Ideal Home Health Services, LLC

“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 record review and interview, the agency failed to ensure the plan of care was individualized and included all of the required elements to manage the care and needs of the patient (G574); failed to ensure services were administered only as ordered by the physician (G580); failed to ensure the physical therapist promptly notified the physician of a significant change (G590); failed to ensure services were integrated when additional needs were identified (G606); failed to ensure skilled nursing coordinated wound care interventions/treatments (G608); and failed to ensure the admission packet contained the clinical manager’s full contact information (G622). 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 Condition of Participation of 42 CFR 484.60 - Care planning, coordination of services, and quality of care.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse followed accepted standards of practice in assuming responsibility for the care of 1 (P-6) of 1 patient who required wound care services (G704); failed to ensure its skilled disciplines performed baseline and ongoing assessments for 1 (P-2) of 1 patient who required ongoing monitoring (G706); failed to ensure services were provided in accordance with the Plan of Care and Physician’s orders for 5 (P-1, P-2, P-3, P-4, P-6) of 5 patients (G710). 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 Condition of Participation of 42 CFR 484.75 Skilled Professional Services”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness plan was tested per regulation requirements and according to agency policy for 2 (2023 and 2024) of 3 years reviewed, resulting in the potential for an unprepared staff response in the event of an actual emergency. Findings include: The agency’s Emergency Preparedness (EP) drills were requested for review on 5/28/26 at 1:15 PM. Upon review of the drills, it was determined the drills for 2023 and 2024 failed to include details of the scenarios used during the drills and failed to include after-action reports to analyze the effectiveness of the drills. A review of agency policy titled “Testing and Evaluation of the Agency’s Plan” revealed the agency will conduct a full-scale exercise every other year and that, “The full-scale exercise is a simulated emergency event, as close to reality as possible.” Additionally, the policy stated the agency will conduct a second full-scale exercise or a tabletop exercise “…that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan.” The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 2:00 PM.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide effective discharge planning for 1 (P-3) of 2 patients reviewed who had been discharged from this agency, resulting in the potential for unmet care needs. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was noted the discharge note written by the skilled nurse dated 9/10/25 stated “She still can use more physical therapy and would like that if possible.” However, the discharge summary also marked “No” next to the question that stated, “Is this patient a candidate for treatment in outpatient therapy?” The reason for discharge indicated “Goals met/max potential reached.” However, upon further review of the record, it was noted that the physical therapy evaluation dated 7/18/25 indicated, “patient was independent with all ADLs, transfers to bed, shower, chair and toilet, ambulation functional distances with assistive devices from hall to kitchen, bathroom and bedroom” [sic] prior to her admission to home care. Goals were set by the physical therapist to improve transfers to “mod/max assistance,” and improve strength in bilateral lower extremities to “1/5 – 4+/5.” A physical therapy note dated 8/28/25 stated, “Patient able to transfer with sit to stand today with mod/min assist. She remains compliant and motivated with HEP….” [sic], showing continued improvement with physical therapy. However, the discharge note written by the physical therapist on 9/5/25 indicated strength in the left lower extremity was still “0/5” (not at goal) but transfers had overall improved from dependent to “max” assist. Therefore, the goals had not been met, and the patient was still making improvements in physical therapy. Therefore, there was documented evidence of a need for continued home care services. A review of agency policy titled “Discharge Planning, Discharge Summary and Discharge OASIS” revealed, “Agency staff has access to contact information for community resources as appropriate to the needs of the patient, and the patient and family are educated about how to obtain further care, treatment, and services.” The policy also stated, “The discharge summary will include but is not limited to:…Any continuing care needs, instruction, or referrals regarding the needs.” During an interview with the administrator (Staff-A) on 5/28/26 at 11:40 AM, Staff-A was asked why P-3 did not continue physical therapy with home care. Staff-A stated P-3 went to outpatient therapy and that they had received documentation about this about a month after discharge. When shown the home care documentation regarding making improvements, still needing assistance, and not being a candidate for outpatient physical therapy, Staff-A agreed the documentation did not show a clear reason or plan for discharge for this patient and acknowledged the findings at the time of interview.”

“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, it was determined the Agency failed to develop a Performance Improvement Project (PIP) within its QAPI (Quality Assessment Performance Improvement) program that documented the reasons for conducting these projects with measurable progress achieved for the chosen PIPs since 2024, resulting in the Agency’s inability to effectively monitor proposed improvements in patient care, health outcomes, patient safety, quality of care and overall performance. Findings include: On 5/28/26, the Agency’s QAPI program binder was reviewed and found no evidence of a PIP that was chosen and approved by the Agency’s Governing Body to gather measurable information/data to track and tread towards pre-established goals within specified timelines to help monitor the quality of the provision of patient care services since 2024. These findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 12:52 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 ensure staff followed accepted standards of practice for infection control for 1 (Staff-D) of 3 staff observed during home visits, resulting in the potential for spread of infection to all patients receiving services from this agency. Findings include: Patient #4 (P-4): During a joint home visit with the home health aide (Staff-D) on 5/27/26 at 8:30 AM, Staff-D was observed putting on gloves prior to the care of P-4. Staff-D was then observed taking P-4’s vitals with her gloved hands and then taking her phone from her pocket (with her now “dirty” gloves) to document the vitals. Staff-D continued to wear the same pair of gloves to get into her “clean” bag to retrieve items such as a stethoscope and cleaning wipes. Following a change of gloves and hand hygiene, Staff-D was observed changing P-4’s brief (that was wet with urine), cleaned his private parts, and removed dirty linens from the bed. Staff-D kept the same gloves on while continuing with other tasks in the room, including touching other “clean” items such as her “clean” bag, P-4’s dresser, P-4’s walker, and P-4’s clean clothes. A review of agency policy titled “Handwashing” (No Date) revealed, “Wash the hands before and after care of patient. Wash the hands before entering the nursing bag.” [sic] Following the visit at 10:00 AM, Staff-D was asked about her hand hygiene and glove use. Staff-D stated she always washes her hands after glove use but acknowledged the missed opportunities for a glove change with hand hygiene during the visit when it was brought to her attention. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/27/26 at 10:35 AM.”

“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 observation, record review and interview, it was determined the Agency failed to ensure Skilled Nursing (SN) followed accepted standards of practice in assuming responsibility for the care of 1 (P-6) of 1 patient who required wound care services, and failed to ensure that SN properly assessed the patient to obtain pertinent clinical findings in 1 (P-7) of 3 patient records reviewed, resulting in a lack of wound care monitoring/interventions and the potential for poor patient outcomes. Findings include: Patient #6 (P-6) was admitted to home care on 5/6/26 with diagnoses which included status post gastro-intestinal (GI) surgery, intestinal adhesions, and hypertension. On 5/27/26, patient record review noted P-6’s Plan of Care (POC) ordered Skilled Nursing (SN) to instruct P-6/Caregiver on wound care as follows: “Keep incision clean and dry, no dressing required unless drainage or clothing is bothersome, ok to shower, wash incision daily with soap and water. SN to assess skin for breakdown every visit.” Additional record review of the SN visit notes dated 5/13/26 and 5/19/26 had the same documentation found under “Wound Care” which were: “Wounds Not Addressed This Visit” concerning “Wound 1: Location - lower mid-abdomen, Type: Surgical Incision, Date of Onset: Present Upon Admission.” On 5/27/26 during a joint home visit with SN, it was observed that P-6’s abdominal incision was not assessed by the SN and no education concerning wound care was evidenced in 3 of 3 SN visits provided. Further, the only wound care documentation that SN provided was at the start of care (5/6/26) which documented the surgical wound was “Not healing” and had positive sanguinous drainage (minimal) without odor. The POC also stipulated that if there was any drainage, wound dressing(s) would be needed. No evidence was found during record review that SN had applied a dressing to the open abdominal wound. Also, SN documented on 5/6/26 under “Treatment Performed This Visit: None required” despite the wound “Not healing” per SN notes on 5/6/26. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 12:58 PM. Staff B further acknowledged better wound care documentation was needed throughout P-6’s admission to home care. Patient #7 (P-7) was admitted to home care on 4/24/26 with diagnoses which included viral enteritis, heart disease with diastolic congestive heart failure, and history of falls. P-7 was hospitalized on 4/20/26 due to “syncope (passing out from a sudden drop in blood pressure) versus fall.” The discharge plan from the hospital included checking for orthostatic blood pressure (BP) changes that may occur when standing up from a sitting position. During a joint home visit with physical therapy (PT) services on 5/27/26, it was observed that P-7 had become somewhat dizzy shortly after standing and losing her balance while walking with PT services. PT services did not check P-7’s BP to assess for any orthostatic changes. The Agency had no documented orthostatic BP readings for P-7 to rule out and educate P-7/Caregiver on potential orthostatic BP findings by the conclusion of the survey on 5/28/26. P-7 was discharged from SN services on 4/27/26 but failed to attain pertinent clinical findings prior to discharge that may have contributed to P-7’s hospitalization on 4/20/26. On 5/28/26, patient record review noted SN performed the initial comprehensive assessment (4/24/26) which listed 17 goals for P-7 to attain prior to discharge. On the next SN visit (4/27/26), P-7 was discharged from SN services with all 17 goals being met per SN discharge summary. Evidence that indicated P-7/Caregiver had started working on or attained at least 7 of the listed goals were not found during record review. Based on the evidence above, it was determined the clinical responsibilities of the Agency’s SN and PT services were lacking. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 1:10 PM.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care for 3 (P-1, P-3, P-5) of 4 patients in which Home Health Aide services were ordered, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was determined the initial assessment by the registered nurse dated 7/16/25 indicated P-3 required “nectar thick” liquids due to difficulty swallowing following a recent stroke. Upon further review of the record, it was determined the aide care plan failed to include this as a safety precaution. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM. Patient #1 (P-1)’s start of care (SOC) was 12/30/25 with diagnoses that included Acute Kidney Failure and Cardiogenic Shock. During the record review on 5/26/26 at 11:30 a.m., it was noted that the Plan of Care (POC) revealed the following safety measures; slow position change, support during transfer and ambulation, use of assistive devices, Diabetic precautions and Fall precautions. The Aide Care Plan was void of the aforementioned safety precautions. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 5/28/26 at P-5’s SOC was 5/20/26 with diagnoses that included CVA (stroke) and Right-sided Hemiplegia. During the record review on 5/27/26 at 12:30 p.m., it was noted that the POC listed the following safety measures: Slow position change, support during transfer and ambulation, Seizure precautions, Proper position during meals, Fall precautions, use of assistive devices, Diabetic precautions and Bleeding precautions. The Aide Care Plan was void of the aforementioned safety precautions. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:40 p.m.”

“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 5/26/26 at 9:25 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 by the contract agency, Staff-A stated, “Our contract provides for all the services/disciplines.” When asked to clarify which service was directly provided by the Agency, Staff-A reported, “Nursing.” On 5/27/26 at 1:13 p.m., during a review of the agency’s contracts, it was noted that that the services provided included Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social work and Home Health Aide services. The agency failed to ensure that at least one qualifying service was provided directly by agency employees. The Administrator (Staff-A) and the Clinical manager (Staff-B) both reviewed and acknowledged the above findings during an interview on 5/27/26 at 10:50 a.m.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was informed of, consented to, or given the right to refuse care prior to the provision of treatment for 3 (P-2, P-3 and P-6) of 3 patients, resulting in the potential for a violation of patient rights. Findings include: Patient #6 (P-6) was admitted to home care on 5/6/26 with diagnoses which included status post gastro-intestinal surgery, intestinal adhesions, and hypertension. On 5/27/26, patient record review noted the referral for home care ordered skilled nursing, physical therapy, and home health aide (HHa) services to provide care to P-6. Additional review found no evidence that HHa services were provided as ordered and no evidence that the patient refused or was informed of HHa services. No physician or Agency communication was found which explained why HHa services were never provided. The above finding was reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 12:55 PM. Patient #3 (P-3): During record review on 5/26/26, it was determined the initial referral to start home care services (dated 7/11/25) included services from skilled nursing, physical therapy, occupational therapy, speech therapy, and home health aide. Upon review of the visit notes, it was determined P-3 received services from skilled nursing, physical therapy, speech therapy, and home health aide. Upon review of the consent form signed by the patient at the start of care (dated 7/16/25), it was noted the sections next to occupational therapy and speech therapy were left blank. Therefore, there was no evidence P-3 had consented to speech therapy or refuses a home health aide. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 2:00 PM. Patient #2 (P-2)’s start of care was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 5/27/26 at 12:55 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) services to be provided at a frequency of 1x/wk. x 4 wks. The patient’s Consent for Treatment dated 5/12/26, signed by both the patient and the agency representative, reflected a SN visit frequency of 1x/wk. x 9 wks. The agency failed to ensure P-2 was informed of an accurate frequency in which SN services would be provided, prior to the provision of services. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.m.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse conducted the initial assessment within 48 hours, to establish the immediate care needs and homebound status for 1 (P-5) of 1 patient, resulting in the potential for unidentified care needs and poor patient outcomes. Findings include: Patient #5 (P-5)’s start of care was 5/20/26 with diagnoses that included CVA (stroke) and right-sided Hemiplegia. The referral for home care was dated 5/18/26 and ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) and Medical Social Work (MSW) services to be provided. On 5/28/26 at 12:30 p.m., during the clinical record review, it was noted that the Physical Therapist (PT) conducted the initial assessment. The Plan of Care indicated the SN would evaluate and treat the patient after the holiday. Upon further review, there was no documented evidence that the patient requested a later start date or that the Physician had been notified of the agency’s decision to have PT conduct the initial assessment. The agency failed to ensure the SN conducted the initial assessment to determine P-5’s immediate care needs and homebound status. The Administrator and Clinical Manager reviewed and acknowledged the above information during an interview on 5/28/26 at 3:40 p.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 and clinical needs at the time of admission for 2 (P-3, P-6) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #6 (P-6) was admitted to home care on 5/6/26 with diagnoses which included status post gastro-intestinal (GI) surgery, intestinal adhesions, and hypertension. On 5/27/26, patient record review noted that Skilled Nursing’s (SN) initial comprehensive assessment lacked measurements concerning a post-operative abdominal wound (assessment failed to include surgical date) that still had positive sanguineous (fresh, bright red blood) drainage (minimal). In addition, SN failed to address if P-6 had any type of wound covering/dressing during the assessment and failed to intervene that if any drainage was present (per hospital physician discharge instructions), a wound dressing would be needed. SN documented under “Wound Care Notes” that none were required despite further documenting that the wound was “Not healing”. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 1:06 PM. Patient #3 (P-3): During record review on 5/26/26, it was determined the comprehensive assessment identified a diagnosis of “Personal history of (healed) traumatic fracture” [sic] with an onset or exacerbation date of 7/16/25 - the start of care date for home care. However, there were no details or assessments about this injury to determine what body part was affected or when it had occurred. The “healed” part of the diagnosis and new onset date listed in the comprehensive assessment is conflicting and does not provide a clear picture of the patient’s current or potential status. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM.”

“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 patient’s needs were adequately met in the home for 2 (P-2, P-3) of 2 patients who required therapy and assistance with grooming, resulting in the potential for physiological decline, low self-esteem and poor hygiene. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was noted the Outcome Assessment and Information Set (OASIS) dated 7/16/25 indicated P-3 “Needed some help” with self-care activities prior to admission, include for bathing, dressing, and toileting. The OASIS also indicated P-3 required “substantial/maximal assistance” for these activities at start of care as well as having “minimal use of her left upper extremity.” Therefore, P-3 was not at her baseline following her recent stroke. Additionally, the physical therapy evaluation dated 7/18/25 (part of the comprehensive assessment) indicated “…patient was independent with all ADLs, transfers to bed, shower, chair and toilet…”prior to admission. The physical therapy evaluation also indicated P-3 was fully dependent on assistance for transfers at the start of care – further indicating the patient was not at her baseline in these areas. Upon further review of the comprehensive assessment information, it was noted that occupation therapy was not identified as a need for P-3, even though documentation indicated a strong need and it was also ordered on the initial referral to start home care. During an interview with the administrator (Staff-A) on 5/28/26, Staff-A was asked about the need for occupational therapy for this patient following a recent stroke with new deficits. Staff-A was unable to provide a reason occupational therapy was not identified as a need for this patient and acknowledged the findings at the time of interview. Additionally, the OASIS identified “speech” as a functional limitation and listed the 2nd, 3rd, and 4th diagnoses as diagnoses related to speech and swallowing difficulties. Upon further review of the record, it was noted the plan of care indicated speech therapy would start the week of 7/27/25 and did not start until 8/1/25 – more than 2 weeks after an acute need was identified. During an interview with Staff-A on 5/28/26 at 11:40 AM, Staff-A was asked about the reason for the late speech therapy start for a patient with a significant identified need for speech therapy following a new stroke diagnosis. Staff-A stated that was when the speech therapist was available. Staff-A stated it is hard to find speech therapists but agreed this did not meet the needs of the patient and acknowledged the findings at the time of interview. Patient #2 (P-2)’s start of care was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Diabetes Mellitus and Congestive Heart Failure. The clinical record review was conducted on 5/27/26 at 12:55 p.m. During the review, it was noted that section M1800 of the Initial Comprehensive Assessment dated 5/12/26 stated someone must assist with grooming, dressing; required assistance with bathing. Someone must help to maintain toileting hygiene. Unable to transfer self. Patient is incontinent. Upon further review, there was no documented evidence that a home health aide was offered or provided to assist with grooming needs. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.m.”

“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 provide evidence the Physician had been notified of the untoward findings identified during the drug review for 2 (P-1, P-2) of 2 patients, resulting in the potential for unidentified effects of harmful ingestion of medications. Findings include: Patient #1 (P-1)’s start of care (SOC) was 12/30/25 with diagnoses that included Acute Kidney Failure and Cardiogenic Shock. During the record review on 5/26/26 at 11:30 a.m., it was noted that the Skilled Nurse (SN) identified duplicate drug therapy and major/review suggested drug to drug interactions during the drug review conducted on 12/30/25. Upon further review, there was no documented evidence that the Physician had been notified of the untoward findings. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 5/28/26 at 2:42 p.m. P-2’s SOC was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 5/27/26 at 12:55 p.m., it was noted that the SN identified duplicate drug therapy, and major/review suggested drug to drug interactions during the drug review conducted on 5/12/26. Upon further review, there was no documented evidence that the Physician had been notified of the untoward findings. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.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 accurately reflected the primary caregivers willingness, ability, and availability to provide care for 1 (P-2) of 1 patient assessed as needing assistance with activities of daily living, resulting in the potential for poor grooming and unmet care needs. Findings include: Patient #2 (P-2)’s start of care (SOC) was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. During the record review on 5/27/26 at 12:55 p.m., it was noted that section M1800 (Grooming) of the Initial Comprehensive Assessment stated that someone must assist with grooming, dressing; required assistance with bathing; Someone must help to maintain toileting hygiene. Unable to transfer self. Patient is incontinent. Section M1100 of the Comprehensive Assessment was void of a documented available caregiver who would be willing to provide assistance with Activities of Daily Living (ADL’s). The Administrator (Staff-A) and the Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.m.”

“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 was individualized and included all of the required elements to manage the care and needs for 2 (P-1, P-2) of 2 patients, resulting in patients not receiving care in accordance with their identified needs. Findings include: Patient #1 (P-1)’s start of care (SOC) was 12/30/25 with diagnoses that included Acute Kidney Failure, Cardiogenic Shock and Diabetes Mellitus. The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 5/26/26 at 11:30 a.m., during the clinical record review, it was noted that POC indicated that all of P-1’s 14 diagnoses exacerbated on 11/28/25 and 12/30/25 (date of admission). There were no interventions, reportable parameters or associated goals that addressed the exacerbated diagnoses. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged these findings during an interview on 5/28/26 at 2;42 p.m. P-2’s SOC was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. The POC ordered SN, PT and OT services to be provided. During the record review on 5/27/26 at 12:55 p.m., it was noted that the POC listed P-2’s diagnoses with an exacerbation date of 5/9/26 and 5/12/26. There were no interventions, reportable parameters or associated measurable goals to address the diagnoses reported as having exacerbated on the date of admission or 3 days prior. Additionally, the hospital referral paperwork dated 5/11/26 indicated P-2 had a Venous Ulcer lower right leg that he keeps scratching. The agency failed to include this information, along with wound care orders, in the POC Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 5/28/26 at 3:20 p.m.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were administered only as ordered by the physician in 2 (P-3 and P-4) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was determined the initial referral to start home care dated 7/11/25 included services from skilled nursing, physical therapy, occupational therapy, speech therapy, and home health aide. Upon further view of the record, it was determined P-3 did not receive any visits from occupational therapy. During an interview with the administrator (Staff-A) on 5/28/26 at 11:40 AM, Staff-A was asked why P-3 had not been seen by occupational therapy. Staff-A stated sometimes there was not a need for it or patients do not want many people coming to their home, however, Staff-A was not able to provide documented evidence of why P-3 did not receive services from occupational therapy as ordered by the physician. Staff-A acknowledged the findings at the time of interview. Patient #4 (P-4): During record review on 5/27/26, it was noted that the face-to-face visit note written by the physician on 1/19/26 did not include which home health services were ordered under the section that stated, “I certify that, based on my findings, the following services are medically necessary home health services (Check all that apply):”. The only item under this section was a handwritten note that stated “*Palliative care,” which is not a home health care service. During an interview on 5/28/26 at 11:40 AM, the administrator (Staff-A) confirmed the face-to-face visit note was used to initiate home care services. When asked how the agency was able to initiate home care services without any services checked, Staff-A stated staff get a verbal order from the physician on the start of care date to inform the physician. Upon review of the verbal order indicating a need for physical therapy and a home health aide, it was determined that the patient had already been admitted and seen by the agency as it included visit frequencies, medication review, and a summary of care. Additionally, the order stated, “[Doctor] was notified today’s SOC, Order, Reconciled medications, Verified diagnosis, discuss POC and MD approval,” [sic] further indicating the verbal order was written after initiation of home care services. Therefore, the agency started home care services without an order from the physician. A review of agency policy titled “Physician’s Plan of Treatment/Change Orders” (Revised Jan 2021) revealed, “Clinicians receives the verbal order before services are provided.” Staff-A acknowledged the findings at the time of interview.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapist promptly notified the physician of a significant change in 2 (P-2 and P-4) of 2 patients reviewed with elevated blood pressure readings, resulting in the potential for unidentified, untreated health concerns and unmet patient care needs. Findings include: Patient #4 (P-4): During record review on 5/27/26, it was noted the plan of care included an order to “Notify physician of:…Systolic BP greater than (>) 160 or less than () 90 or less than (<) 50.” Upon review of the physical therapy notes, it was determined P-4’s blood pressure was 166/87 on 2/11/26 and 159/96 on 3/5/26. Both were marked in red in the electronic medical record system to indicate that they were outside of the established parameters, however, there was no evidence the doctor was notified as ordered. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM. Patient #2 (P-2)’s start of care was 5/12/26 with diagnoses that included Hypertensive Heart Disease and Congestive Heart Failure. The Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the clinical record review on 5/27/26 at 12:55 p.m., it was noted that during a PT visit on 5/22/26 P-2 had a blood pressure of 172/89. A PT visit note dated 5/25/26 documented a blood pressure reading of 174/86. The Plan of Care (POC) instructed, “Notify physician of: Systolic BP (blood pressure) greater than 160 or less than 90; Diastolic BP greater than 90 or less than 50.” Upon further review, the PT visit notes, there was no documented evidence that the PT promptly notified the Physician of P-2’s elevated blood pressure readings as instructed in the Plan of Care. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.m.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were integrated when additional needs were identified in 1 (P-3) of 7 patients reviewed, resulting in the potential for unmet care needs. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was noted a skilled nursing visit note dated 7/31/25 stated “Can we contact a medical social worker and ask them if there is community resources available that would help her obtain a wheelchair ramp for her home. Patient is unable to leave the home without a wheelchair ramp unless she has significant help from other people. I will follow up with patient for revisit on August 11.” [sic] Additionally, the note stated, “Patient states that she would like to have speech therapy come out and work with her and would also like to increase her physical therapy if possible.” [sic] Upon review of the skilled nursing notes following that visit (dated 8/11/25 and 8/26/25), it was determined there was no follow-up by the skilled nurse regarding a social work evaluation for this patient or evidence of communication with the physical therapist or speech therapist. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure skilled nursing (SN) coordinated wound care interventions/treatments in 1 (P-6) of 7 patients reviewed, resulting in the potential for a poor clinical outcome. Findings include: Patient #6 (P-6) was admitted to home care on 5/6/26 with diagnoses which included status post gastro-intestinal (GI) surgery, intestinal adhesions, and hypertension. On 5/27/26, patient record review noted hospital discharge instructions (5/3/26) from P-6’s GI surgeon which documented the following wound care needs, “No need to apply dressing unless wound has drainage. Also wash daily with mild soap and water in the shower. No tub soaking...” The Agency’s Skilled Nurse failed to coordinate and pass along the above wound care needs to P-6/Caregiver in any of the 3 home visits (5/13/26 through 5/27/26). Further, the home care physician also ordered Skilled Nurse to instruct the same hospital wound care instructions as above to P-6, but no evidence was found in the medical record this was done. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 12:58 PM.”

“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 record review and interview, the agency failed to ensure the Admission packet contained the Clinical Manager’s full contact information, resulting in the potential for unaddressed clinical care concerns and unmet care needs. Findings include: On 5/26/26 at 9:57 a.m., during a review of the agency’s Admission Packet, it was noted that there was no name or contact information for the agency’s Clinical Manager (Staff-B). The Administrator (Staff-A) and Staff-B reviewed and acknowledged these findings during an interview on 5/28/26 at 2:38 p.m.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines performed baseline and ongoing assessments for 2 (P-2 and P-3) of 2 patients, resulting in the potential for unidentified, untreated health concerns and unmet patient care needs. Findings include: Patient #3 (P-3): During record review on 5/26/26, it was noted the plan of care included an order for “SN to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 6/10, pain medications not effective, patient unable to tolerate pain medications, pain affecting ability to perform patient’s normal activities.” [sic] However, upon review of skilled nursing notes from 7/16/25 to 9/10/25, it was determined that 6 of 6 skilled nursing visit notes failed to assess P-3’s pain as the pain section in the visit note was left completely blank. A review of agency policy titled “Pain Management” revealed that pain “Reassessments will occur on an ongoing, regular basis.” The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM. Patient #2 (P-2)’s start of care was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. The Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the clinical record review on 5/27/26 at 12:55 p.m., it was noted that the hospital referral notes dated 5/11/26 revealed P-2 had a Venous Ulcer right lower leg. The Initial Comprehensive Assessment, completed by the Registered Nurse, was void of a baseline wound assessment. The section titled “Past Medical History (Mark all that apply)” listed Stasis Ulcer as an option to check, however, it was left blank. The section titled “Integumentary Status” documented, “Skin turgor: Fair; Skin color; Pink/WNL (within normal limits); Skin: Dry.” The option to select Ulcer was left blank. Section M1332 “Current number of stasis ulcers that are observable” was left blank. There was no documented evidence to support that the SN conducted a baseline assessment of P-2’s skin at the time of admission. Additional review of the clinical record revealed that there was no baseline blood sugar obtained at the time of admission in light of P-2’s diagnosis of Diabetes Mellitus. Further, a PT visit note dated 5/22/26 documented a blood pressure of 172/89. Another PT visit note dated 5/25/26 documented a blood pressure reading of 174/86. Both readings were above the Physician set reportable parameters noted in the Plan of Care. Under the section of the PT visit notes titled “BP” (blood pressure), were options to assess blood pressure prior to therapy, during the therapy session, and upon completion of the session. The PT did not recheck P-2’s blood pressure during or after the therapy session to ensure P-2 was stable. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:20 p.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided in accordance with the Plan of Care and Physician’s orders for 5 (P-1, P-2, P-3, P-4, P-6) of 5 patients, resulting in the potential for decline in health and unmet care needs. Findings include: Patient #6 (P-6) was admitted to home care on 5/6/26 with diagnoses which included status post gastro-intestinal (GI) surgery, intestinal adhesions, and hypertension. On 5/27/26, patient record review noted P-6’s Plan of Care (POC) ordered SN to instruct “P-6/Caregiver on wound care as follows: Keep incision clean and dry, no dressing required unless drainage or clothing is bothersome, ok to shower, wash incision daily with soap and water. SN to assess skin for breakdown every visit.” Additional record review of the SN visit notes dated 5/13/26 and 5/19/26, had the same documentation found under “Wound Care” which were, “Wounds Not Addressed This Visit” concerning “Wound 1: Location - lower mid-abdomen, Type: Surgical Incision, Date of Onset: Present Upon Admission.” On 5/27/26 during a joint home visit with SN, it was observed no assessment of P-6’s abdominal incision was performed and no education concerning wound care was evidenced in any of the 3 SN visits provided. Further, the only wound care documentation that SN provided was at the start of care (5/6/26) which documented the surgical wound was “Not healing” and had positive sanguinous drainage (minimal without odor.” The POC also stipulated that if there was any drainage, a wound dressing would be needed. No evidence was seen in the patient record that any dressing was applied to the open abdominal wound, and SN further documented on 5/6/26 under “Treatment Performed This Visit: None required.” The agency failed to ensure all services were provided in accordance with the POC orders. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 12:58 PM. Staff B further acknowledged better wound care documentation was needed throughout P-6’s admission to home care. Patient #3 (P-3): During record review on 5/26/26, it was noted the plan of care dated 7/16/25 included an order for “…glucometer use and preparation and administration of diabetic medications ordered by the physician.” It also included an order to “Notify physician of:…Fasting blood sugar greater than (>) 200 or less than () 250 or less than (<) 60.” Upon review of skilled nursing notes from 7/16/25 to 9/10/25, it was determined that 6 of 6 visit notes failed to include a blood sugar reading or education on glucometer use or diabetic medication administration. During an interview with the administrator (Staff-A) on 5/28/26 at 11:40 AM, it was determined P-3 did not use/have a glucometer and was not on any diabetic medication, however, Staff-A acknowledged the orders in the plan of care were not followed as written/ordered. Patient #4 (P-4): During record review on 5/27/26, it was noted the plan of care dated 1/20/26 included an order that stated, “PT to assess SPO2 before and after exercise.” SPO2 is oxygen saturation in the blood measured with a device placed on the patient’s finger. Upon further review of the record, it was determined that 9 of 9 physical therapy visits from 1/23/26 through 3/12/26 only included an SPO2 assessment prior to exercise. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM. Patient #1 (P-1)’s start of care (SOC) was 12/30/25 with diagnoses that included Acute Kidney Failure and Cardiogenic Shock. The referral for home care dated 12/29/25 ordered Skilled Nursing (SN), Physical therapy (PT), Occupational therapy (OT) and Home Health Aide (HHa) services to be provided. At the time of the clinical record review on 5/26/26 at 11:30 a.m., no OT services had not been provided as ordered. Additionally, The Plan of Care (POC) instructed, “SN to perform fingerstick for fasting blood sugar/random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia.” A SN visit note dated 1/4/26 documented, “Blood sugar not taken today.” There were no other documented blood sugars available for review. The agency failed to ensure services were provided as ordered. The Administrator (Staff-A) and Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 5/28/26 at 2:42 p.m. P-2’s SOC was 5/12/26 with diagnoses that included Hypertensive Heart Disease, Congestive Heart Failure and Diabetes Mellitus. The Plan of Care (POC) instructed “SN to perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done or if patient reports signs/symptoms of hypo/hyperglycemia..., SN to instruct patient on daily weight self-monitoring program where the patient utilized the same scales on a hard, flat surface each morning prior to breakfast and after urination. Report to SN weight gain of 3 lb./1 day; 5 lb./1 wk.” During the clinical record review on 5/27/26 at 12:55 p.m., it was noted that the SN failed to document a baseline blood sugar in the Initial comprehensive Assessment dated 5/12/26. A SN visit note dated 5/19/26 had no documented blood sugar. A PT visit note dated 5/22/26 read, “Weight not assessed, sugar not tested.” A PT visit note dated 5/25/26 documented “Weight not assessed, not diabetic.” The agency failed to ensure the patient’s blood sugar and weights were checked and documented as ordered in the POC. Staff-A and Staff-B reviewed and acknowledged these findings during an interview on 5/28/26 at 3:20 p.m.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide provided services as ordered in the plan of care for 2 (P-3, P-4) of 3 patients reviewed who received home health aide services, resulting in the potential for poor patient outcomes. Findings include: Patient #3 (P-3): During record review on 5/28/26, it was noted that the aide care plan included an intervention to record the date of the last bowel movement at every visit. Upon review of the aide visit notes from 7/24/25 through 8/28/25, it was determined that 7 of 7 home health aide visit notes failed to include the date of the last bowel movement. Additionally, the aide visit note dated 8/6/25 stated “Assist with range of motion legs arm movement in bed with client,” [sic] however, it was noted range of motion was not ordered on the aide care plan. The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM. Patient #4 (P-4): During record review of the first 12 home health aide visits on 5/27/26, the following was noted: On 1/27/26, ordered vital signs were left blank and there was no information on frequency or completion of the tasks ordered on the aide care plan. A narrative section included some of the tasks performed, however, the note was void of information regarding what tasks were on the aide care plan. On 1/29/26, ordered vital signs were left blank and there was no documentation that all the tasks were completed next to the listed frequency. A narrative section included some of the tasks performed, however, it did not include all the tasks ordered. On 1/30/26, ordered vital signs were left blank and there was no documentation that all the tasks were completed next to the listed frequency. The narrative section was also left blank. On 2/2/26, ordered vital signs were left blank and several tasks did not indicate that they had been completed as ordered. A narrative section included some of the tasks performed, however, it did not include all the tasks ordered. On 2/11/26, ordered vital signs were left blank. Additionally, it was ordered to record the date of the last bowel movement at every visit, however, it was determined 11 of the12 home health aide visit notes reviewed failed to document the date of the last bowel movement. During an interview with the administrator (Staff-A) on 5/28/26 at 11:40 AM, Staff-A was asked how to determine if the aide completed a task during a visit. Staff-A stated it should state “Completed” next to each ordered task frequency on the visit note. Staff-A reviewed the findings noted above and acknowledged them at the time of interview.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure accurate aide supervision for 1 (P-4) of 3 patients reviewed who received home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #4 (P-4): During review of home health aide supervision notes on 5/27/26, it was noted the physical therapist documented “Satisfactory” next to the task of “Documents appropriately” on aide supervision notes dated 1/31/26 and 2/16/26. However, upon review of the first 12 home health aide visits between 1/27/26 and 3/12/26, it was determined 11 of 12 visits were missing some portion of the documentation (see G800). The physical therapist failed to adequately supervise the home health aide’s documentation. A review of agency policy titled “Professional and Ancillary Services” (No Date) revealed, “Home health aide services shall include but not be limited to:…Documenting clinical notes.” The administrator (Staff-A) reviewed and acknowledged the findings during an interview on 5/28/26 at 11:40 AM.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the transfer/discharge summaries were complete in 2 (P-1, P-5) of 3 patients who were discharged/transferred 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) was admitted to home care on 4/24/26 with diagnoses which included viral enteritis, heart disease with diastolic congestive heart failure, and history of falls. P-7 was hospitalized on 4/20/26 due to “syncope (passing out from a sudden drop in blood pressure) versus fall.” The discharge plan from the hospital included checking for orthostatic blood pressure (BP) changes that may occur when standing up from a sitting position. On 5/28/26, patient record review noted Skilled Nursing (SN) performed the initial comprehensive assessment (4/24/26) which listed 17 goals for P-7 to attain prior to discharge. On the next SN visit (4/27/26), P-7 was discharged from SN services with all 17 goals being met per SN discharge summary. Evidence that indicated P-7/Caregiver had started working on or attained at least 7 of the listed goals were not found during record review. In addition, during a joint home visit with physical therapy (PT) services on 5/27/26, it was observed that P-7 had become somewhat dizzy shortly after standing and losing her balance while walking with PT services. No signs or symptoms of viral enteritis had been experienced by P-7 since SN had discharged P-7 on 4/27/26. Subsequently, any dizziness when standing up by P-7 would not be attributed to viral enteritis but instead potential orthostatic BP changes. The Agency had no documented orthostatic BP readings for P-7 to rule out and educate P-7/Caregiver on potential orthostatic BP findings by the conclusion of the survey on 5/28/26. The discharge summary completed by SN on 4/27/26 had failed to address multiple listed goals and attain pertinent clinical findings that may have contributed to P-7’s hospitalization on 4/20/26. The above findings were reviewed and acknowledged by the Agency’s Administrator (Staff-A) and Clinical Manager (Staff B) during an interview on 5/28/26 at 1:10 PM. Staff B further acknowledged the discharge summary from SN should have included orthostatic BP findings when queried. Patient #1 (P-1)’s start of care (SOC)was 12/30/25 with diagnoses that included Acute Kidney Failure and Cardiogenic Shock. During the clinical record review on 5/26/26 at 11:30 a.m., it was noted that P-1 was transferred and admitted to an inpatient facility. The Transfer Summary was noted to be incomplete. The section titled “Physical and Psychological status”: documented “just started care on 12/30/26.” The section titled “Reason for Transfer” was left blank. There was no detailed summary of the patient’s status at the time of transfer to an in-patient facility or the reason for the transfer. Further, there was no documented evidence that the summary was forwarded to the receiving facility and the Physician within 2 days of agency becoming aware of the transfer. The Administrator (Staff-A) and the Clinical Manager (Staff-B) reviewed and acknowledged the above information during an interview on 5/28/26 at 2:42 p.m. P-5’s SOC was 5/20/26 with diagnoses of CVA (stroke) and Right-Sided Hemiplegia. During the record review on 5/28/26 at 12:30 p.m., it was noted that P-5 was transferred and admitted to an inpatient facility on 5/26/26 for undocumented reasons. The Transfer summary dated 5/28/26 was incomplete. The section titled “Reason for Transfer” stated, “Hospitalized.” Further, there was no documented evidence that a completed summary was forwarded to the receiving facility or the Physician within 2 days of the agency becoming aware of the transfer. Staff-A and Staff-B reviewed and acknowledged the above findings during an interview on 5/28/26 at 3:40 p.m.”