Cns Homecare, Inc.

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure PT (physical therapy) services adequately assessed and monitored the needs of the patient in 1 (P-5) of 4 records reviewed with PT as the only skilled service ordered, resulting in the potential for poor clinical outcomes for this patient. Findings included: Patient #5 (P-5) was admitted to home care on 03/18/2026, with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). During patient record review on 09/02/2026 at 10:58 AM, the physician referral for home care documented P-5’s diabetes averaged 166 mg/dL (moderately uncontrolled) and had a pressure ulcer (stage-2/slight open area) on buttock. PT performed the initial comprehensive assessment on 03/18/2026 as the only skilled service assigned to the case. Patient record review from 03/18/2026 through 04/29/2026 (date of emergent transfer to the hospital-reason unknown) found that none of the above medical concerns were monitored by PT services. No objective measurements such as weight or lower extremity circumference measurements to monitor fluid overload caused by CHF exacerbation (worsening) were found after admission on 03/18/2026. No blood sugars were evidenced in the patient record as PT documented the following on the comprehensive assessment: “Client does not check his blood sugar levels.” No effort was found by PT services to get an explanation why P-5 did not check his blood sugars, and no documented education/teaching to P-5 was found as to the potential consequences of unmanaged insulin dependent diabetes. The PT also failed to assess and account for the stage-2 pressure ulcer on buttock noted on the physician referral in 12 of 12 PT visits. Additional record review noted the home health aide assigned to the case provided skin care interventions that were not approved in the aide care plan. The PT who was responsible for monitoring all the aide’s patient care activities failed to recognize and follow up on the aide’s unauthorized skin care interventions. On 9/03/2026 at 12:50 PM, the findings above were reviewed and acknowledged during an interview with the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager. All staff above agreed the clinical record should have included the missing clinical information noted above when asked during the end of the interview at 1:12 PM.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that individuals who furnished Home Health Aide (HHa) services on its behalf, met the competency evaluation requirements for 2 (HHa #1 and HHa #2) of 2 Home Health Aides employed by this agency, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: On 09/01/2026 at 1:00 PM a review of the agency’s Home Health Aide personnel files revealed the following: Home Health Aide (HHa) #1’s date of hire was 10/13/2020. During the review, it was noted that HHa #1 completed a “Home Health Care Aide Self-Evaluation & Skills Checklist” on 10/13/2020. The nurse signed off on the document on 10/16/2020. On 09/01/2026 at 1:05 PM, during the review, the Human Resources staff person (Staff-E) stated, “The nurse uses this same form, makes a copy of it and initials each selected item.” There was no evidence that the nurse observed HHa #1 perform the required task and deemed her competent prior to the provision of care and services. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and the Intake Coordinator (Staff-D) reviewed and acknowledged these findings during an interview on 09/02/2026 at 2:35 PM. HHa #2’s date of hire was 08/26/2025. HHa #2 completed a Home Health Care Aide Self-Evaluation & Skills Checklist dated 08/24/2025. The nurse signed off on the document on 09/25/2025. There was no evidence that the nurse observed the aide perform any of the required tasks with an actual or pseudo patient. The agency failed to ensure the aide had been deemed competent prior to the provision of care. Staff-A, Staff-B, Staff-C and Staff-D reviewed and acknowledged the above findings during an interview on 09/02/2026 at 2:35 PM.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 2 (HHa #1, HHa #2) of 2 Home Health Aides received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 09/01/2026 at 1:00 PM a review of the agency’s Home Health Aide personnel files revealed the following: Home Health Aide (HHa) #1’s date of hire was 10/13/2020. During the review, it was noted that HHa #1 completed 12 in-services for the calendar year 2025. Upon further review, no times had been allocated to the in-services. It could, therefore, not be determined how many in-service hours had been completed. HHa #2’s date of hire was 08/26/2025. During the review, it was noted that HHa #2 completed 5 in-service hours for calendar year 2025. No times had been allocated to the in-services; therefore, it could not be determined how many in-service hours had been completed. The agency failed to provide documented evidence to ensure the home health aides completed 12 hours of annual in-services, as per this requirement. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the above findings during an interview on 09/02/2026 at 2:35 PM.”

“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 Physical Therapist failed to prepare clear written patient care instructions, including safety precautions, for the home health aide regarding client needs prior to the provision of care for 2 (P-3, P-5) of 3 patients in which Home Health Aide services were ordered, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: Patient #5 (P-5) was admitted to home care on 03/18/2026 with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). The Plan of Care (POC) ordered Home Health Aide services to be provided at a frequency of 1W9 (once a week for nine weeks). During record review on 09/02/2026 at 11:52 AM, it was noted main POC/485 listed the following 10 safety precautions: “Keep Pathway Clear; Slow Position Change; Support During Transfer and Ambulation; Proper Position During Meals; Fall Precautions; Use of Assistive Devices; Diabetic Precautions; Cardiac precautions; Medication precautions; and Respiratory Precautions.” Further review noted the aide POC failed to include any of the above safety precautions to alert the aide and to be mindful of potential risk factors during patient care home visits. During an interview on 09/03/2026 at 11:01 AM, the findings above were reviewed and acknowledged by the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager. Patient #3 (P-3)’s start of care was 04/30/2026. The certification period of review was 08/28/2026 through 09/03/2026 with diagnoses that included Osteoarthritis and Amnesia. The Plan of Care ordered Home Health Aide services to be provided at a frequency of 1x/wk. x 7 wks. During the record review on 09/02/2026 at 11:35 AM, it was noted that the Plan of Care listed the following safety precautions: Slow position change, support during transfer and ambulation, proper position during meals, fall precautions. The Aide Care Plan dated 08/28/2026 was void of the aforementioned safety precautions. The Administrator, Director of Operations, Clinical Manager and the Intake Coordinator reviewed and acknowledged these findings during an interview on 09/02/2026 at 2:22 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 that 2 (P-2, P-9) of 2 patients were aware of the disciplines who would be providing services, as well as their actual visit frequencies, resulting in the patient not being included in the overall planning of their care. Findings include: Patient #9’s (P-9) Start of Care (SOC) was dated 06/17/2026. The Plan of Care (POC) identified diagnoses of Weakness, Enterocolitis and Urine Retention. During record review on 09/01/2026 at 3:30 PM, it was noted that the referral stated, “Discharge to: Home with Skilled Home Care. Discharge Orders: Occupational Therapy (OT)…Physical Therapy (PT)…Skilled Nursing (SN)…Home health aide (HHA)…” The consent signed by the patient on 06/17/2026 and the comprehensive assessment completed by SN on 06/17/2026 were blank under the OT and HHA section and there was no documentation of the patient refusing OT and HHA services. The agency failed to provided services as ordered. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient #2 (P-2)’s start of care date was 04/30/2026. During the record review on 08/31/2026 at 2:45 PM, it was noted that the Plan of Care ordered Physical Therapy (PT) services to be provided at a frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks., 1x/wk. x 5 wks. The patient’s consent form dated 04/30/2026, signed by the patient reflected a visit frequency of 1x/wk. x 1 wk., 2x/wk. x 3 wks., 1x/wk. x 1 wk. The agency failed to ensure the patient was informed of the accurate visit frequency prior to the provision of care and services. The Administrator, Director of Operations, Clinical Manager and the Intake Coordinator reviewed and acknowledged these findings during an interview on 09/02/2026 at 1:40 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 Registered Nurse conducted the initial assessment within 48 hours of the date of the referral for 1 (P-3) of 1 patient who required skilled services, resulting in the potential for lack of established immediate care needs or identification of homebound status. Findings include: Patient #3 (P-3)’s start of care was 04/30/2026 with diagnoses that included Osteoarthritis and Atherosclerotic Heart Disease. During the record review on 09/02/2026 at 11:35 PM, it was noted the Plan of Care (POC) ordered Physical Therapy (PT) and Skilled Nursing (SN) services to be provided. The POC stated SN to assess the patient the following week (05/03/2026). The agency failed to ensure the SN conducted the initial assessment to identify immediate care needs and establish homebound status. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged these findings during an interview on 09/02/2025 at 2:22 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 home for 1 (P-2) of 1 patient who required assistance with grooming, resulting in the potential for poor hygiene, low-self-esteem and unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 07/31/2026 with diagnoses that included Parkinson’s disease and Diabetes Mellitus. The Plan of Care ordered Physical Therapy (PT) services to be provided. During the clinical record review on 08/31/2026 at 2:45 PM, it was noted that the patient was discharged from the agency’s services on 08/11/2026. Section M1100 (Supportive Assistance) of the Initial Comprehensive Assessment dated 07/31/2026, completed by the PT, was void of a documented available and willing caregiver who would provide assistance with grooming. Additionally, section M1800 (Grooming) revealed the patient required assistance with grooming, toileting, hygiene and dressing. Upon further review, there was no documented evidence that a home health aide was offered or provided. The agency failed to ensure the patient’s activity of daily living (ADL) needs were adequately met in the patient’s home. The Administrator (Staff-A), Director of Operations (Staff-B) and Clinical Manager (Staff-C) reviewed and acknowledged these findings during an interview on 09/02/2026 at 1:40 PM”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record documented all medications and failed to provide documented evidence that a drug interaction report was completed for 6 (P-5, P-6, P-7, P-8, P-9, P-10) of 10 records reviewed. This deficient practice results in the potential for unrecognized side effects and drug interactions that could affect all patients serviced by the agency. Findings included: Patient #6’s (P-6) Start of Care (SOC) was dated 07/23/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 with Right Foot Ulcer Stage 3 and Peripheral Vascular Disease. During record review on 09/02/2026 at 11:00 AM, it was noted that there were discrepancies from the medication profile provided to the patient and the medication profile in the Electronic Medical Record (EMR). The missing medications from the EMR are the following: Xarelto. The medications that were in the mediation profile but not on the referral are the following: Docusate Sodium. Furthermore, there was no documented evidence, during the 09/02/2026 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. Patient #7’s (P-7) Start of Care (SOC) was dated 09/9/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Spinal Stenosis and Osteoarthritis. During record review on 08/31/2026 at 12:15 PM, it was noted that there were discrepancies from the medication profile provided to the patient and the medication profile in the EMR. The missing medications from the EMR are the following: Bacitracin ointment, Oxybutynin, Vitamin C, Aspirin, Vitamin D, Voltaren, Flonase, Vitamin B, Zinc Sulfate, Levothyroxine, Lisinopril, and Simvastatin. Furthermore, there was no documented evidence, during the 08/31/2026 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. Patient #8’s (P-8) Start of Care (SOC) was dated 08/08/2026. The Plan of Care (POC) identified diagnoses of 4th Vertebrae Fracture, Falls and Dementia. During record review on 09/02/2026 at 1:00 PM, there was no documented evidence that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. Patient #9’s (P-9) Start of Care (SOC) was dated 06/17/2026. The Plan of Care (POC) identified diagnoses of Weakness, Enterocolitis and Urine Retention. During record review on 09/01/2026 at 3:30 PM, it was noted that the medication profile documented the same medication twice: Start Date: 06/16/2026 Pro-Stat Oral 30 ml Every 12 hours. Start Date: 05/11/2026 Pro-Stat Oral 1 ml Take 30mls once a day. Furthermore, there was no documented evidence, during the 09/01/2026 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. Patient #10’s (P-10) Start of Care (SOC) was dated 08/20/2026. The Plan of Care (POC) identified diagnosis of Left Knee Replacement. During record review on 09/01/2026 at 9:45 AM, there was no documented evidence that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. A review of the agency policy occurred on date titled “Medications” (Undated). The policy states, “The Comprehensive Assessment includes a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions. The drug regimen review includes an evaluation of all prescribed and over-the-counter medications the patient is using at the time of the Comprehensive Assessment. The assessing clinician evaluates all medication for identification of the following: Potential adverse effects; Potential drug reactions; Signiant side effects; Significant drug interactions…” The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient #5 (P-5) was admitted to home care on 03/18/2026, with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). During patient record review on 09/02/2026 at 10:58 AM, no documented evidence was found that indicated a comprehensive drug review was performed. In addition, PT documented there were no medication discrepancies and subsequently no physician notification was needed or found in the patient record. However, several medication discrepancies were found when compared to the active medication list found in the physician referral for home care (effective 03/12/2026). Examples of medications listed on the referral but not included on the P-5’s Plan of Care/active medication list are: Lispro insulin sliding scale to give specific units of insulin to help bring blood sugars back to normal baseline for P-5; Morphine Sulphate as needed for pain or shortness of breath; and Norco 5 mg. of Codeine with 325 mg. of Tylenol. Overall, P-5’s home care medication list had 1 PRN (as needed) vs. the PRN meds listed on the home care referral were 11. On 9/03/2026 at 1:08 PM, the findings above were reviewed and acknowledged during an interview with the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager. The agency failed to ensure PT services performed an appropriate and comprehensive review of all of P-5’s medications as required.”

“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) was complete, detailed and individualized in 10 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, P-10) of 10 records reviewed, resulting in the potential for untreated, breakthrough pain and an incomplete historical picture of the patient’s clinical needs. Findings include: Patient #6’s (P-6) Start of Care (SOC) was dated 07/23/2026. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 with Right Foot Ulcer Stage 3 and Peripheral Vascular Disease. During record review on 09/02/2026 at 11:00 AM, it was noted that the referral dated 07/21/2026 stated, “Pls (Please) apply betadine wet to dry dressing to R (Right) foot wound 3x (3 times) a week until healed.” The POC failed to document the wound care orders to the foot wound. A review of the agency policy occurred on date titled “Care Planning Process” (Undated The policy states, “The plan, based on the patient’s immediate and long-term needs, which shall include, but is not limited to the following: …Medications and treatments...” The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient numbers #’s 1-10 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, and P-10): Record review on 08/31/2026 through 09/03/2026, noted all 10 records failed to incorporate pain parameters in the event patients experienced severe, chronic or sudden onset pain that was unrelieved after treatment and interventions. This puts all patients’ quality of life and sense of well-being at risk. Patient numbers #’s 1-10 (P-1, P-2, P-3, P-4, P-5, P-6, P-7, P-8, P-9, and P-10): Record review on 08/31/2026 through 09/03/2026, noted all 10 records did not include any dates of onset/exacerbation for all listed patient diagnoses. Subsequently, the clinical history for each patient was incomplete in determining the extent of patient care needs. On 9/03/2026 at 11:42 AM, the findings above were reviewed and acknowledged during an interview with the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-7) of 10 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 09/09/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Spinal Stenosis and Osteoarthritis. During record review on 08/31/2026 at 12:15 PM, it was noted that the POC ordered Home Health Aide (HHa) at a frequency of 1w6 (1 time a week for 6 weeks). On 10/8/25, the HHa documented a “Missed Visit Form” stating, “Comments” Had a visit it a issue with Medicare cause I cant submit.” (SIC) On 10/31/25, the HHa documented a “Missed Visit Form” stating, “Didn’t see client my visit was over client got re certified my schedule was busy to see client on that day.” (SIC) There was no attempt to complete the HHa visit frequency as ordered. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026 at 9:20 AM.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to promptly alert the physician of patient changes in 2 (P-3 and P-7) of 10 patients, resulting in the potential for poor clinical outcomes. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 09/9/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Spinal Stenosis and Osteoarthritis. During record review on 08/31/2026 at 12:15 PM, it was noted that the POC ordered Home Health Aide (HHA) at a frequency of 1w6. The HHA POC had orders to notify the physician of vital sign parameters out of range: … BP Diastolic 90. On 10/24/2025, the HHA documented a BP Diastolic of 40. On 11/06/2025 the HHA documented a BP Diastolic of 40 and Pulse of 96. There was no documented evidence in the Electronic Medical Record (EMR) that the physician had been notified of the patient’s vital signs outside of range. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient #3 (P-3)’s start of care was 04/30/2026 with diagnoses that included Osteoarthritis, Atherosclerotic Heart Disease and Amnesia. During the record review on 09/02/2026 at 11:35 AM, it was noted that a Physician’s order dated 05/14/2026 read, “MSW (Medical Social Worker) to evaluate for community resources and placement options.” A “Missed Visit Form” dated 05/29/2026 read, “No answer to phone call. for weeks I have been unable to reach the patient’s son or daughter related to scheduling another visit to the home. It has been unclear as to social work support services based on the assessment from the initial visit to the home. MD (Medical Doctor) notified: No.” A “Missed Visit form (MSW Discharge) dated 06/05/2026 read, “Again, made several attempts to reach both the patient’s son and daughter. I finally was able to reach the patient’s son by phone and he reported having personal care resources in the home and is currently working on having someone move into the upstairs bedroom full time to assist the patient in the home daily. He also reported having another person coming into the home for additional support when needed. Patient’s son reported MSW services are not needed at this time. MD notified: No.” Upon further review, there was no documented evidence that the Social Worker notified the Physician of the discontinued service. The Administrator, Director of Operations, Clinical Manager and Intake Coordinator reviewed and acknowledged the above findings during an interview on 09/02/2026 at 2:22 PM.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHa) provided care in accordance with the aide plan of care in 1 (P-5) of 3 records with aide services provided, resulting in unauthorized patient care interventions and the potential for poor patient outcomes. Findings include: Patient #5 (P-5) was admitted to home care on 03/18/2026 with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). The Plan of Care (POC) ordered Home Health Aide services to be provided at a frequency of 1W9 (once a week for nine weeks). During patient record review on 09/02/2026 at 11:58 AM, it was noted the HHa visit note on 03/24/2026 (first visit) documented, “Skin ok noticed lil bed on buttocks area put sm barrel cream on it.” (sic) Further review of the aide POC found no interventions pertaining to skin care treatments and no documentation of notification to the PT (physical therapy) who was the lone skilled service assigned with HHa supervision. During the next HHa visit on 04/02/2026, the aide documented, “Cream on redness on his bottom area” and notification to PT services of this intervention was not found in the medical record. On 04/09/2026, the aide documented P-5’s systolic blood pressure was 176 mmHg. with parameters to call if greater than 160. The HHa further documented, “Checked BP (blood pressure) twice still high resident state he had his BP med an hour ago.” (sic) Only one BP was documented on the 04/09/2026 visit note which did not detail if the systolic reading of 176 was the first or last BP reading. In addition, the HHa visit note on 04/14/2026 documented, “Rash is clearing up on his bottom area” with no PT notification found. Subsequently, no evidence was found in the medical record that the physician was made aware of P-5’s high BP reading or the skin concerns of “redness” and “rash” symptoms the HHa documented on. During an interview on 09/03/2026 at 11:22 AM, the findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C), Intake Coordinator (Staff-D), and Human Resources Manager (Staff-E). Staff-C further acknowledged the HHa should not be performing interventions that were not written of the aide POC, and any concerns would require supervisor notification that same day.”

“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 clinical notes were complete, accurate, and maintained for 2 (P-5, P-8) of 10 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #8’s (P-8) Start of Care (SOC) was dated 08/08/2026. The Plan of Care (POC) identified diagnoses of 4th Vertebrae Fracture, Falls and Dementia. During record review on 09/02/2026 at 1:00 PM, it was noted that Physical Therapy (PT) completed an evaluation on 008/08/2026 and ordered PT services at a frequency of 1w8 (1 time a week for 8 weeks). It was noted that the following visits were not completed within the Electronic Medical Record (EMR): 08/17/2026, 08/28/2026 and 09/01/2026. During the entrance interview on 08/31/2026 at 9:40 AM, Staff-D was questioned regarding visit note completion time frame and stated, “24 to 48 hours.” The agency failed to maintain a complete and accurate medical record. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient #5 (P-5) was admitted to home care on 03/18/2026 with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). During patient record review on 09/02/2026 at 1:18 PM, the initial comprehensive assessment performed by PT (physical therapy) services on 03/18/2026 noted the entire respiratory sections was blank except for a pulse oximetry (a spot check of the oxygen level in the blood). Further, P-5 is an insulin dependent diabetic (primary diagnosis), and the initial comprehensive assessment was void of any blood sugar readings throughout admission (11 of 11 opportunities during PT visits) before being transferred to the hospital for “unknown reasons”. In addition, review of the transfer summary dated 04/29/2026, was incomplete and inaccurate. For example, under “Course of Illness and Treatment” the transfer summary was blank for 2 of 2 ordered services (physical therapy and home health aide). In addition, the “Goals Summary/Outcomes” and the “Care Coordination” sections were left blank. The “Goal Summary” section documented, “No goals have been identified to this patient.” Also, the current medication list within the transfer summary had several discrepancies when compared to the physician referral for home care and home care orders. On 9/03/2026 at 11:39 AM, the findings above were reviewed and acknowledged during an interview with the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager. All staff above agreed the clinical record needs to be accurate in all aspects and should have included the missing clinical information noted above when asked during the end of the interview at 11:42 AM.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Discharge Summary was forwarded to the Physician within 5 days of the date of discharge for 2 (P-2, P-7) of 3 patients who were discharged from the agency’s services; and failed to complete a comprehensive transfer summary for 1 (P-5) of 2 patients who were transferred to an inpatient facility, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 09/9/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Spinal Stenosis and Osteoarthritis. During record review on 08/31/2026 at 12:15 PM, it was noted that Physical Therapy (PT) completed a discharge on 12/31/25. The Electronic Medical Record (EMR) contained faxed evidence that the discharge summary was sent to the physician on 01/15/2026, 11 business days after the patient’s discharge. The agency failed to send the discharge summary within 5 business days. The Administrator (Staff-A), Director of Operations (Staff-B), Clinical Manager (Staff-C) and Intake Coordinator (Staff-D) reviewed and acknowledged the findings listed above in an interview on 09/03/2026/26 at 9:20 AM. Patient #5 (P-5) was admitted to home care on 03/18/2026 with diagnoses that included diabetes-type 2, hypertensive heart disease with CHF (congestive heart failure), and COPD (chronic obstructive pulmonary disease). During patient record review on 09/02/2026 at 1:18 PM, it was noted the transfer summary dated 04/29/2026 was incomplete of pertinent information and clinical findings. Examples include: Reason for transfer was “unknown” and under “Course of Illness and Treatment” the transfer summary was blank for 2 of 2 ordered services (physical therapy and home health aide). In addition, the “Goals Summary/Outcomes” and the “Care Coordination” sections were left blank. The “Goal Summary” section documented, “No goals have been identified to this patient.” Also, the current medication list within the transfer summary had several discrepancies when compared to the physician referral for home care and home care orders. On 9/03/2026 at 11:34 AM, the findings above were reviewed and acknowledged during an interview with the agency’s Administrator, Director of Operations, Clinical Manager, Intake Coordinator, and Human Resources Manager. Patient #2 (P-2)’s start of care was 07/31/2026 with diagnoses that included Parkinson’s Disease and Diabetes Mellitus. The Plan of Care ordered Physical Therapy (PT) services to be provided. During the record review on 08/31/2026 at 2:45 PM, it was noted that the patient was discharged from the agency’s services on 08/11/2026. The PT Discharge Summary dated 08/11/2026 was forwarded to the Physician on 08/19/2026, which was 8 days after the date of discharge. The agency failed to ensure the Discharge Summary was forwarded to the Physician within 5 days of discharge, as per this requirement. The Administrator, Director of Operations, Clinical Manager and the Intake Coordinator reviewed and acknowledged the above findings during an interview on 09/02/2026 at 1:40 PM.”