Sierra Pride Home Healthcare Agency

“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 review and update its emergency preparedness (EP) plan as required at least every two years, and include strategies to address identified high-risk emergency situations, resulting in no directions for agency personnel in the event of an actual emergency or disaster and the potential for poor patient outcomes. Findings include: On 7/23/26 at 9:11 AM, review of the agency’s emergency preparedness (EP) binder found no evidence that the EP plan had been reviewed and updated within the last 2 years. In addition, the last all-hazards risk assessment (HRA) was conducted on 11/22/22, which the agency’s EP plan is based on. At 9:18 AM, agency staff were requested to find and submit any evidence that its EP plan had been reviewed, updated and signed off in the Governing Body’s meeting minutes or other agency records. At 9:32 AM, staff were unable to find any evidence that this was performed within the required 2-year timeframe. During an interview on 7/23/26 9:35 AM, Staff-A acknowledged the deficient finding above.”

“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 develop and update its emergency preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the agency’s inability to implement appropriate emergency actions which could negatively affect the health and safety of all patients serviced by this agency. Findings include: On 7/23/26 at 9:13 AM, review of the agency’s emergency preparedness (EP) binder found no evidence that the EP’s policies and procedures (P&P) were reviewed and updated within the last 2 years. At 9:19 AM, agency staff were requested to find and submit any evidence that the P&P that help govern its EP plan had been reviewed and updated in the Governing Body’s meeting minutes or any other agency records. At 9:34 AM, staff were unable to find any evidence that this had been performed for at least the last 2 years as required. During an interview on 7/23/26 at 9:36 AM, Staff-A acknowledged the deficient finding above.”

“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 skilled nursing (SN) goals on the Plan of Care (POC) were measurable and appropriate in 4 (P-1, P-4, P-6, P-7) of 7 records reviewed, resulting in the potential for unmet patient care needs. Findings include: Patient #6 (P-6)’s Start of Care was 7/19/25, with diagnoses of encounter for adjustment and management of VAD, change and removal of surgical wound dressing. The POC ordered Skilled Nursing and physical therapy services. During record review on 7/21/26 at 3:00 PM, it was noted that the goals on the POC were not measurable. For example, one goal stated, “Patient caregiver will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures...by end of episode.” Another stated, “ Patient/caregiver will verbalize/demonstrate knowledge of and compliance with medication management...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient #7 (P-7)’s Start of Care was 7/7/26, with diagnoses of embolism, transient ischemic attack (TIA), and arrythmia. The Plan of Care ordered Skilled Nursing and physical therapy services. During record review on 7/22/26 at 11:00 AM, it was discovered that the goals on the plan of care were not measurable. For example, one stated, “Patient/caregiver will verbalize understanding of proper orientation techniques to use when patient becomes disoriented.” Another stated, “Patient/caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by the end of the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The administrator (Staff-A) reviewed and confirmed the above findings during an interview on 7/23/26 at 11:55 AM. Patient #1 (P-1) was admitted to the home care agency on 5/11/26, and included diagnoses of hypertension, chronic kidney disease, gastro-esophageal reflux disease, and history of falls. On 7/21/26, patient record review of the SN goals on P-1’s plan of care (POC) noted 17 of 17 listed goals were not written in measurable terms. Examples include: “Patient will verbalize understanding of proper use of pain medication by 7/9/26; Patient weight will be maintained between 155 and 160 lbs. during the episode; Patient/Caregiver will be independent with medication management by 7/9/26. Further, the weight goal in the POC was found to be inappropriate as the goal parameter 160 lbs. was also the same weight value to notify the physician due to that weight being unsafe for P-1 in the same POC. Patient #4 (P-4) was admitted to the home care agency on 7/3/26, and included diagnoses of heart disease, diabetes type-2, urinary tract infection, and chronic kidney disease. On 7/23/26, patient record review of the SN goals on P-4’s POC noted 20 of 20 listed goals were not written in measurable terms. Examples include: “Patient will verbalize understanding of proper use of pain medication by 8/31/26; Patient/Caregiver will be independent with setting up medication boxes by 8/31/26; The patient will be free from injury during the certification period by 8/31/26. During an interview on 7/23/26 at 11:38 AM, the Administrator (Staff-A) reviewed and acknowledged the above findings. Staff-A stated this did not meet agency expectations regarding measurable goals when asked during the interview.”

“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-1) of 1 record reviewed with home health aide services, resulting in the potential for the provision of unsafe care. Findings include: Patient #1 (P-1) was admitted to the home care agency on 5/11/26 and included diagnoses of hypertension, chronic kidney disease, gastro-esophageal reflux disease, and history of falls. On 7/21/26, review of the plan of care (POC)/485 under “Safety Measures” noted 16 individual safety precautions such as bleeding, use as assistive devices, fall and medical gas precautions. When compared to the POC specific for the home health aide, none of the 16 precautions were found. The findings above were reviewed and acknowledged by the Administrator (Staff-A) during an interview on 7/23/26 at 9:43 AM. Staff-A further noted that this did not meet agency expectations when asked and that the aide POC should include all safety precautions found on the 485 POC.”

“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 documents in the clinical records were complete and appropriately authenticated with a signature, title, dated, and timed in 2 (P-1, P-4) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care provided by the agency. Findings include: Patient #1 (P-1) was admitted to the home care agency on 5/11/26, and included diagnoses of hypertension, chronic kidney disease, gastro-esophageal reflux disease, and history of falls. On 7/21/26, review of the patient record noted an order that documented, “Pt (patient) Declining” RPT (Registered Physical Therapist) [sic]. However, under “Clinician Signature” and “Physician Signature” both were unsigned and undated with no supporting documentation this order was ever authenticated as required by accepted professional standards of care. Patient #4 (P-4) was admitted to the home care agency on 7/3/26, and included diagnoses of heart disease, diabetes type-2, urinary tract infection, and chronic kidney disease. On 7/22/26, review of the patient record noted an order that documented, “OT (Occupational Therapy): Hole home visit. No OT available at this time. Case Manager (Staff-A) is aware during acceptance of referral. Physician notified/updated.” [sic]. However, under “Clinician Signature” and “Physician Signature” both were unsigned and undated with no supporting documentation this order was ever authenticated as required by accepted professional standards of care. In addition, Staff-A noted when a skilled clinician takes a verbal order by the physician, the clinician authenticates the order with their signature and time taken. Staff-A acknowledged this did not meet agency expectations when asked during interview on 7/23/26 at 1125 AM.”

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide accurate information to patients regarding the complaint process in the start of care folder, resulting in the potential for complaints to go unresolved. Findings include: During record review on 7/20/26, it was discovered that the patients start of care (SOC) folders had the Community Health Accreditation Program (CHAP) listed as a resource for patient complaints. The agency is no longer associated with CHAP and that resource is no longer available to the patients. During an interview on 7/23/26 at 11:55 AM., the administrator (Staff-A) acknowledged the above findings.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-5) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services, and the potential for unmet care needs. Findings include: Patient #5 (P-5)’s Start of Care was 3/6/26, with diagnoses of Type 2 diabetes, fitting and adjusting of urinary device, and congestive heart failure. The Plan of Care ordered Skilled Nursing services. During record review on 7/20/26 at 11:45 AM, it was discovered that there was no documented evidence that the patient was provided the “Notice of Medicare Provider Non-Coverage” prior to being discharged from the agency. The agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. The administrator (Staff-A) reviewed and confirmed the above findings during an interview on 7/23/26 at 11:55 AM.”

“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 for 2 (P-1, P-2) of 7 records reviewed, resulting in incomplete clinical information to aid in determining the needs of the patients and for measuring the patient’s progress toward goals/outcomes. Findings include: Patient #1 (P-1) was admitted to the home care agency on 5/11/26, and included diagnoses of hypertension, chronic kidney disease, gastro-esophageal reflux disease, and history of falls. On 7/21/26, review of the start of care (SOC) comprehensive assessment performed by skilled nursing (SN) on 5/11/26, found no evidence that SN obtained a blood oxygen saturation. This value was needed to determine if the patient was safely within ordered parameters due to high-risk findings. Examples include: SN documented within the SOC assessment that P-1 had a history of congestive heart failure (CHF). Second, the patient had +2 pitting (moderately severe) edema (swelling) of bilateral lower extremities associated with CHF and was short of breath (SOB) when walking less than 20 feet. The findings above indicate a high potential that P-1’s blood oxygen level could be compromised with associated poor clinical outcomes. Patient #2 (P-2) was admitted to the home care agency on 7/1/26, and included diagnoses of right total knee replacement, diabetes type-2, and chronic obstructive pulmonary disease (COPD). On 7/21/26, review of the SOC comprehensive assessment performed by SN on 7/1/26, found concerning assessment findings by SN with no evidence that the physician was notified and that SN failed to obtain a blood oxygen saturation when warranted. SN documented P-2’s last bowel movement occurred on 6/15/26 while being prescribed heavy narcotics (Fentanyl and Dilaudid) which are strongly associated with constipation. In addition, P-2’s pain level during the assessment was 8/10 (10 being most severe) in lower back region. Further, SN documented under “Respiratory” that P-2 was “WNL/within normal limits” while leaving the entire “Respiratory” section blank, including “CTA” (listening to active clear lung breathing) and verification that blood oxygen levels were in a safe range despite being SOB when walking less than 20 feet and COPD diagnosis. Also, SN documented that P-2 had a PICC (peripherally inserted central catheter) line but failed to note which arm and what length the exposed portion of the PICC line was. This measurement is part of standards of care concerning PICC line management to verify internal placement has not changed from treatments, interventions and general bodily movements. During an interview on 7/23/26 at 10:33 AM, Staff-A acknowledged the deficient findings above and noted this did not meet agency expectations when asked.”

“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 the patient’s prescribed medications to determine any untoward interactions, physician’s response, and follow-up for 5 (P-1, P-2, P-5, P-6, P-7) of 7 records reviewed, resulting in the potential for harmful medication effects. Findings include: Patient #5 (P-5)’s Start of Care was 3/6/26, with diagnoses of Type 2 diabetes, fitting and adjusting of urinary device, and congestive heart failure. The Plan of Care ordered Skilled Nursing services. During record review on 7/20/26 at 11:45 AM, it was discovered that section M2001 of the Initial Start of Care (SOC) Comprehensive Assessment documented “Issues found during review.” The Medication Profile dated 6/5/26, under the Drug Regimen Review section documented, “Issues found”. There was no documented Medication Reconciliation in the record. There is no documented follow-up of the issues found from the SOC Assessment, the Medication Profile, or what the physician’s response was. During a home visit on 7/20/26, P-5 was observed wearing continuous oxygen at 2 liters per minute. The Medication Profile failed to include oxygen when the patient was on continuous oxygen at 2 liters per minute. Patient #6 (P-6)’s Start of Care was 7/19/25, with diagnoses of encounter for adjustment and management of VAD, change and removal of surgical wound dressing. The Plan of Care ordered Skilled Nursing and physical therapy services. During record review on 7/21/26 at 3:00 PM, it was discovered that section M2001 of the Initial Start of Care (SOC) Comprehensive Assessment documented “Issues found during review.” The Medication Profile dated 7/19/25, under the Drug Regimen Review section was blank. There was no documented Medication Reconciliation in the record. There is no documented follow-up of the issues found from the SOC Assessment, or what the physician’s response was. Patient #7 (P-7)’s Start of Care was 7/7/26, with diagnoses of embolism, transient ischemic attack (TIA), and arrythmia. The Plan of Care ordered Skilled Nursing and physical therapy services. During record review on 7/22/26 at 11:00 AM, it was discovered that section M2001 of the Initial Start of Care (SOC) Comprehensive Assessment documented “Issues found during review.” A drug review was performed on 7/22/26 and indicated issues found. There is no documented follow-up of the issues found from the SOC Assessment, the Medication Reconciliation, whether the physician was notified, or what the physician’s response was. Agency Policy: Medication Administration, page 312-315 and revised April of 2025 stated, “1. Agency staff shall check all medications the patient is taking to identify and promptly report to the physician any significant side effects or contraindications including the following: a. Known allergy or previous adverse reaction to a medication. b. Medication incompatibility for potential interaction. c. possible ineffective drug therapy... The administrator (Staff-A) reviewed and confirmed the above findings during an interview on 7/23/26 at 11:55 AM. Patient #1 (P-1) was admitted to the home care agency on 5/11/26, and included diagnoses of hypertension, chronic kidney disease, gastro-esophageal reflux disease, and history of falls. On 7/21/26, review of the start of care (SOC) comprehensive assessment performed by Skilled Nursing (SN), documented under the section “M2001” that medication issues were found. However, there is no documented follow-up concerning the issues found from the SOC Assessment, the Medication Reconciliation, or whether the physician was notified and what that response was. Patient #2 (P-2) was admitted to the home care agency on 7/1/26, and included diagnoses of right total knee replacement, diabetes type-2, and chronic obstructive pulmonary disease (COPD). On 7/21/26, review of review of the SOC comprehensive assessment performed by SN, documented under the section “M2001” that medication issues were found. SN documented “No” under “M2003-Medication Follow-up” to the physician. After the SOC on 7/1/26, the medication reconciliation was performed on 7/12/26, 12 days after SN noted issues found with P-2’s medications. On 7/22/26, P-2’s medication list was entered into Drugs.com (on-line professional pharmaceutical resource for health professionals) and 10 severe interactions with 3 instances of duplicative therapies found mainly due to the combination of Fentanyl (narcotic), Hydromorphone (narcotic), Oxycodone (narcotic), Flexeril (muscle relaxant), and Neurontin (anticonvulsant) and P-2’s 16 other medications. During an interview on 7/23/26 at 11:12 AM, the Administrator (Staff-A) reviewed and acknowledged the above findings. Staff-A stated this did not meet agency expectations when asked during the interview.”

“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 and included pain parameters in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed; failed to include a comprehensive list of current medications in 1 (P-3) of 7 records reviewed; failed to include safety precautions in 1 (P-5) of 7 records reviewed; and failed to include relevant medical equipment in 1 (P-4) of 7 records reviewed, resulting in the potential for unreported clinical results and an incomplete picture of the patient’s clinical needs. Findings include: Patient #5 (P-5)’s Start of Care was 3/6/26, with diagnoses of Type 2 diabetes, fitting and adjusting of urinary device, and congestive heart failure. The POC dated 3/6/26, ordered Skilled Nursing services. During record review on 7/20/26 at 11:45 AM, it was discovered that no anticoagulant/bleeding precautions were documented under the safety measures section on the POC with Eliquis (Anticoagulant/blood thinner) ordered for 2 times a day. The administrator (Staff-A) reviewed and confirmed the above findings during an interview on 7/23/26 at 11:55 AM. Patient #’s 1-7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7): Record review on 7/21/26 through 7/23/26 noted all 7 records failed to incorporate pain parameters in the event a patient would experience unacceptable levels of pain for that specific patient and subsequent need for interventions/treatment to reduce pain. Patient # 3 (P-3): Record review on 7/21/26 noted P-3’s medication list on the POC failed to include Plavix 75mg. daily, a blood thinner needed to reduce the risk of blood clots that the physician ordered to be continued on the hospital discharge summary on 7/21/26. Patient #4 (P-4) was admitted to the home care agency on 7/3/26, and included diagnoses of heart disease, diabetes type-2, urinary tract infection, and chronic kidney disease. On 7/22/26, review of the medical history found on the referral for home care noted the following documentation: “Acute compression fracture of L2 (lower back vertebrae) ...Patient was given a lumbosacral orthosis brace to be worn when out of bed.” Further review on 7/22/26 found no evidence on the POC that included the need for the back brace when out of bed to alert the skilled disciplines assigned on the case (Skilled Nursing and Physical Therapy). During an interview on 7/23/26 at 11:44 AM, the Administrator (Staff-A) reviewed and acknowledged the above findings. Staff-A stated that none of the findings above met agency expectations when asked during the interview.”

“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 provide Occupational Therapy (OT) services as ordered in 2 (P-2, P-4) of 4 records reviewed with ordered occupational therapy (OT) services, resulting in the potential for the provision of inappropriate care and lack of skilled services. Findings include: Patient #2 (P-2) was admitted to the home care agency on 7/1/26, and included diagnoses of right total knee replacement, diabetes type-2, and chronic obstructive pulmonary disease (COPD). On 7/21/26, patient record review noted the referral for home care ordered Physical Therapy (PT), OT, and Skilled Nursing (SN) services to evaluate and treat P-2’s medical needs. Further review found no evidence that OT services were ever provided by the agency. No patient refusal or physician notification was evidenced in the medical record. Patient #4 (P-4) was admitted to the home care agency on 7/3/26, and included diagnoses of heart disease, diabetes type-2, urinary tract infection, and chronic kidney disease. On 7/22/26, review of the patient record noted the referral for home care on 7/2/26 ordered SN, PT, OT services to evaluate and treat the patient. Further review found an order (undated) that documented, “OT (Occupational Therapy): Hold home visit. No OT available at this time. Case Manager (Staff-A) is aware during acceptance of referral. Physician notified/updated.” However, the order was never authenticated as “Clinician Signature” and “Physician Signature” remained unsigned/undated through 7/23/26. Subsequently, the order for OT services remained as did the agency’s non-compliance in provided OT services as ordered on the home care referral. During an interview on 7/23/26 at 11:27 AM, the Administrator (Staff-A) reviewed and acknowledged the above findings.”

“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 discharge summaries were complete in 2 (P-3, P-6) of 2 discharged patient records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Patient #6 (P-6)’s Start of Care was 7/19/25, with diagnoses of encounter for adjustment and management of VAD, and change and removal of surgical wound dressing. The Plan of Care ordered Skilled Nursing (SN) and physical therapy (PT) services. During record review on 7/21/26 at 3:00 PM, it was discovered that in the discharge OASIS under “Discharge from Agency Summary”, there was only PT discharge information. No skilled nursing information was documented in the summary. There was also no SN discharge summary documented in the record. The discharge summary from PT services failed to include all necessary information to the physician to ensure continuity of care. The administrator (Staff-A) reviewed and confirmed the above findings during an interview on 7/23/26 at 11:55 AM. Patient #3 (P-3): This patient was admitted to home care on 7/21/25 for status-post heart attack, congestive heart failure (CHF), and chronic obstructive pulmonary disease with acute respiratory failure with hypoxia. P-3 was discharged from home care services on 9/2/25 per patient request. On 7/22/26, patient record review noted under “Discharge from Agency Summary” was incomplete and void of any skilled nursing (SN) findings throughout the entire admission to home care. In addition, no information was provided to the physician within the summary that explained why P-3 had decided to cancel services provided by the home care agency. Further, SN findings of patient refusal to go to the emergency room on 8/21/26 with a blood pressure (BP) of 220/115 mmHg (millimeters of mercury) and also the next day (8/22/26) with a documented BP of 221/197 mmHg were not found in the discharge summary among other SN medical concerns. The findings above were reviewed and acknowledged by the Administrator (Staff-A) during an interview on 7/23/26 at 10:20 AM. Staff-A further noted that this did not meet agency expectations when queried.”