Able Care

“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 the physical therapist conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed (see G516); failed to ensure that a comprehensive assessment was completed timely in 1 (P-4) of 7 records reviewed (see G520); and failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 1 (P-4) of 7 records reviewed (see G528). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.55: Comprehensive assessment of patients.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the Clinical Director (CD-1) failed to ensure the oversight of: coordination of patient care (see G0962); physician referrals for the initiation of home care services (see G0964); and the development of an individualized plan of care (see G0968), resulting in the agency’s potential mismanagement of resources essential for delivering optimal care, which may result in unmet care needs and poor patient outcomes. The cumulative effect of these systemic problems resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.105 Organization and Administration of Services. .”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the Physical Therapist (PT) failed to provide services in accordance with the Plan of Care (POC) for 1 (P-7) of 5 records reviewed with PT services, and failed to sign the plan of care for 1 patient (P-2) from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning, unmet care needs and no physician oversite. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, review of P-7’s POC (effective 8/18/25) ordered Physical Therapy (PT) services to be provided at a frequency of once weekly times 9 weeks. On 1/22/26, record review noted PT missed 3 consecutive weekly visits (9/27/25, 10/2/25, and 10/9/25). The PT missed visit (MV) notes documented the following for each MV: “No Answer to Phone Call.” Skilled nursing performed a ROC (resumption of care) visit on 9/26/25. There was no documented effort of PT services trying to make up any of the missed visits to fulfill the order. During an interview on 1/26/26 at 12:34, the Clinical Director (CD-1) and Administrator reviewed and acknowledged the above findings. CD-1 further stated, “That falls into my court.” Patient #2 (P-2): The admission to home care was on 7/25/25, with diagnoses which included polyosteoarthritis, sacroiliitis, and L hip replacement. On 1/20/26, review of P-2’s Plan of Care (POC) dated 7/25/25 had a physician signature date of 10/16/25, 83 days after the start of care (SOC). During an interview on 1/21/26 at 3:30 p.m., the Administrator (Adm-1) and the Clinical Director (CD-1), acknowledged the above finding.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed expected infection control standards of practice during 1 (P-1) of 3 joint home visits conducted during the survey, potentially resulting in the risk of communicable disease transmission. Findings include: On 1/21/26 at 3:30 p.m., a joint home visit was conducted with an agency physical therapy assistant (PTA-1). During the visit, PTA-1 was observed while retrieving unused gloves and vital sign equipment from his patient supply bag (brought in with him for the visit). After putting the unused gloves on and performing multiple patient tasks, PTA-1 placed both of his gloved hands (dirty) back into the bag to search for alcohol prep pads. When he was ready to clean his vital sign monitoring equipment with the alcohol prep pads, PTA-1 removed the glove from his right hand while holding the equipment in his gloved left hand (dirty) to wipe the equipment down. PTA-1 did not take the dirty glove off the left hand or cleanse his hands until after each piece of equipment had been wiped down. On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, the above findings were reviewed. CD-1 agreed that PTA-1 did not follow agency infection control expectation as he should not have used dirty gloves to enter his bag and should not have wiped down equipment without first removing both dirty gloves and washing his hands.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse included all pertinent safety measures in the home health aide (HHa) plan of care in 1 (Patient/P-7) of 1 record reviewed with home health aide services, resulting in the potential for the provision of unsafe care. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. P-5’s plan of care documented the following safety precautions: “Keep side rails up, slow position change, support during transfers and ambulation, seizure precautions...” When comparing these precautions to those listed on the HHa plan of care, it was noted the HHa plan of care failed to include seizure precautions or that the bed rails needed to be up to help ensure patient safety. These findings were reviewed with and acknowledged by the Administrator and Clinical Director during an interview on 1/26/26 at 12:18 PM.”

“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 right of the patient to consent to or refuse care before treatment in 1 (P-1) of 7 records reviewed, potentially resulting in limited care options for this patient. Findings include: Patient #1 (P-1): This patient was admitted to the home health agency on 10/8/25 with a primary diagnosis of chronic obstructive pulmonary disease. The record was reviewed on 1/21/26. During review, it was noted that the agency’s home care consent form signed by P-1 on 10/8/25 did not include which initial disciplines would be providing care, or the frequency of care. Agency policy titled “Consent for Care/Treatment” (undated) was provided for surveyor review on 1/26/26. On page one (noted as page 256), it stated “To establish, from the onset, the patient/client/legal guardian’s permission for (agency) and it’s personnel to render care as requested and as per physician’s orders… Every effort shall be made to ensure the signer fully understands what he/she is agreeing to.” On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, CD-1 acknowledged this finding.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist (PT) conducted an initial assessment within 48 hours of the physician referral in 1 (P-4) of 7 records reviewed, resulting in a delay in assessment of immediate care needs and the potential for a poor patient outcome. Patient#4 (P-4): This patient was referred to this agency with a physician referral dated 1/13/26 for PT services related to weakness and a diagnosis of congested heart failure. During an interview and record view on 1/26/26 at 1:36 PM, review found no evidence of an initial assessment by PT services. At time of discovery the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed that an initial assessment was not completed within 48 hours.”

“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 timely for 1 (P-4) of 7 total sample records reviewed, resulting in a delay in assessment of immediate care and support needs of the patient and the potential for poor patient outcomes. Patient #4 (P-4): This patient was referred to this agency with a physician referral dated 1/13/26 for physical therapy (PT) services related to weakness and a diagnosis of congested heart failure. During an interview and record review on 1/26/26 at 1:36 PM, no evidence was found of that the initial and comprehensive assessments were performed by PT services. At time of discovery the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed the initial and comprehensive assessments were not completed.”

“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 that a comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 1 (P-4) of 7 total sample records reviewed, resulting in incomplete clinical information gathering and possible poor patient outcomes. Patient #4 (P-4): The date of physician referral was 1/13/26 for physical therapy services. No evidence was found that the initial and comprehensive assessments (CA) were performed by the agency as of 1/26/26. During the interview on 1/26/26 at 1:36 PM, the administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed that the initial and comprehensive assessments were not completed.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care (POC) was detailed and individualized in 4 (Patient/P-2, P-4, P-5 and P-7) of 7 total records reviewed, resulting in the potential for poor clinical outcomes and unidentified goals, unmet patient goals. Findings include: Patient #5 (P-5): This active patient had an admission to home care on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure), diabetes type-2 and abnormal gait. During record review on 1/22/26, P-5’s POC (effective 7/30/24) failed to have any type of pre-established weight or measuring parameters to monitoring for exacerbation (worsening) of fluid overload caused by P-5’s CHF diagnosis. Further record review noted during a hospital admission, P-5’s weight was documented as being 117 pounds on 1/28/25. Two days later during a resumption of care (1/30/25) by home care’s PT services, noted a documented weight of 126 pounds. This 9-pound weight gain had no weight parameters to report, subsequently there was no physician communication found in the medical record of this significant weight gain. The POC also failed to include blood sugar safety parameters despite having an abnormally high reading (191 mg/dL) during the face-to-face physician visit on 8/29/24. During record review on 1/22/26, P-5’s POC (7/30/24) noted 25 of 26 SN goals were not written in measurable terms that could be tracked and trended to show progress made (or lack of). In addition, 26 of 26 goals were generic, non-patient specific that had no improvement from a pre-established measurable baseline. Examples include as follow: “Patient will have no hospitalizations during certification period; The patient will be free from injury during certification period; Patient will be free from falls during certification period.” Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. During record review on 1/22/26, P-7’s POC (10/22/24) noted 14 of 15 were not written in measurable terms that could be tracked and trended to show progress made (or lack of). In addition, 15 of 15 goals were generic, non-patient specific that had no improvement from a pre-established measurable baseline. Examples include as follow: “Patient will have no hospitalizations during certification period; The patient will be free from injury during certification period; Patient will be free from falls during certification period.” Further, the one goal that was semi-measurable was written as follows: “Patient will achieve a pain level less than 0/10 within 2 weeks.” This indicated P-7’s pain, which was documented as “0” at the start of care, would be an acceptable goal if it had increased to 9/10 scale (10 being the worst possible) which would be inappropriate. During an interview on 1/26/26 at 12:28 PM, the Administrator and Clinical Director reviewed and acknowledged the above findings. Patient #4 (P-4) was admitted to the agency on 10/22/25 with a diagnosis of lymphedema, pressure ulcer stage 2, and chronic venous hypertension with ulcer of lower extremities. On 01/22/26, a review of the plan of care effective 10/22/25, revealed 21 out of 21 listed goals were not written in objective measurable terms. For example, “The Patient/Caregiver will verbalize and demonstrate edema-relieving measures by: 12/20/2025”. Another goal stated, “Patient will be without signs/symptoms of UTI (pain, foul odor, cloudy or blood-tinged urine and fever) during this episode”. During an interview on 1/26/26 at 1:00 PM, with the Administrator (ADM-1) and Clinical Director (CD-1), both reviewed and acknowledged the findings above. Patient #2 (P-2): The admission to home care was on 7/25/25, with diagnoses which included polyosteoarthritis, sacroiliitis, and L hip replacement. On 1/20/26, review of P-2’s Plan of Care (POC) dated 7/25/25 revealed that only 1 of 17 goals were measurable. Example, “Wounds will heal without complications.” Another example, “The Patient/Caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911.” There was no way to ascertain progress toward goals for 16 of the 17 patient goals. During an interview on 1/21/26 at 3:30 p.m., the Administrator (Adm-1) and the Clinical Director (CD-1), acknowledged the above finding.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was revised after nursing services were added in 1 (P-1) of 7 records reviewed, resulting in no measurable outcomes or goals for nursing services to track patient progress. Findings include: Patient #1 (P-1): This patient was admitted to the home health agency on 10/8/25 with a primary diagnosis of chronic obstructive pulmonary disease. The record was reviewed on 1/21/26. During review, it was noted that the referral dated 10/1/25 included orders for physical therapy only. The start of care comprehensive assessment was completed on 10/8/25 by the physical therapist. The plan of care (POC) for the certification period of 10/8/25 through 12/6/25 included interventions, measurable outcomes and goals, and orders for physical therapy. A physician order dated 10/10/25 (2 days after the start of care) was noted in the medical record and included orders for skilled nursing (SN) once every other week to monitor cardiovascular status, medication regimen, and disease management. A nursing visit note titled “SN Evaluation” was completed on 10/10/25. There was no revision to the POC found within the medical record for the certification period stated above which included interventions, measurable outcomes, and goals related to nursing services. Agency policy titled “Plan of Care” (undated), was provided for surveyor review on 1/26/26. On page one (noted as page 317), it stated “The Plan of Care or service is developed or revised within three working days of the initiation of each service or of reassessment of the patient/client… The RN develops the care plan following the initial visit to best meet the patient/client needs.” On 1/26/26 at 10:40 a.m., an interview was conducted with the agency Administrator (Adm-1) and the Clinical Director (CD-1). During the interview, CD-1 acknowledged the above finding.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the home care agency failed to ensure skilled nursing (SN) provided appropriate supervision of services provided by the Licensed Practical Nurse (LPN) every 30 days for 1 (Patient/P-5) of 4 records reviewed with LPN services, resulting in a lack of supervision and oversight of patient care services and the potential for poor clinical outcomes. Findings include: Patient #5 (P-5): The admission to home care was on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure) and abnormal gait. On 1/22/26, record review noted the Plan of Care (POC) ordered a SN visit frequency of once-a-week times 9 weeks effective 9/23/25. Further review noted the last documented RN supervisory note was on 10/23/25. LPN services provided subsequent care to P-5 on: 11/6/25, 11/13/25, 11/26/25 (after recertification), 12/10/25, 12/18/25, and 12/26/25. No evidence was found in the medical record indicating the RN had provided any supervision over LPN services since 10/23/25. The findings above were reviewed and acknowledged by the agency’s Clinical Director (CD-1) during an interview on 1/26/26 at 12:14 PM. CD-1 was queried at 12:16 PM what the agency expectation was for the time interval that the RN was to document supervision of LPN services. CD-1 replied, “Every 30 days.””

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the home care agency failed to ensure Physical Therapy (PT) provided appropriate supervision of services provided by the Physical Therapy Assistant (PTA) every 30 days for 1 (Patient/P-7) of 3 records reviewed with PTA services, resulting in a lack of supervision and oversight of patient care services and the potential for poor clinical outcomes. Findings include: Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, record review noted the Plan of Care (POC) ordered a PT visit frequency of once-a-week times 8 weeks effective 8/16/25 which was also the last documented PT supervisory note. P-7 had a PT re-evaluation on 10/14/25 with a visit frequency of once-a-week times 6 weeks. During the times noted above, PTA services provided care to P-7 on: 8/18/25, 8/27/25, 9/2/25, 9/8/25, 10/24/25 (after 3 consecutive missed visits and re-evaluation on 10/14/25), 10/30/25, 11/4/25, 11/11/25, and 11/17/25. No evidence was found in the medical record indicating the PT had provided any supervision over PTA services as required since 8/16/25. The findings above were reviewed and acknowledged by the agency’s Clinical Director (CD-1) during an interview on 1/26/26 at 12:17 PM. CD-1 was queried at 12:19 PM what the agency expectation was for the time interval that PT was to document supervision of PTA services. CD-1 replied, “Every 30 days.””

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) coordinated patient care for 1 (P-4) of 7 total sample records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs. Patient #4 (P4): This patient was recertified (12/21/25 to 2/18/26) with diagnoses of lymphedema and chronic venous hypertension with lower extremity ulcer. P-4 had a change in health insurance effective January 1, 2026, that resulted in the need for the agency to discharge the patient prior to the completion of this episode. The following outlines the admission, discharge, services performed, and continuity of patient care needs. Recertification episode (12/21/25-2/18/26) ordered skilled nursing (SN) services with a visit frequency of 1w8 (one day a week for eight weeks).12/22/25: Order to hold PT services.12/23/25: SN/LPN visit- Visit documented in the electronic medical record (EMR).12/29/26: SN/LPN visit- Documented in EMR as a late entry on 1/22/26.1/2/26 Discharge- Documented in the EMR as a late entry on 1/22/26.Services provided after discharge:1/6/26: SN/LPN visit- Not documented in the EMR.1/12/26: SN/LPN visit- Not documented in the EMR.1/22/26: SN/LPN visit- Not documented in the EMR.1/13/26 Physician referral for PT services The following record review and interview based on the outline above provides supported evidence of the agency’s lack of care coordination for P-4. The review of records on 1/21/26 noted an order dated 12/22/25 by the clinical coordinator (CD-1) that documented the following: “... patient is unable to tolerate Physical Therapy services... Physical Therapy on hold”. This order is confusing considering PT was never ordered. No documented evidence of follow-up on the patient’s status or clarification of the need for PT services. The review of the Plan of Care (POC) effective 12/21/25, ordered for SN services with a visit frequency of 1w8. As of 1/21/26, the clinical record documented the patient was seen by SN (1 of 8 ordered visits) on 12/23/25. CD-1 was queried on 1/21/26 at 2:10 PM, regarding the lack of ordered SN visits and responded, “There should be an order to show that visits decreased”. No orders were evidenced that visits were to be decreased. Further review on 1/22/26 at 3:00 PM, noted that P-4’s medical record was amended on 1/22/26 and included the clinical entries of an SN/LPN visit 12/29/25 and an Agency discharge dated 1/2/26. The interview continued at time of the review with ADM-1 and CD-1 acknowledging the above findings which did not reflect agency policy referenced below. Agency Policy: “Home Health Services Documentation”, pg.263 (undated) stated,” Documentation is completed in a timely manner...”. Follow up interview with ADM-1 and CD-1 on 1/26/26 at 1:15 PM was performed to ascertain what timeliness meant. CD-1 responded to the agency’s expectation that documentation is to be updated and completed weekly starting Tuesday and ending every Monday. On 1/22/26 at 3:30 PM, ADM-1 and CD-1 were queried about P-4’s discharge from the agency. Both explained that P-4 remained an active patient and had three weekly visits (1/6/26,1/12/26, and 1/22/26) after discharge. ADM-1 and CD-1 further explained that the LPN cannot document visits until the discharge is processed in the EMR software. Further review of the record on 1/22/26 at 3:35 PM found no evidence of efforts from the agency to execute an alternative documentation method to verify services provided or coordinate patient care. ADM-1 and CD-1 reviewed and acknowledged the above findings, which did not reflect agency policy referenced below. Policy review on 1/26/26 titled, “Coordination of Services” pg.336, (undated) stated, “As an integral part of providing quality care to the patients/clients… it is necessary that the various disciplines (including physicians) involved in the care communicate with each other on a regular basis… Documentation of such communication shall be placed in the medical record.” On 1/26/26 the agency supplied this surveyor with a home care referral effective 1/13/26. The referral ordered “PT Service Need-Weakness”. No evidence was found during the review of an attempt to coordinate PT services or that services had been performed. During the interview on 1/26/26 at 1:36 PM, ADM-1 and CD-1 reviewed and verified all findings above and that PT services were not provided as ordered.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) coordinated referrals for 1 (P4) of 7 records reviewed, resulting in the potential decline in physical functioning, unidentified health concerns and unmet care needs. Patient #4 (P-4): This patient was recertified on 1/13/26, for physical therapy (PT) services related to weakness and a diagnosis of congested heart failure. Review of the clinical record on 1/26/26, noted a failure by the agency to incorporate the home care referral into the medial record. The agency however provided documentation that was outside of the agency’s medical record to the surveyor on 1/26/26. This outside documentation was the physician’s referral for home care on 1/13/26 which neglected any efforts by CD-1 to coordinate the provision of ordered PT services. The above findings were reviewed with and acknowledged by the administrator (ADM-1) and CD-1on 1/26/25 at 1:45 PM. Both further acknowledged that this did not meet agency expectation nor its policy referenced below. Agency Policy: “Referrals: Care, Treatment & Services”, pg.323, (undated) states, “Appropriate staff is assigned according to the disciplines ordered on the referral ... Actual “Start of Care” [sic] is usually within 24 hours of receipt of the referral, but no more than 48 hours...”.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Director (CD-1) provided oversight of the development, implementation, and updates of an individualized care plan for 1 (P4) of 7 records reviewed, resulting in the potential of unidentified health concerns and unmet care needs. Patient #4 (P-4): This patient was recertified (12/21/25 to 2/18/26) with diagnoses of lymphedema and chronic venous hypertension with lower extremity ulcer. During record review on 1/21/26, it was noted the Plan of Care (POC) effective 12/21/25, failed to incorporate the treatment/interventions needed to meet the clinical needs of the patient noted below. Evidence was noted during record review that strongly indicated P-4’s need for weekly dressing changes and unna boot application (specialized treatment with, semi rigid compression bandages, medicated with zinc) noted below. The recertification physician face-to face (dated 12/10/25) documented under the HPI (history of present illness) section, “RN continue to come for dressing change/unna boots”.OASIS-E1 Recertification (dated 12/18/25) under Skilled Interventions documented, “Recertification of skilled nursing services is medically necessary… recurrent skin integrity issues, chronic bilateral lower-extremity (BLE) lymphedema requiring ongoing weekly multilayer compression wraps and overall functional decline”. The last physician order on 8/23/25, documented “Weekly cleanse BIL lower extremities with NS wound cleanser, apply caloseptine and medahoney (medications to aid healing) to BIL lower extremities, apply triple layer unna boot, kerlix and coban”. [sic].The LPN visit note 12/23/25 documented “Writer (LPN-1) removed old UNA boots, applied new Unna boots to BLE (bilateral lower extremities) measuring 12 cm Ble. no open pressure ulcers or wounds. discoloration and redness present BLE...”. [sic] The 12/29/25 LPN visit not also had documentation of unna boot application.Review of the POC found no interventions for dressing changes or multilayer compression wraps (unna boots) noted above. The administrator (ADM-1) and clinical director (CD-1) acknowledged and confirmed on 1/26/25 at 1:45 PM the findings above, which did not meet agency expectations or its policy referenced below. Agency Policy: “Plan of Care: Care, Treatment & Services”, pg.317 (undated) stated, “The Plan of Care or services consistently reflects current problems, goals and interventions corresponding to the care provided.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included consent for treatment for home care services as required in 1 (Patient/P-7) of 7 total sample records reviewed, resulting in the agency not having a complete clinical record and the failure to secure HIPAA (Health Insurance Portability and Accountability Act) related documentation in an appropriate timeframe. P-7: The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/20/26 at 3:50 PM, record review of a binder which contained patient signed consents since 2023, found no evidence of P-7’s consent for home care services. When agency’s Clinical Director (CD-1) was asked to provide evidence of P-7’s consent, CD-1 stated they would look for it. On 1/21/26 at 4:10 PM, a copy of P-7’s consent from 10/22/24 was found in the patient consent binder. When CD-1 was queried where it was found since it was not made available on 1/21/26, CD-1 stated a clinician had kept the consent at their home since admission (last 15 months). Documented effort to retrieve the original copy of P-7’s consent was not found in any agency records. The Administrator and CD-1 acknowledged the above findings during an interview on 1/26/26 at 12:05 PM.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure discharge summaries were sent to the physician within 5 business days of discharge in 4 (P-4, P-5, P-6 and P-7) of 4 records reviewed in which the patient was discharged from service; and failed to ensure transfer summaries were sent to the physician within 2 business days of transfer in 1 (P-5) of 1 record review with a hospital transfer, resulting in the physician not having knowledge of the patient’s health status at the time of discharge and the potential to negatively affect all 10 patients currently receiving services from this agency. Findings include: Patient #5 (P-5): The admission to home care was on 7/30/24, with diagnoses which included COPD (chronic obstructive pulmonary disease, CHF (congestive heart failure) and abnormal gait. On 1/22/26, record review noted P-5 was discharged from PT services on 5/3/25 and on 1/26/26 at 11:25 AM during an interview, the agency’s Administrator (Adm-1) and Clinical Director (CD-1) were asked to provide documentation to verify the time the discharge summary was sent out to the physician for review. Both Adm-1 and CD-1 acknowledged during the interview that the agency does not currently have a process in place that documents the time(s) discharge summaries are sent out. Further record review found that P-5 was transferred to the hospital on 1/28/25 due to GI (gastro-intestinal) issues. Adm-1 and CD-1 were asked at 11:28 AM to provide documentation to verify the time the transfer summary was sent out to the receiving hospital/physician for review. Again, both Adm-1 and CD-1 acknowledged during the interview that the agency does not currently have a process in place that documents the time(s) transfer summaries are sent out. Patient #7 (P-7): The admission to home care was on 10/22/24, with diagnoses which included osteoarthritis, cerebral infarction (brain stroke), and Down syndrome. On 1/22/26, record review noted P-7 was discharged from PT services on 12/10/25 and on 1/26/26 at 12:57 AM during an interview, the agency’s Administrator (Adm-1) and Clinical Director (CD-1) were asked to provide documentation to verify the time the discharge summary was sent out to the physician for review. Both Adm-1 and CD-1 acknowledged again during the interview that the agency does not have a process that documents the time(s) discharge summaries are sent out. Patient #4- P-4’s start of care was on 10/22/25, episode period 10/22/25 to 12/20/25, for skilled nursing and physical therapy (PT) services. Record review on 1/21/26 indicated that the PT discharge summary was completed on 12/10/25 and signed by the physician on 1/12/26. There is no documented evidence that discharge summary was sent to the physician within 5 business days of the patient’s discharge. During the interview with the agency’s administrator (ADM-1) and clinical director (CD-1) on 01/21/26 at 12.34 PM it was confirmed that the discharge summary was not sent to the physician within 5 days of the patient’s discharge confirming findings above. Additionally, P-4 was recertified (12/21/25 through 2/18/26). The record review on 1/21/26 noted that the agency had a planned discharge on 12/30/25 that was not documented. During the interview with ADM-1 and CD-1 on 1/21/26 at 2:10 PM they explained P-4’s insurance changed from United Health Care to Humana effective January 1, 2026, requiring the patient to be discharged pending Humana authorization. During the interview with P-4 on 1/21/25 at 2:50 PM, he confirmed the new insurance began in January 2026. The record review on 1/22/26 at 3:00 PM noted that the discharge scheduled for 12/30/25 was completed on 1/2/26 by the registered nurse and documented to the record on 1/22/26 (20 days after discharge). There was no documented evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. During the interview with ADM-1 and CD-1 on 01/22/26 at 3:11 PM it was confirmed that the documentation of the 1/2/26 discharge was on 1/22/26 and that the discharge summary was not sent to the physician within 5 days of the patient’s discharge confirming findings above. Patient #6- P-6 was admitted on 08/25/25 for Physical Therapy (PT) services with the primary diagnosis of type 2 diabetes, heart failure, and a left ankle fracture. Record review on 01/21/26 indicates that the discharge OASIS (outcome and assessment information set) was completed by PT on 09/25/25. There was no documented evidence that a discharge summary was sent to the physician within 5 business days of the patient’s discharge. A review of the agency’s policy 1/26/26 titled “Discharge” pp. 156-157 (undated), states, “A discharge summary shall be completed on all patients from the agency with copies forwarded to the physician upon request”.”