Vn Home Health Care

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in lack of direction for agency personnel in the event of an actual emergency or disaster. Findings include: On 3/2/26 at 11:05 a.m., during a review of the agency’s “Emergency Preparedness Disaster Plan”, it was noted that the plan was undated. There was no documented evidence that the plan had been reviewed and updated at least every 2 years as per this requirement. Additionally, the plan was void of any mitigating strategies to address the hazards/potential hazards identified in the agency’s Hazardous Vulnerability Assessment. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:20 a.m.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting the potential for undesired responses in the event of an emergency. Findings include: On 3/2/26 at 11:05 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the “Emergency and disaster Preparedness Policy/Procedure #: E-410” was last “reviewed” on 9/2025. There was no specific documented date of review and no indication or name of who reviewed the policy. Additionally, there was no documented evidence that the policies/procedures had been updated at least every 2 years as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:20 a.m.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure an individual Emergency Preparedness Plan was completed for 1 (P-2) of 3 patients observed during a home visit, resulting in the potential for unprepared responses in the event of an actual emergency or disaster. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. On 3/3/26 at 11:15 a.m., a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During a review of P-2’s Admission Packet, it was noted that the patient’s individualized Emergency Preparedness Plan was blank. There was no information provided that would assist staff or patients in the event of an emergency. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section, that had been reviewed and updated at least every two years. Findings included: On 3/2/26 at 11:05 a.m., during a review of the agency’s Emergency Preparedness Plan, there was no evidence that the agency’s Testing and Training requirements had been reviewed and updated at least every 2 years, as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:20 a.m.”

“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 Plan of Care (POC) for skilled nursing (SN) included objective measurable goals in 4 (P-4, P-5, P-6, and P-7) of 7 records reviewed; failed to provide skilled nursing services as ordered in 1 (P-6) of 7 records reviewed; and failed to include pertinent safety precautions in 1 (P-7) of 7 records reviewed, resulting in the potential for unmet patient care needs. Findings include: Patients #5, #6, and #7: On 3/3/26 through 3/5/26, review of each of the patient’s POC noted the following: P-5 (5 of 5 SN goals), P-6 (2 of 2 SN goals), and P-7 (31 of 31 SN goals) were not written in objective measurable terms to track and trend progress made (or lack of) as required. Example goals include: “Patient demonstrate necessary skills to self-manage disease process including medication management, when to notify physician, s/s (signs and symptoms) necessitating emergent care, nutrition and activity… Patient/Caregiver will be able to identify fall risk factors by 3/16/25.” Patient #6 (P-6) had the POC ordered SN services twice weekly for 3 weeks, followed by weekly visits for 3 weeks, effective 1/19/26. Patient record review on 3/4/26 noted only 1 SN visit was provided weekly from 1/19/25 through 1/31/25. No physician notification or patient refusal was found in the P-6’s medical record. Patient #7 (P-7) was ordered to have supplemental oxygen on 3/16/25 at a rate of 2 Liters/minute when short of breath due to congestive heart failure. The POC failed to include oxygen precautions to help ensure safety for all individuals in the home. The findings above were reviewed and acknowledged by the administrator (Staff-A) during interviews conducted on 3/5/26 at 12:37 PM through 1:57 PM. Patient #4 (P-4) was admitted to the agency on 7/31/25 with a diagnosis of breast cancer and pleural effusions. On 3/2/26, a review of the Plan of Care (POC) effective 7/31/25, revealed 31 out of 32 listed goals were not written in objective measurable terms. For example, “Patient will maintain blood sugar within normal range by end of episode as evidenced by reading within therapeutic range” Another goal stated, “Patient will remain free of any and all infections during this episode of care”. The Agency Administrator (Staff-A) acknowledged the findings during an interview on 3/5/26 at 2:11 PM, which did not meet agency expectations or their policy referenced below. A review of agency policy titled, “Physician’s Plan of Treatment/Change Orders” (undated), revealed, “The plan of treatment shall include but not be limited to … Measurable outcomes and goals…””

“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, interview and record review, the agency failed to ensure its discipline utilized Infection Control standards of practice during the provision of care and services for 1 (P-2) of 3 patients observed during home visits, resulting in the potential for the development and spread of infection. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. On 3/3/26 at 11:15 a.m., a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, the following observations were made: Staff-C assessed the patient’s vital signs (blood pressure, oxygen saturation, temperature, lung sounds). Staff-C then proceeded with the therapy session utilizing hand weights and ankle weights. During the observation, Staff-C donned a pair of gloves. Staff-C kept the same pair of gloves on for the duration of the visit. Upon completion of the session, Staff-C placed her blood pressure cuff and stethoscope inside her work bag. Staff-C then placed her pulse oximetry unit, hand weights and ankle weights inside plastic bags and inside her work bag. Staff-C did not clean any of her equipment prior to returning the items to her work bag. Additionally, Staff-C still had the same single pair of gloves on that were donned at the beginning of care. Upon conclusion of the visit, Staff-C was interviewed. When queried about the observations made during the visit, Staff-C offered no response. The Administrator was informed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”

“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 record review and interview, the agency failed to ensure the registered nurse included safety measures in the aide plan of care in 1 (P-6) of 2 records reviewed with home health aide services, resulting in the potential for the provision of unsafe care. Findings include: Based on record review and interview, the agency failed to ensure the registered nurse included safety measures in the aide plan of care in 1 (P-6) of 2 records reviewed with home health aide services, resulting in the potential for the provision of unsafe care. Findings include: Patient #6 (P-6) was admitted to the home care agency on 12/26/25 for pressure ulcer-stage 3 on left buttock, hypertension, heart failure-unspecified, and dysphagia. On 3/4/26, patient record review noted P-6 had a speech therapy (ST) evaluation during hospitalization on 12/12/26. ST documented, “No straws or regular cups” to reduce to risk of aspiration (accidental inhalation of swallowing liquids or food into the lungs) and enteral feeding (liquid nutrition directly into the stomach through a feeding tube) “four times a day.” Hospital discharge instructions on 12/17/25 documented, “Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped.” Hospital records also noted P-6 had multiple falls (11/30/25 and 12/1/25) as P-6 was “too close to the edge of the bed and couldn’t stop rolling and flipped of the bed.” During home admission on 12/26/25, the Plan of Care (POC) documented “Bed confinement status” due to the above falls risk and the use of a bedside commode. However, review of the aide plan of care on 3/4/25 found no documentation concerning safety instructions of P-6’s hospital bed regarding side rails to protect from additional falls, no acknowledgement to use the bedside commode, no aspiration precautions such as no straws/regular cups, and no documentation of the HOB being elevated related to feedings. The findings above were reviewed and acknowledged by the administrator (Staff-A) during an interview on 3/5/26 at 12:50 PM. Staff-A was further noted that this did not meet agency expectations.”

“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 provide proper written notice of non-coverage prior to terminating ongoing services for 1 (P-1) of 3 patients discharged from the agency’s services. Findings include: Patient #1 (P-1)’s start of care was 4/21/25 with diagnoses that included End Stage Heart Failure and Abnormal Gait. During the clinical record review on 3/2/26 at 11:45 a.m., it was noted that P-1 was discharged from the agency’s services on 6/4/25. Upon further review, it was noted that P-1 was issued and signed the notice of non-coverage on the same date she was discharged from the agency’s services. The agency failed to ensure the notice of non-coverage was provided prior to terminating services. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26.”

“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 to determine the immediate care and support needs of the patient, for 1 (P-2) of 1 patient in which nursing services was ordered, resulting in the delay in nursing services and the potential for decline in health status. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis that included Idiopathic Progressive Neuropathy. During the clinical record review on 3/2/26 at 2:40 p.m., it was noted that the referral for home care was dated 1/21/26. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the review, it was noted that the SN conducted the initial Comprehensive Assessment 6 days after the date of the referral on 1/27/26. There was no documented rationale for the delay in needed services. Further, there was no evidence that the Physician had been notified or approved the delay in care. The Administrator reviewed and acknowledged these findings during an interview on 3/5/26 at 10:05 a.m.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapist conducted the initial assessment visit within 48 hours of referral to determine the immediate care and support needs of the patient, for 1 (P-1) of 1 patient in which therapy services was ordered. Findings include: Patient #1 (P-1)’s start of care (SOC) was 4/21/25 with diagnoses that included End Stage Heart Failure and Abnormal Gait. During the clinical record review on 3/2/26 at 11:45 a.m., it was noted that the referral for home care was dated 4/16/25, and ordered Physical Therapy (PT) services to be provided. Upon further review, it was noted that PT conducted the initial assessment 5 days after the date of the referral. The PT failed to conduct the initial assessment within 48 hours of the referral to ascertain the patient’s immediate care needs and establish homebound status as per this requirement. Further, there was no documented evidence that the Physician was notified and/or approved of the delay in services. The Administrator reviewed and confirmed these findings during an interview on 3/5/26 at 9:55 a.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 ensure the comprehensive assessment accurately reflected the patient’s current health status in 3 (P-4, P-6 and P-7) of 7 records reviewed, resulting in a lack of information to aid in determining patient care needs and the potential for poor clinical outcomes. Findings include: Patient #6 (P-6): The start of care (SOC) to the agency was 12/26/25 and included diagnoses of a pressure ulcer-stage 3 on left buttock, hypertension, heart failure-unspecified, and dysphagia. On 3/4/26, patient record review noted P-6 had a speech therapy (ST) evaluation during hospitalization on 12/12/26. ST documented, “No straws or regular cups” to reduce to risk of aspiration (accidental inhalation of swallowing liquids or food into the lungs) and enteral feeding (liquid nutrition directly into the stomach through a feeding tube) “four times a day.” Hospital discharge instructions on 12/17/25 documented, “Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped.” The SOC comprehensive assessment failed to take note of and include any of the above findings. Subsequently, the plan of care for P-6 had no interventions/treatments to mitigate the above safety concerns. Patient #7 (P-7): The SOC was dated 3/16/25 and included diagnoses of heart disease with congestive heart failure, diabetes-type 2, and chronic kidney disease-stage 5. P-7 also had a diagnosis of “Dependence on supplemental oxygen” and review of the SOC comprehensive assessment documented an absence of “No Smoking” signs in P-7’s home. However, this finding had no evidence of being followed up on during the SOC assessment or any other assessments from admission through 4/6/25 (last entry in the medical record). On 4/6/25, P-7 was transferred to the hospital (reason unknown) with no resumption of care by the agency. The assessment failed to note when oxygen was started, how often P-7 required oxygen, and the patient’s response when using the oxygen. Another example is P-7’s diabetes with a diagnosis of “Long term (current) use of insulin”. The SOC assessment under “Endocrine” that details diabetic history failed to acknowledge the use of insulin and when the insulin was started or the management of insulin administration for P-7. The findings above were reviewed and acknowledged by the administrator (Staff-A) during an interview on 3/5/26 at 1:53 PM. Patient #4 (P-4): The start of care (SOC) to the agency was 7/31/25 with the diagnoses of breast cancer and pleural effusions. During the review of the medical records on 3/3/26 it revealed that P-4 was discharged from a senior nursing facility (SNF) on 7/30/25 to home with a pleurx drain (thin tube placed in the chest to drain excess fluid around the lungs, into a vacuum bottle). The discharge summary from the SNF noted that P-4 was being treated for pleural effusions and under the care of Pulmonology (lung doctor) with “pleurx drain since May 2025.” The notes further explained that the patient was seen by the SNF provider on 7/21/25 “for clarification orders… no orders for how often pleurx drain needs to be drained. Per review of pulmonology notes, will resume weekly draining. Dressing change with draining, needs to be sterile change.” The review the SOC comprehensive assessment noted under the “Respiratory Status: “Patient recently hospitalized for pleural effusion with tube to right side of chest wall intact. (Patient has return visit to dr for pleural effusion evaluation).” The assessment lacked documentation of a drain and or puncture site under the assessments of special treatments, potential risk for infection, and surgical wounds. Subsequently, the plan of care for P-4 was without interventions/treatments needed to manage the care of the pleurx drain. During the interview 3/5/26 at 2:11 PM the findings were reviewed and acknowledged by the Agency’s administrator (Staff-A).”

“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, interview and record review, the agency failed to ensure the Initial Comprehensive Assessment included a thorough and accurate review of all medications for 1 (P-2) of 1 patient observed during a home visit, resulting in the potential for harmful medication effects. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. During the record review on 3/2/26 at 2:40 p.m., it was noted that section M2001 of the comprehensive assessment completed by the Registered Nurse documented, “No issues found during review.” However, the agency’s drug interaction report revealed multiple moderate drug to drug interactions. On 3/3/26 at 11:15 a.m., a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, it was noted that there was no medication profile that listed all the patient’s medications. Further observations revealed a bag of prescription medications on the patient’s floor. When queried about the medications, P-2 responded, “I’ve had those medications ever since I first became sick.” When asked if she still takes any of the identified medications, P-2 said, “I don’t think so because there’s another bag of pills in the kitchen. My son takes care of that for me.” Based on the above findings, there was no evidence that the Registered Nurse included all the patient’s medications, including prescription and over the counter medications to determine any untoward interactions. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”

“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 (POC) included pertinent safety precautions in 2 (P-6, P-7) of 7 records reviewed, resulting in the potential for poor clinical outcomes and patient harm. Findings include: Patient #6 (P-6): The start of care (SOC) to the agency was 12/26/25 and included diagnoses of a pressure ulcer-stage 3 on left buttock, hypertension, heart failure-unspecified, and dysphagia. On 3/4/26, patient record review noted P-6 had a speech therapy (ST) evaluation during hospitalization on 12/12/26. ST documented, “No straws or regular cups” to reduce to risk of aspiration (accidental inhalation of swallowing liquids or food into the lungs) and enteral feeding (liquid nutrition directly into the stomach through a feeding tube) “four times a day.” Hospital discharge instructions on 12/17/25 documented, “Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped.” The POC for P-6 had no interventions or treatments to mitigate the above safety concerns. Patient #7 (P-7): The SOC was dated 3/16/25 and included diagnoses of heart disease with congestive heart failure, diabetes-type 2, and chronic kidney disease-stage 5. P-7 also had a diagnosis of “Dependence on supplemental oxygen” and review of the SOC comprehensive assessment documented an absence of “No Smoking” signs in P-7’s home. However, this finding had no evidence of being followed up on during the SOC assessment or any other assessments from admission to hospital transfer with no return on 4/6/25. The lack of oxygen safety precautions on P-7’s POC allowed the risk associated with oxygen use to go unrecognized. The findings above were reviewed and acknowledged by the administrator (Staff-A) during an interview on 3/5/26 at 1:49 PM.”

“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, record review and interview, the agency failed to ensure the physician was promptly notified of a significant change in condition for 1 (P-2) of 1 patient who experienced a significant reduction in weight, resulting in the potential for unidentified, underlying, untreated patient care concerns. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. On 3/2/26 at 2:40 p.m., during the clinical record review, it was noted that the skilled nursing (SN) visit notes documented the following: SN visit note dated 1/27/26 documented P-2’s baseline weight of 130 pounds (lbs.) It was unclear if this was an actual or stated weight. SN visit note dated 2/5/26 documented a weight of 129 lbs. SN visit note dated 2/10/26 documented a weight of 130 lbs. SN visit note dated 2/17/26 documented a weight of 111 lbs. This change reflected a 19 lb. unplanned weight loss. There was no documented evidence that the Physician had been promptly notified of this significant change in patient status. SN visit note dated 2/24/26 documented a weight of 112 lbs. On 3/3/26/at 11:15 a.m., a scheduled survey home visit was conducted with the Physical Therapist (Staff-C). During the visit, P-2 stated, “My doctor isn’t happy about my current weight. I’m currently at 112 lbs. I have to force myself to eat. I’m doing the best I can.” The agency failed to ensure the Physician was promptly notified of the patient’s sudden 19 lb. weight loss. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m. No additional response was offered.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that patient care services were coordinated to meet the clinical needs of a patient in 1 (P-7) of 2 records reviewed with hospital transfers, resulting in the potential for an unnecessary hospital transfer. Findings include: Patient #7 (P-7): This patient was admitted to the home care agency on 3/16/25 and included diagnoses of heart disease with congestive heart failure (CHF), diabetes-type 2, and chronic kidney disease-stage 5. The physician face to face with home care referral dated 3/5/25, documented the following concerning the health care acuities of P-7: “10 admissions this year for CHF... Was seen at (Hospital) on 2/26 for IV diuresis without a change in her weight and continued with NYHA class 4 (most severe stage of heart failure) symptoms... 2/10/26 - Admitted to (Hospital) for acute decompensated HFrEF (heart failure with reduced ejection fraction) and acute hypoxic resp failure.” (sic) On 3/5/26, (Hospital physician) further documented, “If possible, would obtain standing weights given discrepancy between reported weight and bed scale weight.” On 3/4/26, record review noted the plan of care (POC) ordered a skilled nursing (SN) visit frequency of 1WK1, 2WK1 (twice a week for 1 week), and 1WK6 effective 3/16/25. Further record review found the following concerns given the high risk for complications based on the history above: On 3/20/25, SN (Staff-J) provided a home visit and documented P-7’s oxygen saturation was 90% on room air, down from 95% (room air) on 3/18/25 and 93% (room air) during admission on 3/16/25. The assessment section under “Respiratory” was blank other than a checked box noting intermittent oxygen use of 2 Liters per minute. No physician communication or follow-up visit by the agency was coordinated to assess if the 90% oxygen reading was an aberration or a continuing trend. P-7 was transferred to the hospital 4 days later on 3/24/25 due to CHF exacerbation (worsening) symptoms. P-7 was discharged from the hospital, and the agency performed a ROC (resumption of care) visit on 3/28/25. Record review found no physician discharge summary that described the treatments, interventions and clinical findings resultant from the hospital admission on 3/24/25. No documented effort was found in agency records that this information was requested, which would be vital for the ROC nurse to know in updating the POC to mitigate the risk of further hospitalization. The SN visit frequency was kept at once weekly times 4 weeks. Also, record review found 4 of 4 SN visits failed to note how P-7’s weights were obtained (stated vs. actual by standing) as documented by the physician on 3/5/25 to ensure accuracy. No assessments or communication by the agency was provided until a missed visit note by SN on 4/3/25 due to an appointment for P-7 that day. No attempts of efforts were documented to assess or visit P-7 the rest of the week ending on 4/5/25. The patient was once again transferred to the hospital on 4/6/25 with no return and subsequent discharge from the agency. No SN visits were provided after the ROC visit (9 days), and no coordinated effort was made by the agency via SN, the physician, and agency administration to ensure appropriate monitoring and hospital clinical findings were in place to meet the clinical needs of this patient. The findings above were reviewed and acknowledged by the administrator (Staff-A) on 3/5/26 at 1:32 PM. Staff-A noted this did not meet agency expectations nor its policy referenced below. Agency Policy: “Care Coordination/Case Conferences) III.16 (undated) stated, “Assure communication and coordination of services in patient-goal directed activity on the part of each team member... Provide an arena for team members to discuss problematic concerns.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to provide 1 (P-2) of 3 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient’s prescribed medications, in plain language, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. On 3/3/26 at 11:15 a.m., a scheduled survey home visit was conducted with the Physical therapist (Staff-C). During a review of the patient’s admission packet, it was noted that the Medication Profile was blank. During the visit, Staff-C stated, “The nurse is usually responsible for the medication list.” The agency failed to ensure a Medication Profile was in place that listed the patient’s prescribed medications, dosages and side effects as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include contact information for the Home Health Agency’s Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 3/2/26 at 10:25 a.m. the agency’s Admission Packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms and Emergency Preparedness documents. Upon review, it was noted that there was no contact information for the agency’s Clinical Manager. The Administrator reviewed and acknowledged these findings during an interview on 3/5/26 at 10:20 a.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure Occupational Therapy services were provided as ordered by the Physician and in the Plan of Care for 1 (P-2) of 2 patients with Occupational Therapy services ordered; and failed to ensure Speech Therapy services were provided for as ordered for 1 (P-6) of 1 patient with Speech Therapy services ordered, resulting in the potential for physical decline, and unmet care needs. Findings include: Patient #6 (P-6) was admitted to the home care agency on 12/26/25 for pressure ulcer-stage 3 on left buttock, hypertension, heart failure-unspecified, and dysphagia. On 3/4/26, patient record review noted the following hospital physician order dated 12/18/25: “DISCHARGE resident to home with discharge instructions and medications, HHC (home health care) Nurse, Nurse Aide, PT/OT, SLP (speech-language pathologist).” Further review of P-6’s Plan of Care/orders found no evidence that SLP services were provided from admission through survey exit on 3/5/26. In addition, no documentation was found of any refusal by P-6 (oriented times 2-3) and no notification to the physician that SLP services would not be provided as ordered. The findings above were reviewed and acknowledged by the administrator (Staff-A) during an interview conducted on 3/5/26 at 12:56 PM. Staff-A further acknowledged that all services ordered on the home care referral should have documentation of why they were not provided with another physician order. Patient #2 (P-2)’s start of care was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. During the clinical record review on 3/2/26 at 2:40 p.m., it was noted that a Physician’s order dated 1/27/26 ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The Physician’s signed Plan of Care ordered SN, PT and OT services to be provided. At the time of this review, no OT services had been provided as ordered. Additionally, no OT services had been provided by the survey’s exit on 3/5/26. Further, there was no documented evidence that P-2 declined to receive OT services. The Administrator reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”

“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, the agency failed to ensure a clinical manager was available during operating hours, resulting in the potential for unmet health care needs for all 12 patients currently receiving services at the time of the survey. Findings include: During the survey entrance conference on 3/2/26 at 9:50 AM, the agency’s administrator stated the clinical manager was on vacation and the alternate administrator was providing coverage. However, presence of a clinical manager was not observed or noted throughout any of the survey, which was conducted during normal operating business hours from 3/2/26 through 3/5/26 during the hours of 9:30 AM through 3:30 PM. The findings above were reviewed and acknowledged by Staff-A during an interview at the survey’s exit conference on 3/5/26 at 3:05 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 a detailed discharge summary was sent to the physician within 5 business days of discharge for 4 (P-1, P-2, P-4, and P-7) of 4 patients who were discharged from the agency or agency services, and failed to ensure a transfer summary was sent to the physician within 2 business days for 2 (P-4, P-7) of 2 patients requiring transfer of care, resulting in lack of information to aid in post-discharge/transfer continuity of care. Findings include: Patient #7 (P-7): The SOC was dated 3/16/25 and included diagnoses of heart disease with congestive heart failure (CHF), diabetes-type 2, and chronic kidney disease-stage 5. On 3/4/26, patient record review noted P-7 was transferred to the hospital on 3/24/25 due to CHF exacerbation (worsening) symptoms. P-7 was discharged from the hospital, and the agency performed a ROC (resumption of care) visit on 3/28/25. The patient was once again transferred to the hospital on 4/6/25 with no return and subsequent discharge from the agency. The findings above were reviewed and acknowledged by the administrator (Staff-A) on 3/5/26 at 1:32 PM. Staff-A was requested to show evidence that the transfer and discharge summaries were sent to the physician. Staff-A responded that the agency notifies the physician of transfers and discharges but acknowledged the agency does not have a system in place that time stamps and captures when all the summaries are sent to the physician. No evidence was found during the interview that showed the above transfer and discharge summary were sent to the physician within the required timeframes (2 business of transfer and 5 business days of discharge). Patient #4 (P-4) was admitted to the agency, episode 7/31/25 through 9/8/25, with the diagnoses of breast cancer and pleural effusions. Review of records on 3/3/26 revealed that P-4 required emergency care and ultimately hospitalization twice (8/7/25 and 8/17/25) during the episode period. A Transfer OASIS (outcome and assessment information set) was completed by skilled nursing on 8/7/25 and 8/17/25 and noted that copies of the transfer summaries were sent to the “Physician” one day after the transfers were documented (8/8/25 and 8/18/25). Additional review of records noted a Transfer Discharge OASIS dated 9/2/25 with marked boxes that the “Inpatient receiving facility” and the “Physician” were sent a transfer summary on 9/3/25. There is no documented evidence that the summaries were forwarded to the physician within 2 days of the date(s) of transfer or 5 days of the date of discharge. During an interview on 3/5/26 at 2:15 PM with the Agency administrator (Staff-A) the above findings were reviewed. Staff-A explained that transfer and discharge summaries are sent out via fax. Staff-A shared a document of the agency’s record keeping of transfer and discharge summaries being sent out. The record did not include who the summaries were sent to. During the interview Staff-A continued to search in the archived faxes for evidence that the transfer summaries were forwarded to the physician and announced, “One was sent out on 8/21/25, the 5th day”. Noted that is outside the requirement of the 2 business days on which the agency is to send physicians the transfer summary. Staff-A acknowledged the findings above that the agency failed to provide documented evidence that the transfer and discharge summaries were sent to the physician within the required timeframes, which did not meet agency expectations or their policy referenced below. A review of agency policy titled “Discharge Planning, Discharge Summary and Discharge OASIS”, (undated), revealed … “All discharge summaries shall be sent to the patient’s physician within 5 days of the patient’s discharge from services”. Patient #1 (P-1)’s start of care (SOC) was 4/21/25 with diagnoses that included End Stage Heart Failure and Abnormal Gait. During the clinical record review on 3/2/26 at 11:45 a.m., it was noted that the Physical Therapist (PT) discharged P-1 from the agency’s services on June 4, 2025. The Administrator (Staff-A) reviewed the above findings during an interview on 3/5/26 at 9:55 a.m. and presented a document which gave a date in which the Physician was “notified.” Upon further review, there was no documented evidence that a PT Discharge Summary was forwarded to the Physician within 5 days of the date of discharge. P-2’s SOC was 1/27/26 with a diagnosis of Idiopathic Progressive Neuropathy. During the record review on 3/2/26 at 2:40 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) and PT services. The patient was discharged from SN services on 2/24/26. Upon further review, there was no documented evidence that a SN discharge Summary was forwarded to the Physician within 5 days of the date of discharge. Staff-A reviewed and acknowledged the above findings during an interview on 3/5/26 at 10:05 a.m.”