriately authenticated and dated in 1 (P-7) of 7 records reviewed; and failed to ensure all clinical record entries were clear and complete in 1 (P-7) of 7 records reviewed, resulting in an incomplete clinical record. Findings include: A review of agency policy titled “Clinical Documentation” (not dated) revealed, “2. A separate note shall be completed for each visit/shift and signed and dated by the appropriate professional.” Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was noted the following visit notes lacked authentication and date: The occupational therapy visit note from 4/23/25 was not signed or dated upon completion. The physical therapy visit note from 4/28/25 was not signed or dated upon completion. The physical therapy visit note from 4/30/25 was not signed or dated upon completion. The occupational therapy visit note from 5/5/25 was not signed or dated upon completion. The physical therapy visit note from 5/20/25 was not signed or dated upon completion. During an interview with the office manager (OM #1) on 7/16/25 at 1:13 PM, OM #1 was asked why the visit notes above did not contain proper authentication. OM #1 stated sometimes the clinicians forget to sign the notes before “sending” them in the EMR. OM #1 stated the clinicians “send” them when they are done with their documentation, so they are likely complete, however, OM #1 acknowledged the lack of proper authentication at the time of interview. The administrator (Adm #1) also reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM. Additionally, during review of the comprehensive assessment for the resumption of care dated 5/17/25, it was noted “Pressure injury of sacral area healed.” Upon review of the skilled nursing notes dated 5/19/25, 5/21/25, 5/23/25, 5/28/25, 5/30/25, 6/4/25, and 6/6/25, it was noted the wound care section indicated wound care to “LEFT HEEL: Cleanse left sacral wound with wound cleanser/apply with abd pad and wrap with kerlix, Ace wrap daily.” [sic] During an interview with the registered nurse (RN #1) on 7/17/25 at 2:40 PM, RN #1 reviewed the entries and stated it was likely a typo, however, RN #1 agreed the documentation was not clear as to what wound care was being provided to this patient. Adm #1 and OM #1 were also present during the interview and acknowledged the findings.”

“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 1 (P-1) of 3 patients observed during home visits, and 1 patient (P-4) of 7 patients receiving services from the agency were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, and any changes to the Plan of Care or provision of services, resulting in lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Heart Disease and Acute Kidney failure. The Plan of Care ordered Skilled Nursing, Occupational Therapy and Physical Therapy services to be provided. On 7/16/25 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #2). During a review of the patient’s admission packet, it was noted that there was no completed calendar of proposed visits to be made by the ordered disciplines. The Administrator, Alternate Administrator, Clinical Manager (via phone) and Office Manager reviewed and acknowledged these findings during an interview on 7/17/25 at 12:50 p.m. Patient #4 (P-4)’s Start of Care was dated 2/3/25. The Plan of Care for the certification period 2/3/35 to 4/3/25 identified diagnoses of Type 2 diabetes, Atrial Fibrillation, Spondylosis without myelopathy or radiculopathy, Hypertension, Constipation, Gastroesophageal reflux disease, and hyperlipidemia. The patient was receiving Skilled Nursing services as follows: 2 times a week for 2 weeks starting 2/3/25; 1 time a week for 4 weeks starting 2/16/25; 1 time a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/23/25; and 1 time a week for 5 weeks starting 3/2/25. During a review of the record, it was noted a document with the title “Home Health Change of Care Notice (HHCCN)” form was included in the record. The document was blank of any information with the exception that the patient had signed the document. There was no documented date, no information regarding the items/services that were being changed, or the reason for change. These findings were reviewed and acknowledged with the Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) during an interview on July 17, 2025, at 1:45 p.m.”

“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 Comprehensive Assessment within 48 hours of the date of referral for 1 (P-1) of 1 record where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: Patient #1 (P-1)’s start of care (SOC) was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease. During the record review on 7/16/25 at 9:35 a.m., it was noted that the referral for home care was dated 5/30/25 and ordered Skilled Nursing (SN), Occupational Therapy (OT) and Physical Therapy (PT) services to be provided. The SN did not conduct the Initial Comprehensive Assessment until 6/5/25. This was 5 days after the date of the referral. There was no documented rationale for the delay in SOC and no evidence that the patient declined services or requested a later start date. Additionally, there was no documented evidence that the Physician was made aware of the delay in the provision of services. The Administrator, Alternate Administrator, Clinical Manager (via phone) and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 12:50 p.m.”

“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 conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status leading to home care needs in 6 (P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in incomplete clinical information to aid in determining the needs of the patient. Findings included: A review of the agency policy on 7/17/25 titled “Plan of Care – C-580 (undated). The policy states, “Special Instructions: 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis(es), principle and secondary, including dates of onset...” Patient #2’s (P-2) Start of Care (SOC) was dated 3/26/25. The Plan of Care (POC) identified diagnoses of Leukemia, Anemia and Hypertension. During record review on 7/15/25, it was noted that the SOC comprehensive assessment dated 3/26/25, documented under “Primary Diagnosis and Other Diagnoses”, all 19 “Other” diagnoses had an exacerbation date of 3/26/25. No 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 6/19/25. The Plan of Care (POC) identified diagnoses of Hypertension, Muscle Weakness and Difficulty in Walking. During record review on 6/19/25, it was noted that the SOC comprehensive assessment dated 6/19/25, documented under “Primary Diagnosis and Other Diagnoses”, all 8 diagnoses had an exacerbation date of 6/19/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:35 pm. Patient #4 (P-4)’s Start of Care was dated 2/3/25. The Plan of Care for the certification period 2/3/35 to 4/3/25 identified diagnoses of Type 2 diabetes, Atrial Fibrillation, Spondylosis without myelopathy or radiculopathy, Hypertension, Constipation, Gastroesophageal reflux disease, and hyperlipidemia. The patient was receiving Skilled Nursing services as follows: 2 times a week for 2 weeks starting 2/3/25; 1 time a week for 4 weeks starting 2/16/25; 1 time a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/23/25; and 1 time a week for 5 weeks starting 3/2/25. Upon review of the Start of Care Comprehensive Assessment dated 6/24/2025, it was noted all 20 diagnoses listed under Primary Diagnosis and other diagnoses had a date of onset of 2/3/2025. There was no further documentation regarding patient history, treatments, outcomes, and reason for the need for home health care services, or how the patient would have the same onset date for 20 diagnoses. Patient #5 (P-5)’s Start of Care was dated 6/24/25. The Plan of Care for the certification period 6/24/25 to 8/22/25 identified diagnoses of Stage 2 Pressure Ulcer of Right buttock; Encounters for change or removal of nonsurgical wound dressing; Acute embolism and deep vein thrombus of left lower extremity, Hypertension, Hyperlipidemia, Benign prostatic hyperplasia without lower urinary tract symptoms, Muscle Weakness, and abnormalities of gait. The patient was receiving Skilled Nursing Services 1 time per week for 6 weeks and Physical Therapy Services 2 times per week for 5 weeks. Upon review of the Comprehensive Assessment on 7/15/25, it was noted under the category of Primary and Other Diagnoses that the dates of onset for all 13 diagnoses were documented as 6/24/2025. There was no further documentation regarding patient history, treatments, outcomes, and reason for the need for home health care services, or how the patient would have the same onset date for 13 diagnoses. These findings were reviewed and acknowledged with the Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) during an interview on July 17, 2025, at 1:45 p.m. Patient #6 (P-6) was admitted to this home care agency on 6/13/25 with the diagnosis of bilateral knee osteoarthritis. During record review on 7/16/25, it was noted the comprehensive assessment in the Outcome and Assessment Information Set (OASIS) indicated P-6 used a quad cane as an assistive device prior to admission. Upon further review of the OASIS, it was noted a narrative section under “Assessment Summary” stated, “Prior to this recent decline in functional status Patient was independent with bed mobility, transfers and gait with 4ww (4 wheeled walker) and was able to manage ADL’s with supervision.” [sic]. This information is conflicting; therefore, it does not present a clear picture of the patient’s status and current home care needs. Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was noted the OASIS indicated the patient had a “recent left femur fracture.” Additionally, review of records sent from the physician upon referral to the home care agency revealed P-7 “underwent a left hip ORIF” (open reduction internal fixation surgery) following a fall that resulted in a “closed nondisplaced intertrochanteric fracture of the left femur, sacral fracture, and pelvic fracture.” The comprehensive assessment failed to include information regarding when the initial left femur injury occurred, failed to include that P-7 had a surgical intervention as a result, and failed to include when the surgical intervention occurred; therefore, it does not present a clear picture of the patient’s status and current home care needs. The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM.”

“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 comprehensive assessment included a review of all medications to determine any adverse effects in 3 (P-1, P-3, and P-7) of 7 patient records reviewed; and failed to ensure the physician was notified of potential drug interactions in 2 (P-1, P-3) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all 52 patients currently serviced by this agency. Findings include: Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Acute Kidney Failure. During the clinical record review on 7/16/25 at 9:35 a.m., it was noted that section M2001 (Drug review) of the Initial Comprehensive Assessment dated 6/5/25 documented, “Yes issues found during review.” On 7/16/25 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #2). During the visit, PT #2 applied Biofreeze Gel (topical analgesic used for pain relief) to the patient’s back and bilateral knees. Further review of the clinical record on 7/16/25 at 1:00 p.m., revealed that Biofreeze was in fact listed on the patient’s medication profile. However, the section that listed all medications that had been included in the drug review was void of Biofreeze Gel. There was no indication that the skilled discipline included all the patient’s medications in the comprehensive drug review. The Administrator, Alternate Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 12:50 p.m. A review of the agency policy on 7/16/25 titled “Medication Profile C-700” (undated). The policy states, “Special Instructions: 1. At the time of admission, the admission professional shall check all medications a client may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication. The clinician shall promptly report any identified problems to the physician/allowed non-physician practitioner (NPP). Patient #3’s (P-3) Start of Care (SOC) was dated 6/19/25. The Plan of Care (POC) identified diagnoses of Hypertension, Muscle Weakness and Difficulty in Walking. During record review on 6/19/25, it was noted that the Medication Profile was competed and signed on 6/19/25 by the registered nurse (RN). The Medication Profile stated, “Interactions between your drugs. Major. Allopurinol and hydrochlorothiazide. Coadministration of allopurinol with thiazide diuretics may increase the occurrence of hypersensitivity reactions, particularly in patients with decreased renal function.” The comprehensive assessment completed by the RN on 6/19/25 stated, “(M2003) Medication follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? Yes.” The Electronic Medical Record (EMR) had no evidence that the physician was made aware of the major medication interactions. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:55 pm. Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was noted the comprehensive assessment for the resumption of care dated 5/17/25 indicated the patient stated an antibiotic. A review of physician orders revealed the patient started a home infusion of Daptomycin (an antibiotic) on 5/17/25 following a hospitalization for bacteremia (a bloodstream infection). Upon further review of the record, it was determined this medication was not added to the medication profile to be reconciled with P-1’s other medications. A review of agency policy titled “Medication Profile” (not dated) revealed, “10. The Medication Profile shall be reviewed by a Registered Nurse every sixty (60) days and updated whenever there is a change or discontinuation in medication.” The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM.”

“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 ensure the plan of care covered all pertinent interventions with reportable parameters and objectively measurable goals specific to the patient’s needs for 5 (P-1, P-2, P-4, P-5, and P-7) of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs, the potential for decline in overall health and poor patient outcomes. Findings include: A review of the agency policy on 7/17/25 titled “Care Plans – C-660” (undated). The policy states, “Special Instructions: 3. The Care Plan shall include, but not be limited to: …b. Reasonable, measurable, and realistic goals as determined by the assessment and client expectations...” Patient #2’s (P-2) Start of Care (SOC) was dated 3/26/25. The Plan of Care (POC) identified diagnoses of Leukemia, Anemia and Hypertension. During record review on 7/15/25, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, “Pt (patient)/Pcg (paid care giver) will demonstrate self monitoring of pulse/blood pressure/weights/other and reporting readings outside physician established parameters by 5 weeks.” Additionally, another goal stated, “Pt/Pcg will state understanding of measures to manage disease and identify S/S (signs and symptoms) to report by 5 weeks.” There was no evidence of how these goals could be quantitatively measured. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:45 pm. Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Acute Renal Failure. The Plan of Care ordered Skilled Nursing, Occupational Therapy and Physical Therapy services to be provided. During the clinical record review on 7/16/25 at 9:35 a.m., it was noted that the Plan of Care listed the patient’s 21 diagnoses as having exacerbated on the same date of admission to the agency (6/5/25). Upon further review, there were no interventions, reportable parameters or associated measurable goals to address the identified exacerbated diagnoses. The Administrator, Alternate Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 12:50 p.m. Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was noted the following goals were listed by occupational therapy on the plan of care: “Patient will be in a safe physical environment, as evidenced by 3 wks” [sic] “Patient will have ADL’s met, as evidenced by 3 wks”[sic] “Patient will obtain maximum level of functioning, as evidenced by 3 wks” [sic] These goals lack measurable, patient-specific, quantifiable data to assess progress towards meeting them. The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM. Patient #4 (P-4)’s Start of Care was dated 2/3/25. The Plan of Care for the certification period 2/3/25 to 4/3/25 identified diagnoses of Type 2 diabetes, Atrial Fibrillation, Spondylosis without myelopathy or radiculopathy, Hypertension, Constipation, Gastroesophageal reflux disease, and hyperlipidemia. The patient was receiving Skilled Nursing services as follows: 2 times a week for 2 weeks starting 2/3/25; 1 time a week for 4 weeks starting 2/16/25; 1 time a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/21/25; 2 times a week for 1 week starting 2/23/25; and 1 time a week for 5 weeks starting 3/2/25. The Plan of Care included the following goals: “Patient/Patient Caregiver will state understanding of measures to manage disease and identify signs/symptoms to report by 6 weeks; Patient/Caregiver will verbalize/demonstrate management of incontinence without skin breakdown by 7 weeks; Patient will verbalize signs and symptoms of hypo/hyperglycemia, measures to manage and when to report to RN/physician by 7 weeks.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. Patient #5 (P-5)’s Start of Care was dated 6/24/25. The Plan of Care for the certification period 6/24/25 to 8/22/25 identified diagnoses of Stage 2 Pressure Ulcer of Right buttock; Encounters for change or removal of nonsurgical wound dressing; Acute embolism and deep vein thrombus of left lower extremity, Hypertension, Hyperlipidemia, Benign prostatic hyperplasia without lower urinary tract symptoms, Muscle Weakness, and abnormalities of gait. The patient was receiving Skilled Nursing Services 1 times per week for 6 weeks and Physical Therapy Services 2 times per week for 5 weeks. The Plan of Care included the following goals: “Demonstrate proper use of Durable Medical Equipment within 5 weeks; Demonstrates ability to follow home exercise program by 5 weeks; Independent with safety issues within 5 weeks.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed and acknowledged with the Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) during an interview on July 17, 2025, at 1:45 p.m.”

“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 skilled discipline promptly notified the Physician of 1 (P-1) of 1 patient who experienced elevated blood pressure readings, from a total of 7 sampled records reviewed, resulting in the potential for untreated health concerns and decline in health status. Findings include: Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney disease. On 7/16/25 at 9:35 a.m., during the record review, it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Occupational Therapy (OT) and Physical Therapy (PT) services to be provided. On 7/16/25 at 11:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #2). During the visit, Pt #2 took the patient’s blood pressure (BP) and got a reading of 158/100. The POC instructed to notify the Physician of a systolic BP greater than (>) 160 and a diastolic BP > 90. PT #2 continued with the therapy session but did not promptly notify the Physician regarding the elevated reading. Further review of the clinical record revealed a PT visit note by PT #2 dated 6/28/25 with a documented BP reading of 165/93 and a PT visit note dated 7/2/25 with a BP reading of 162/85. Both readings were outside of the reportable parameters. There was no documented evidence that the Physician had been promptly notified of any of the above readings by the survey’s exit on 7/17/25. The Administrator, Alternate Administrator, Clinical Manager (via phone) and Office Manager reviewed and acknowledged these findings during an interview on 7/17/25 at 12:50 p.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 provide services ordered by the physician as indicated in the plan of care in 1 (P-7) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was noted the plan of care ordered a skilled nursing intervention to report to the physician if, “Weigh gain of 5lbs in 1 week.” [sic] Upon review of the skilled nursing notes, it was determined no weight was recorded for the patient during the weeks of 5/18/25, 5/25/25, and 6/1/25; therefore, P-7’s weight was not being monitored as ordered in the plan of care. The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM.”

“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 the clinical record was complete for 1 (P-3) of 7 records reviewed; and failed to ensure skilled professionals prepared clinical notes per agency policy in 2 (P-6 and P-7) of 7 records reviewed, resulting in undocumented health concerns and potential poor outcomes. Findings include: A review of the agency policy on 7/16/25 titled “Clinical Record Content/Medical Record Retention C-870” (undated). The policy states, “A clinical record will be maintained for every client receiving home health services. All client information shall be regarded as confidential and available only to authorized users. Clinical records are legal documents containing comprehensive, accurate, and organized information concerning the client’s health and emotional status, treatments, and services rendered by the Registered Professional Nurses and other health care team members.” Patient #3’s (P-3) Start of Care (SOC) was dated 6/19/25. The Plan of Care (POC) identified diagnoses of Hypertension, Muscle Weakness and Difficulty in Walking. During record review on 6/19/25, it was noted that physical therapy (PT) completed an evaluation on 6/24/25 and ordered PT at a frequency of 2w (2 visits a week for 5 weeks), 1w1. The completed PT visit for 7/3/25 was blank. The PT failed to complete the clinical note. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:45 pm. A review of agency policy titled “Clinical Documentation” (not dated) revealed, “5. Documentation of services ordered on the plan of care will be completed the day services is rendered and incorporated into the clinical record withing seven (7) days after the care has been provided.” A review of agency policy titled “Skilled Professional Services” (not dated) revealed, “1. Skilled professionals must assume responsibility for, but not be restricted to the following: a…f. Preparing clinical notes…” Patient #6 (P-6) was admitted to this home care agency on 6/13/25 with the diagnosis of bilateral knee osteoarthritis. During record review on 7/16/25, it was determined the following visit notes were completed late: The physical therapy visit note dated 6/16/25 was signed 6/26/25 (3 days late). The physical therapy visit note dated 6/30/25 was signed 7/15/25 (8 days late). The physical therapy visit note dated 7/2/25 was signed 7/15/25 (6 days late). The physical therapy visit note dated 7/7/25 was not yet started as of 7/16/25. Patient #7 (P-7) was admitted to this home care agency on 4/18/25 with the diagnosis of type II diabetes mellitus with a left foot ulcer, pressure ulcer of the sacral region, and a non-displaced fracture of the left femur. During record review on 7/16/25, it was determined the following visit notes were completed late: The skilled nursing visit note dated 4/23/25 was signed 5/6/25 (6 days late). The skilled nursing visit note dated 4/25/25 was signed 5/6/25 (4 days late). The physical therapy visit note dated 4/26/25 was signed 5/6/25 (4 days late). The skilled nursing visit note dated 5/19/25 was signed 7/6/25 (11 days late). The skilled nursing visit note dated 5/23/25 was signed 7/6/25 (7 days late). The physical therapy visit note dated 6/3/25 was signed 6/30/25 (20 days late). The physical therapy visit note dated 6/5/25 was signed 6/30/25 (18 days late). The administrator (Adm #1), registered nurse (RN #1), and office manager (OM #1) reviewed and acknowledged the findings during an interview on 7/17/25 at 2:40 PM.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation and interview, it was determined the Administrator failed to ensure the Clinical Manager was available at all times during operating hours, resulting in lack of clinical supervision and oversight and the potential for unmet care needs for all 52 patients currently serviced by this agency. Findings include: On 7/16/25 during a Survey team discussion, it was brought to this writer’s attention that the Clinical Manager (CM #1) underwent a medical procedure and would not be in. When asked if there was an alternate Clinical Manager, the Office Manager (OM #1) stated, “The Alternate Clinical Manager (CM #2) was going out of state to visit her son. She was going to try to make plans to come back, but I haven’t heard from her since last night and CM #1’s phone is going right to voicemail.” On 7/16/25 at 3:38 p.m., the agency’s Registered Nurse (RN #1) arrived at the office and stated, “She (CM #1) had a Cardiac Cath yesterday and she’s still down. I called CM #2 and she’s still on vacation. she won’t be back until next week. I’m not sure that I can answer any of your questions, but if there’s any way that I can help, I will.” On 7/17/25 at 8:30 a.m., OM #1 reported, “I’m concerned now because I still can’t get ahold of her (CM #1). The agency failed to ensure the Clinical Manager was available during all hours of operation. These findings were reviewed with the Administrator, Alternate Administrator and OM #1 during an interview on 7/17/25 at 1:11 p.m.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the agency failed to maintain a record of referral and acceptance of patients for services for 1 (P-3) of 7 records reviewed, resulting in unmet record maintenance and availability. Findings include: A review of the agency policy on 7/17/25 titled “Clinical Manager – B-105” (undated). The policy states, “Special Instructions: The oversight provided by the clinical manager(s) includes: …c. Coordinating referrals....” Patient #3’s (P-8) Start of Care (SOC) was dated 6/19/25. The Plan of Care (POC) identified diagnoses of Hypertension, Muscle Weakness and Difficulty in Walking. During record review on 6/19/25, it was noted that there was no documented referral within the chart. The agency failed to coordinate and maintain patient referrals, resulting in potential unmet needs. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:45 pm.”

“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 2 (P-1, P-2), of 2 records in which the patient was discharged/transferred from the agency’s services, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: A review of the agency policy on 7/17/25 titled “Discharge Summary – C-820” (undated). The policy states, “Special Instructions: 2. The Discharge Summary will incorporate findings from the discharge OASIS assessment and shall include, but not be limited, to: …b. Reason for admission to home health. c. Type of services provided and frequency of services… f. Client discharge condition. g. Outcomes in meeting the goals in the plan of care. h. Client and family post-discharge instruction…” Patient #2’s (P-2) Start of Care (SOC) was dated 3/26/25. The Plan of Care (POC) identified diagnoses of Leukemia, Anemia and Hypertension (HTN). During record review on 7/15/25, it was noted that the Skilled Nursing (SN) discharge dated 4/23/25 stated, “Services Provided: Blank. Services to continue at nursing discharge: Blank (Physical Therapy continued service). Summary of care/goals achieved: Patient/caregiver verbalizes understanding with teaching on COVID-19, HTN, anemia and management of care by diet, medication, exercise, modifying lifestyle changes.” The discharge summary failed to follow policy and detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient’s health status at the time of discharge. The Alternate Administrator (Adm #2), Registered Nurse (RN #1) and Office Manager (OM #1) reviewed and acknowledged the findings listed above in an interview on 7/17/25 at 3:50 pm. Patient #1 (P-1)’s start of care was 6/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Acute Renal Failure. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 7/16/25 at 9:35 a.m., during the clinical record review, it was noted that the patient was discharged from OT services on 6/30/25. There was no documented evidence that the OT Discharge Summary was forwarded to the Physician within 5 days of the date of discharge. Further, the patient was discharged from SN services on 7/1/25. Upon review, the SN Discharge Summary was void of a summary that detailed the course of care provided with responses and the patient’s overall health status at the time of discharge. Additionally, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. The Administrator, Alternate Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 7/17/25 at 12:50 p.m.”