Corsocare Home Health

“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 record review and interview, the agency failed to ensure a registered nurse completed the initial assessment within 48 hours of referral (see G0514); failed to ensure the comprehensive assessment was completed by all disciplines within 5 days per agency expectation (see G0520); failed to ensure the comprehensive assessment included an accurate representation of the patient’s current health status (see G0528); failed to ensure the comprehensive assessment included a review of all medications the patient was taking to identify significant drug interactions and side effects (see G0536); and, failed to ensure the comprehensive assessment identified the primary caregiver and their willingness, ability, and schedule to provide care (see G0538). The cumulative effects of this systemic problem resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Conditions of Participation at 42 CFR §484.55 Comprehensive Assessment of Patients.”

“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, interview, and record review, the agency failed to ensure the physical therapy assistant followed accepted standards of practice for infection control during 1 (P-2) of 3 joint home visits, potentially resulting in the transmission of infectious agents. Findings include: Agency policy titled “Hand Hygiene” (undated) was provided for surveyor review on 1/7/25. On the first page of the policy, it stated “Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC (Centers for Disease Control) regulations and guidelines for hand hygiene in health care settings… 2. Hand decontamination using an alcohol-based hand rub should be performed… Before entering the Clinical Bag… After removing gloves…”. Patient #2 (P-2): This patient was admitted to the home care agency on 12/5/25 with diagnoses including sarcopenia (gradual loss of muscle mass) and kidney disease due to high blood pressure. On 1/6/26 at 10:00 a.m., a joint home visit was conducted with an agency physical therapy assistant (PTA-1) for surveyor observation of care provided in the home setting. During the visit, it was observed that PTA-1 put on a pair of clean gloves and began a physical assessment of P-2. After the assessment, PTA-1 put hand sanitizer on the gloves he was wearing and began to rub his gloved hands together. PTA-1 then used the same gloves to enter the clinical bag (brought in with him to the home visit) to retrieve a gait belt (belt used to assist patients when transferring or walking). PTA-1 did not remove the dirty gloves and sanitize his hands until after using a disinfectant wipe to wipe down reusable equipment which would be returned to his clinical bag. On 1/7/26 at 11:00 a.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed. Adm-1 acknowledged that gloves used by their agency home care staff were disposable and not intended to be disinfected with hand sanitizer and reused.”

“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 documentation was clear and complete in 3 (P-1, P-5, and P-7) of 7 records reviewed, resulting in an inaccurate and incomplete medical record. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care to the right lower extremity and type II diabetes. During record review on 1/7/26, it was determined that the physical therapy assistant notes dated 11/4/25, 11/6/25, and 11/13/25 documented “No” under a question that stated, “Does the patient have a diagnosis of heart failure (CHF)?”. This was incorrect as CHF is listed as a diagnosis on the plan of care. Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was noted a physical therapy note dated 10/4/25 documented “No” under a question that stated, “Is the supervisory visit being performed for a diabetic client?” This was incorrect as diabetes is listed as a diagnosis on the plan of care. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25 with diagnoses including aftercare following a left knee replacement; type 2 Diabetes; and heart failure. The medical record was reviewed on 1/6/26. During review, the following discrepancies in the charting were noted: The registered nurse (RN) completed the comprehensive assessment on 9/30/25. In the section titled “Hospital Risk Assessment”, the RN documented that ability of “PATIENT/CAREGIVER” to safely and accurately administer medication was not determined because the caregiver was not present. In the section titled “Interventions Provided”, the RN listed 7 of 10 interventions (instruction provided or discussions) which were documented as being done with the “PATIENT/CAREGIVER”. It is unclear from the RN documentation whether the caregiver was present during the assessment or not. The RN documented a visit occurring on 10/3/25. In the assessment portion of the visit, the RN documented P-1’s current pain scale rating was 4/10 (scale where 0 is no pain, 10 is the worst pain). In the vital sign section, the RN documented P-1’s heart rate as 103 beats per minute (bpm). The heart rate reading was noted to be outside physician ordered parameters (as set between 50 and 100 bpm on the plan of care). In the “Narrative” section, the RN documented “PATIENTS PAIN 3/10, VITAL SIGNS OBTAINED WNL (within normal limits) …”. It was unclear from the RN documentation whether P-1’s pain was a 3 or 4 (out of 10) or whether his heart rate was above the parameters set or within normal limits. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were allowed to consent to or refuse care in advance of treatment in 2 (P-1 and P-5) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #5 (P-5) was admitted to this home care agency on 10/27/25 with the diagnoses of wound care to the right lower extremity and type II diabetes. During record review on 1/7/26, it was determined the referral to start care (dated 10/22/25) ordered services from skilled nursing, physical therapy, occupational therapy, and a home health aide. Upon further review of the record, it was determined a welcome call dated 10/22/25 indicated the patient accepted services from skilled nursing, physical therapy, and occupational therapy. However, it was not documented that services from a home health aide were offered to or refused by the patient. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25 with diagnoses including aftercare following a left knee replacement; type 2 Diabetes; and heart failure. The medical record was reviewed on 1/6/26. The referral for home care dated 9/26/25 included physician orders for a home health aide (HHa). The home care agency made a “Welcome Call” on 9/29/25 at 12:04 p.m. which included a statement that P-1 accepted services including the HHa. The start of care comprehensive assessment was completed on 9/30/25 by a nurse. During review of the assessment, it was noted that the nurse identified that P-1 needed setup or clean-up assistance with oral hygiene; supervision or touching assistance with upper body dressing, lower body dressing, putting on or taking off footwear, washing, rinsing, and drying self during bathing activities; mobility on and off the toilet; and, someone must help the patient put on undergarments, slacks, socks or shoes. There were no HHa visits entered in P-1’s medical record. There was no evidence documented which indicated that P-1 was offered or refused HHa services. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse completed the initial assessment within 48 hours of referral in 3 (P-4, P-5 and P-7) of 7 records reviewed, resulting in the potential for delayed identification of immediate care needs. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care for ulceration of the right ankle and type II diabetes. During record review on 1/6/26, it was determined the referral to start care was dated 10/22/25. A welcome call was also documented in the coordination notes on 10/22/25, which indicated home care services were accepted by the patient. Upon further review of the record, it was noted the skilled nurse did not call to schedule the patient for the initial assessment until 10/25/25 – 3 days after the referral was received by the agency. New orders were obtained to move the start of care date to 10/27/25 due to the patient being “unavailable”, however, the call to set up the initial visit was not completed until after the initial assessment was due. Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/7/26, it was determined the referral to start care was dated 8/8/25 and received by the agency on 8/9/25 according to the fax confirmation date. Upon further review of the record, it was noted the referral coordinator left the patient message for the welcome call on 8/12/25 – 3 days after the referral was received by the agency. A welcome call was completed on 8/13/25. On 8/16/25, the skilled nurse documented, “AFTER SEVERAL ATTEMPTS OVER THREE DAYS, REACHED PATIENT ON 8/16/25 TO SCHEDULE SOC. PT REQUESTING SOC FOR 8/17/25. WILL OBTAIN DELAY ORDER WHEN OFFICE OPENS.” [sic] Although documentation indicated difficulty contacting the patient and orders were received to delay the start of care, the call to set up the initial visit was not completed until after the initial assessment was due. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 1/1/26 with the primary diagnosis of a left femur neck fracture. The medical record was reviewed on 1/8/26. During review, it was noted that the physician referral was dated and signed on 12/29/25. The initial assessment was not made by the nurse until 1/1/26 (3 days later). There was no evidence in the medical record that P-4 asked for the delay in the start of care. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, this finding was reviewed and acknowledged by Adm-1.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by all disciplines within 5 days per agency expectation in 2 (P-1 and P-7) of 7 records reviewed, resulting in the potential for unmet care needs and a delay in care. Findings include: Patient #7 (P-7) was admitted to this home care agency on 8/17/25 with diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was determined the initial referral to start care ordered services from skilled nursing, physical therapy, and occupational therapy. Additionally, it was noted that the start of care date for this patient was 8/17/25 and was completed by the skilled nurse. Upon further review of the record, it was determined a coordination noted dated 8/27/25 indicated the physical therapist first called the patient’s daughter to schedule the evaluation on 8/26/25 – 9 days after the start of care. A coordination note indicated that the daughter requested to start physical therapy on 9/2/25 due to the upcoming holiday and other appointments and a new order was obtained regarding the delay, however, the initial contact to schedule was made greater than 5 days after the start of care. The initial evaluation for physical therapy was not performed until 16 days after the start of care. Additionally, it was noted the occupational therapist did not evaluate the patient until 8/27/25 – 10 days after the start of care. There was no coordination note or new orders to explain the reason for the late start. During an interview with the administrator (Adm-1) on 1/8/26 at 2:15 PM, Adm-1 was asked about the agency expectation for all disciplines to complete their evaluation after the start of care. Adm-1 stated it is expected that all disciplines will complete their evaluation within 5 days of the start of care as it is part of the comprehensive assessment. Adm-1 reviewed the above findings and acknowledged them at the time of interview. Agency policy titled “Patient Missed Visits” (policy # HHC-033), was provided for surveyor review on 1/7/25. On page 1., it stated “Information confirming contact with the Physician is documented with the date, time, and reason for the missed visit. The reason must be legitimate, and patient related, i.e. patient request, patient not at home, etc.” Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25 with diagnoses including aftercare following a left knee replacement; type 2 Diabetes; and heart failure. The medical record was reviewed on 1/6/26. During review, it was noted that the referral for home care dated 9/26/25 included physician orders for occupational therapy (OT) services. The start of care (SOC) comprehensive assessment was completed on 9/30/25. OT services did not complete an evaluation until 10/9/25 (7 days after the SOC). There was a coordination note entered into the medical record on 10/9/25 by the OT which stated that consent was provided by the physician on 10/8/25 at 3:15 p.m. for a delay in the OT evaluation. There was no documentation provided which included a patient related reason for the delay in OT service and the physician consent for the delay was 6 days after the SOC (after the fact). On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, this finding was reviewed. Adm-1 stated that skilled disciplines that are ordered on the referral are expected to complete a patient evaluation within 5 days from the SOC as part of the comprehensive assessment of the patient. The above finding was acknowledged by Adm-1.”

“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 included an accurate representation of the patient’s current health status for 5 (P-1, P-2, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care to the right lower extremity and type II diabetes. During record review on 1/7/26, it was noted the Outcome Assessment and Information Set (OASIS) in the comprehensive assessment indicated “No – No issues found during review” under the drug review section. Upon further review of the record, it was determined the drug interaction report included 1 severe medication interaction. The information is conflicting; therefore, it does not reflect an accurate picture of the patient. Additionally, the plan of care listed 26 diagnoses with an onset or exacerbation date of 10/27/25 (the start of care date) - including chronic conditions. This does not provide a clear picture of the patient’s current status. Patient #6 (P-6) was admitted to this home care agency on 8/12/25 with the diagnoses of a stage 3 pressure ulcer of the right heel, heart failure, and dementia. During record review on 1/6/26, it was noted the plan of care listed 13 diagnoses with an onset or exacerbation date of 8/12/25 (the start of care date) - including chronic conditions. This does not provide a clear picture of the patient’s current status. Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/7/26, it was noted the OASIS in the comprehensive assessment indicated “No – No issues found during review” under the drug review section. Upon further review of the record, it was determined the drug interaction report included 1 severe medication interaction. The information is conflicting; therefore, it does not reflect an accurate picture of the patient. Additionally, the plan of care included 32 diagnoses with an onset or exacerbation date of 8/17/25 (the start of care date) - including chronic conditions. This does not provide a clear picture of the patient’s current status. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25. The medical record was reviewed on 1/6/26. During review, it was noted that the comprehensive assessment listed 15 diagnoses. Only 2 of 15 diagnoses were documented as being exacerbated on 9/30/25 (aftercare following joint surgery and osteoarthritis of left knee), the other 13 were documented as having an onset of 9/30/25 (date of admission). Diagnosis #11 was long term (current) use of aspirin; diagnosis #12 was long term (current) use of oral hypoglycemic drugs. The comprehensive assessment did not document how the 13 diagnoses with onset at admission affected P-1’s current health status, how they contributed to a need for home care, or related interventions to monitor for all. Patient #2 (P-2): This patient was admitted to the home care agency on 12/5/25. The medical record was reviewed on 1/5/26. During review, it was noted that the comprehensive assessment listed 10 diagnoses. Only 1 of 10 diagnoses was documented as being exacerbated on 12/5/25 (sarcopenia), the other 9 were documented as having an onset of 12/5/25 (date of admission). The comprehensive assessment did not document how the 9 diagnoses with onset at admission affected P-2’s current health status, how they contributed to a need for home care, or related interventions to monitor them all. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“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 that the comprehensive assessment included a review of all medications the patient was taking to identify significant drug interactions and side effects in 3 (P-1, P-2, and P-7) of 7 records reviewed, potentially resulting in unrecognized adverse interactions or side effects. Findings include: Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was noted the comprehensive assessment indicated P-7 had a diagnosis of “dependence on supplemental oxygen” and was on 3 liters of oxygen. Upon further review of the record, it was determined the medication list in the comprehensive assessment failed to include oxygen. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Agency policy titled “Medications” (policy # HHC-037), was provided for surveyor review on 1/7/26. On page 3., it stated “The drug regimen review includes an evaluation of ALL prescribed and over-the-counter medications the patient is using at the time of the Unique/Individualized Comprehensive Assessment. The assessing Clinician evaluates ALL medications for identification of the following… Potential drug interactions… Significant side effects… Significant drug interactions… Any Level One or Level Two potential interactions and/or medication duplicates identified are immediately brought to the attention of the Physician…” Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25 with diagnoses including aftercare following a left knee replacement; type 2 Diabetes; and heart failure. The medical record was reviewed on 1/6/26. During review of the comprehensive assessment completed by the registered nurse (RN-1) on 9/30/25, it was noted that RN-1 documented a “Drug Regimen Review” was completed, and selected “No Issues Found During Review”. On 10/1/25, two coordination notes were entered by RN-1 regarding P-1’s medications. One of the notes stated that a medication reconciliation had been completed. The other note listed a “Level 2” severe interaction between 2 medications that P-1 was taking, and had no additional information added in the section of the note titled “Enter Details”. Neither of the coordination notes entered by RN-1 indicated that the physician was notified of the severe interaction found. During surveyor review of P-1’s medications on file with the home care agency on 1/7/26, a drug interactions report was generated using the agency’s electronic medical record (EMR) system. The drug interactions report identified the same “Severity Level 2-Severe Interaction” between the 2 medications which were listed in RN-1’s coordination note written on 10/1/25. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1) and the Quality Assurance Performance Improvement Coordinator (QC-1). During the interview, Adm-1 and QC-1 were asked if the severe interaction was identified by the RN and reported to the physician. QC-1 stated that the EMR system automatically generates a coordination note with any interactions when the RN inputs the medications into the EMR system. QC-1 clarified that when the EMR system generates the note, it uses the name of the RN entering the information. QC-1 stated that RN-1 should have documented in the same coordination note (under “Enter Details”) if the physician was notified of the severe interaction. QC-1 agreed that it was unclear if RN-1 was aware of the generated coordination note with the level 2 severe interaction for P-1’s medications. QC-1 agreed that RN-1 failed to enter a physician notification and response to the severe interaction. After review, Adm-1 and QC-1 acknowledged the findings. Patient #2 (P-2): This patient was admitted to the home care agency on 12/5/25 with diagnoses including sarcopenia (gradual loss of muscle mass) and kidney disease due to high blood pressure. On 1/6/26 at 10:00 a.m., a joint home visit was conducted with an agency physical therapy assistant (PTA-1) for observation in the home setting. During the visit, P-2’s current medication list was provided for surveyor review by the assisted living facility (ALF) in which P-2 resided. The ALF medication list was noted to be current, and printed as of 1/6/26 at 9:37 a.m. After the home visit, P-2’s ALF medication list and the home health agency (HHA) medication list from the comprehensive assessment were compared. During the comparison, the following discrepancies were noted: Different doses: Acetaminophen (over the counter pain medication) 500 milligrams (mg) – ALF shows 2 times daily; HHA shows once daily (500 mg less than ALF dose) Pantoprazole (stomach acid reducer) 40 mg- ALF shows twice daily; HHA shows once daily (40 mg less than ALF dose) Hydralazine (lowers blood pressure) 10 mg- ALF shows 3 times a day; HHA shows once daily (40 mg less than ALF dose) Senexon-S (laxative) 8.6/50 mg- ALF shows 2 times daily; HHA shows once daily (8.6/50 mg less than ALF dose) Lasix (diuretic)- ALF shows 40 mg once a day; HHA shows 20 mg once a day (20 mg less than ALF dose) Doxazosin (lowers blood pressure)- ALF shows 8 mg daily; HHA shows 4 mg daily (4 mg less than ALF) Different medications: The ALF had 5 daily scheduled medications which were not listed on the HHA medication list (Aripiprazole- antipsychotic; Donepezil- treats Alzheimer’s disease; Metolazone- a diuretic; Ramelteon- a sedative; and Calmoseptine- a protective topical skin barrier ointment). Additionally, the ALF had 3 medications given as needed which were not on the HHA medication list (Acetaminophen; Alprazolam- to reduce anxiety; and Calmoseptine). On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“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 primary caregiver and their willingness, ability, and schedule to provide care for 1 (P-4) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #4 (P-4) was admitted to this home health agency on 1/1/26 with diagnoses of a left femur fracture. During record review on 1/8/26, it was noted the comprehensive assessment identified that P-4 lived in a “congregate situation” and received assistance “around the clock.” The comprehensive assessment also noted P-4 received “assistance from persons other than home care staff,” had “paid help,” and that she required assistance from others for many tasks, including ambulation and activities of daily living. Additionally, a safety measure on the plan of care indicated the patient required 24-hour supervision. Upon further review of the record, it was determined that although the comprehensive assessment identified a daughter-in-law and assisted living staff as caregivers, it failed to identify who provided care, what care was provided, and the schedule/availability of caregivers. It was unclear who helped the patient and how. A review of agency policy titled “Patient Clinical Record” (dated 1/3/20) revealed, “Each patient’s clinical record shall include, but is not limited to, the following:…6. Appropriate identifying information for the patient, household members, and Caregivers…”. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included measurable goals of care in 2 (P-2 and P4) of 7 records reviewed, and failed to include patient specific interventions in 2 (P-4 and P-5) of 7 records reviewed, potentially resulting in delayed progress toward goals and a lack of clear direction for the patient. Findings include: Patient #5 (P-5) was admitted to this homecare agency on 10/27/25 with the diagnoses of wound care to the right lower extremity and type II diabetes mellitus. During record review on 1/7/26, it was noted the plan of care included an intervention for the skilled nurse for “INSTRUCTONS/REFINFORCEMENT OF DIABETIC CARE TO INCLUDE DIET, SKIN CARE, ADMINISTRATION OF INSULIN, BLOOD GLUCOSE TESTING, AND DIABETIC FOOT CARE.” The plan of care also included an intervention that a skilled nurse “MAY PERFORM FINGER STICK BLOOD SUGAR AS NEEDED FOR SIGNS/SYMPTOMS OF HYPER/HYPOGLYCEMIA.” [sic] Upon further review of the record, it was determined the comprehensive assessment identified that P-5 controlled his diabetes with diet and did not take insulin or test his blood sugar, therefore, the interventions on the plan of care are not patient specific. Additionally, during an interview with the administrator (Adm-1) on 1/8/26 at 2:15 PM, Adm-1 was asked if staff carried glucometers to test blood sugar if a patient didn’t have one. Adm-1 stated staff do not carry glucometers, therefore, Adm-1 agreed the intervention was not relevant to this patient. Adm-1 acknowledged the findings at the time of interview. Agency policy titled “Patient Plan of Care” (policy # HHC-031, dated 1/3/2020), was provided for surveyor review on 1/7/26. On page 3., it stated “POC (plan of care) is based on the patient’s immediate and long-term care needs, which shall include, but not be limited to the following… 15. Patient-specific interventions and education. 16. Measurable outcomes and goals identified by the Agency and the patient…” Patient #2 (P-2): This patient was admitted to the home care agency on 12/5/25 with diagnoses including sarcopenia (gradual loss of muscle mass) and kidney disease due to high blood pressure. The medical record was reviewed on 1/5/26. During review of the plan of care (POC) dated for the certification period 12/5/25 to 2/2/26, it was noted that goals of care were not individualized or measurable. Examples of the physical therapy goals included: Patient/Caregiver will verbalize effective pain control and understand both pharmacologic and non-pharmacologic methods. This will be evidenced by safe walking (1/10 to 2/10) to be completed in 4 weeks. Patient/Caregiver to demonstrate understanding of and compliance with 2 (enter number of) energy conservation measures, as evidenced by increased tolerance during functional activities to be completed in 4 weeks. Patient/Caregiver will demonstrate safe transfers using appropriate body mechanics and equipment, as evidenced by independent transfers or with physical assistance of caregiver; to be completed in 4 weeks. Examples of occupational therapy goals included: Patient/Caregiver will demonstrate understanding of effective pain control techniques to decrease pain level and improve the patient’s ability to participate in ADLs and life tasks in the home setting, to be completed within 3 weeks. Patient will demonstrate increased independence in toileting and dressing in the home setting, to be completed in 3 weeks. It is unclear how the therapists will use the above goals to measure progress toward the goals. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, this finding was reviewed and acknowledged by Adm-1. Patient #4 (P-4): This patient was admitted to the home care agency on 1/1/26 with the primary diagnosis of a left femur neck fracture. The medical record was reviewed on 1/8/26. During review of the POC for the certification period 1/1/26 to 3/1/26, it was noted that that physician orders for skilled nursing (SN) included the following: SN to assess/evaluate co-morbid conditions including congestive heart failure (CHF); SN to provide skilled teaching/reinforcement of management of CHF in the home setting including implementation of daily weight log; Licensed professional to report weight which falls below 95 pounds (lbs.) or above 105 lbs. The POC identified goals of care that included the patient/caregiver will demonstrate daily weight monitoring by using a weight log in the home. The comprehensive assessment completed on 1/1/26 by the nurse included documentation in the “Cardiovascular” section that stated the patient did not have the ability to weight themselves daily and the barrier was that P-4 was “unable to balance on scale”. It is unclear how the nurse would report changes in P-4’s weight or how selecting daily weight as a treatment intervention and goal was patient specific when P-4 could not balance on a scale. On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were authenticated and dated by the physician per agency policy in 1 (P-7) of 7 records reviewed, resulting in the potential for unapproved care. Findings include: A review of agency policy titled “Physician Change/Verbal Orders” (dated 10/8/19) revealed, “While the timeframe for prompt Physician notification of changes in the patient’s condition varies depending on the type of information and its criticality, the Agency expects the Physician signs change orders withing thirty (30) days of issuing the order.” Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was determined a physician signature for the following verbal orders was obtained in greater than 30 days: A verbal order by the physical therapist dated 8/27/25 to delay the start of physical therapy care was signed on 10/28/25 – after the patient was discharged and 62 days after it was written. A verbal order by the physical therapist dated 9/9/25 to put physical therapy on hold for the week was signed on 10/28/25 – after the patient was discharged and 49 days after it was written. A verbal order by the skilled nurse dated 9/18/25 for 2 additional visits due to earlier missed visits was signed on 10/28/25 – after the patient was discharged and 40 days after it was written. During an interview with the administrator (Adm-1) on 1/8/26 at 2:15 PM, Adm-1 reviewed the findings and stated it was hard to get signatures from some doctors. Adm-1 acknowledged the findings at the time of interview.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals followed the plan of care in 1 (P-5) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care to the right lower extremity and type II diabetes. During record review on 1/7/26, it was determined the plan of care included an intervention that stated, “LICENSED PROFESSIONAL TO REPORT VITAL SIGNS FALLING OUTSIDE THE FOLLOWING ESTABLISHED PARAMETERS…FBS (fasting blood sugar) 300 RBS (random blood sugar)300...”. [sic] Upon further review of the record, it was determined P-5 did not have a glucometer and did not take his blood sugar as his diabetes was controlled by diet. Additionally, during an interview with the administrator (Adm-1) on 1/8/26 at 2:15 PM, Adm-1 reported staff do not carry glucometers to test blood sugar for patient who do not have one. Therefore, there are no recordings for blood sugar for this patient and the intervention in the plan of care cannot be followed. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals provided patient and caregiver education based on needs identified in the comprehensive assessment in 1 (P-5) of 7 records reviewed, potentially resulting in a poor understanding of the patient’s unique condition. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care for ulceration of the right ankle and type II diabetes. During record review on 1/6/26, it was noted a daily visit note by skilled nursing dated 11/5/25 documented the following intervention for diabetes education: “4. Instruct patient/caregiver what to do if symptoms of high blood sugar occur: Details/comments: instructed to call the nurse or physician if blood sugar is high. Test before you eat and two hours after. This will tell you how well your medication is controlling your blood sugar. It will also shed light on what food is boosting your sugar too high and thus should be avoided. If blood sugars are high every morning, that’s important because it means that your liver is producing too much sugar during the night. That might require new or an additional medicine. Tell your nurse if this is happening. Get more exercise, or limit carbs at your next meal.” [sic] Upon further review of the record, it was determined the comprehensive assessment identified that P-5 controlled his diabetes with diet and did not take insulin or test his blood sugar, therefore, the education provided to this patient and caregiver was not relevant to the patient’s needs. Additionally, it was noted the Outcome Assessment and Information Set (OASIS) dated 10/27/25 indicated “PATIENT UNSTEADY STANDING, RISK FOR FALLS” regarding being able to be weighed daily due to a left leg amputation and right heel wound. A skilled nursing note dated 10/31/25 indicated the patient’s wife was to obtain a scale to begin daily weights and for the “SN TO REVIEW TECHNIQUE FOR SAFETY AT NEXT SN VISIT” due to a high risk for falls. According to the skilled nursing note dated 11/3/2025, the patient’s wife had not gotten a scale yet. Upon review of the physical therapy assistant and occupational therapy notes dated 11/4/25 and the next skilled nursing note dated 11/5/25, it was determined “Yes” was answered after a question that asked, “Does the patient have the ability to weight themselves daily?” However, there was no evidence that the patient and his wife were educated on how to safely use the scale. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure their skilled professionals prepared timely clinical notes according to agency policy in 4 (P-1, P-2, P-5, and P-7) of 7 records reviewed, potentially resulting in poor communication among agency team members and poor continuity of care. Findings include: Patient #5 (P-5) was admitted to this home health agency on 10/27/25 with the diagnoses of wound care for ulceration of the right ankle and type II diabetes. During record review on 1/6/26, it was determined the following notes were completed in greater than 48 hours per agency policy: A skilled nursing note dated 10/31/25 was completed on 11/3/25. A physical therapy note dated 11/17/25 was completed on 11/22/25. A physical therapy note dated 11/21/25 was completed on 11/28/25. A physical therapy note dated 12/23/25 was completed on 12/29/25. Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was determined the following notes were completed in greater than 48 hours per agency policy: The start of care by skilled nursing dated 8/17/25 was completed on 8/22/25. A skilled nursing note dated 8/25/25 was completed on 9/1/25. A missed visit for skilled nursing dated 9/4/25 was completed on 9/8/25. An occupational therapy note dated 9/17/25 was completed on 9/21/25. The discharge note written by the physical therapist dated 10/15/25 was completed on 10/22/25. The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM. Agency policy titled “Employee Per Visit Compensation” (policy # HHC-071, dated 1/3/2020), was provided for surveyor review on 1/7/26. On page 2., it stated “A visit is not complete until all required documentation is accurately completed including all forms and signatures… Documentation is to be completed within 24-48 hours of the visit.” Patient #1 (P-1): This patient was admitted to the home care agency on 9/30/25 with diagnoses including aftercare following a left knee replacement; type 2 Diabetes; and heart failure. The medical record was reviewed on 1/6/26. During review, it was noted that the following visit documentation was entered into the medical record later than the agency policy required (48 hours/2 days): On 10/3/25, a Registered Nurse (RN) subsequent visit was made but documentation was not completed until 10/7/25 (4 days later). On 10/9/25 an RN subsequent visit was made but documentation was not completed until 10/12/25 (3 days later). Patient #2 (P-2): This patient was admitted to the home care agency on 12/5/25 with diagnoses including sarcopenia (gradual loss of muscle mass) and kidney disease due to high blood pressure. The medical record was reviewed on 1/5/26. During review, it was noted that the following visit documentation was entered into the medical record later than the agency policy required (48 hours/2 days): On 12/5/25, the physical therapist made the admission visit, but the documentation was not completed until 12/9/25 (4 days later). On 12/24/25, an occupational therapy (OT) subsequent visit was made but the documentation was not completed until 12/28/25 (4 days later). On 12/31/25, an OT discharge visit was made but the documentation was not completed until 1/5/26 (5 days later). On 1/8/26 at 430 p.m., an interview was conducted with the agency Administrator (Adm-1). During the interview, the above findings were reviewed and acknowledged by Adm-1.”

“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 completed discharge summary was sent to the health care professional responsible for care following discharge from the agency within 5 business days in 1 (P-7) of 2 discharged records reviewed, resulting in the potential for unmet care needs and poor continuity of care. Findings include: Patient #7 (P-7) was admitted to this home health agency on 8/17/25 with the diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type II diabetes. During record review on 1/5/26, it was noted a non- visit discharge was completed by the physical therapist on 10/15/25 due to multiple cancellations. Upon further review of the record, it was determined the discharge summary was not sent to the physician until 10/28/25 – 9 business days after the patient was discharged from the agency. A review of agency policy titled “Patient Discharge/Transfer” (dated 1/3/20) revealed, “The PCP or other professional caring for the patient after discharge will receive a copy of the Discharge Summary within 5 business days.” The administrator (Adm-1) reviewed and acknowledged the findings during an interview on 1/8/26 at 4:30 PM.”