Alpha Therapeutics, PC

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, record review and interview, it was determined that the Physical Therapist failed to monitor standing and active blood pressure in 1 (P-3) of 1 record reviewed with Orthostatic Hypotension (see G708); the agency failed to ensure services were provided as ordered by the physician as indicated in the plan of care in 2 (P-4 and P-7) of 7 records reviewed (see G710); failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 (P-1) of 7 records reviewed (see G714); and failed to ensure the clinical record was completed and included detailed Physical Therapy notes for 1 (P-6) record with the ordered services, from a total of 7 sampled records reviewed (See G716). The cumulative effect of these systemic failures resulted in a potential hospitalization for unidentified patient needs; the possibility for decline in physical functioning and unmet care needs; and the physician not having a complete clinical picture of the patient’s health status during the period of care.”

“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 1 (P-6) of 1 patient whose record was reviewed, received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, resulting in the patient not receiving services based on their identified needs. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During a review of the clinical record on 1/21/26 at 11:00 a.m., it was noted that no Plan of Care (POC) had been established that included interventions, reportable parameters and associated measurable goals that directed staff on the course of care to be provided. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 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 the medical record was clear and complete in 1 (P-4) of 7 records reviewed, resulting in the potential for and unclear and incomplete medical record. Findings include: Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted a physical therapy goal on the plan of care stated the following: “Patient will improve balance as evidenced by the Tinetti score from 3/5 to 3+/5 - 4/5 to allow patient to walk safely.” [sic] This was a documentation error as “3/5 to 3+/5 – 4/5” is a measurement for manual muscle testing, not a Tinetti score. Additionally, it was noted a physical therapy note dated 6/20/25 stated, “Monitor vital signs/blood sugar/diabetic foot care” under “Summary of Patient Overall Performance on this Visit.” This was a documentation error as this patient is not diabetic. A review of agency policy titled “Medical Record Content” (revised February 2024) revealed, “1. The Agency will initiate and maintain and individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations.” The administrator (Staff A) and the alternate administrator (Staff B) acknowledged the findings during an interview on 1/26/26 at 1:30 PM.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were able to consent to or refuse care in advance of treatment in 2 (P-1, P-4) of 7 records reviewed, resulting in the potential for a violation of patient rights. Findings include: Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted the plan of care (dated 5/29/25) ordered services from skilled nursing, physical therapy, and occupational therapy. Upon review of the consent form signed by the patient at the start of care (also dated 5/29/25), it was determined the patient accepted services from skilled nursing and physical therapy. There was no frequency listed next to occupational therapy to indicate the patient accepted services. Upon further review of the record, it was determined P-4 started occupational therapy on 5/30/25 without providing consent first. A review of agency policy titled “Consent” (revised February 2024) revealed, “1. All care provided by the Agency requires consent for care.” The policy also revealed, “10. The patient has the right to participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to:…The disciplines that will furnish the care.” The administrator (Staff A) and the alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 1/26/26 at 1:30 PM. Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the referral stated, “Order Description: Discharge to assisted living facility on 1/19/25 home with home health care, RN (Registered Nurse), aide (Home Health Aide), PT (Physical Therapy) SLP (Speech Language Pathologist), and OT (Occupational Therapist)”. The consent signed by the patient on 1/23/25 and the comprehensive assessment completed by the RN on 1/23/25 were blank under the SLP and Home Health Aide (HHA) section and there was no documentation of the patient refusing SLP and HHA. The agency failed to provide services as ordered and consented to. The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was completed within 48 hours of referral in 1 (P-4) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted the referral to start home care services was written on 5/21/25 and faxed to the agency on 5/23/25. Upon further review of the record, it was noted the initial assessment did not occur until 5/29/25 – 6 days after the referral was received by the agency. A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2024) revealed, “A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner-ordered start of care date.” During an interview with the administrator (Staff A) on 1/26/26 at 1:30 PM, Staff A was asked about the delay in the initial assessment. Staff A provided evidence of a verbal order dated 5/29/26 which indicated, “Patient requested SOC date of 05/29/2025, Dr. agrees to SOC date of 05/29/2025.” [sic] This order was dated after the initial assessment was due. After further review, Staff A reported the electronic medical record system will not allow her to choose a date prior to the start of care date for verbal orders, even if it was received prior to that date. However, Staff A was unable to provide evidence of communication with the patient or physician regarding the start of care date prior to 5/29/25. Staff A acknowledged the findings at the time of interview.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Initial Comprehensive Assessment was complete and accurately reflected the needs of 6 (P-1, P-2, P-3, P-4, P-6, and P-7) of 7 records reviewed, resulting in the potential for unidentified, untreated health care needs. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure with Hypoxia. During the clinical record review on 1/21/26 at 11:00 a.m., it was noted that the Initial Comprehensive Assessment, dated 12/19/25, completed by the Physical Therapist documented the patient’s 8 diagnoses as having exacerbated on the date of admission to the agency (12/19/25). There was no further documented information regarding the diagnoses. Additionally, the Skilled Nursing evaluation dated 12/22/25 was noted to be incomplete. The above documents did not accurately reflect the needs of the patient at the time of admission. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m. Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted the comprehensive assessment listed a total 17 diagnoses with a start date of 5/29/25. These included diagnoses such as “Personal history of nicotine dependence” and “Long term (current) use of opiate analgesic,” further showing that all the listed diagnoses were not new. The comprehensive assessment failed to document a clear picture of the patient’s health status at the time of admission. Patient #7 (P-7) was admitted to this home care agency on 12/11/25 with the diagnoses of right knee osteoarthritis and repeated falls. During record review on 1/2/26, it was noted the comprehensive assessment listed a total of 16 diagnoses with a start date of 12/11/25. These included diagnoses such as “Long term (current) use of insulin” and “Long term (current) use of oral hypoglycemic drug,” further showing that all the listed diagnoses were not new. The comprehensive assessment failed to document a clear picture of the patient’s health status at the time of admission. A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2024) revealed, “8. The Initial Comprehensive Assessment also includes: Relevant diagnoses and current health status, including all active health and medical problems.” The administrator (Staff A) reviewed and acknowledged the findings during an interview on 1/22/26 at 2:30 PM. Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the SOC comprehensive assessment dated 1/2325, documented under “Primary Diagnosis and Other Diagnoses”, all 18 diagnoses had an onset and exacerbation date of 1/23/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. Patient #2’s (P-2) Start of Care (SOC) was dated 12/17/25. The Plan of Care (POC) identified diagnoses of Acute Embolism, Muscle Wasting and Hypertension. During record review on 1/22/26, it was noted that the SOC comprehensive assessment dated 12/17/25, documented under “Primary Diagnosis and Other Diagnoses”, all 10 diagnoses had an exacerbation date of 12/17/25. No onset, 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 10/9/25. The Plan of Care (POC) identified diagnoses of Orthostatic Hypotension, Dorsalgia, Unsteadiness on Feet, Hypertensive Chronic Kidney Disease, Diabetes Type 2 and Falls. During record review on 1/22/26, it was noted that the SOC comprehensive assessment dated 10/9/25, documented under “Primary Diagnosis and Other Diagnoses”, all 18 diagnoses had an exacerbation date of 10/9/25. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure activity of daily living needs were adequately met in the patient’s home for 1 (P-6) of 1 patient who required assistance with grooming, resulting in the potential for low self-esteem, poor hygiene and unmet care needs. Findings include: Patient (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During the clinical record review on 1/21/26 at 11:00 a.m., it was noted that the Initial Comprehensive Assessment dated 12/19/25, completed by the Physical Therapist (PT), documented, “Relevant Medical History..., Patient is 93 y/o male with PMH of Hypertension, Anemia, Polycythemia, DVT (deep vein thrombosis) with chief complaints of shortness of breath, was admitted to (hospital name). Patient was diagnosed with pneumonia. At Present patient continues to have difficulty in performing ADLs (activities of daily living) including bed mobility, transfers, balance and gait. Patient has good rehab potential and needs PT services..., Patient is confined because of illness, needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers..., Patient is incontinent.” Section M1100 stated, “Patient lives with other persons in the home, occasional short-term assistance.” Section M2102 stated, “Non-agency caregivers need training and supportive services to provide assistance.” Upon further review, there was no documented available or willing caregiver to provide assistance with grooming. Additionally, there was no documented evidence that a home health aide was offered or provided to assist with grooming. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to identify potential drug interactions or drug duplications and an accurate medication profile in 6 (P-1, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed, resulting in the potential for harmful drug interactions and poor patient outcomes. Findings include: Patient (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During a review of the clinical record on 1/21/26 at 11:00 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented, “Yes-issues found during review.” Section M2003 documented, Physician notified. Upon further review, there was no drug interaction report available for review and no indication of what untoward findings were reported to the Physician. The agency failed to provide documented evidence to support that a drug review had actually been conducted or that the Physician had been notified of the findings, as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m. Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was determined the record included a “Patient Medication Record” that listed P-4’s medications. This form also documented that “MD notified and is aware of medication interaction and duplicate analgesics, and laxatives medication.” [sic] Upon further review of the medication profile, it was determined there was no evidence of what specific issues were identified to report to the physician. Patient #5 (P-5) was admitted to this home care agency on 12/24/25 with the diagnoses of left shoulder pain and a history of falling. During record review on 1/22/26, it was determined the record included a “Patient Medication Record” that listed P-5’s medications. This form also documented that “MD notified and is aware of medication interaction and duplicate analgesics, and laxatives medication.” [sic] Upon further review of the medication profile, it was determined there was no evidence of what specific issues were identified to report to the physician. Patient #7 (P-7) was admitted to this home care agency on 12/11/25 with the diagnoses of right knee osteoarthritis and repeated falls. During record review on 1/2/26, it was determined the record included a “Patient Medication Record” that listed P-7’s medications. This form also documented that “MD notified and is aware of medication interaction and duplicate analgesics, and laxatives medication.” [sic] Upon further review of the medication profile, it was determined there was no evidence of what specific issues were identified to report to the physician. Additionally, was noted the medication profile indicated the patient was only allergic to “sulfa drugs.” However, upon review of the referral from the physician dated 12/9/25, it was determined P-7 was allergic to latex, “substance with medication sulfonamide structure” (sulfa drugs), and cephalexin. During a home visit with P-7 and the physical therapist (Staff C) on 1/22/26 at 10:00 AM, it observed that a white board on the wall in P-7’s kitchen displayed the following insulin dosages: “Breakfast 10, Lunch 18, Dinner, 12, Am – 30 first thing.” [sic] Upon review of the medications listed on the medication profile, it was noted the medication profile indicated insulin dosages as follows: “…inject 8 units at breakfast, 18 units at lunch, 12 units at dinner” [sic], and basaglar (another diabetic medication) at “32 units administer under skin daily.” [sic] During an interview with P-7 at 11:00 AM, P-7 was asked if the insulin dosages on her white board were correct. Without looking at the white board, P-7 stated “yes” and was able to repeat the dosages on the board. P-7 was asked if there had been any recent changes to her dosage. P-7 stated there were no recent changes, and she been taking that amount for a “long time”. Upon an interview with Staff C at 11:05 AM, Staff C stated she wrote down the dosages on the bottles in P-7’s apartment and that P-7’s daughter may have changed the dosages on her own. However, Staff C acknowledged she did not confirm with the patient if she was taking what was listed on the bottle and stated she would contact the physician to let him know. A review of agency policy titled “Medication Reconciliation” (revised February 2024) revealed, “1. At the time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency.” The policy also revealed, “Any concerns or discrepancies will be reconciled by a RN with the patient’s physician/practitioner” and “Discrepancies include duplications, omissions, changes, contraindications and/or unclear information.” During an interview with the administrator (Staff A) and alternate administrator (Staff B) on 1/26/26 at 1:30 PM, Staff A and Staff B were asked if the records contained documentation of what specific interactions were identified for each patient. Staff A stated the identified interactions “disappear” after the report is run, and the only way she knew to see them again was to run a new report. Staff A stated she thought it was an issue with the electronic medical record system. Staff A and Staff B reviewed and acknowledged all the findings above at the time of interview. Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the Skilled Nurse (SN) completed a comprehensive assessment on 1/23/25 that stated, “Medication Administration Record: Medication 1: High-risk Norco, Ultram… Physician contacted Re: SOC, POC, medication reconciliation completed.” The medication profile completed by the SN on 1/23/25 stated, “Physician notified of severe medication interactions? Yes. Please explain: Blank.” There is no documented evidence that the physician was made aware of the high-risk interaction between Norco and Ultram. Patient #3’s (P-3) Start of Care (SOC) was dated 10/9/25. The Plan of Care (POC) identified diagnoses of Orthostatic Hypotension, Dorsalgia, Unsteadiness on Feet, Hypertensive Chronic Kidney Disease, Diabetes Type 2 and Falls. During record review on 1/22/26, it was noted that the referral stated, “Insulin Glargine (100unit/ml(3 mL) Insulin Pen, 12 units subcutaneous daily) Active.” The Physical Therapist completed the medication profile on 10/19/25 and stated, “Lantus SoloStar Subcutaneous 100 UNIT/ML 1 Daily… Physician contacted regarding medication discrepancies: Yes. Please explain: Blank. Action taken: Yes. Please explain: Blank. Physician notified of severe medication interactions? Yes. Please explain: Blank.” The comprehensive assessment completed by the PT on 10/9/25 stated, “Physician Contacted Re: SOC, POC, medication reconciliation completed.” There is no documented evidence of what the medication discrepancies and severe medication interactions were and the Lantus dose is not accurate. A review of the agency policy occurred on 1/26/26 titled “Medication Reconciliation” (Revised February 2024). The policy states, “Policy: The Agency will reconcile patient’s medications at time of admission and on an ongoing basis 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 non-compliance with therapy… Procedure: 1. At time of admission, the admitting RN, PT or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Any concerns or discrepancies will be reconciled by a RN with the patient’s physician/practitioner…” The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 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 included all required information in 4 (P-1, P-4, P-5, and P-7) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted the comprehensive assessment by the skilled nurse on 5/29/25 indicated the patient had a pain level of 5 out of 10. Upon further review of the record, it was determined the plan of care failed to include parameters to monitor pain levels for a patient with identified pain. Additionally, the plan of care listed 17 diagnoses with a start date the same as the date of admission (5/29/25). However, the plan of care failed to include interventions or goals to address each diagnosis listed. Patient #5 (P-5) was admitted to this home care agency on 12/24/25 with the diagnoses of left shoulder pain and a history of falling. During record review on 1/22/26, it was noted the comprehensive assessment by the physical therapist dated 12/25/25 indicated the patient had 8 out of 10 pain in her left shoulder. Upon further review of the record, it was determined the plan of care failed to include parameters to monitor pain levels for a patient with identified pain. Additionally, it was noted physical therapy notes dated 1/6/26 and 1/9/26 documented an intervention of “BL shoulder STM with sub zero pain gel x 5 mins each” [sic] (soft tissue massage to both shoulders). However, the plan of care failed to include an intervention for manual therapy or massage. Patient #7 (P-7) was admitted to this home care agency on 12/11/25 with the diagnoses of right knee osteoarthritis and repeated falls. During record review on 1/2/26, it was noted the comprehensive assessment indicated the patient had a diagnosis of diabetes. Upon further review of the record, it was determined the plan of care failed to include diabetic supplies. Additionally, the plan of care listed 16 diagnoses with a start date the same as the date of admission (12/11/25). However, the plan of care failed to include interventions or goals to address each diagnosis listed. A review of agency policy titled “Plan of Care” (reviewed February 2024) revealed, “4. The individualized plan of care must include the following:…The types of services, supplies and equipment required…All medications and treatments, Safety measures to protect against injury…”. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 1/26/26 at 1:30 PM. Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w1 (1 time a week for 1 week), 2w1, 1w1. The POC contained an order stating, “SN to cleanse wounds with wound cleanser, apply hydrocolloid to each wound.” The agency failed to document the frequency of the wound care order. A review of the agency policy occurred on 1/26/26 titled “Care Planning Process” (Revised February 2024). The policy states, “5. Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: …Specific care or services to be provided including frequency, type and duration.” The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm.”

“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 record review and interview, the agency failed to generate a Medication Profile that listed the patient’s prescribed medications, frequencies and dosages for 1 (P-6) of 7 records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During a review of the clinical record on 1/21/26 at 11:00 a.m., it was noted that no Medication Profile had been generated that listed all the patient’s medications, dosages and frequencies, as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on record review and interview, the Physical Therapist failed to monitor standing and active blood pressure in 1 (P-3) of 1 record reviewed with Orthostatic Hypotension, which resulted in the potential hospitalization for a fall. Findings include: Patient #3’s (P-3) Start of Care (SOC) was dated 10/9/25. The Plan of Care (POC) identified diagnoses of Orthostatic Hypotension, Dorsalgia, Unsteadiness on Feet, Hypertensive Chronic Kidney Disease, Diabetes Type 2 and Falls. Per Mayo Clinic, Orthostatic Hypotension is defined as a form of low blood pressure that happens when standing after sitting or lying down. This can cause dizziness or lightheadedness and possibly fainting. This involves measuring blood pressure while sitting and standing. During record review on 1/22/26, it was noted that the POC ordered Physical Therapy (PT) at a frequency of 2w4 (2 times a week for 4 weeks), 1w4. The Physical Therapist completed a comprehensive assessment on 10/9/25 and stated, “Homebound? Yes. Specify: Due to recent lumbar radiculopathy, debility, the patient is unable to leave the house alone… History of falls (2 or more falls – or any fall with an injury – in the past 12 months)… Patient c/o (complains of) pain in lower back and LE (Lower Extremity), patient was referred from Dr (Doctor) office to try physical therapy for pain and strengthening… Patient lives in ranch house with husband, patient has RW (Rolling Walker), and tub shower chair. Patient was independent in all ADL (Activities of Daily Living) with RW prior to hospitalization two months ago, patient now uses RW. Current functional level: Patient needs 1 person assist for transfer and ambulation, pain in lower back, sob (shortness of breath) with ambulation, unable to do 2 step to enter and exit house…patient needs MINA (Minimal Assistance) for transfer from bed/chair due to dizziness upon standing… patient able to ambulate 25 ft with RW needs MINA and close WC (Wheelchair) to follow due to dizziness and hypotension associated with change in position, patient needs skilled therapy to prevent fall, to improve strength, balance and safe gait…” The Physical Therapist completed blood pressure monitoring sitting prior to exercises on 10/9/25, 10/10/25, 10/14/25, 10/17/25, 10/20/25, 10/30/25 and the 30-day evaluation on 11/3/25. On 11/10/25, the Physical Therapist completed a Transfer stating, “Reason for Hospitalization: Injury caused by fall.” On 11/18/25, the Physical Therapist completed a resumption of care stating, “Medical Diagnosis: Fall, right rotator cuff injury, soft tissue injury… Patient recently hospitalized due to fall at home. Patient discharged now from hospital and referred back to home care. Patient now c/o pain in right shoulder and elbow due to soft tissue injury. Patient demonstrates decreased strength and ROM (Range of Motion) in right shoulder… patient continues to demonstrate difficulty in walking, able to ambulate 10 ft with RW. Patient needs MOD A (Moderate Assistance) for bed mobility and transfer.” The agency failed to monitor during and post blood pressure readings that could have potentially avoided the patients fall and hospitalization. The Administrator (Staff A) and Alternate Administrator/PT (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm. The Physical Therapist was questioned regarding Orthostatic Hypotension and exercises and stated, “I should have been checking the patients’ blood pressure during and after exercises. A review of the agency policy occurred on 1/26/26 titled “Plan of Care – CMS #485 and Physician Orders” (Revised February 2024). The policy states, “4. The individualized plan of care must include the following: Patient-specific interventions and education, measurable outcomes and goals identified by the Agency and the patient.” A review of the agency policy occurred on 1/26/26 titled “Care Planning Process” (Revised February 2024). The policy states, “Procedure: 1. The patient care plan for therapy services (PT, OT and SLP) will be: …All initial and ongoing assessments will utilize relevant baseline date to determine patient problems, needs, interventions and goals. A review of the agency job description occurred on 1/26/26 titled “Registered Physical Therapist” (Revised February 2022). The job description states, “Responsibilities: 1. Understands and adheres to established policies and procedures… 17. Helps develop the plan of care and revise as necessary...””

“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 services were provided as ordered by the physician as indicated in the plan of care in 2 (P-4 and P-7) of 7 records reviewed, resulting in the potential of unmet care needs and poor patient outcomes. Findings include: Patient #4 (P-4) was admitted to this home care agency on 5/29/25 with the diagnoses of acute kidney failure, hypertensive heart disease without heart failure, and ataxia. During record review on 1/21/26, it was noted the plan of care ordered services from skilled nursing 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 4 weeks. Upon further review of the record, it was noted P-4 did not receive any additional visits from skilled nursing after the initial visit on 5/29/25. During an interview with the administrator (Staff A) on 1/26/26 at 1:30 PM, Staff A located a note on the Outcome and Assessment Information Set (OASIS) form documented under a section titled “Orders for Discipline and Treatment” that P-4 “refused further SN visits.” However, Staff A acknowledged that is not what was written on the plan of care and agreed upon by the physician. There were also no additional orders written to discontinue skilled nursing services. Staff A acknowledged the findings at the time of interview. During further record review for P-4 on 1/21/26, it was noted a missed visit was documented on 6/17/25 by the physical therapist. According to the missed visit note, the doctor was notified by fax, however, there was no documentation that there was an attempt to reschedule the missed visit to meet the frequency ordered in the plan of care. Additionally, it was noted a missed visit was documented on 6/19/25 by the occupational therapist. According to the missed visit note, the doctor was notified by phone, however, there was no documentation that there was an attempt to reschedule the missed visit to meet the frequency ordered in the plan of care. Patient #7 (P-7) was admitted to this home care agency on 12/11/25 with the diagnoses of right knee osteoarthritis and repeated falls. During record review on 1/2/26, it was noted a missed visit was documented on 12/12/25 and 12/25/25 by the physical therapist. According to both missed visit notes, the doctor was notified by fax, however, there was no documentation that there was an attempt to reschedule the missed visit to meet the frequency ordered in the plan of care. During an interview with the administrator (Staff A) on 1/26/26 at 1:30 PM, Staff A was asked to provide the agency policy regarding missed visits. Staff A stated she wasn’t able to find that policy, however, Staff A stated the agency expectation was to attempt to reschedule the missed visit that week, if possible, to meet the frequency ordered in the plan of care. Staff A was asked where attempts to reschedule were documented, however, Staff A stated she did not think it was being documented by staff, even if they attempted to reschedule a visit. Staff A acknowledged the findings at the time of interview.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 (P-1) of 7 records reviewed, for a potential of improper wound care and unmet care needs. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w1 (1 time a week for 1 week), 2w1, 1w1. The POC stated, “SN to cleanse wounds with wound cleanser, apply hydrocolloid to each wound… Goal: … Wound(s) will heal without complication by: 2/8/2025.” The comprehensive assessment completed by the SN on 1/23/25 stated, “Patient lives in congregate situation (for example, assisted living, residential care home)… Wound 1 – Location: Left dorsal 5th toe… Stage: 2 – Size: Length: 0.9cm, Width: 0.9cm, Depth: 0.1cm… Wound 2 – Location: Left proximal great toe… Stage: 2 – Size: Length: 1.5cm, Width: 1.2cm, Depth: 0.1cm… Wound 3 – Location: Right great toe… Stage: 2 – Size: Length: 0.1cm, Width: 0.2cm, Depth: 0.1cm… Wound 4 – Location: Right dorsal foot… Stage: 2 – Size: Length: 0.6cm, Width: 0.5cm, Depth: 0.1cm… Wound 5 – Location: Right proximal dorsal foot… Stage: 2 – Size: Length: 0.2cm, Width: 0.3cm, Depth: 0.1cm… Wound 6 – Location: Right dorsal ankle… Stage: 2 – Size: Length: 0.3cm, Width: 0.3cm, Depth: 0.1cm… Wound 7 – Location: Right dorsal ankle distal to #6 (Wound 6)… Stage: 2 – Size: Length: 0.2cm, Width: 0.4cm, Depth: 0.1cm…” The SN completed 2 additional visits on 1/27/25 and 1/31/25 that contained wound measurements. On 1/31/25, the SN documented, “Wound 1 – Location: Left dorsal 5th toe… Stage: 2 – Size: Length: 0.5cm, Width: 0.5cm, Depth: 0.1cm… Wound 2 – Location: Left proximal great toe… Stage: 2 – Size: Length: 0cm, Width: 0cm, Depth: 0cm… Wound 3 – Location: Right great toe… Stage: 2 – Size: Length: 0.1cm, Width: 0.1cm, Depth: 0.1cm… Wound 4 – Location: Right dorsal foot… Stage: 2 – Size: Length: 0.3cm, Width: 0.4cm, Depth: 0.1cm… Wound 5 – Location: Right proximal dorsal foot… Stage: 2 – Size: Length: 0.2cm, Width: 0.3cm, Depth: 0.1cm… Wound 6 – Location: Right dorsal ankle… Stage: 2 – Size: Length: 0.3cm, Width: 0.3cm, Depth: 0.1cm… Wound 7 – Location: Right dorsal ankle distal to #6 (Wound 6)… Stage: 2 – Size: Length: 0.2cm, Width: 0.4cm, Depth: 0.1cm…” On 2/7/25, the SN completed a “Missed Visit” and “Discharge Summary” The missed visited stated, “Reason: Patient – Family Uncooperative. Comments: Blank.” The Discharge Summary stated, “Reason for Discharge: Goals met / max potential reached… Goals Not Met: Blank… Information provided for continuing needs / Specific discharge instructions: Blank.” There is no documented evidence of wound care education provided to the patient and or caregiver. The agency discharged a patient with active wounds with no documentation of who would manage and treat, thus potentially resulting in a negative patient outcome of worsening wounds. A review of the agency policy occurred on 1/26/26 titled “Plan of Care – CMS #485 and Physician/Practitioners Orders” (Revised February 2024). The policy states, “Procedure: 2. Each patient must receive an individualized written plan of care...The individualized plan of care must also specify the patient and caregiver education and training. 4. The individualized plan of care must include the following: Patient and caregiver education and training to facilitate timely discharge… patient-specific interventions and education, measurable outcomes and goals identified by the Agency and the patient… Skilled professionals follow the plan of care and minimally perform: Patient, family and caregiver counseling and education...” A review of the agency policy occurred on 1/26/26 titled “Discharge Summary” (Revised February 2024). The policy states, “Procedure: 1. A Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist. The Discharge Summary will include, but is not limited to: …Patient/family post-discharge instructions, goals and treatment preferences.” The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm and stated, “The patient should not have been discharged without documented evidence of a caregiver being able to complete the wound care or the wounds being healed.””

“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 completed and included detailed Physical Therapy notes for 1 (P-6) of 1 record reviewed with the ordered services, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During the clinical record review on 1/21/26 at 11:00 a.m., it was noted that P-6 was to receive Physical Therapy (PT) services at a frequency of 1x/wk. x 1 wk., 2x/wk. x 4 wks., 1x/wk. x 3 wks. During the review it was noted that there were no PT visit notes during the week of 12/21/25, 12/28/25, 1/4/26 and 1/11/26, for a total of 8 undocumented visits. The agency failed to ensure that PT visit notes were completed as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included a detailed Skilled Nursing evaluation for 1 (P-6) of 1 record with the ordered service, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During the clinical record review on 1/21/26 at 11:00 a.m., it was noted that the Skilled Nursing (SN) Evaluation dated 12/22/25 was incomplete. Sections titled Genitourinary, Musculoskeletal, Psychosocial, Pain, digestive Nutrition were all left blank. There were no identified goals. The section titled, “Coordination Plan” was left blank. Additionally, the SN visit note dated 12/29/25 revealed “Not Started.” The agency failed to ensure the clinical record was complete and included a detailed SN Evaluation. The Administrator reviewed and acknowledged the above findings during an interview on 1/21/26 at 2:45 p.m.”

“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 Skilled Nursing and Occupational Therapy discharge summary was fully completed, and forwarded to the physician within 5 days of discharge in 2 (P-1, P-6) of 3 records who were discharged from the agency’s services, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #6 (P-6)’s start of care was 12/19/25 with diagnoses that included Pneumonia and Acute Respiratory Failure. During the clinical record review on 1/21/26 at 11:00 a.m., it was noted that the patient was discharged from Skilled Nursing (SN) services on 1/2/26. Upon further review, it was noted that there was no SN Discharge Summary available for review. The agency failed to ensure its’ skilled discipline completed a Discharge Summary detailing the course of care provided, with responses and the patient’s overall health status at the time of discharge and forwarded it to the Physician within 5 days of the date of discharge. The Administrator reviewed and acknowledged these findings during an interview on 1/21/26 at 2:45 p.m. Patient #1’s (P-1) Start of Care (SOC) was dated 1/23/25. The Plan of Care (POC) identified diagnoses of Multiple Stage 2 Pressure Ulcers, Hemiplegia and Chronic Kidney Disease. During record review on 1/21/26, it was noted that the Skilled Nurse (SN) completed a discharge on 2/7/25. The SN discharge summary stated, “Care Summary (care given, progress, regress including therapies): Patient elected to have family present on 1/23/2025, Dr. agrees to SOC date of 1/23/2025 68 year old female is referred to home care by SNF (Skilled Nursing Facility)…Nurse 1w1 (1 time a week for 1 week), 2w1, 1w1, PT (Physical Therapy) for gait training, restrengthening, OT (Occupation Therapy) for safety and ADLs (Activities of Daily Living). Medication reconciliation, instructed on Emergency Care Plan, High Risk medications, Signs and symptoms to report to Dr or SN, fall prevention, safety in ADLs with ordered assistive devices, pain management, hand washing, signs of infection to report, nurse 1w1, 2w1, 1w1 to treat pressure ulcers.” Furthermore, the OT completed a discharge summary on 2/13/25 and stated, “Care Summary (care given, progress, regress including therapies): Blank.” The discharge summaries failed to 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 in measurable terms. A review of the agency policy occurred on 1/26/26 titled “Discharge Summary” (Revised February 2024). The policy states, “Procedure: 1. A Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist. The Discharge Summary will include, but is not limited to: …Reason for discharge…Patient’s discharge condition…Patient’s outcomes in meeting goals in the plan of care.” The Administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings listed above in an interview on 1/26/26 at 12:45 pm.”