Extracare Home Health Services

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the comprehensive assessment reflected the patient’s status for 1 (P-5) of 7 patient records reviewed (G528); failed to ensure the comprehensive assessment included the patient’s strengths, goals, or preferences for 1 (P-5) of 7 patient records reviewed (G530); failed to ensure the comprehensive assessment documented discharge needs and discipline of services for 1 (P-5) of 7 patient records reviewed (G534); failed to ensure the comprehensive assessment included a review of all current medications for 3 (P-5, P-6 & P-7) of 7 patient records reviewed (G536); failed to ensure the comprehensive assessment included the patient’s caregiver’s willingness, ability and availability for 1 (P-5) of 7 patient records reviewed (G538), resulting in the potential for unmet patient care needs and poor patient outcomes. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.55: Comprehensive Assessment of Patients.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the plan of care included patient-specific measurable goals and outcomes for 1 (P-4) of 7 patient records reviewed (G572); failed to ensure the plan of care included all the required elements to provide quality and safety in patient care for 4 (P4, P-5, P-6, & P-7) of 7 patient records reviewed (G574); failed to ensure all physician orders were documented in the plan of care for 1 (P-4) of 7 patient records reviewed (G576); failed to provide care only as ordered by the physician for 1 (P-1, P-3, P-7) of 2 patients (G580); failed to ensure the plan of care was reviewed and revised by the physician for 1 (P-4) of 7 patient records reviewed (G588); failed to provide current written medication information, schedule, and instructions for 1 (P-4) of 3 patients observed (G616); failed to ensure the name and contact information of the clinical manager was provided for 1 (P-4) of 3 patients observed (G622), resulting in the potential for unmet patient care needs and poor patient outcomes. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.60: Care Planning, Coordination of Services, and Quality of Care.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program documented actions to measure, track and analyze quality indicators for improvement of patient care services (See G 642); failed to develop a program of relevant data collection used to monitor safety and effectiveness of services provided, and failed that all data collection was approved by the Governing Board (GB) (See G 644); failed to develop performance improvement activities that were based on high risk, problem-prone areas affecting the quality of patient care services (See G 646); failed to develop performance improvement activities to track and trend adverse patient events, analyze potential causes and implement preventive interventions (See G 654); failed to take actions geared for performance improvement and then monitor any improvements made are sustained (See G 656); failed to develop the required performance improvement projects with reasoning why they were chosen (See G 658); and failed to ensure its GB assumed overall responsibility for the regulatory requirements needed for a QAPI program (See G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.65 – Quality Assessment and Performance Improvement (QAPI).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on observation, record review and interview, the agency failed to develop an infection control program that monitored staff’s performance regarding any of the six accepted standard infection control practices to prevent the transmission of infections and communicable diseases (See G 682); failed to ensure the infection control program was active and provided surveillance, identification, prevention, control and investigation of infectious and communicable diseases, and was a part of the agency’s Quality Assessment and Performance Improvement (QAPI) program (See G 684); and failed to document infection control education to staff, patients, and caregivers since 2021 (See G 686). The cumulative effects of these systemic problems resulted in the agency’s inability to ensure the provision of safe health care for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that the Clinical Manager and or the designated alternate was available during all operating hours (G950); failed to ensure the oversight of the coordination of referrals for 1 (P-4) of 7 patient records reviewed (G964); the continued assessment of patient care needs for 1 (P-5) of 7 patient records reviewed (G966); and the development of an individualized plan of care for 1 (P-4) of 7 records reviewed (G968), resulting in the agency’s potential for mismanagement of resources essential for delivering optimal care, which may result in unmet care needs and poor patient outcomes. The cumulative effect of this systemic problem resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.105 Organization and Administration of Services.”

“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 maintain Emergency Preparedness policies and procedures that had been reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared. Findings include: On 4/13/26 at 10:55 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the Emergency Preparedness Plan was dated 2021. Upon further review, there was no Emergency Preparedness Policy available for review. The Administrator and Office Manager reviewed the above findings during an interview on 4/16/26 at 9:50 a.m..”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an inclusive Communication Plan, resulting in the inability to communicate with staff and officials in the event of an actual disaster and uncoordinated care for all patients serviced by this agency in the event of a facility emergency or disaster. Findings include: On 4/13/26 at 10:55 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the Communication Plan was void of methods that would be used to communicate with the agency’s patients, families and all other persons in the event of an interruption in communication systems. The Administrator and Office Manager reviewed and acknowledged these findings during an interview on 4/16/26 at 9:50 a.m..”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness Communication Plan that complied with Federal, State and local laws to include required subject areas and had been reviewed and updated at least every 2 years, resulting in lack of an effective communication plan and the potential for interruption in the provision of needed care and services in the event of an emergency or disaster. Findings include: On 4/13/26 at 10:55 a.m., during a review of the agency’s Emergency Preparedness Plan, it was noted that the plan was void of the names and contact information for staff, entities providing services under arrangement, patients’, patient’s Physicians and volunteers, as appropriate. The Administrator and Office Manager reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:50 a.m..”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated and revised for 1 (P-1) of 1 patient who was recertified for continued services, resulting in the lack of information in determining the care and support needs of the patient. Findings include: Patient #1 (P-1)’s start of care was 12/18/25 with diagnoses that included Lumbar Radiculopathy and Low Back Pain. On 4/13/26 during the Entrance Conference, the Administrator (Staff-A) stated the agency made the decision to switch from one Electronic Medical Record (EMR) system to a less expensive system several months ago. Staff-A further reported that because of this switch, all of his documentation as a Physical Therapist (PT) was and is done in his own handwriting as he isn’t familiar with the new EMR system. During the record review on 4/13/26 at 3:15 p.m. it was noted that P-1 was to be recertified for continuing care on 2/11/26. A document titled “Physical Therapy Revisit Note”, dated 2/11/26 had the word “Recertification” circled in red at the top of the note. Most of the handwriting was illegible and could not be understood. One section of the document read, “recertify for further improvement...” During an interview with Staff-A and the Office Manager (Staff-B) on 4/16/26 at 9:09 a.m., Staff-A stated that there was an electronic version of the document in the EMR system. Upon review, it was noted that the Recertification Oasis (Comprehensive Assessment) had not been completed by Staff-A. When queried as to why the assessment had not been completed on the required form, Staff-A responded, “I don’t complete the Oasis because that information is in my PT notes.” The agency failed to ensure the Comprehensive Assessment was updated and revised according to the needs of the patient, as per this requirement. Staff-A and Staff-B reviewed and acknowledged this information during the above interview.”

“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 that the plan of care (POC) included objective measurable goals specific to the needs of the patient in 1 (P-4) of 7 patient records reviewed. Patient #4 (P-4): During the review of records on 4/14/26 it was noted the POC for the recertification period 3/5/26 through 5/3/26 did not identify objective patient-specific measurable goals. This is evidenced by the void of documentation in the POC, section 22. “Goals/Rehabilitation Potential/Discharge Plans”. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:53 PM, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “A plan of care is developed from the information gathered during the initial assessment to determine: Patient goals and desired outcomes, measurable outcomes…””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to identify any measurable improvement indicators for its Quality Assessment and Performance Improvement (QAPI) program since 2021, resulting in the potential for repeated unmet patient outcomes, poor safety for patients, and provision of substandard care. Findings include: On 4/15/26, QAPI program review found no evidence regarding the program’s scope and context concerning measurable improvement in quality indicators that would be analyzed and tracked, such as adverse patient events and other patient care services to determine if the provision of patient care was safe and appropriate since 2021. This finding was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:35 PM.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop a data collection program that utilized quality indicators and failed to document its Governing Body’s (GB) approval of the frequency and detail of the data collection for the Quality Assessment Performance Improvement (QAPI) program since 2021, resulting in the potential for poor quality of services towards patient care. Findings include: On 4/15/26, the Agency’s QAPI documentation was reviewed which revealed a failure to document efforts to systematically collect program data that was approved by the GB. The QAPI binder contained no data that could be tracked and trended towards pre-established goals for improved quality measures. The last documented QAPI entry was in 2021 regarding COVID-19. The QAPI program has been non-operational since then. These findings was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:37 PM.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to initiate any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the provision of substandard care and unmet patient care needs. Findings include: On 4/15/26, review of the agency’s QAPI program found no evidence that the agency has developed any of the required program activities which focused on high-risk, problem-prone areas needed for an effective functioning QAPI program since 2021. This finding was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:39 PM.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop performance improvement activities, as part of the Agency’s Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyzing the cause and implementing preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 4/15/26, review of the agency’s QAPI documentation found no evidence of any performance improvement projects that would collect specified data to track and trend adverse patient events, analyze causative factors and implement preventive interventions as required since 2021. This finding was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:41 PM.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct any performance improvement projects (PIP) as required since 2021, resulting in the lack of quality improvement measures intended for patient care services. Findings include: On 4/15/26, the agency’s Quality Assessment Performance Improvement (QAPI) program was reviewed and found no evidence of a PIP that was chosen and approved to gather measurable information/data to track and trend towards pre-established goals that reflected the scope and context of previous patient care services performed since 2021. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:43 PM.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Governing Body (GB) was involved in the Quality Assessment and Performance Improvement (QAPI) program since 2021, resulting in the lack of oversight concerning the quality of patient care services rendered. Findings include: On 4/15/26, the agency’s QAPI program was reviewed and found no evidence that indicated the GB was actively involved in its QAPI program since 2021. Further review of the GB meeting minutes beginning on 1/18/21, through the last meeting on 1/21/25, found no acknowledgement of a QAPI program or evaluation of reviewed data since 2021. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:44 PM.”

“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, record review and interview, the agency failed to utilize infection control standards of practice during the provision of care for 2 (P-2, P-6) of 2 patients observed during home visits, resulting in the potential for the development and spread of infection. Findings include: Patient #6 (P-6): On 6/14/26 during a joint home visit with the physical therapist (PT/Staff-A), it was observed the PT failed to disinfect common use equipment (blood pressure cuff) before and after patient use. This finding was acknowledged by the agency’s administrator (Staff-A) during an interview on 4/16/26 at 11:44 AM. In addition, review of the agency’s infection control program found no documented evidence of monitoring staff compliance concerning any of the 6 recognized core infection control practices (hand hygiene; environmental cleaning and disinfection; injection and medication safety; use of personal protective equipment; minimizing potential exposures; and cleaning and disinfection of medical equipment) since 2021. The findings above were reviewed and acknowledged by Staff-A and Office Manager (Staff B) during an interview on 4/15/26 at 2:45 PM. Patient #2 (P-2)’s start of care was 1/27/26 with diagnoses that included Osteoarthritis, Diabetes Mellitus and Low Back Pain. During the record review on 4/14/26 at 10:45 a.m., it was noted that the Plan of Care ordered Physical therapy (PT) services to be provided. On 4/14/26 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT/Administrator/Staff-A). During the visit, Staff-A checked the patient’s vital signs (blood pressure, pulse, temperature). Upon completion of the visit, Staff-A returned his equipment (stethoscope, blood pressure cuff and thermometer) to his work bag. Staff-A did not clean the equipment prior to placement in the work bag. Staff-B/Administrator and the Office Manager reviewed and acknowledged the above observations during an interview on 4/16/26 at 9:20 a.m.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, and failed to ensure the infection control program was an integral part of the agency’s Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for increased, untreated infections among staff and all patients serviced by this agency. Findings include: On 4/15/26, the agency’s QAPI program concerning infection control (IC) documentation was reviewed. No documentation was found within IC program since 2021. Subsequently, there was no evidence that the agency had maintained a comprehensive IC program designed for the monitoring and identification of disease/infections with resulting actions to mitigate the potential infectious spread to patients and staff. The findings above were reviewed and acknowledged by Staff-A and Office Manager (Staff B) during an interview on 4/15/26 at 2:46 PM.”

“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 documented evidence that infection control (IC) education was provided to all staff utilized by the agency, and failed to show IC education was instructed to patients/caregivers within the IC program since 2021, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency. Findings include: On 4/15/26, the IC program documentation was reviewed for evidence that the agency had provided IC education to all staff (direct and contracted) as required. No evidence was found that indicated this was done since 2021. Further, the IC program failed to have any evidence that IC education was also provided to patients/caregivers since 2021. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:48 PM.”

“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 the physical therapist (PT) adequately assessed and monitored the needs of the patient in 1 (P-7) of 7 patient records reviewed, resulting in unrecognized clinical needs and the potential for poor outcomes. Findings included: Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review of P-7’s comprehensive assessment by skilled nursing (SN) documented under respiratory status patient’s lung sounds were diminished and becomes “dyspneic (noticeably short of breath) when walking more than 20 feet.” Further, SN classified P-7’s COPD level at a 3, meaning it was “poorly controlled” with multiple hospitalizations within the last 6 months and was using “breathing treatments” for symptom relief. On 4/15/26, review of PT’s visit notes (including initial evaluation and discharge from agency) had an ordered frequency of 1W1 (once weekly for one week), 2W6; noted all (14 of 14) visits failed to document any respiratory findings concerning signs and symptoms of dyspnea and failed to obtain P-7’s oxygen level at rest and while performing therapeutic exercises with ambulation greater than 20 feet (goal was to reach 150 feet.) During each of the 14 PT visits, P-7 was documented as having pain issues of the back, both shoulders. However, pain measurements were not documented in 4 of the visits. Further, the PT visit notes (14 of 14) failed to document “Ambulation” in measurable terms. Examples include, “From sitting area to kitchen, back to sitting area” (1/12/26); “With walker from living room to outer door back to bathroom x 2.” There was no documented evidence of a measurable progression in ambulation to verify if the goal of 150 feet was ever met before being discharged. The PT failed to responsibly assess and evaluate the significant needs of the patient noted above. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:58 AM. Staff-A who was also the PT on the case (P-7) further acknowledged that better assessments with corroborating documentation will take place going forward.”

“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 prepared clear, written patient care instructions found on the home health aide (HHa) plan of care for 1 (P-7) of 1 patient with ordered HHa services, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review of P-7’s plan of care (POC), effective 1/9/26, ordered the provision of home health aide (HHa) services at 4 visits weekly for 4 weeks (effective 1/9/26). Review of the HHa POC written by skilled nursing on 1/9/26, failed to include any of the safety precautions found on the primary POC/485 under “Safety Measures” and were as follows: “Emergency Plan Developed, Fall Precautions, Universal Precautions/Infection Control, Slow Position Change, Keep Pathways Clear, Use of Assistive Devices, Proper Position During Meals”. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:42 AM. Both noted the aide POC will include all the safety precautions listed on the main POC/485 going forward.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 4/13/26 at 9:48 a.m., during the entrance conference, the Administrator (Staff-A) was asked what services were currently provided by the agency and reported, “We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health Aide (HHa) services.” When asked if they utilized contract personnel, Staff-A said “Yes.” When asked which services were provided directly by the agency, Staff-A replied, “PT.” “We contract SN, OT and ST.” A review of the agency’s contract was conducted on 4/13/26 at 1:55 p.m. Upon review, it was noted that the contract listed Skilled Nursing, Occupational Therapy, Home Health Aide and Physical Therapy services. There was no agreement for Speech Therapy or Medical Social Work services made available for review. The agency failed to ensure that at least one qualifying service was provided directly by agency employees. The Administrator (Staff-A) and the Office Manager (Staff-B) reviewed and acknowledged these findings during an interview on 4/16/26.”

“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 all entries contained in the clinical record were clear and legible, resulting in the potential for lack of continuity of care and unmet patient care needs. Findings include: On 4/13/26 at 9:48 a.m., during the Entrance Conference, the Administrator (Staff-A) stated the agency made the decision to switch from one Electronic Medical Record (EMR) system to a less expensive system several months ago. Staff-A further reported that because of this switch, all of his documentation as a Physical Therapist (PT) was and is done in his own handwriting as he isn’t familiar with the new EMR system. During a review of clinical records (P-1 through P-7), it was noted that several of the therapy notes and assessments were illegible. Staff-A, the author of the illegible documents, was asked periodically to decipher the illegible writing. The agency failed to ensure all clinical documents were legible and in writing that could be understood by all clinicians employed by this agency. Staff-A reviewed and acknowledged the above findings at the time of discovery.”

“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 observation, interview and record review, the agency failed to honor the right to refuse care/treatment during therapy and ensure inclusion of overall planning of care for 1 (P-2) of 1 patient observed during a home visit, resulting in the potential for missed visits and unmet care needs. Findings include: Policy: Refusal of Treatment, Policy Number: C304, dated 8/10 stated, “Upon admission and throughout the course of care, patient, family and/or care giver will: Be allowed to refuse all or part of his/her care to the extent permitted by law..., The patient physician is notified via telephone of a refusal as soon as possible..., Documentation of such refusal is made part of the clinical record...” Patient #2 (P-2)’s start of care was 1/27/26 with diagnoses that included Osteoarthritis, Diabetes Mellitus and Low Back Pain. During the record review on 4/14/26 at 10:45 a.m., it was noted that the Plan of Care ordered Physical Therapy (PT/Administrator/Staff-A) services to be provided. On 4/14/26 at 3:30 p.m., a scheduled survey home visit was conducted with Staff-A. Prior to the beginning of care, it was noted that there was no completed calendar of proposed visits to be made by Staff-A in P-2’s admission packet. The agency failed to ensure P-2 was informed of care and services in advance of care. During the visit Staff-A was observed assessing the patient’s vital signs, (Blood Pressure, Pulse, Temperature). Staff-A then proceeded to apply a topical analgesic (pain cream) to the patient’s neck area, left shoulder and bilateral lower legs for complaints of 10/10 generalized pain. Upon completion of the topical application, Staff-A informed P-2 that they would begin therapy exercises to which P-2 replied, “I don’t want to do any exercises today. I’m in too much pain.” Staff-A told P-2, “Let’s just show the Surveyor how you can walk and do your exercises.” P-2 began to cry and restated, “I’m in pain. I told you I can’t do it.” This writer interjected and informed Staff-A that care was not to be based on this writer’s presence and that care should solely be based on the needs of the patient. Staff-A persisted by asking P-2, “Okay, how about if you just stand and we can use your cane and walk.” P-2 offered no response, then began to cry uncontrollably and stated, “I need to go to the hospital. I need a wheelchair.” The Group Home Manager, who was nearby, stated, “She’s (P-2) fine. She acts like this all the time. When you leave, she’ll be back to her normal self.” Staff-A then concluded the visit and exited the premises. Staff-A failed to acknowledge P-2’s symptoms, complaints of pain and refusal of care. Further, Staff-A failed to assess P-2 upon completion of the visit due to complaints of 10/10 pain. Additionally, Staff-A failed to promptly notify the Physician and document P-2’s choice to refuse care in the clinical record. The agency failed to ensure the patient’s right to refuse care was honored. Staff-A (Administrator) and the Office Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:20 a.m.”

“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 the Notice of Medicare Non-Coverage (NOMNC) in advance of terminating home care services for 2 (P-1, P-7) of 2 patients, resulting in patients not having the right to dispute the termination of Medicare covered services. Findings include: Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). The plan of care (POC) ordered a skilled nursing (SN) visit frequency of 1W1 (once weekly for one week), 2W1, and 1W2. The POC also ordered a physical therapy (PT) visit frequency of 1W1 followed by 2W6. On 4/15/26, record review noted P-7 was discharged from the agency on 2/19/26 by PT services. Further review found no documented evidence that P-7 had signed a completed NOMNC form concerning the discontinuation of SN services (1/27/26) and PT services (2/19/26) at least 2 days before the last covered service date as required. The agency failed to allow for the opportunity of P-7 to dispute when skilled services would end. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:49 AM. Patient #1 (P-1)’s start of care was 12/18/25 with diagnoses that included Radiculopathy and Low Back Pain. During the clinical record review on 4/13/26 at 3:15 p.m., it was noted that P-1 was discharged from the agency’s services on 3/12/26. There was no documented evidence to show that P-1 had been given the Notice of Non-Coverage prior to terminating ongoing services. The Administrator and Office Manager reviewed and acknowledged these findings during an interview on 4/16/26 at 9:09 a.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-5, P-6) of 7 patient records reviewed, resulting in incomplete clinical information used to develop a plan of care based on the needs of the patient. Patient #6 (P-6): This patient was admitted to home care on 4/8/26, with diagnoses which included bilateral primary osteoarthritis, hypertension, and muscle weakness. On 4/14/26, review of the initial comprehensive assessment performed by physical therapy (PT) services on 4/8/26 noted the following concerns: Under section M1021/1023 “Diagnoses and Symptom Control” the PT documented osteoarthritis, hypertension, and muscle weakness. However, PT failed to include diagnoses of seizure disorder, peripheral vascular disease, coronary artery disease, dementia with no behavioral disturbances, schizophrenia, depression, and legally blind in left eye. In addition, medical history regarding severity or P-6’s ability for symptom management control was not found concerning the missed diagnoses noted above from the physician’s referral. Subsequently, the comprehensive assessment failed to incorporate seizure precautions that should have then been added to P-6’s plan of care. Further, the comprehensive assessment failed to include findings from a recent hospitalization (1/29/26) where P-6 had hypokalemia and had an order to start taking a dose of 10 milli-equivalents of potassium daily. No acknowledgement of this new medication was found in the medical record for P-6. The findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:54 AM. Staff-A further noted this did not meet agency expectations when asked nor agency policy referenced in P-5’s citation. Patient #5 (P-5) was admitted to the agency 4/8/26 with the diagnosis of cerebral palsy (abnormal brain development impacting muscle movement). The record review conducted on 4/14/26 revealed a medical document included with the referral, titled “SOAP Notes” dated 4/1/26, that documented P-5’ past medical history of cerebral palsy, seizures, mental disability and frequent falls. Further noting no falls in 6 months since using the assistant aids of a helmet and gait belt. The assessment findings during the visit included chronic left knee pain, “small area of bruise under the right eye, AO x1-2 (alert and orientated to person and place), and judgment/insight limited.” The notes documented a plan for in home PT services for weakness, gait instability, fall preventions, gait assistance, and to “continue with wheelchair”. The review of the OASIS (Outcome and Assessment Information Set) dated 4/8/26, revealed that the comprehensive assessment did not capture the patient’s current health status as noted by the physician in the “SOAP Notes”. This is evidenced by the following examples of omitted documentation from the comprehensive assessment. No documented assessments under the following sections: Neurological, Cardiovascular Status, Respiratory Status, blood sugar, and Integumentary Status. The “Ambulation/Locomotion” assessment documented “Able to walk only with the supervision or assistance of another person at all times.” The trial assessment of ambulation was void of documentation. No documentation of past medical history.The assessment of pain included “Pain Effect on Sleep” with a documented response of “Frequently”. No documentation of the pain location, intensity, aggravating factors, treatment and treatment effectiveness.No documentation on the use of a wheelchair, helmet or gait belt under mobility and DME (durable medical equipment) assessments.Ability of walking documented “Not applicable”.Safety measures void of seizure and fall precautions. The agency failed to document a comprehensive assessment that captured all the clinical data needed to develop a plan of care that included the patient’s current health, psychosocial, functional, and cognitive status. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:50 PM. Staff-A explained that some of the comprehensive assessments are documented on paper in the PT evaluation documentation. Staff-A confirmed the understanding that the review of findings pertains to the electronically documented comprehensive assessment within the OASIS at start of care, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “During the initial comprehensive patient assessment all relevant baseline data, the OASIS data Set… is documented in the patient’s clinical record, including at least: … The patient’s current medical, mental and psychosocial status, including dates of onsets and/or exacerbations.””

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient’s strengths, goals, or preferences for 1 (P-5) of 7 patient records reviewed, preventing the patient and caregiver to actively participate in the development of the plan of care. Patient #5 (P-5): During the review on 4/14/26 of the start of care OASIS (Outcome and Assessment Information Set) dated 4/8/26, it was noted that the “Patient input into their care preferences” was blank leaving the comprehensive assessment void of the patient’s strengths, care preferences, nursing, social, medical and rehabilitation needs, measurable outcomes, and discharge plans. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:50 PM, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “During the initial comprehensive patient assessment all relevant baseline data, the OASIS data Set… is documented in the patient’s clinical record, including at least: … Identified patient strengths through clinician assessment and patient input.””

“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 the comprehensive assessment documented discharge needs and discipline of services for 1 (P-5) of 7 patient records reviewed. Patient #5 (P-5): During the record review on 4/14/26 of the OASIS (Outcome and Assessment Information Set) dated 4/8/26, it was noted that the “Discharge Plans” documented “Discharge when optimal function attained with”; the “attained with” options: “Family Assistance, Comm. Services, IHSS [sic] in x number of weeks or days”, were not selected. Further review noted the documentation of “Skilled Intervention” and “Visit Frequency” were blank. The findings support the agency failed to complete a comprehensive assessment that documented a defined discharge plan, the discipline and the skilled interventions appropriate to meet the care needs of the patient. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:50 PM, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “During the initial comprehensive patient assessment all relevant baseline data, the OASIS data Set… is documented in the patient’s clinical record, including at least: … P. Specific, individualized patient care needs/problems pertinent to the care being provided.” Further noting, “A plan of care is developed from the information gathered during the initial assessment to determine: Patient problems and their medical … discharge planning needs.””

“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 comprehensive assessment included a review of all medications to determine any adverse effects, and failed to ensure the physician was notified of the identified drug interactions for 6 (P-1, P-2, P-3, P-5, P-6, P-7) of 6 patients, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: Patient #6 (P-6): This patient was admitted to home care on 4/8/26, with diagnoses which included bilateral primary osteoarthritis, hypertension, and muscle weakness. On 4/14/26, review of P-6’s initial comprehensive assessment which was performed by physical therapy (PT) services on 4/8/26, had documented the following under section M2001/Drug Regimen Review: “No issues found during review”. Under section M2003/Medication Follow-up, the PT documented “Skip Answer” regarding if the agency had contacted the physician on any medication concerns. PT also documented “No” under section M2010/Patient-Caregiver High Risk Drug Education if any instruction was given to P-6 on her current medications at the time. When this documentation was compared to the agency’s own medication reconciliation software performed on 4/8/26, the following was revealed: 4 major or severe (highest possible level) drug to drug interactions were found. Clinical symptoms varied from “fast, irregular heartbeat” to “high fever, seizures, confusion ...” The agency failed to use its own software dedicated to alerting clinicians of significant interactions in which to notify the physician to resolve any concerns. Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review of P-7’s initial comprehensive assessment which was performed by skilled nursing (SN) services on 1/9/26, had documented the following under section M2001/Drug Regimen Review: “No issues found during review”. Under section M2003/Medication Follow-up, the PT documented “Skip Answer” regarding if the agency had contacted the physician on any medication concerns. When this documentation was compared to the agency’s own medication reconciliation software performed on 1/9/26, the following was revealed: 2 major or severe drug to drug interactions were found. Both carried the risk of heart rhythm changes, chest pain, trouble breathing ... “ The findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:52 AM. Staff-A stated this did not meet agency expectations when asked, or its policy referenced below. Agency Policy: “Medication Profile” Policy Number C311 (undated) stated, “Any discrepancies (omissions, duplications, potential interactions) must be resolved.” Patient #5 (P-5) was admitted to the agency 4/8/26 with the diagnosis of cerebral palsy (abnormal brain development impacting muscle movement). The record review of the paper clinical record conducted on 4/14/26 revealed the scanned copy of the medication administration record (MAR) dated 4/1/26 through 4/30/26, from the home where P-5 resides. The MAR documented P-5’s current medication regimen. The review on 4/15/26 of the electronic medical records (EMR) noted the medication profile dated 4/8/26 did not include medications that were listed on the MAR. The following medications were listed on the MAR and not documented in the EMR medication profile: Lorazepam 1 mg twice daily, one extra as needed.Melatonin 5 mg one tablet at bedtime.Duloxetine HCL DR 20 mg one every morning.Paliperidone ER (extended release) 9 mg one tablet once daily. The following are noted medication discrepancies in doses: Ferrous Sulfate dose: Medication profile documented dose is 106 mg, and the MAR documented dose is 324 mg.Propranolol dose: Medication profile documented dose is 40 mg, and the MAR documented dose is 20 mg take ½ tablet in the morning and one tablet at bedtime. Further review of the comprehensive assessment revealed that the agency did not complete a medication reconciliation, evidenced by the void of documented medications in the “Current Medications” section of the OASIS (Outcome and Assessment Information Set), dated 4/8/26. Additionally, it was documented “No” to the question, “High-Risk Drug Classes: Used and Indication A. Antipsychotic is Taking”. This conflicts with the medication profile and MAR documentation that P-5 is prescribed an antipsychotic, haloperidol. The review of the documented “Drug Interactions” obtained from the medication profile identified 5 major interactions. The comprehensive assessment documented a conflicting assessment with the documentation of “No” to the question, “Did a complete drug regimen review identify potential clinically significant medication issues?” The review was void of evidence that the agency communicated a review of medications or major interactions with the physician. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:53 PM, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “During the initial comprehensive patient assessment all relevant baseline data, the OASIS data Set… is documented in the patient’s clinical record, including at least: Medications that the patient is currently taking … The patient’s medication will be reconciled to reflect an accurate medication record.” Patient #1 (P-1)’s start of care (SOC) was 12/18/25 with diagnoses that included Lumbar Radiculopathy and Low Back Pain. During the record review on 4/13/26 at 3:15 p.m., it was noted that section M2001 (Drug Review) of the Initial Comprehensive Assessment, completed by the Physical Therapist (PT), documented, “No issues found during review.” The agency’s “Drug Interaction Report” revealed 12 moderate drug to drug interactions and 2 major drug to drug interactions. The agency failed to ensure the comprehensive assessment included a thorough review of all the patient’s medications. The Administrator (Staff-A) and Office Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:09 a.m. P-2’s SOC was 1/27/26 with diagnoses that included Osteoarthritis, Diabetes Mellitus and Low Back Pain. During the record review on 4/14/26 at 10:45 a.m., it was noted that section M2001 of the Comprehensive Assessment, completed by the PT, documented, “No issues found during review.” The agency’s drug interaction report revealed 16 moderate drug to drug interactions. Upon further review, it was noted that there were 7 medications listed on P-2’s plan of care, however, the patient’s “Medication Record” listed 17 medications. Additionally, the drug interaction report listed 13 prescribed medications. The agency failed to ensure the comprehensive assessment included a thorough review of all the patient’s medications. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 4/16/26 at 9”09 a.m. P-3’s SOC was 2/23/26 with diagnoses that included Schizophrenia, Muscle Weakness and Hypertension. During the record review on 4/15/26 at 12:35 p.m., it was noted that section M2001 of the Comprehensive Assessment, completed by the PT documented, “No issues found during review.” The agency’s Drug Interaction Report revealed 2 major drug to drug interactions and 16 moderate drug to drug interactions. There was no evidence to support that the agency conducted a comprehensive drug review to ascertain any untoward interactions. Staff-A and Staff-B review and acknowledged the above findings during an interview on 4/16/26 at 9:30 a.m.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment identified the patient’s primary caregiver for 1 (P-5) of 7 patient records reviewed, resulting in the potential of unmet needs. Patient #5 (P-5) was admitted to the agency 4/8/26 for physical therapy services with the diagnosis of cerebral palsy, seizures, and mental disability. The record review conducted on 4/14/26 revealed physician office visit notes, titled “SOAP Notes” dated 4/1/26. It noted the patient resided in a group home and had a legal guardian. It was further noted that the comprehensive assessment did not identify if P-5 had a committed and willing primary caregiver or identify the legal guardian. This is evidenced by the review OASIS (Outcome and Assessment Information Set), dated 4/8/26, that noted under section (M1100) “Patient Living Situation” P-5 “Lives with other persons in a home” and under section (M2101) P-5 received required supervision / assistance by “Non-agency caregiver(s) currently provide assistance.” Further review noted that the “Patient Legal Representative” and “Patient chosen caregivers and scope they will perform” was blank. The assessment was void of the identification of P-5’s full living arrangements, legal guardian and non-agency caregiver(s) and their ability, capabilities, and willingness to meet P-5’s care needs. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:53 PM, which did not reflect agency policy referenced below. Agency policy C310 review on 4/16/26 titled, “Initial Assessment” (revised 1/20/18), revealed that “A patient representative, legal representative or patient selected representative will be determined and documented in the clinical record.””

“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 pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of 6 (P-1, P-3, P-4, P-5, P-6, P-7) of 6 patients, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Patient #6 (P-6): This patient was admitted to home care on 4/8/26, with diagnoses which included bilateral primary osteoarthritis, hypertension, and muscle weakness. On 4/14/26, review of P-6’s POC found no evidence of vital sign safety parameters to alert clinicians when to notify the physician of abnormal, potentially dangerous readings. Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review of P-7’s POC found no evidence of vital sign safety parameters to alert clinicians when to notify the physician of abnormal, potentially dangerous readings. These findings were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:42 AM. Patient #4 (P-4): The patient was recertified to the agency 3/5/26 through 5/3/26 with peripheral vascular disease and a lower left leg wound for skilled nursing services for wound care and physical therapy for balance, muscle strengthening, improved mobility and transferring. The record review on 4/14/26 noted the POC was labeled as “Draft” (40 days after the start of the episode). Further review noted that 9 of the 29 sections of the POC were blank leaving the POC incomplete without the required clinical information needed to develop a plan of care. Sections void of documentation included: “DME (durable medical equipment) and Supplies; Safety Measures; Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Orders for Discipline and Treatments (Specify Amount/Frequency/Duration), Goals/Rehabilitation Potential/Discharge Plans.” Patient #5 (P-5) was admitted to the agency 4/8/26 with the diagnosis of cerebral palsy, seizures, mental disability, and history of falls. P-5 also requires the use of a wheelchair, helmet, and gait belt, and is dependent on assistance for all activities of daily living. The record review on 4/14/16 noted the POC was labeled as “Draft” (6 days after the start of care) and void of all the required clinical information needed to develop a plan of care. This is evidenced by the void documentation for the sections “Nutritional Requirements, Allergies, Mental Status, Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)”. Further review noted the safety measures documented included “safe environment “and did not include fall or seizure safety measures. The agency failed to ensure that all required information needed to develop a patient specific care plan was included in the POC. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM, which did not reflect agency policy referenced below. Agency policy C312 review on 4/16/26 titled, “Care Planning” (dated 8/2010) revealed that the “The Plan of Treatment is based upon the physician’s orders and encompasses the equipment, supplies and services required to meet the patient’s needs.” The policy also documented the agency definition of plan of treatment which included “…types of services/equipment/medical supplies needed, frequency of visits, goals and interventions … functional limitations, precautions, activities, mental status, nutritional requirements, medication, treatments, safety measures and discharge plans.” Patient #1 (P-1)’s start of care (SOC) was 12/18/25. The period of review was 2/16/26 through 3/12/26 with diagnoses that included Lumbar Radiculopathy and Low Back Pain. The plan of care (POC) ordered Physical Therapy (PT) services to be provided. During the record review on 4/13/26 at 3:15 p.m., it was noted that the POC was incomplete for the aforementioned certification period. There were no interventions, reportable parameters or associated measurable goals. Additionally, all of P-1’s diagnoses reportedly exacerbated on the same date of admission (12/18/25). The POC did not address the identified needs of the patient. The Administrator (Staff-A) and Office Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:09 a.m. P-3’s start of care was 2/23/26 with diagnoses that included Schizophrenia, Muscle Weakness and Hypertension. The POC ordered PT services to be provided. During record review on 4/15/26 at 12:35 p.m., it was noted that the POC was void of any therapy interventions and reportable parameters in which to notify the Physician. Additionally, the POC listed P-3’s diagnoses as having exacerbated on the same date of admission to the agency (2/23/26). There were no interventions, reportable parameters or associated measurable goals that addressed the diagnoses reported to have exacerbated on the date of admission. The POC failed to address the needs of the patient. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:30 a.m.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the plan of care (POC) included all patient care orders for 1 (P-4) of 7 patient records reviewed, resulting in the potential for unmet needs. Patient #4 (P-4): The patient was recertified to the agency 3/5/26 through 5/3/26 with peripheral vascular disease and a lower left leg wound for skilled nursing services and physical therapy (PT) services. The review of records on 4/14/26, noted the POC for 3/5/26 through 5/3/26, did not include patient care orders, discipline of services, treatments or interventions. This is evidenced by the void of documentation in the section “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)”. The review noted verbal orders that were signed by the physician on 3/16/26. The POC did not reflect an update to include the “Verbal Order Record” with a documented “Effective Date” 3/3/26 that noted that the patient would benefit from PT services for muscle strengthening, improved balance, mobility, and transferring, with an order for PT to evaluate and treat. Further review of the records noted orders titled “Visiting wound specialist and primary care” dated 2/16/26, with wound care orders “Clean with wound cleanser. Pat dry apply calcium alginate silver to wound bed apply unna boot with compression system with coban and kerlix. Change every other day and when saturated. Wound care RN to change twice a week.” The POC was void of current wound care orders for the recertification period. On 4/14/26 at 12:30 PM an interview was conducted with the nurse caring for P-4 (Staff-C). During the interview Staff-C was queried about the POC and the wound care orders being followed. Staff-C responded that the recertification assessment was completed and the POC “should be in the system.” Staff-C explained that the last orders received (2/16/26) from the wound care physician have not changed and that order is what is followed when caring for the wound. During the joint home visit on 4/14/26 at 1:00 PM, it was observed that Staff-C provided wound care following the orders dated 2/16/26. The review of the OASIS (Outcome and Assessment Information Set) dated 3/3/26, confirmed that the assessment identified SN (skilled nursing) interventions, the care of the wound, and the frequency in which services will be provided for SN. The agency failed to incorporate the comprehensive assessment into the development of a POC to ensure it included all physician orders, interventions and treatments needed to meet the care needs of the patient. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM.”

“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 care and services were provided only as ordered by the Physician for 4 (P-1, P-2, P-3, P-7) of 4 patients, resulting in the patients not receiving services in accordance with their identified needs. Findings include: Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review P-7’s plan of care (POC) noted the following order under “Integumentary (skin) Status”: SN (skilled nursing) to assess and treat pressure ulcer, teach patient and caregiver wound care and how to prevent pressure ulcer. Additional review of SN visit notes documented the following wound care treatment on 1/13/26: “SN cleaned the wound with warm water and soap, pat dried, applied calmoceptin (sic) cream, left open to air. SN’s wound care interventions had no physician order found in the medical record to authorize the wound treatment provided by SN. On the next SN visit (1/16/26), the documented wound care treatment was identical word for word with no supporting order found in the medical record. Further, “Calmoceptin” or any other topical skin cream was not found on the POC medication list at any time from admission to agency discharge on 2/19/26. The agency failed to document any effort(s) made to reach out to the physician to clarify specific details and interventions concerning P-7’s wound care. Subsequently, SN performed wound care without an authenticating physician’s order. The findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 12:02 PM. Patient #1 (P-1)’s start of care (SOC) was 12/18/25 with diagnoses that included Lumbar Radiculopathy, and Low Back Pain. During the clinical record review on 4/13/26 at 3:15 p.m., it was noted that P-1 was recertified for continued care on 2/11/26. It was further noted that P-1 was discharged from the agency’s services on 3/12/26. At the time of this review, the plan of care (POC) had not been signed by the Physician to authorize the provision of care and services. The Administrator (Staff-A) and Office Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:09 a.m. Shortly after the above interview, Staff-A presented this writer with what appeared to be a signed copy of the POC. The document was signed and dated 4/14/26 (during the survey). This was greater than 30 days after the patient was discharged from the agency’s services. The agency failed to provide care and services only as ordered by the Physician. P-2’s SOC was 1/27/26 with diagnoses that included Osteoarthritis, Diabetes Mellitus and Low Back Pain. The POC ordered (Physical Therapy) PT services to be provided. During the record review on 4/14/26 at 10:45 a.m., there was an untitled document requesting recertification of care and documented, “Effective 3/26/26 Cert (certification) period 1/27/26 to 3/27/26 (current cert period); Recert period from 3/28/26.” No end date provided. “2xwk. for 6 wk. starting 3/30/26.” The document was authored and signed by the Physical Therapist (Staff-A); however, the document was void of a Physician’s signature and date authorizing the continuation of services. The agency failed to provide services only as ordered by the Physician. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:20 a.m. P-3’s SOC was 2/23/26 with diagnoses that included Schizophrenia, Muscle Weakness and Hypertension. The POC ordered PT services to be provided at a frequency of 3x/wk. x 4 wks.; 2x/wk. x 2 wks. During the clinical record review on 4/15/26 at 12:35 p.m., it was noted that the PT discharged the patient from the agency’s services on 3/26/26. This was one week earlier than the ordered frequency was to end. Upon further review, there was no Physician’s order to discontinue services, and no documentation of patient refusal of further visits. PT failed to follow the ordered visit frequency. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:30 a.m.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. 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 reviewed and revised by the physician for 1 (P-4) of 7 patient records reviewed. Patient #4 (P-4): The review of records on 4/14/26 revealed that 40 days from the start of the recertification period (3/5/26), there was no evidence in the POC denoting it had been developed to include orders, interventions, and treatments for physician review and authentication. This is evidenced by the void of documentation in the section “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” and the authentication by a physician. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide current written medication information, schedule, and instructions for 1 (P-4) of 3 patients observed, resulting in the potential of poor patient outcomes. Patient #4 (P-4) was admitted to the agency 5/14/24 with peripheral vascular disease and a lower left leg wound. During the joint home visit on 4/14/26 at 1:00 PM, it was observed that the medication list provided by the agency in the admission folder was dated 5/14/24. Further review of records on 4/15/26, noted the medication profile for the recertification period 3/5/26 through 5/3/26, in the electronic medical record (EMR), had the following medications listed that were not included on the list observed during the home visit: Wellbutrin XL 150 mg (milligram) 24 hr (hour) extended release 2 tablets once in the morning, dated 5/12/25.Wellbutrin XL 150 mg 24 hr extended release 1 tablet once daily at bedtime, dated 1/15/26.Metoprolol 25 mg 24 hr extended-release oral once daily, dated 5/9/25.Melatonin 3 mg oral daily, dated 5/14/24.Vitamin D3 25 mcg (microgram) tablet oral once daily, dated 5/14/24. The medication list in the home listed Aspirin EC (enteric coated) 81 mg daily which was not documented on the medication profile in the EMR. Further review of the medication list noted it did not include written entries indicating the agency’s efforts to provide the patient current medication information. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:53 PM, which did not reflect agency policy referenced below. Agency Policy C311 review on 4/16/26 titled, Medication Profile”, (dated 8/2010), noted that “Medications records in the home will be updated with each change in medication, dose, frequency of medication, addition or discontinuation of medication.””

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the name and contact information of the Clinical Manager was provided for 1 (P-4) of 3 patients observed. Patient #4 (P-4) was admitted to the agency 5/14/24 with peripheral vascular disease and a lower left leg wound. During the joint home visit on 4/14/26 at 1:00 PM, it was observed that the admission packet in the home did not include contact information for the Clinical Manager. This is evidenced by the section to write the Clinical Manager’s contact information on the front of the admission packet was blank. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on record review and interview, the agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that instituted actions for the purpose of collecting performance improvement data and failed to implement a process to re-evaluate subsequent data to determine if intended improvements are sustained. Findings include: On 4/15/26, review of the agency’s QAPI documentation found no evidence of performance improvement projects since 2021. Further, a process or methodology for the re-assessment of collected data was not found in agency documentation to ensure improvements made would be sustained over time. This finding was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/15/26 at 2:42 PM.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure that the clinical manager and or the designated alternate were available during all operating hours. During the entrance conference 4/13/26 at 9:48 AM with the administrator (Staff-A) and Office Manager (Staff-B), it was obtained through interview that the Clinical Manager (Staff-D) has been on leave and Staff-A is the alternate clinical manager. Staff-A also is the only physical therapist providing services for the agency. It is noted that when services are provided there are gaps in coverage of the clinical manager during all operating hours. This is evidenced by the review on 4/13/26 of the unduplicated census noted that all 7 active patients have ordered physical therapy (PT) services. The gap in coverage was observed on 4/14/26, Staff-A provided services for 2 of the 7 patients, one scheduled for 2:00 PM and the other for 3:00 PM. The travel time to get to the first appointment was one hour. Staff-A was not available for 4 hours (1:00 PM – 5:00 PM) of the agency’s operating hours. On 4/16/26 at 12:49 PM Staff-A and Staff-B were interviewed and queried about the coordination of care and coverage of the clinical manager during operating hours while Staff-A is not available and out of the office seeing patients. It was explained that Staff-B takes calls and relays messages to Staff-A. It is noted that Staff-A as acting clinical manager and the only PT providing services is not available during all operating hours while providing PT services. The above findings were reviewed and acknowledged during the time of interview.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the Clinical Manager and or the designated alternate coordinated referrals for 1 (P-4) of 7 patient records reviewed, resulting in the potential of unidentified health concerns and unmet care needs. Patient #4 (P-4) was admitted to the agency 5/14/24 with peripheral vascular disease and lower leg wound. The review of records on 4/14/26 noted the record to be void of a referral for the start of care. Additionally, it was noted that the record was void of medical records and physician assessments needed to obtain a comprehensive assessment and affirm the determination of homebound status. The agency failed to provide oversight to ensure a referral is obtained and documented in the clinical record before services are provided. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Manager and or the designated alternate provided oversight of the continued assessment of patient care needs by ensuring a comprehensive assessment was completed with all the required elements for 1 (P-5) of 7 patients records reviewed, resulting in the lack of clinical information needed to meet patient care needs. Patient #5 (P-5) was admitted to the agency 4/8/26 with the diagnoses of cerebral palsy, seizures, and mental disability, history of falls; and required the use of a wheelchair, helmet, and gait belt, and is full assistance for all activities of daily living. During the review of records on 4/16/26, it was noted that a comprehensive assessment did not include an assessment that reflected the patient’s current health, psychosocial, and functional needs of the patient as noted above. This is evidenced by the review of the OASIS (Outcome and Assessment Information Set) dated 4/8/26, that noted the following assessments were not included in the comprehensive assessment. Neurological, Cardiovascular, Respiratory, and Integumentary assessments. A baseline ambulation assessment. Past medical history.The assessment of pain location, intensity, aggravating factors, treatment and treatment effectiveness.The use of a wheelchair, helmet or gait belt. Safety measures for seizure and fall precautions.Patient strengths, skilled service needs, measurable goals and discharge plans.Current medication reconciliation.The patient’s legal guardian or primary caregiver.The agency failed to provide oversight and ensure a comprehensive assessment that captured all the clinical information needed for the continued assessment of the patient’s care needs was completed at the start of care. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12 50 PM.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Manager and or the designated alternate provided oversight of the development of an individualized plan of care in 1 (P-4) of 7 records reviewed, resulting in the potential of unmet patient care needs. Patient #4 (P-4): The patient was recertified through the agency 3/5/26 through 5/3/26 with peripheral vascular disease and a lower left leg wound for skilled nursing services for wound care and physical therapy for balance, muscle strengthening, improved mobility and transferring. During the review of records on 4/14/26, it was noted that the Plan of Care (POC) effective 3/5/26 was not individualized to correspond with the care that the patient required to treat the primary diagnosis and needs of the patient as noted above. This is evidenced by the following review findings that the POC did not provide documented: Objective patient-specific measurable goalsSupplies or equipment needed for care needsFunctional limitationsSkilled services and frequencyInterventions and treatmentsPhysician ordersSafety precautionsDischarge planningThe above findings were acknowledged during an interview with the Administrator / alternate Clinical Manager (Staff-A) and the Office Manager (Staff-B) on 4/16/26 at 12:55 PM. During the interview Staff-A explained that they discovered this week that there was a technical issue with the electronic medical record system, and the POC did not populate. At the time of the review on 4/14/26 it was 40 days after the start of the recertification period (3/5/26) and the evidence supports the agency failed to provide oversight to ensure a POC was developed.”

“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 complete, provided the patient’s current health status at the time of discharge, and forwarded to the Physician within 5 days of the date of discharge for 3 (P-1, P-3, P-7) of 3 patients who were discharged from the agency’s services, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #7 (P-7): This patient was admitted to home care on 1/9/26, with diagnoses which included osteoarthritis-unspecified, sacral pressure ulcer (stage-2), and COPD (chronic obstructive pulmonary disease). On 4/15/26, review of P-7’s plan of care (POC) ordered a skilled nursing (SN) visit frequency of 1W1 (once weekly for one week), 2W1, and 1W2. The POC also ordered physical therapy (PT) services for 1W1, 2W6. Further record review noted that P-7 was discharged from SN services on 1/27/26 and discharged from the agency by PT services on 2/19/26. The SN Discharge (DC) Summary detailed over 110 discharge instructions that was auto populated. No language was found within the DC summary that was individualized to P-7 and what P-7’s response or ability to carry out any of the 110+ instructions. The DC summary was also void of any findings/results from the care/treatments/interventions provided by SN throughout the home care episode and P-7’s health status at the time of discharge. Additionally, the agency had no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge as required. P-7 was discharged from the PT services/agency on 2/19/26. Upon further review, there was no evidence that the PT Discharge Summary had been forwarded to the Physician within 5 days of the date of discharge. The findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A) and Office Manager (Staff B) during an interview on 4/16/26 at 11:54 AM. Patient #1 (P-1)’s start of care (SOC) was 12/18/25 with diagnoses that included Lumbar Radiculopathy and Low Back Pain. The Plan of Care (POC) ordered Physical Therapy (PT) services to be provided. During the record review on 4/13/26 at 3:15 p.m., it was noted that PT discharged P-1 from the agency’s services on 3/12/26. There was no documented evidence that the Discharge Summary was forwarded to the Physician within 5 days of the date of discharge. The Administrator (Staff-A) and Office Manager (Staff-B) reviewed and acknowledged the above information during an interview on 4/16/26 at 9:09 a.m. P-3’s SOC was 2/23/26 with diagnoses that included Schizophrenia, Muscle Weakness and Hypertension. The POC ordered PT services to be provided. During the clinical record review, it was noted that PT discharged P-1 from the agency’s services on 3/26/26. The section of the summary titled “Care Coordination” was left blank. There was no documented evidence that the Discharge Summary had been forwarded to the Physician within 5 days of the date of discharge. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 4/16/26 at 9:30 a.m.”