Apex Home Healthcare, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness program that included the required elements that must be reviewed and updated at least every 2 years, resulting in the potential to affect the Agency’s ability to provide safe patient care in the event of an actual emergency. Findings Include: On 4/14/26, review of the agency’s emergency preparedness plan failed to provide any evidence that a review or updates had been documented. The policy titled “Emergency Management” was revised 05/2020. The agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed and updated at least every 2 years as required. The Administrator (Staff A) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 11:30 am.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency’s emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster. This deficient practice could affect all patients serviced by this agency. Findings include: During review of the agency’s emergency preparedness (EP) documents and policies on 4/14/26, it was noted that the agency did not have documented evidence of initial training for Staff D and Staff F, of 9 direct and contracted employees. Additionally, the last documented EP drill was documented as 7/13/22. The agency failed to document initial EP training and complete required drills. The Administrator (Staff A) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 11:30 am.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed accepted standards of infection control for 1 (Staff E) of 3 staff observed during home visits, resulting in the potential for an increased risk for spread of infection to all patients receiving services from this agency. Findings include: Patient #3 (P-3): During a joint home visit with the physical therapist assistant (Staff E) on 4/14/26 at 2:30 PM, Staff E was observed putting gloves on to work with P-3 after sanitizing his hands. Throughout the treatment, Staff E was observed reaching into his “clean” bag to get more equipment on multiple occasions with his “dirty” gloves still on. Staff E failed to remove his gloves and sanitize his hands prior to touching “clean” equipment. Additionally, Staff E was observed using a cloth gait belt (a belt used to help stabilize a patient with decreased balance) on P-3 during ambulation. Following the visit, Staff E was asked about how he kept the gait belt clean between patients. Staff E indicated he used a sanitizing wipe when he was done (which was observed by the surveyor during the visit). However, Staff E acknowledged the wipes were not meant for sanitizing fabric after it was brought to his attention. The administrator (Staff A) was made aware of the findings and acknowledged them during an interview on 4/15/26 at 9:15 AM.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide initial infection control education for 2 (Staff D and Staff F) of 2 staff hired since the last survey in 2023; and failed to provide annual infection control education for 6 (Staff A, Staff B, Staff C, Staff D, Staff E, and Staff H) of 6 staff reviewed, resulting in the potential for poor infection control practices. Findings include: The agency’s infection control program was reviewed on 4/14/26 at 9:40 AM. Following review of the binder provided, the administrator (Staff A) was asked to provide evidence of initial infection control education for staff who were hired since the last survey in 2023. Staff A stated it should be on the orientation check list in the personnel files. Staff A provided personnel files for the 2 staff members hired since the last survey (Staff D and Staff F). Upon review of the files, it was determined that neither file contained an orientation checklist, therefore, there was no evidence of initial infection control education. Staff A acknowledged the findings at the time of interview. Additionally, Staff A was asked for evidence of annual infection control education for Staff A, Staff B, Staff C, Staff D, Staff E, and Staff H. Staff A stated, “I don’t think we have that,” and acknowledged the findings at the time of interview. A review of agency policy titled “Infection Control Education” (dated 4/2020) revealed, “Orientation: All personnel are oriented to the policies and procedures regarding infection control during their orientation and training period.” Additionally, the policy stated, “b. Employee inservices on Bloodborne Pathogens and Tuberculosis Precautions shall be made available at least once every calendar year,” and that “Annual Inservice include at least the following:” and listed 12 additional infection control topics.”

“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, it was determined skilled nursing failed to include safety measures on the aide’s care plan in 1 (P-5) of 3 records reviewed in which Home Health Aide services were provided, resulting in the potential for injuries and the provision of unsafe care during aide services. Findings include: Patient #5 (P-5): The SOC was 4/21/25, with diagnoses of polyarthritis, pain, congestive heart failure (CHF) and atrial fibrillation. The plan of care (POC) included orders for the following visit frequencies: HHa (Home Health Aide) 2 visits a week for 2 weeks, and 1 visit a week for 1 week. The following POC (485) safety precautions were noted during review on 4/13/26: “Anticoagulation precautions, fall precautions...” During record review on 4/13/26, the “Aide Care Plan” dated 4/21/25, completed by skilled nursing, failed to include any anticoagulant precautions for a patient that is taking a prescription anticoagulant (Eliquis). The administrator (Staff-A) acknowledged the findings during an interview on 4/15/26 at 2:45 p.m.”

“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 inform the patient in advance of the disciplines that will furnish care in 3 (P-1, P-2, and P-7) of 7 patients reviewed, resulting in the patient not having knowledge of the plan for treatment and the potential for unmet care needs. Findings include: Patient #7 (P-7): During record review on 4/15/26, it was determined the referral for home care dated 10/29/25 ordered services from skilled nursing, physical therapy, and occupational therapy. According to the plan of care dated 11/22/25, occupational therapy was refused. Upon review of the consent form completed at the initial visit on 11/22/25 that identified discipline frequencies, it was determined the space next to occupational therapy was left blank. Therefore, there was no evidence the patient refused the service. The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM. Patient #1’s (P-1) Start of Care (SOC) was dated 10/29/25. The Plan of Care (POC) identified diagnoses of Left Heel Pressure Ulcer, Diabetes Type 2 and Hypertension. During record review on 4/13/26, it was noted that the referral stated, “Discharge home with home health services. PT (Physical Therapy), OT (Occupational Therapy), RN (Registered Nurse), HHA (Home Health Aide) and SW (Social Worker).” The consent dated 10/29/25 was blank under the OT, HHA and SW section and there was no signed documentation of the patient refusing OT, HHA, and SW. Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the referral stated, “Home Health Instructions: - Other: PT/OT for mobilization and fall risk assessment.” The consent dated 1/16/26 was blank under the OT section and there was no signed documentation of the patient refusing OT. A review of the agency policy occurred on 4/16/26 titled “Patient Bill of Rights and Responsibilities” (Revised 1/2018). The policy states, “Policy: In support of the home care services philosophy of care, each patient is an active, informed participant in his/her plan of care...” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 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 in 4 (P-2, P-3, P-6 and P-7) of 7 patients reviewed, resulting in the potential for unmet care needs. Findings include: Patient #6 (P-6): The Start of Care (SOC) was dated 6/6/25. The Plan of Care (POC) identified diagnoses of chronic venous insufficiency, nonsurgical wound dressing, and weakness. During record review on 4/14/26, it was noted that the SOC comprehensive assessment dated 6/6/25, documented under “Primary Diagnosis and Other Diagnoses”, all 9 diagnoses had no dates of onset. There were no prior treatments, outcomes, or history of how these diagnoses led to the need for home care documented in the record. During an interview on 4/16/26 at 10:30 a.m., the administrator (Staff-A) acknowledged the above findings. Patient #3 (P-3): During review of the comprehensive assessment on 4/14/26, it was noted the Outcome Assessment and Information Set (OASIS) indicated on page 10 that “Patient not using oxygen.” [sic] Upon further review of the OASIS, it was determined the DME (durable medical equipment) section on page 13 indicated the patient required oxygen supplies in the home. The information is conflicting and therefore does not present a clear assessment of the patient’s current status. Patient #7 (P-7): During record review on 4/15/26, it was noted an update of the comprehensive assessment was completed on 12/30/25 following a hospitalization. Upon review of the resumption of care OASIS dated 12/30/25, it was noted that new diagnoses of “hemiplegia following cerebral infarct (stroke) affecting right dominant side” and “hemiplegia following cerebral infarct affecting nondominant side” were added with an onset date of 12/23/25 (the date the patient was admitted to the hospital). Upon further review of the record, it was determined that the paperwork from the hospital admission stated, “In the emergency room workup was negative for acute stroke.” [sic] Additionally, the initial physical therapy evaluation dated 11/24/25 (prior to the hospital admission) noted “hx. of stroke about a year ago affecting left upper and lower ext. hx. of stroke 6-7 months ago affecting right upper and lower ext” [sic], further indicating these were not new diagnoses. The information is conflicting and therefore does not present a clear assessment of the patient’s current status. The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the SOC comprehensive assessment dated 1/16/26, documented under “Primary Diagnosis and Other Diagnoses”, all 9 diagnoses had an exacerbation or onset date of 1/8/26. No accurate onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 am.”

“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 patient’s clinical record documented all medications with a completed reconciliation for 3 (P-2, P-3 and P-6) of 7 patients reviewed, resulting in the potential for unrecognized medication side effects and complications. Findings included: Patient #6 (P-6): The Start of Care (SOC) was dated 6/6/25. The Plan of Care (POC) identified diagnoses of chronic venous insufficiency, nonsurgical wound dressing, and weakness. During record review on 4/14/26, it was noted that P-6’s Patient Medication Record documented “No discrepancies”, but there was no documented medication reconciliation in the record. The only documented Medication Profile was dated 7/30/25, almost 2 months after the SOC. During an interview on 4/16/26 at 10:30 a.m., the administrator (Staff-A) acknowledged the above findings. Patient #3 (P-3): During a joint home visit with the physical therapist assistant (Staff E) on 4/14/26 at 2:30 PM, P-3’s wife was asked if P-3 had any recent medication changes. P-3’s wife stated yes, and reported P-3 had been taking a 10-milligram tablet of Memantine (a medication used to treat memory) twice a day until his appointment with the doctor on 4/8/26. This was changed to 1 28-milligram tablet, 1 time a day. The information was confirmed on the medication bottle in the home. Upon review of the medications on the plan of care, it was determined the initial dose of Memantine was listed as being taken 1 time per day instead of 2. Additionally, there was no update to the medication list to reflect the change in dosage to the 28-milligram tablet. P-3’s wife also indicated P-3 was given a new prescription from his doctor that day, however, she was unsure of the name of the medication or what it was for (she was supposed to pick it up later that day). During the visit, Staff E failed to ask for details regarding the medication addition so that it could be reconciled on the medication profile. Staff E was interviewed following the home visit and acknowledged the findings. The administrator (Staff A) was also made aware of the findings and acknowledged them during an interview on 4/15/26 at 9:15 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the “Patient Medication Record” was blank and was digitally signed by the Registered Nurse on 1/19/26. The agency failed to maintain an accurate medication record per policy within the Electronic Medical Record. A review of the agency policy occurred on 4/16/26 titled “Medication Profile” (Approved 01/09). The policy states, “All patients of agency Home healthcare will have a current, accurate medication record in the clinical record.” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 am.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a Resumption of Care (ROC) assessment within 48 hours of the patients discharge from a hospital in 1(P-5) of 3 records reviewed in which the patient was transferred to and discharged from a hospital stay, resulting in the potential for unidentified health concerns and failure to meet the patent’s needs. Findings include: Patient #5 (P-5): During record review on 4/13/26, it was noted that P-5 had skilled nursing (SN) and physical therapy (PT) services ordered. During review, it was noted that there was a resumption of care (ROC) from a hospitalization ordered for the agency dated 5/23/25. However, the agency did not resume P-5’s care until 5/27/25, 4 days after the ordered ROC. During an interview on 4/16/26 at 10:30 a.m., the administrator (Staff-A) acknowledged the above findings.”

“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 elements for 1 (P-7) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #7 (P-7): During record review on 4/15/26, it was noted the plan of care dated 11/22/25 included wound care orders that stated, “SN (skilled nurse) to perform wound care on visit days, caregiver to change dressing on other days.” However, the intervention failed to include specifics on how often dressing changes should be completed by the caregiver on non-visit days. The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM.”

“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 services were administered only as ordered by the physician in 2 (P-2 and P-4) of 7 patients reviewed, resulting in the potential for unauthorized delivery of services. Findings include: Patient #4 (P-4): During record review on 4/15/26, it was noted the plan of care dated 8/28/25 indicated P-4 refused services from occupational therapy (OT). On 9/12/25, an order was written by the skilled nurse and sent to the physician that stated, “OT evaluation week of 9/14/25.” [sic] Upon further review of the record, it was determined the order was not signed and returned by the doctor until 10/13/25, however, OT started services on 9/18/25. During an interview with the clinical manager (Staff B) on 4/14/26 at 10:00 AM, Staff B was asked why OT services were started for P-4 before an order was approved by the physician. Staff B stated the order in the record was a verbal order, so it was approved by the physician at the time it was written and signed by her. However, upon review of the order, it was determined there was no indication this was a verbal order taken by Staff B and approved by the physician. The administrator (Staff A) was also present during the interview and acknowledged the findings. A review of agency policy titled “Physician Orders” (dated 5/12) revealed, “Physician telephone orders are documented on a Physician Verbal Order. All orders will be read back for accuracy of content/order.” Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 1/16/26 and ordered RN visits at a frequency of 2w8 (2 visits a week for 8 weeks), 1 PRN (as needed) weekly if needed for wound care. The POC stated orders, “SN (Skilled Nurse) to instruct patient on wound care as follows: RN to change dressing every 3 days and PRN if needed. Instructed patient to leave dressing on until changed by RN. Wound care as ordered. Cleanse wound with wound cleanser. Apply Santyl to wound if available (Dry sterile dressing if Santyl not available). Wrap foot including ankle with kerlix gauze. Secure with tape.” The RN completed a visit on 1/26/26 and documented, “Treatment Performed This Visit: …Cleansed wound with wound cleanser pat dried. Per patient request (patient refused to follow Dr order). Small amount of New Zealand Manuka honey applied to wound bed…Coordination Plan: Progress to Goals: Patient reports not agreeing with wound care orders as physician provided. Conferenced with: MD. Regarding: Patient non-compliant with wound care orders…” The RN failed to follow the ordered physician wound care directions and applications. A review of the agency policy occurred on 4/16/26 titled “Physician Orders (Approved 05/12). The policy states, “Policy: Physician orders will be obtained when indicated by patient need or a change in the patient’s medical condition. All skilled services are provided under the direction of a physician.” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 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 notify the Physician of a change in patient condition for 1 (P-2) of 7 records reviewed, resulting in a potential poor clinical outcome. Findings include: Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the POC noted “Parameters to Notify Physician” stating, “O2 Sat less than ( A review of the agency policy occurred on 4/16/26 titled “On-Going Assessment” (Undated). The policy states, “4. The patients physician will be contacted whenever any of the following occur: Changes in the patient’s condition. Changes that have occurred regarding diagnosis, treatments, medications, functional limitations, and rehabilitation status.” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 am.”

“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 in the plan of care in 5 (P-1, P-2, P-3, P-4, and P-7) of 7 patients reviewed, resulting in the potential for unmet care needs. Findings include: Patient #3 (P-3): During record review on 4/14/26, it was noted the physical therapist documented a missed visit on 3/24/26 due to “No Answer to Phone Call.” There was no evidence the physical therapist attempted to reschedule the missed visit during the week so that the ordered frequency of 2 times per week could be met. Patient #4 (P-4): During record review on 4/15/26, it was noted the physical therapist documented missed visits on 9/22/25 and 10/1/25 due to “No Answer to Phone Call.” There was no evidence the physical therapist attempted to reschedule the missed visits during the week so that the ordered frequency of 2 times per week could be met. Patient #7 (P-7): During record review on 4/15/26, it was noted the physical therapist documented a missed visit on 12/11/25 due to patient request and on 1/13/26 due to “No Answer to Phone Call.” There was no evidence the physical therapist attempted to reschedule the missed visits during the week so that the ordered frequency of 2 times per week could be met. During an interview with the administrator (Staff A) on 4/15/26 at 11:30 AM, Staff A was asked to provide the agency policy for missed visits. Staff A stated there was not a written policy, however, the agency expectation was that staff should attempt to reschedule the visit during the same week when possible, to ensure the frequency ordered in the plan of care could be met. Staff A and the clinical manager (Staff B) confirmed there was no documentation to show that attempts were made to reschedule the missed visits noted above during an interview on 4/16/26 at 10:00 AM. Staff A and Staff B acknowledged the findings at the time of interview. Patient #1’s (P-1) Start of Care (SOC) was dated 10/29/25. The Plan of Care (POC) identified diagnoses of Left Heel Pressure Ulcer, Diabetes Type 2 and Hypertension. During record review on 4/13/26, it was noted that the POC ordered Physical Therapy (PT) services at a frequency of 1w1 (1 time a week for 1 week), 2w7, recert 1 2w7, 1w1, recert 2 2w4, 1w4. The following were documented missed PT visits: 11/18/25, 12/2/25, 1/6/26, 2/3/26, 2/17/26 and 3/10/26. There was no documented evidence to complete the ordered visit frequency. The agency failed to ensure that PT services were provided as ordered. Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the POC ordered PT services at a frequency of 2w6, 1w1, recert 1w1, 2w7. The following were documented missed PT visits: 3/3/26 and 3/31/26. There was no documented evidence to complete the ordered visit frequency. The agency failed to ensure that PT services were provided as ordered. A review of the agency policy occurred on 4/16/26 titled “Care Planning” (Approved 05/12) The policy states, “Plan of Treatment: The clinical plan of treatment, including a comprehensive assessment which includes…frequency of visits...” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 am.”

“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 2 (P-2 and P-7) of 7 patients reviewed, resulting in the potential for improper wound care and unmet care needs. Findings include: Patient #7 (P-7): During record review on 4/15/26, it was determined a wound care order on the plan of care dated 11/22/25 stated, “SN to perform wound care on visit days, caregiver to change dressing on other days.” [sic] Upon review of the next 6 skilled nursing notes from 11/24/25 through 12/17/25, it was determined there was no documented evidence that the patient or caregiver was taught how to care for the wounds on the days the skilled nurse was not there. The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 1/16/26. The Plan of Care (POC) identified diagnoses of Right Heel Pressure Ulcer, Foot Drop and Osteoarthritis. During record review on 4/15/26, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 1/16/26 and ordered RN visits at a frequency of 2w8 (2 visits a week for 8 weeks), 1 PRN (as needed) weekly if needed for wound care. The POC stated orders, “SN (Skilled Nurse) to instruct patient on wound care as follows: RN to change dressing every 3 days and PRN if needed. Instructed patient to leave dressing on until changed by RN. Wound care as ordered. Cleanse wound with wound cleanser. Apply Santyl to wound if available (Dry sterile dressing if Santyl not available). Wrap foot including ankle with kerlix gauze. Secure with tape.” On 2/12/25, the RN documented a “Missed Visit” stating, “Comments: Patient stated she was doing her own wound care for 2/12/2026. Doctor Go aware of patient ability to perform wound care independently.” The Electronic Medical Record (EMR) contained no documented evidence of wound care education and compliance by P-2. The RN failed to document observed evidence that P-2 was capable of the wound care dressing change and compliant with infection control during dressing changes. A review of the agency policy occurred on 4/16/26 titled “Education of Patient and Caregiver” (Approved 05/12). The policy states, “4. All patient and/or caregiver education, their response to and comprehension/demonstration of instructions will be documented in the clinical record on an ongoing basis.” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 am.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide supervision was completed for 1 (P-7) of 3 patients reviewed who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #7 (P-7): During record review on 4/15/26, it was noted a new aide care plan was written on 12/31/25 following a resumption of care that ordered a home health aide 1 time a week for 1 week and 2 times a week for 1 week. It was also determined that an aide supervision note was written on 1/8/26 that documented excellent performance by the aide; however, the aide failed to complete a visit the week before and had not yet completed a visit since the new aide care plan was implemented. Additionally, an aide supervision note was completed on 1/20/26 that again indicated excellent performance by the aide; however, the aide had only made one visit since the new aide care plan (dated 1/17/26 that wasn’t signed by the aide) and had 3 notes left as “Not Started” (dated 1/8/26, 1/10/26, and 1/14/26). Therefore, the skilled nurse failed to accurately supervise the services provided by the home health aide as there was no documented evidence the aide had made the visits according to the plan of care. Review of agency policy titled “Home Health Aide Supervision” (dated 5/12) revealed the skilled nurse will, “Assess the home health aide’s adherence with the established Plan of Care.” Additionally, the policy stated the skilled nurse will, “Assess the home health aide’s documentation to verify that each visit clearly reflects the plan of care and is appropriate for the home health aide visit.” The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM.”

“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 accurate for 1 (P-1) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 10/29/25. The Plan of Care (POC) identified diagnoses of Left Heel Pressure Ulcer, Diabetes Type 2 and Hypertension. During record review on 4/13/26, it was noted that the POC dated 10/29/25 stated, “Allergies: Penicillin.” The referral documented the following allergies: Penicillin, Cephalosporins. The agency failed to document and accurately assess the patient’s allergy to Cephalosporins. A review of the agency policy occurred on 4/16/26 titled “Initial Assessment” (Revised 1/2018) The policy states, “1. During the initial comprehensive patient assessment, all relevant baseline data, the OASIS DATA Set and other relevant information is documented in the patient’s clinical record, including at least: M. Allergies to food and/or medications.” The Administrator (Staff A) and Clinical Manager (Staff B) reviewed and acknowledged the findings listed above in an interview on 4/16/26 at 9:15 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 a transfer summary was sent within 2 business days of being made aware of an unplanned transfer in 3 (P-4, P-5 and P-7) of 3 patients reviewed who were transferred, resulting in the potential for poor continuity of care and poor patient outcomes. Findings include: Patient #5 (P-5): During record review on 4/13/26, it was noted that P-5 had skilled nursing (SN) and physical therapy (PT) services ordered. During review, it was noted that there was a transfer summary dated 4/28/25 for a transfer of P-5 to a hospital. However, there was no evidence the transfer summary had been sent to P-5’s physician or the accepting facility (hospital). There was a second transfer documented in P-5’s record for 6/9/25. However, there was no evidence the second transfer summary had been sent to P-5’s physician or the accepting facility (hospital) either. During further review of P-5’s record, it was discovered that there was no documented evidence that PT had submitted a transfer summary to P-5’s physician or the receiving facility (hospital) for the 4/28/25 or the 6/9/25 transfers. During an interview on 4/16/26 at 10:30 a.m., the administrator (Staff-A) acknowledged the above findings Patient #4 (P-4): During record review on 4/14/26, it was noted a transfer summary was written on 10/25/25 after learning P-4 was hospitalized on 10/22/25. However, it was determined there was no evidence the transfer summary had been sent to the accepting facility. Patient #7 (P-7): During record review on 4/15/26, it was noted a transfer summary was written on 12/23/25 after learning P-7 was hospitalized. However, it was determined there was no evidence the transfer summary had been sent to the accepting facility. The administrator (Staff A) and clinical manager (Staff B) reviewed and acknowledged the findings during an interview on 4/16/26 at 10:00 AM.”