Tlc Home Care of the Twin Cities

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on the number and/or severity of deficiencies cited, the home health agency failed to meet the Condition of Participation: E-0001 at 484.102. The agency failed to maintain an emergency preparedness (EP) plan, determine patient population needs, establish a system to coordinate care, provide training and testing, review and update the EP policy, complete a risk assessment, and communication plan at least every two years. Refer to E0004: Based on interview and document review the agency failed to maintain an emergency preparedness (EP) plan, to include contingency planning and to update the plan at least every two years. This had the opportunity to affect all 40 patients. Refer to E0006: Based on interview and document review the agency failed to include their patient population and vulnerabilities in their emergency preparedness (EP) all-hazards risk assessment. They also failed to consider business functions essential to the agency, include contingency plans and arrangements with other health care entities and failed to update the assessment every two years. This had the opportunity to affect all 40 patients. Refer to E0007: Based on interview and document review the agency failed to specify the population served by the home health agency and determine the types of services it could manage, with a strategy to address the those it could not in an emergency and review the plan every two years. This had the opportunity to affect all 40 patients. Refer to E0009: Based on interview and document review the agency failed to have establish a process to cooperate and collaborate with local, state, tribal, regional and federal emergency preparedness (EP) officials. This had the opportunity to affect all 40 patients. Refer to E0013: Based on interview and document review the agency failed to review and update their emergency preparedness (EP) risk assessment, policies and procedures at least every two years. This had the opportunity to affect all 40 patients. Refer to E0019: Based on interview and document review the agency failed to establish and maintain a process to inform state and local emergency preparedness (EP) officials about home care patients in need of evacuation from their residences due to an emergency. This had the opportunity to affect all 40 patients. Refer to E0021: Based on interview and document review the agency failed to establish a system to follow-up with staff and patients to determine necessary services in the event of an emergency and a system to inform state and local officials of on-duty staff and patients they are unable to contact. This had the opportunity to affect all 40 patients. Refer to E0024: Based on interview and document review the agency failed to include the use of volunteers in the event of an emergency or disaster in their emergency preparedness (EP) policy and planning. This had the opportunity to affect all 40 patients. Refer to E0029: Based on interview and document review the agency failed to review and update their emergency preparedness (EP) communication plan at least every two years. This had the opportunity to affect all 40 patients. Refer to E0030: Based on interview and document review the agency failed to establish and maintain a emergency preparedness (EP) communication plan including a list of contacts. This had the opportunity to affect all 40 patients. Refer to E0034: Based on interview and document review the agency’s emergency preparedness (EP) plan failed to establish a method to provide assistance to the authority having jurisdiction during an emergency or disaster. This had the opportunity to affect all 40 patients. Refer to E0036: Based on interview and document review the agency failed to conduct emergency preparedness (EP) training and testing. This had the opportunity to affect all 40 patients. Refer to E0037: Based on interview and document review the agency failed to maintain an emergency preparedness (EP) training and testing program. This had the opportunity to affect all 40 patients. Refer to E0039: Based on interview and document review the agency failed to conduct emergency preparedness exercises. This had the opportunity to affect all 40 patients.”

“Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This Condition is not met as evidenced by: Based on the manner and degree of noncompliance, the agency failed to meet the Condition of Participation: G560 at 42 CFR 484.58. The agency failed to develop and implement effective discharge planning processes and failed to send all necessary medication information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This had the potential to affect all 40 patients receiving care from the agency. Findings include: Refer to G562: Based on interview and record review the home health agency (HHA) failed to develop and implement an effective discharge planning process for 2 of 7 patients (P1 and P3) reviewed for discharge. P1 was discharged due to the facility mismanaging the nurses’ schedules resulting in missed visits. The agency failed to obtain ongoing payment authorization for P3 resulting in the agency discharging him. The HHA failed to communicate the discharges with P1 and P3’s providers. Both P1 and P3 had hospital admissions and passed away. Refer to G564: Based on interview and record review the home health agency (HHA) failed to send all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences, to the facility or health care practitioner to ensure the safe and effective transition of care for 2 of 7 (P1 and P3) residents reviewed for discharge.”

“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 the number and/or severity of deficiencies cited, the home health agency (HHA) failed to meet the Condition of Participation at G570 42 CFR 484.60. The agency failed to create and follow individual plans of care, received care consistent with provider orders, ensure all regulatory requirement were in the plan of care, coordinate patient care plans among providers, ensure the services met professional standards, perform comprehensive assessments, notify providers of patient change of condition, provide appropriate patient education, and schedule home visits. The is deficient practice had the potential to affect all 40 patients the HHA was servicing. Refer to G572 - Based on interview and record review the home health agency (HHA) failed to ensure 4 of 7 (P1, P2, P3 & P4) patients reviewed received care consistent with the providers orders when reviewed for plan of care. Refer to G574 - Based on interview and record review, the agency failed to ensure all regulatory requirements were included in the plan of care (POC) for 5 of 7 patients (P1, P2, P3, P4, P6 & P7) who received home care services. Refer to G580 - Based on observation, interview, and record review the home health agency (HHA) failed to provide drugs and services only as ordered by a physician for 3 of 7 patients (P1, P2, & P6) reviewed for physician orders. The HHA was completing skilled nursing without physician orders when patients plan of care/485 expired or did not include medication. Refer to G588 - Based on interview and record review the home health agency (HHA) failed to ensure plans of care (POC) were reviewed and signed by their provider every 60 days for 3 of 7 patients (P1, P2, & P4) reviewed for care and services. Refer to G590 - Based on interview and record review the home health agency (HHA) failed to promptly inform the physician of significant changes for 1 of 7 patients (P1) reviewed for home health services. Refer to G592 - Based on interview and record review the home health agency (HHA) failed to revise the plan of care for patient change of status for 2 of 7 (P1 and P3) patients reviewed for updated comprehensive assessments. Refer to G602 - Based on interview and record review the home health agency (HHA) failed to assure communication with all physicians involved in the plan of care was being conducted for 3 of 7 patients (P2, P7, & P8) reviewed for communication with all physicians who were receiving home health services. Refer to G614 - Based on observation, interview, and record review the home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedules for 6 of 7 patients (P1, P2, P3, P4, P7 & P8) reviewed for scheduling.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on the number and/or severity of deficiencies cited, the home health agency failed to meet the Condition of Participation: G640 at 42 CFR 484.65. The agency failed to establish a quality assessment performance improvement program(QAPI); to measure, analyze and track quality indicators; to establish a system to collect and evaluate program data; establish performance improvement activities; establish a system to track adverse patient events, analyze their causes and implement preventive actions; perform actions aimed at performance improvement and tracking performance; conduct performance improvement projects; and ensure the agency had and operating QAPI program. This had the opportunity to affect all 40 patients. Findings include: Refer to G642: Based on interview and document review, the facility failed to establish a process to measure, analyze and track quality indicators. This had the opportunity to affect all 40 patients. Refer to G644: Based on interview and document review, the facility failed to establish a system to collect and evaluate program data. This had the opportunity to affect all 40 patients. Refer to G646: Based on interview and document review, the facility failed to establish performance improvement activities. Refer to G654: Based on interview and document review, the facility failed to establish a system to track adverse patient events, analyze their causes, and implement preventive actions. Refer to G656: Based on interview and document review, the facility failed to perform actions aimed at performance improvement and tracking performance following those actions. Refer to G658: Based on interview and document review, the facility failed to conduct performance improvement projects. Refer to G660: Based on interview and document review, the facility failed to ensure the agency had an operating quality assessment performance improvement (QAPI) program with clear expectation of patient safety and included findings of fraud or waste. This had the opportunity to affect all 40 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 the number of citations cited, the home health agency failed to meet the Condition of Participation: G940 at CFR 484.105. The agency failed to appoint an administrator and a clinical services director, to provide oversight of day-to-day operations, assure patient needs were continually assessed, assure implementation of care and to coordinate patient and personnel assignments. This had the opportunity to affect all 40 patients. Findings include: Refer to G946: Based on interview and document review the agency failed to appoint the administrator for the agency. Refer to G948: Based on interview and document review the agency failed to ensure the administrator was responsible for the day-to-day operations. Refer to G950: Based on interview and document review the agency failed to ensure clinical manager was available at all times. Refer to G954: Based on interview and document review the agency failed to ensure a qualified pre-designated person, authorized in writing by the administrator and governing body, was available to assume the administrator’s responsibilities. Refer to G958: Based on interview and document review the agency failed to hire a clinical manager to provide oversight of patient care and personnel. Refer to G960: Based on interview and document review the agency failed to make patient and personnel assignments and provide oversight by the clinical manager. Refer to G962: Based on interview and document review the agency failed to provide oversight in coordinating patient care. Refer to G966: Based on interview and document review the agency failed to provide oversight in assuring patient needs are continually assessed. Refer to G968: Based on interview and document review the agency failed to ensure implementation of the patients’ plans of care (POC).”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and document review the agency failed to maintain an emergency preparedness (EP) plan, to include contingency planning and to update the plan at least every two years. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency EP policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The policy failed to include a system to provide continuity of care if a disruption in care were caused by an emergency. They lacked formal arrangements with providers to ensure the home health patients’ care was not interrupted and lacked a process to address obtaining necessary supplies.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and document review the agency failed to include their patient population and vulnerabilities in their emergency preparedness (EP) all-hazards risk assessment. They also failed to consider business functions essential to the agency, include contingency plans and arrangements with other health care entities and failed to update the assessment every two years. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency Emergency Preparedness policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The EP policy and Hazard Vulnerability Risk Assessment, dated 3/1/2020, failed to include identification of all business functions essential to their operation that should be continued during an emergency, identification of patient population needs and vulnerabilities, consideration of the agency’s location, determination of what arrangements might be necessary in the event of an emergency with other entities to ensure the home health patients’ care was not interrupted.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and document review the agency failed to specify the population served by the home health agency and determine the types of services it could manage, with a strategy to address the those it could not in an emergency and review the plan every two years. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s emergency preparedness program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency Organizational Chart for Disaster Response Team chart, dated 3/1/2020, identified the administrator as the administrator, RN-B as the public information officer, and the liaison officer as an employee no longer employed at the agency. At the time of the survey, the agency did not have an administrative assistant or staffing coordinator. The agency’s EP plan, dated 3/1/2020, identified the administrator as the incident commander, the person within the agency who would establish and maintain command and develop the EP plan. It identified the public information officer as the director of nursing (DON), the person designated as the central point of information dissemination. The administrative assistant as the liaison officer, who would be the point of contact for other agencies and office staff. The staffing coordinator would contact all field staff/caregivers during an emergency situation. The agency lacked a system for succession planning and delegation of authority. The agency Emergency Preparedness policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The policy failed to specify the population of patients served, a system to provide continuity of care if a disruption in care were caused by an emergency, formal arrangements with providers to ensure the home health patients’ care was not interrupted or they could be moved to another location for care, and a strategy to respond to patient needs the agency cannot provide in an emergency.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and document review the agency failed to have establish a process to cooperate and collaborate with local, state, tribal, regional and federal emergency preparedness (EP) officials. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency lacked documentation of cooperation and collaboration with state, local, tribal and federal EP officials. The agency Emergency Preparedness policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The policy lacked direction to cooperate and collaborate with state and local officials to ensure emergency and disaster preparedness.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and document review the agency failed to review and update their emergency preparedness (EP) risk assessment, policies and procedures at least every two years. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency lacked documentation the EP risk assessment and EP policy was reviewed or revised after it was established on 3/1/2020. The agency Emergency Preparedness policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and document review the agency failed to establish and maintain a process to inform state and local emergency preparedness (EP) officials about home care patients in need of evacuation from their residences due to an emergency. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency Organizational Chart for Disaster Response Team chart, dated 3/1/2020, identified the administrator as the administrator, RN-B as the public information officer. The agency’s EP Communication Plan policy, dated 3/1/2020, in the event of an emergency the administrator will contact the public information officer (DON) to inform them of the disaster situation. The public information officer (DON) will contact local emergency services, such as the fire department, police department, department of health, and local hospitals as well as nurses and liaison officer. Nurses will call patients. Liaison officer will inform office staff. The agency’s EP plan, dated 3/1/2020, identified the administrator as the incident commander, the person within the agency who would establish and maintain command and develop the EP plan. It identified the public information officer as the director of nursing (DON), the person designated as the central point of information dissemination. It also directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The policy lacked a contingency plan in the event patient evacuation was required during a community-wide emergency. The agency lacked a process for succession planning and delegation of authority and a system to coordinate the reporting of staff and patients who cannot be contacted during an emergency or disaster situation.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview and document review the agency failed to establish a system to follow-up with staff and patients to determine necessary services in the event of an emergency and a system to inform state and local officials of on-duty staff and patients they are unable to contact. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s emergency preparedness (EP) program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency’s EP plan, dated 3/1/2020, identified the administrator as the incident commander, the person within the agency who would establish and maintain command and develop the EP plan. It identified the public information officer as the director of nursing (DON), the person designated as the central point of information dissemination. The administrative assistant as the liaison officer, who would be the point of contact for other agencies and office staff. The staffing coordinator would contact all field staff/caregivers during an emergency situation. The agency lacked a system for succession planning and delegation of authority. The employee list lacked an administrative assistant and staffing coordinator. The agency EP policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The agency EP Incident Command Center policy, dated 3/1/2020, directed once the emergency response plan is activated, the administrator will notify the public information officer and liaison officer to initiate staff and client call down procedure. Staffing coordinators would be responsible for contact all field staff/caregivers, and case managers responsible for contacting all clients.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and document review the agency failed to include the use of volunteers in the event of an emergency or disaster in their emergency preparedness (EP) policy and planning. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s emergency preparedness (EP) program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. The agency EP policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The policy lacked inclusion of volunteers for non-essential healthcare persons to assist with tasks during an emergency or disaster.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on interview and document review the agency failed to review and update their emergency preparedness (EP) communication plan at least every two years. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency EP policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The agency EP Communication Plan policy, dated 3/1/12020, directed in the event of an emergency, the administrator will contact the public information officer (DON) to inform them of the disaster situation. The public information officer (DON) will contact the local emergency services, such as the fire department, police department, department of health, and local hospitals. The public information officer will contact the liaison officer and all RNs and LPNs to inform them of the emergency. The liaison officer will inform the office staff, including staffing coordinators, medical records coordinator, and receptionist. The staffing coordinators will then begin calling the field staff /caregivers to inform them of the emergency. The agency lacked documentation the EP communication plan was reviewed or revised after it was established on 3/1/2020. The plan lacked direction for communication across healthcare providers and coordinate care.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on interview and document review the agency failed to establish and maintain a emergency preparedness (EP) communication plan including a list of contacts. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. He explained the agency was in transition and did not have office support established. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency’s Organizational Chart for Disaster Response Team chart, dated 3/1/2020, identified the administrator as the administrator, RN-B as the DON/public information officer, and the liaison officer as an employee no longer employed at the agency. The agency’s EP Communication Plan policy, dated 3/1/2020, lacked contact information for the staff, patients, physicians, and volunteers. The agency EP policy, dated 3/1/2020, directed processes and systems will be reviewed regularly, but at least annually to ensure safety is assured. The agency lacked documentation the EP policy was reviewed or revised after it was established on 3/1/2020.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on interview and document review the agency’s emergency preparedness (EP) plan failed to establish a method to provide assistance to the authority having jurisdiction during an emergency or disaster. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency lacked documentation of engagement with healthcare coalitions or associations to coordinate care at the time of an emergency or disaster. The agency’s EP policy, dated 3/1/2020, did not include a method to provide information about the agency’s needs and ability to provide assistance to the authority having jurisdiction, the incident command center or designee.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on interview and document review the agency failed to conduct emergency preparedness (EP) training and testing. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s EP program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 8:12 a.m., RN-A stated he was unsure if he had EP training when he was hired. He did not recall EP training in the last 2 years. During an interview on 5/12/26, at 3:18 p.m., RN-C stated she had online training when she was hired but did not recall EP training. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. The agency lacked documentation of EP training for RN-A, RN-B, RN-C. During observation of the agency’s online EP training module, the training lacked an agency-specific communication plan and the agency’s EP policies and procedures. The agency EP policy, dated 3/1/2020, directed all staff members will be oriented to the emergency management plan and their associated responsibilities. Reviews will be held at least annually.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and document review the agency failed to maintain an emergency preparedness (EP) training and testing program. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. She stated EP training was taught upon hire. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s emergency preparedness program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. During an interview on 5/12/26, at 8:12 a.m., RN-A stated he was unsure if he had EP training when he was hired. He did not recall EP training in the last 2 years. During an interview on 5/12/26, at 3:18 p.m., RN-C stated she had online training when she was hired but did not recall EP training. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. The agency lacked documentation of EP training for RN-A, RN-B, RN-C. During observation of the agency’s online EP training module, the training lacked an agency-specific communication plan and the agency’s EP policies and procedures. The agency’s EP training program lacked documentation of review and updates within the last two years. The agency EP policy, dated 3/1/2020, directed all staff members will be oriented to the emergency management plan and their associated responsibilities. Reviews will be held at least annually.”

“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 interview and document review the agency failed to conduct emergency preparedness exercises. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and stepped down from the position in September 2025. During an interview on 5/8/26, at 12:15 p.m., the administrator in training stated he was not aware of the agency’s emergency preparedness program. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated their EP program was updated after the COVID pandemic in 2020. He was unaware of requirement for exercises conducted by the agency. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025 and continued to consult with the agency but was not involved in day-to-day operations. She stated the EP program was first developed “years ago in the pandemic era” and no reviews or updates were completed in the last two years that she was aware of. She stated no exercises were conducted to test the EP plan. The agency lacked documentation of exercises or actual emergencies to test the EP plan. The agency EP policy, dated 3/1/2020, directed all administrative emergency or disaster activities will be documented by the director of clinical services and/or the administrator. If the emergency management plan is implemented, it will be evaluated for effectiveness and documentation will be on file. Effectiveness of processes and systems will be reviewed regularly, but at least annually to assure safety is assured.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to electronically report Outcome and Assessment Information Set (OASIS) to the state agency during the 60-days recertification period for the home health agency (HHA) for 4 of 7 patients (P1, P2, P7 and P8) reviewed for OASIS assessment. Findings include: P1’s admission profile indicated he was admitted to the HHA on 12/4/2024. P1’s discharge summary indicated he was discharged from the HHA on 3/27/26. P1’s medical record list of OASIS submission report viewed on 5/11/2026 indicated P1 had a start of care Oasis completed on 12/4/24, a recertification on 1/28/25 and 3/31/25. A discharge oasis dated 3/27/26 was started in the electric system, however not completed or submitted by the time of the survey. P2’s admission profile indicated she was admitted to the HHA on 8/2/2025. P2’s medical record list of OASIS submission report indicated P2 had a start of care of Oasis on 8/2/2025. No other Oasis submission reports were submitted for P2 from 8/2/2025 – 5/11/2026. P2 was an active client during the survey. P7’s admission profile indicated he was admitted to the HHA on 9/28/2021. P7’s medical record list of OASIS submissions report viewed on 5/11/26 indicated P8 had OASIS assessments completed every 60 days with his recertification from his start of care on 9/28/2021 – 3/6/2025. There were no OASIS submissions following the 3/6/2025 submission – 5/11/2026. P7 was an active client at the HHA during the survey. P8’s admissions profile indicated he was admitted to the HHA on 7/16/2018. P8’s medical record list of OASIS submissions report viewed on 5/11/26 indicated P9 had OASIS submissions every 60 days from 3/6/2020 – 10/8/2025. There were no further OASIS submissions following the 10/8/2025 – 5/11/26. P9 was an active client at the HHA during the survey. Upon interview on 5/6/26 at 10:00 a.m. the Administrator stated she expected the nurses were completing the OASIS on time, she was not aware there were admissions dating back almost a year that were not completed. She stated there used to be an office staff assistance who tracked the OASIS submissions, however she had resigned. An HHA policy titled Client Assessment dated 10/1996 indicated the OASIS needed to be completed within 5 days of open (admissions) and needed to be completed within a 5 day window of the expiration of the 485 (recertification).”

“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 interview and record review the home health agency (HHA) failed to develop and implement an effective discharge planning process for 2 of 7 patients (P1 and P3) reviewed for discharge. P1 was discharged due to the facility mismanaging the nurses’ schedules resulting in missed visits. The agency failed to obtain ongoing payment authorization for P3 resulting in the agency discharging him. The HHA failed to communicate the discharges with P1 and P3’s providers. Both P1 and P3 had hospital admissions and passed away. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 for certification, indicated P1’s diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s discharge summary dated 5/5/26, indicated P1’s discharge date was 3/27/26. He was discharged to “unknown”. The reason for discharge was the agency was unable to get a hold of him. A comment indicated that the writer called the client to complete the recertification but was unable to get a hold of him. His emergency contact was listed as his spouse. The frequency of services and outcomes in meeting the goals in the plan of care was left blank. His functional limitations were listed as “unable to assess this time”. The following information was left blank: Nutritional requirementsClinical summaryInformation related to any Advanced DirectivesSkin/Wound careSurgical ProceduresAllergiesVitals signsDiagnosesSignificant Health HistoryMedicationsPhysician information – including name, phone number, fax number or if a copy was sent.Patient and/or family post-discharge instructions indicated not completed, an assessment was not done. His mental status was depressed. P1’s discharge summary failed to be sent to the Primary Care Provider (PCP), as well as all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences. The discharge summary was signed by registered nurse (RN)-B on 5/5/26 at 4:28 p.m. during the survey process. During interview on 5/5/26 at 8:10 a.m., P1’s community case worker stated P1 had been hospitalized. The hospital notified her that P1’s HHA had not seen him for about a month and he had not been taking his medications. P1’s case worker told the HHA she was assigning a new HHA to P1 and gave them the new agencies information. P1’s HHA did not send patient information to the case worker, they sent an old copy of P1’s medications to the new agency, but no other health information. P1’s new HHA would not see him until they had proper information. The community case worker had a colleague set up P1’s medications per his hospital discharge summary dated 3/29/26. No other health assessments were completed. P1 was admitted back to the hospital on 4/20/26 and passed away on 4/21/26. The HHA had discharged him 3/27/26 prior to his hospital discharge, but an HHA nurse completed a nursing visit on 4/1/26. During interview on 5/5/26 at 1:40 p.m., licensed practical nurse (LPN)-A stated she was not aware of a discharge on P1. She had resigned from the agency in 3/2026; however, she was keeping a few clients. She reached out to P1 on 4/1/26 and asked him if he needed a visit and he responded that he did. She stated the nurses make their own schedules so she saw him and then sent a text message to RN-A indicating she would not be providing care to P1 anymore. During interview on 5/6/26 at 10:00 a.m., the Administrator stated the HHA has always sent all pertinent patient information to another agency when requested. She was not aware that P1 had been discharged and information from a new agency had been requested. During interview on 5/7/26 at 4:00 p.m., RN-A stated he was aware he was going to be the nurse completing visits for P1 and throughout the month of March he was trying to get a hold of him. He was unable to reach P1, so he discharged him on 3/27/26. He was not aware that (LPN)-A completed a visit on 4/1/26 or that another agency had requested transfer information. He denied notifying P1’s provider as he was not aware of the discharge process. Requests were made to speak with the providers at the hospital who cared for P1 on both of his admissions, however there were no responses. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 required skilled nursing weekly visits for blood glucose levels, diabetic compliance, and International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s discharge summary dated 4/14/26, indicated P3 was discharged from the agency to home. Reason for discharge was expired authorization. Services included just skilled nursing. The following goals were listed: Effective Date: 03/04/2026 Goal Status: Progressing Order: Skilled Nursing to Assess and Eval Every other month for recertification Goal: Effective Date: 03/04/2026 Goal Status: Progressing Order: Assess/Monitor Blood Sugar levels and compliance with Diabetic Management Goal: Blood sugars will remain within normal range Effective Date: 03/04/2026 Goal Status: Progressing Order: Observation and Assessment Medication Compliance , Response Goal: Patient/caregiver will comply with prescribed medications within 60 days Effective Date: 03/04/2026 Goal Status: Progressing Order: Nurse to check INR as directed by PMD Goal: Effective Date: 03/04/2026 Goal Status: Progressing Order: Effective Date: 03/04/2026 Verbal Date: 03/04/2026 SN: Every other week for general health assessment and monitoring. Check INR as ordered by PMD RCT: Every other month Goal: Client will continue receiving home health care as much as possible. Will be safe at home without falls Client will demonstrate knowledge of his disease process Client will remain in stable diabetic condition without complications Client will remain in stable cardiac condition. His nutritional requirements were diabetic and a heart healthy diet. His diagnoses were: Type 2 diabetes mellitus without complications. He was stable at the time of discharge. His medications were listed along with his provider’s name, phone and fax number. P3’s advanced directives were: Patient does not have Advance Directives, Patient does not have a Living Will, Patient does not have a DPOA, Patient has Advanced Directives Material provided, Patient has been educated on Adv. Directives, Patient refuses Advance Directives. No information was provided under the following: Emergency contact Skin/wound care Surgical procedures No indication the discharge was sent to the provider and no provider signature. P3’s discharge summary failed to be sent to the Primary Care Provider (PCP) all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences. On 5/5/26 at 10:45 a.m., (RN)-B stated P3 had not had an authorization for payment for months. She completed a visit on 4/3/26 and told P3 that it would be his last visit because the HHA did not have authorization so he would have to go to his clinic for his next INR check. (RN)-B did not complete P3’s discharge at the time of his visit. She asked the surveyor during the interview if she should discharge P3. She back dated a discharge to 4/16/26 in the HHA’s software system. At a later interview on 5/12/26 at 11:11 a.m., she stated she had made the discharge date 4/14/26 because that would be the date, he would miss a visit with the agency. During interview on 5/5/26 at 1:23 p.m., P3’s family member (FM)-B stated she was not informed P3 was told the HHA was not going to see him past 4/3/26. On 4/23/26 she noticed a nurse had not been following P3 so she attempted to call the HHA and could not get a hold of anyone. She reached out to P3’s provider and received orders for his Warfarin and set-up his medications herself. P3 was taken to the hospital on 4/26/26 with an INR of 18, his normal therapeutic range was ordered to be 2.0 – 3.0. P3 was given Vitamin K to assist with his blood clotting and then his blood became too think, so he then given Heparin injections to thin his blood again. In a subsequent interview on 5/14/26 at 11:23 a.m., FM-B called and stated P3 passed away in the hospital on 5/13/26. FM-C questioned if his missed visits had started all of his “blood problems” and led to his hospitalization. Upon interview on 5/6/26 at 10:00 a.m., the Administrator stated she knew many patients did not have authorization and the new Administrator was looking into those authorizations. She was not aware that P3 had been discharged. Her expectation was that the nurses notify the provider and any other pertinent staff involved in the patient’s care. Upon interview on 5/7/26 at 9:58 a.m., P1’s community RN case manager stated it was the HHA’s duty to send requests for authorizations. P3’s ended on 2/26/26. The case manager stated she started receiving team messages from the anti-coagulation group (department that specializes in patients who take blood thinning medications) that P3 was not receiving services anymore. She reached out to P3’s provider and she was not aware of any changes in P3’s services. She stated she could have back dated P3’s authorization. She should have been notified that the HHA discharged P3 because his services were based on a high-risk medication dosing. Multiple requests were made for P3’s hospital documentation notes, however none were received along with multiple calls to the hospital requesting interviews with no returned calls. An HHA policy titled Client Discharge Process with a revision date of 5/1999 indicated: The client’s discharge potential shall be documented on the Plan of Treatment/485.The discharge plan must be discussed with the physician prior to discharge with orders obtained to discontinue services.The Registered Nurse shall meet with the personnel involved in the client’s care to review the impending discharge, ensuring that the client meets the discharge criteria.The Registered Nurse shall review the clinical record to assure accuracy and completion. A Discharge Plan should be developed which includes written/verbal instruction regarding the client’s ongoing care needs and available resources.The Registered Nurse shall ensure that the treatment goals/client outcomes have been met or, if unmet needs are present, that appropriate referrals are made to the agencies/institutions to meet continuing client needs.Refer to Client Transfer Policy for additional information on the transfer referral process.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to send all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences, to the facility or health care practitioner to ensure the safe and effective transition of care for 2 of 7 (P1 and P3) residents reviewed for discharge. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 for certification, indicated P1 had a diagnosis of alcoholic cirrhosis of the liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen). P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s discharge summary dated 5/5/26 indicated P1’s discharge date was 3/27/26. He was discharged to “unknown”. The reason for discharge was the agency was unable to get a hold of him. A comment indicated that the writer called the client to complete the recertification but was unable to get a hold of him. His emergency contact was listed as his spouse. The frequency of services and outcomes in meeting the goals in the plan of care was left blank. His functional limitations were listed as “unable to assess this time”. The following information was left blank: Nutritional requirementsClinical summaryInformation related to any Advanced DirectivesSkin/Wound careSurgical ProceduresAllergiesVitals signsDiagnosesSignificant Health HistoryMedicationsPhysician information – including name, phone number, fax number or if a copy was sent.Patient and/or family post-discharge instructions indicated not completed, an assessment was not done. His mental status was depressed. P1’s discharge summary failed to be sent to the Primary Care Provider (PCP) all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences. The discharge summary was sign stamped by registered nurse (RN)-B on 5/5/26 at 4:28 p.m. during the survey process. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s discharge summary dated 4/14/26 indicated P3 was discharged from the agency to home. His reason for discharge was his authorization had expired. His services were skilled nursing. The goals listed were: Effective Date: 03/04/2026 Goal Status: Progressing Order: Skilled Nursing to Assess and Eval Every other month for recertification Goal: Effective Date: 03/04/2026 Goal Status: Progressing Order: Assess/Monitor Blood Sugar levels and compliance with Diabetic Management Goal: Blood sugars will remain within normal range Effective Date: 03/04/2026 Goal Status: Progressing Order: Observation and Assessment Medication Compliance , Response Goal: Patient/caregiver will comply with prescribed medications within 60 days Effective Date: 03/04/2026 Goal Status: Progressing Order: Nurse to check INR as directed by PMD Goal: Effective Date: 03/04/2026 Goal Status: Progressing Order: Effective Date: 03/04/2026 Verbal Date: 03/04/2026 SN: Every other week for general health assessment and monitoring. Check INR as ordered by PMD RCT: Every other month Goal: Client will continue receiving home health care as much as possible Will be safe at home without falls Client will demonstrate knowledge of his disease process Client will remain in stable diabetic condition without complications Client will remain in stable cardiac condition. His nutritional requirements were diabetic and a heart healthy diet. His diagnoses were: Type 2 diabetes mellitus without complications. He was stable at the time of discharge. His medications were listed along with his providers name, phone and fax number. His advanced directives were: Patient does not have Advance Directives, Patient does not have a Living Will, Patient does not have a DPOA, Patient has Advanced Directives Material provided, Patient has been educated on Adv. Directives, Patient refuses Advance Directives. No information was provided under the following: Emergency contact Skin/wound care Surgical procedures No indication the discharge was sent to the provider and no provider signature. P3’s discharge summary failed to be sent to the Primary Care Provider (PCP) all the necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences. During interview on 5/5/26 at 10:00 a.m., the Administrator stated the discharge must be completed per company policy and regulatory guidelines and each nurse was responsible. An HHA policy titled Discharge summary dated 11/30/1994 indicated: A Discharge Summary form shall be completed by the Registered Nurse or Therapist with a copy mailed to the physician. The Discharge Summary shall include, but not be limited, to: Admission and discharge datesServices providedDiagnosis(es)Status upon admissionStatus at time of dischargeNotification of dischargeReason for dischargeTransfer information, as applicableThe Registered Nurse will assure that the treatment goals/client outcomes have been met or, if unmet needs are present, that appropriate referrals are made to agencies/institutions to meet continuing client needs. If the client is being referred to another agency or facility, a Transfer Summary form shall also be completed. The original Discharge Summary shall be filed in the clinical record.”

“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 interview and record review the home health agency (HHA) failed to ensure 4 of 7 (P1, P2, P3 & P4) patients reviewed received care consistent with the providers orders when reviewed for plan of care. Based on interview and record review the home health agency (HHA) failed to ensure 4 of 7 (P1, P2, P3 & P4) patients reviewed received care consistent with the providers orders when reviewed for plan of care. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 for recertification, indicated P1 diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen). P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s record review from 8/1/25 – 5/11/26 the records did not indicate any orders since the POC of 6/2/25 – 7/31/25. P1’s skilled nursing visit note summary indicated P1 received skilled nursing visits on: 2/18/26, 3/4/26 and 4/1/26. P1 was not seen on 3/15/26 and no visits were documented after 4/1/26 his every other week provider order. There was no documentation of missed visits. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. P2’s record review from 10/1/25 – 5/11/26 did not indicate any orders since the POC of 8/2/25 – 9/30/25. P2’s skilled nursing visit note summary indicated P2 received skilled nursing visits on: 1/16/26 and 2/26/26. P2 was to be seen monthly in February, her visit was 10 days late and no further visits were made or documented after 2/26/26 leaving P2 without a visit for 10 weeks upon the HHA’s survey. There was no documentation of missed visits. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s skilled nursing visit note summary indicated P3 received skilled nursing services on: 2/20/26, 3/5/26, 3/12/26 and 4/3/26. P3’s skilled nursing visits were scheduled for every other indicating he had a missed visit on 3/26/26 and there was no documentation of visits after 4/3/26. There was no documentation of missed visits. P4’s POC/485 for certification period 4/6/26 – 6/5/26 indicated P4’s diagnoses were Multiple Sclerosis (disabling autoimmune disease of the central nervous system) and Type 2 diabetes mellitus with hyperglycemia (increased blood sugar levels). P4 required weekly skilled nursing visits for assessment of general health, skin, pain, mood, vital signs, and edema. She required medication set-up and compliance monitoring and administration of an Avonex injection (medication for Multiple Sclerosis). P4’s skilled nursing visit note summary indicated P4 received skilled nursing visits on: 2/6/26, 2/20/26, 3/9/26, 3/27/26 and 4/3/26. P4 had missed visits on 2/13/26, 2/27/26, and 3/16/26. There was no documentation of visits received after 4/3/26. There was no documentation of missed visits. Upon interview on 5/5/26 at 10:00 a.m. the Administrator stated she was aware the agency had failed to follow physician orders related to missed visits due to a nurse resigning and confusion with who was going to take over her visits. Her expectation was that a missed visit report be completed after each missed visit. An HHA policy titled Policy for Missed Visits dated 5/2017 indicated for any visits missed, that contradicts what is prescribed by the physician in the current orders. An order cancelling the visit must be sent to the physician. Procedure: If a nursing visit is missed the nurse will write a missed visit order to the physician cancelling the visit and will document type of visit, date of missed visit and reason for missed visit. Order will be faxed to physician for signature.If an HHA visit or PCA visit that has been ordered by the physician has been missed, the staffer will notify the RN case manager. The RN case manager for the client will send an order cancelling the visit and document type of visit, date, and reason for missed visit. Order will be faxed to physician for signature.The documentation will be put in the clients electronic folder.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to establish a process to measure, analyze and track quality indicators. This had the opportunity to affect all 40 patients. Findings include: The agency lacked a process to measure, analyze and track quality indicators. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and they met every three to six months. He stated the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose and created a spreadsheet at one point to track medical records and authorizations and the agency did not currently have a DON. The agency Quality Assurance/Improvement policy, dated 10/1996 directed the agency would assess and evaluate the quality of client care services and appropriateness for care using structural, process and outcome measures. Methods of organizational review and data collection will include, but are not limited to: Quarterly clinical record reviewClient satisfaction surveysAnnual program evaluationUtilization reviewIncident reportsClient complaintsEvaluation of clinical competenceMonitor and review of client outcomesFindings include: The agency lacked the process to measure, analyze and track quality indicators. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and they met every three to six months. He stated the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose and created a spreadsheet at one point to track medical records and authorizations and the agency did not currently have a DON. The agency Quality Assurance/Improvement policy, dated 10/1996 directed the agency would assess and evaluate the quality of client care services and appropriateness for care using structural, process and outcome measures. Methods of organizational review and data collection will include, but are not limited to: Quarterly clinical record reviewClient satisfaction surveysAnnual program evaluationUtilization reviewIncident reportsClient complaintsEvaluation of clinical competenceMonitor and review of client outcomes”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to establish a system to collect and evaluate program data. This had the opportunity to affect all 40 patients. Findings include: The agency lacked the process to collect, utilize, and evaluate data to monitor patient care and identify opportunities for improvement. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months, He stated the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose and created a spreadsheet at one point to track medical records and authorizations and the agency did not currently have a DON. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing, and improving its performance. Outcome measurements of these performance improvements will be monitored on a continuous basis, and all results will be reported at least annually to the advisory board. The data will be collected on all services including those provided under contract. Methods of organizational review and data collection will include, but are not limited to: Quarterly clinical record reviewClient satisfaction surveysAnnual program evaluationUtilization reviewIncident reportsClient complaintsEvaluation of clinical competenceMonitor and review of client outcomes”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to establish performance improvement activities. This had the opportunity to affect all 40 patients. Findings include: The agency lacked performance improvement activity. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months and the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose and created a spreadsheet at one point to track medical records and authorizations and the agency did not currently have a DON. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing and improving its performance. Outcome measurements of these performance improvements will be monitored on a continuous basis, and all results will be reported at least annually to the advisory board. The quality improvement program will address client service areas that are high volume, high risk or problem prone.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to establish a system to track adverse patient events, analyze their causes, and implement preventive actions. This had the opportunity to affect all 40 patients. Findings include: The agency lacked a system to track adverse patient events, investigate and determine actions to prevent future occurrence. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months and the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing and improving its performance.”

“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 interview and document review, the facility failed to conduct performance improvement projects. This had the opportunity to affect all 40 patients. Findings include: The agency failed to develop performance improvement projects based on scope, complexity and past performance of the agency. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26 ,at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months and the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing and improving its performance. The quality improvement program will address client service areas that are high volume, high risk or problem prone.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to ensure the agency had an operating quality assessment performance improvement (QAPI) program with clear expectation of patient safety and included findings of fraud or waste. This had the opportunity to affect all 40 patients. Findings include: The agency failed to develop performance improvement projects based on scope, complexity and past performance of the agency. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months and the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose. Governing body meeting notes were requested but not received. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing and improving its performance. Outcome measurements of these performance improvements will be monitored on a continuous basis and all results will be reported at least annually to the advisory board. The quality improvement program will address client service areas that are high volume, high risk or problem prone.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to establish and maintain an agency-wide program for surveillance, prevention, control, and investigation of infectious and communicable diseases. This had the opportunity to affect all 40 home health patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and had no responsibility for the agency’s infection control program. She had not trained a new DON or any other nurses to take over infection control. During an interview on 5/8/26, at 12:18 p.m., the owner stated they have not had a DON since September 2025, but RN-B continued to oversee the infection control program. During an interview on 5/12/26, at 10:05 a.m., the administrator stated their DON stepped down in September of 2025, and had not been replaced. Online training was assigned to staff. The agency’s Communicable Disease policy, dated 3/1/2020, directed the employees of their responsibility to report their own symptoms of illness to the DON. The policy lacked direction regarding patient illness symptom tracking, prevention of illness for patients, and investigation. Documentation of a system to report, monitor, review, analyze and identify potential causes of infections was requested but was not received. The agency Communicable Disease policy, dated 3/1/2020, directed managers and supervisors should set a good example by washing their hands before eating and after using the restroom, regularly using hand sanitizer, seeking medical attention for scrapes and cuts, making sure any open wound is kept clean and covered, and encouraging this same behavior from all employees. The policy also directs employees of their responsibility to report symptoms of communicable illness that increase the risk the illness may be transmitted to another, been diagnoses with a communicable disease that is not sufficiently controlled, been in close contact with a person diagnosed with or being screened for a communicable illness, is or should be quarantined related to communicable illness, or cannot effectively cover a contagious skin condition. An infection control policy was requested but was not received.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and document review, the facility failed to provide infection control education to staff and patients. This had the opportunity to affect all 40 patients. Findings include: During an observation on 5/8/26, at 10:00 a.m., P6 lacked infection control education in her home. Review of RN-A’s file lacked evidence of infection control education. Review of RN-B’s file lacked periodic review of infection control education, with most recent education dated 5/23/11. A request was made for RN-G’s file but was not received. During an interview on 5/8/26, at 10:30 a.m., P6 stated the agency had not provided education related to infection control. During an interview on 5/8/26, at 10:40 a.m., registered nurse (RN)-A stated he did not do patient education. During an interview on 5/8/26, at 12:00 p.m., RN-B stated she was no longer the director of nursing (DON) and had no responsibility for the agency’s infection control program. She had not trained a new DON or any other nurses to take over infection control. During an interview on 5/8/26, at 12:18 p.m., the owner stated they have not had a DON since September 2025, but RN-B continued to provide training new staff along with RN-D. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the electronic medical record (EMR) system had a COVID tracking tool added in 2020 but did not track and trend other infections or communicable diseases. She stated their DON stepped down in September of 2025 and had not been replaced. An agency infection control policy was requested but was not received.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on interview and document review the agency failed to hire a clinical manager to provide oversight of patient care and personnel. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 10:40 a.m., registered nurse (RN)-A stated RN-B was the director of nursing (DON) but wasn’t sure because she accepted a full-time position with a different company. During an interview on 5/8/26, at 12:00 p.m., RN-B stated she stepped down from the director of nursing position “last spring” (2025) but still worked for the agency part-time as an RN Case Manager. During an interview on 5/8/26, at 12:18 p.m., the owner stated, RN-B resigned her full-time role as the DON in the fall 2025, then worked as the DON part-time and “all the nurses fill in as needed”. During an interview on 5/12/26, at 3:18 p.m., RN-C stated RN-B was the current DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the DON stepped down from her position in September 2025. The agency was “going through a transition and the agency was working on hiring a DON but due to personal care assistant (PCA) funding on hold, it was delayed. The agency Director of Nursing Job Description, dated 2007, directed the DON is responsible to care out day-to-day client care operations within the organization. Major areas of accountability: Plan, direct and participate in delivery of professional services to home care clientsParticipate in the organizations strategic planning activitiesAssist in the planning and development of the annual budgetsFocus services town diagnosis-specific client care needsParticipate in hospital care conferences to provide home healthcare expertise or client care discharges as neededIntroduce home health care services to clients and families for all new referralsInterface with nurse clinicians/client educators and social workers to provide client care continually, between hospital and homeCoordinate services to meet client needs from the time of a new referral through the initial at home intake visitProvide consultation to staff regarding home care nursing treatmentsMaintain liaison with attending physiciansEstablish and implement priorities when resource limitations requireCoordinate referrals to other community agencies as appropriate”

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on interview and document review the agency failed to provide the current version of the Combined Federal and State Home Care Bill of Rights, dated 2/24/26, for 4 of 4 patients (P3. P4 , P5 & P6) reviewed for patient rights. P3s chart lacked the 2/24/26 version of the Bill of Rights. Her chart had a form indicating she received the 11/2019 version of the Bill of Rights on 4/8/20. The form included the incorrect phone number for the State Agency (SA) P’s4 chart lacked the 2/24/26 version of the Bill of Rights. Her chart had a form indicating she received the 11/2019 version of the Bill of Rights on 3/27/20. The form included the incorrect phone number for the State Agency (SA). Findings include: During document review of the home care admission folder, on 5/8/26, the Bill of Rights was dated 11/2019 and listed the administrator as the agency contact. During an interview on 5/7/26, at 11:00 a.m., the administrator in training stated the Bill of Rights included in the admission folder was the version being used for new patients. He was unaware of the revised Home Care Bill of Rights. P5’s chart lacked evidence he or his caregiver received the Home Care Bill of Rights. P3s chart lacked the 2/24/26 version of the Bill of Rights. Her chart had a form indicating she received the 11/2019 version of the Bill of Rights on 4/8/20. The form included the incorrect phone number for the State Agency (SA) P’s4 chart lacked the 2/24/26 version of the Bill of Rights. Her chart had a form indicating she received the 11/2019 version of the Bill of Rights on 3/27/20. The form included the incorrect phone number for the State Agency (SA). P6’s chart lacked the 2/24/26 version of the Bill of Rights. Her chart had a form indicating she received the 11/2019 version of the Bill of Rights on 3/15/24. The form included the incorrect phone number for the State Agency (SA). During an interview on 5/8/26, at 12:18 p.m., the owner stated the version of the Bill of Rights in the admission folder was the version in use by the agency. He was not aware there was an updated version and did not re-issue the version dated 2/24/26 to the agency’s current patients. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her role as the administrator in March 2025 but continued to provided consultation for the agency. She stated patients are advised of their rights by the Bill of Rights and provided the agency contact number. The agency Admission Process policy, dated 5/2017, directed the client/caregiver was to be provided with a copy of the Home Care Bill of Rights and procedure for filing a complaint at the time of admission. The agency Home Care Bill of Rights/Grievance Procedure, dated 10/1996, directed the director of nursing (DON) or designated RN/therapist shall provide the client with a written notice of the Home Care Bill of Rights in advance of furnishing care to the client or during the initial evaluation visit before the initiation of treatment. The client shall be advised orally and in writing of the agency’s grievance procedure, including information regarding the Home Health Agency Hotline (established by the state) the hours of its operation and that the purpose of the hotline is to receive question or complaints about local home health agencies.The Home Care Bill of Rights shall be redistributed to clients following any revisions or modifications.The metro area phone number listed for the Home Health Agency Hotline was incorrect.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to investigate a patient complaint related to care that was not furnished for 1 of 4 patients (P4) reviewed for investigation of complaints made by the patient. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. Upon interview on 5/5/26 at 4:02 p.m. R2 stated her last visit for her Invega injection was the end of 2/2026. She believed it was mid-April when she called the HHA and complained to a male who answered the phone that her visit was over two weeks late. She was told he would look into her concern. She did not receive any further response from the HHA. On a sequent interview on 5/12/26 at 10:31 a.m. P2 stated the HHA had been reaching out to the past few days and attempting to resolve her concerns. She had been communicating with the ”new administrator.” The agency told P2 they have not authorization her for months and would not be able to see until they had authorization and would stay in touch with her. Upon interview on 5/6/26 the Administrator stated the HHA had not had any complaints in 2026. She did not produce a copy of all grievances for the past 6 months that was requested. Upon interview on 5/12/26 at 10:41 a.m. the Administrator in training stated the HHA was currently working on P2’s grievance. He had been in contact with R2 and explained the agency did not have a nurse and the agency did not have an up-to-date authorization. Once the HHA received the authorization her visits would continue. An HHA policy titled Home Care Bill of Right/Grievance Procedure indicated: If a complaint regarding services provided is received by an Agency staff professional providing care, the Director of Nursing will contact the client, caregiver and/or interested parties, discuss the situation, gather information and attempt to reconcile the situation. The complaint shall be documented on the Client Grievance/Complaint Form. If an oral. complaint is received by any employee; the client shall be instructed to put the complaint in writing. If the client is functionally unable to write, the employee or other designated person shall assist the client to document the situation, with the client’s signature obtained. The Director of Nursing shall prepare a written response and explanation to the complainant as soon as possible, but no later than 15 days after receipt of the complaint. If the Director of Nursing cannot reconcile the situation, the Administrator will review all information, contact the client, caregiver and/or interested parties and attempt to reconcile the situation. If the written complaint is not resolved, it may be appealed to the Governing Body within 30 days of receipt, with a written response of the appeal decision provided. The Governing Body will review the information and all pertinent Agency policies and make a final determination. A written report of findings and recommendations will be made to the complainant and appropriate Agency staff”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to document a patient complaint related to care that was not furnished for 1 of 4 patients (P2) reviewed for investigation of complaints made by the patient. Findings include: P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. Upon interview on 5/5/26 at 4:02 p.m. R2 stated her last visit for her Invega injection was the end of 2/2026. She believed it was mid-April when she called the HHA and complained to a male who answered the phone that her visit was over two weeks late. She was told he would look into her concern. She did not receive any further response from the HHA. On a sequent interview on 5/12/26 at 10:31 a.m. P2 stated the HHA had been reaching out to the past few days and attempting to resolve her concerns. She had been communicating with the ”new administrator.” The agency told P2 they have not authorization her for months and would not be able to see until they had authorization and would stay in touch with her. Upon interview on 5/6/26 the Administrator stated the HHA had not had any complaints in 2026. She did not produce a copy of all grievances for the past 6 months that was requested. Upon interview on 5/12/26 at 10:41 a.m. the Administrator in training stated the HHA was currently working on P2’s grievance. He had been in contact with P2 and explained the agency did not have a nurse and the agency did not have an up-to-date authorization. Once the HHA received the authorization her visits would continue. He denied documenting the complaint. He stated he was not sure of the grievance process. An HHA policy titled Home Care Bill of Right/Grievance Procedure indicated: If a complaint regarding services provided is received by an Agency staff professional providing care, the Director of Nursing will contact the client, caregiver and/or interested parties, discuss the situation, gather information and attempt to reconcile the situation. The complaint shall be documented on the Client Grievance/Complaint Form. If an oral. complaint is received by any employee; the client shall be instructed to put the complaint in writing. If the client is functionally unable to write, the employee or other designated person shall assist the client to document the situation, with the client’s signature obtained.”

“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 interview and record review, the agency failed to ensure all regulatory requirements were included in the plan of care (POC) for 5 of 7 patients (P1, P2, P3, P4, P6 & P7) who received home care services. P6’s POC/485 for certification period 4/16/26 through 6/14/26 indicated P6’s diagnosis was bipolar disorder. The POC lacked additional diagnoses. P6 required skilled nursing visits weekly for observation and assessment medication compliance, response set up medications, order refills and ability to manage diabetes. P6 was oriented and ambulated independently. P6’s medical record lacked medical history and physical. Upon observation on 5/8/26 at 10:00 a.m., RN-A set up P6’s medications according to directions on the labels on the prescription bottles, including two medications not listed on plan of care: spironolactone (a diuretic medication) 12.5 milligrams (mg) and sacubitril-valsartan 24-26 mg (a combination medication for heart failure). Miralax (laxative medication) was observed on P6’s counter. RN-A did not ask P6 if she was taking any additional medication or if there had been any recent medication changes. During an interview with P6 on 5/8/26, at 10:30 a.m., she stated she did not think RN-A knew she was diabetic. She stated she has been taking the Miralax for constipation and could not recall how long she had been taking it. During an interview with RN-A on 5/8/26, at 10:40 a.m., RN-A stated. He stated he did not ask P6 about her medications as there hadn’t been any changes. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 and for certification indicated P1 diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s activities permitted were use of a walker, can and wheelchair for ambulation. His DME and supplies were a bath bench, cane, walker, wheelchair and grab bars. His safety measures were fall precautions/transfer safety, universal precautions, proper use of assistive devices. P1’s POC dated 6/2/25 to 7/31/25 failed to identify any education what the fall and universal precautions were and what the proper use of his assistive devices was. In addition, P1 had no medications listed, nor measurable outcomes to his goal of wanting to walk without a walker. P1’s hospital discharge summary dated 3/29/26 indicated P1’s diagnoses were hypertension (high blood pressure), peripheral neuropathy (damage to the nerves outside the brain and spinal cord causing numbness, tingling, and pain), and chronic lower extremity edema (fluid build-up in the ankles). These diagnoses were not identified on P1’s POC. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. She had no functional limitations or restrictions on activities permitted. She was oriented and depressed. P2’s POC/485 for certification period 8/2/25 – 9/30/25 lacked any measurable outcomes for her goals. The POC lacked cognitive status or any education requirements. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s POC/485 for certification period 4/6/26 – 6/5/26 lacked any measurable outcomes to her goals. The POC lacked cognitive status and any education requirements specifically regarding blood glucose levels and Warfarin precautions. P3 was receiving INR checks for dosing of his Warfarin, however P3’s POC did not indicate a cardiac diagnosis. P4’s POC/485 for certification period 4/6/26 – 6/5/26 indicated P4’s diagnoses were Multiple Sclerosis (disabling autoimmune disease of the central nervous system) and Type 2 diabetes mellitus with hyperglycemia (increased blood sugar levels). P4 required weekly skilled nursing visits for assessment of general health, skin, pain, mood, vital signs and edema. She required medication set-up and compliance monitoring and administration of an Avonex injection (medication for Multiple Sclerosis). P4’s POC/485 for certification period 4/6/26 – 6/5/26 lacked any measurable outcomes to her goals. The POC lacked cognitive status and any education requirements. P7’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P8’s diagnoses were Paranoid Schizophrenia, nicotine dependence and insomnia. P8 required skilled nursing visits for assessment of pain and mental health status along with monthly aripiprazole injections (antipsychotic used to treat Schizophrenia). P8 was oriented. He ambulated with a cane without any restrictions. His prognosis was good. P7’s POC/485 for certification period 5/5/26 – 7/3/26 lacked any measurable outcomes to his goals. The POC lacked cognitive status and any education requirements. P8’s DME and supplies lacked documentation of a cane. Upon interview on 5/6/25 at 10:00 a.m. the Administrator stated her expectations were that the nurses would be completing their plan of cares per the agency’s policy. The HHA police titled Plan of Care undated indicated the plan of care shall be fully completed to include: All pertinent diagnosis(cs), principle and secondary, including dates of onsetMental statusType, frequency, and duration of all visits/servicesSpecific procedures and modalities for therapy servicesDiagnostic tests, including laboratory and x-raysSurgical procedure(s)PrognosisRehabilitation potentialFunctional limitations and precautionsActivities permitted or restrictedSpecific dietary or nutritional requirements or restrictionsMedications, treatments, and proceduresMedical supplies and equipment requiredAny safety measures to protect against injuryInstructions to client/caregiver, as applicableTreatment goalsInstructions for timely discharge or referralDischarge plansName and address of client’s physicianOther appropriate itemsAll of the above items must always be addressed on the plan of care”

“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 observation, interview, and record review the home health agency (HHA) failed to provide drugs and services only as ordered by a physician for 3 of 7 patients (P1, P2, & P6) reviewed for physician orders. The HHA was completing skilled nursing without physician orders when patients plan of care/485 expired or did not include medication. P6’s POC/485 for certification period 4/16/26 through 6/14/26 indicated P6’s diagnosis was bipolar disorder. The POC lacked a physician’s signature. P6 required skilled nursing visits weekly for observation and assessment medication compliance, response set up medications, order refills and ability to manage diabetes. P6 was oriented and ambulated independently. Upon observation on 5/8/26 at 10:00 a.m., RN-A set up P6’s medications. RN-A did not reference a medication profile or physician’s orders. He set up P6’s oral medications according to directions on the labels on the prescription bottles, including two medications not listed on plan of care: spironolactone (a diuretic medication) 12.5 milligrams (mg) and sacubitril-valsartan 24-26 mg (a combination medication for heart failure). Miralax (laxative medication) was observed on P6’s counter. RN-A did not call P6’s physician. P6’s medical record lacked physician signed orders for her spironolactone, sacubitril-valsartan, and Miralax. P6’s nursing visit note, dated 5/8/26, lacked evidence of coordination with P6’s physician. During an interview with P6 on 5/8/26, at 10:30 a.m., she stated she has been taking the Miralax for constipation and could not recall how long she had been taking it. During an interview with RN-A on 5/8/26, at 10:40 a.m., RN-A stated he knew the medications P6 took and looked at the prescription bottles for direction. He was not aware she was taking Miralax, as needed for constipation. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 and for certification indicated P1’s diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. These orders expired on 8/1/25. Upon record review from 8/1/25 – 5/11/26 the records did not indicate any orders since the POC of 6/2/25 – 7/31/25. Upon record review of P1’s skilled nursing visit summary P1 had every other week from 8/6/25 – 3/4/25, a missed visit on 3/18/26 and then another visit on 4/1/26. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. These orders expired on 10/1/25. Upon record review from 10/1/25 – 5/11/26 the records did not indicate any orders since the POC of 8/2/25 – 9/30/25. Upon record review of P2’s skilled nursing visit summary P2 received monthly skilled nursing visits from 11/14/25 – 2/16/26. Upon interview on 5/5/26 at 10:45 a.m. registered nurse (RN)-B stated she was the former director of nursing (DON), however had stepped down months ago and she was not certain who was following-up to make the visits the licensed practical nurses (LPNs) were completing had orders. Upon interview on 5/5/26 at 1:40 p.m. (LPN)-A stated she was the nurse who completed visits on P1 and P2. She was not aware when or how the registered nurses obtained orders on the clients. She stated she had never been told or witnessed a nurse completing an in-home assessment on the clients she saw. Upon interview on 5/6/26 at 10:00 a.m. the Administrator stated she was unaware that some orders had expired. She assumed the former DON, (RN)-B who stayed on a visit nurse had assigned case management to the clients LPN-A was seeing. An HHA policy titled Physician Orders undated indicated all treatments and care must be ordered, dated and signed by the physician. The orders may be initiated per telephone or in writing and must be counter-signed by the physician. Faxed signed physician orders for treatment are acceptable; however, the agency is responsible for obtaining an original signature if an issue surfaces that would require verification of an original signature. Drugs and treatments shall be administered by Agency staff only as ordered by the physician. Verbal orders are accepted by authorized personnel only in accordance with applicable law and organization policy. Orders will be accepted only from licensed physicians who licensure is verified by the Agency.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure plans of care (POC) were reviewed and signed by their provider every 60 days for 3 of 7 patients (P1, P2, & P4) reviewed for care and services. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 indicated P1 had diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. The provider signed these orders. P1’s record review from 8/1/25 – 5/11/26 the records did not indicate any orders since the POC of 6/2/25 – 7/31/25 for the provider to review or sign even though P1 continued to intermittently receive services. P1’s skilled nursing visit note summary indicated P1 received skilled nursing visits on: 2/18/26, 3/4/26 and 4/1/26. P1 was not seen on 3/15/26 and no visits were documented after 4/1/26 his every other week provider order. There was no documentation of missed visits. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. The provider signed these orders. P2’s record review from 10/1/25 – 5/11/26 the records did not indicate any orders since the POC of 8/2/25 – 9/30/25 for the provider to review or sign even though P2 continued to intermittently receive services. P2’s skilled nursing visit note summary indicated P2 received skilled nursing visits on: 1/16/26 and 2/26/26. P2 was to be seen monthly in February, her visit was 10 days late and no further visits were made or documented after 2/26/26 leaving P2 without a visit for 10 weeks upon the HHA’s survey. There was no documentation of missed visits. P4’s POC/485 for certification period 4/6/26 – 6/5/26 indicated P4’s diagnoses were Multiple Sclerosis (disabling autoimmune disease of the central nervous system) and Type 2 diabetes mellitus with hyperglycemia (increased blood sugar levels). P4 required weekly skilled nursing visits for assessment of general health, skin, pain, mood, vital signs, and edema. She required medication set-up and compliance monitoring and administration of an Avonex injection (medication for Multiple Sclerosis). P4’s POC was not documented as reviewed and/or signed by the provider. Upon interview on 5/5/26 at 10:45 a.m. registered nurse (RN)-B stated she was the former director of nursing (DON) at the HHA, and she would track the orders along with an office staff member who recently resigned. She was not certain who was tracking orders currently. Upon interview on 5/5/26 at 3:43 p.m. registered nurse (RN)-A stated he completes the recertification orders for his clients and since a licensed practical nurse (LPN) had resigned he had picked up a few of her clients and realized the recertification orders were late and he was in the process of renewing those orders. Upon interview on 5/6/26 at 10:00 a.m. the Administrator stated she was not aware there were clients who did not have their orders reviewed and signed. The responsibility of making sure the orders were reviewed and signed fell on each nurse case manager. The HHA used to have an office assistant who faxed the recertifications and tracked when the provider signed, however she resigned a few months ago. An HHA policy titled Medical Policies and Physician’s Orders undated Written orders for home health services are obtained and signed by the primary physician. -The original orders form is called the Plan of Care/485. Changes in those orders are usually made through verbal communication with the physician. With or without changes, all orders must be reviewed and renewed every two months and sent to the physician within 2 days of written order. -A nurse or therapist receives verbal orders from the physician. Verbal orders must be sent for confirmation and counter signature by the physician within 10 days. The nurse shall explain to the client and the family on the first visit that continuing responsibility for care cannot be accepted without physician orders. -If indicated, additional visits by TLC can be made with the approval of the DPCS or designee for the purpose of assisting the client in obtaining medical care from a physician. -Resume services and new or changed orders shall be obtained following interruption of TLC service (e.g., an admission to a hospital). -When providing care to a client according to the orders of one physician, additional orders from other physicians shall be approved by the client’s primary physician before the staff can accept them. -All medications the client is taking must be reported to and dosage verified by the primary physician on the Plan of Care/485. -Contraindications/side effects shall be reviewed by the RN case manager and primary physician. -Treatment ordered by the physician shall be the only medical treatments carried out. Medical Director will be notified after all attempts by 1LC staff to retrieve orders based on regulatory guidelines are exhausted.”

“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 interview and record review the home health agency (HHA) failed to promptly inform the physician of significant changes for 1 of 7 patients (P1) reviewed for home health services. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 indicated P1 had diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s activities permitted were use of a walker, cane, and a wheelchair for ambulation. His DME and supplies were a bath bench, cane, walker, wheelchair and grab bars. His safety measures were fall precautions/transfer safety, universal precautions, proper use of assistive devices. There were no interventions for his safety precautions. P1’s hospital admission/discharge summary dated 3/25/26 indicated P1 was a high fall risk, he had a past medical history of alcohol use disorder, chronic neck and back pain, neuropathy, malnutrition, hypertension, and tobacco us. He reportedly fell due to syncope with orthostatic hypotension (dizziness upon standing due to decreased blood pressure). P1 had weaknesses and was dehydrated. There was no discharge orders as P1 left the hospital against medical advice (AMA). Upon record review from 3/4/26 – 5/11/26 P1’s medical record lacked any notification to his primary care provider (PCP). P1’s skilled visit note dated 3/4/26 indicated his blood pressure was 164/89 normal range (90-120/60-80). His pain level was 9/10 in his back. General notes indicated P1 was seen for weekly skilled nursing visit, in good spirits and talkative. P1 continued to have hypotension and hypertension fluctuation (high and low blood pressure readings) His Lisinopril (blood pressure medication) was on hold until further notice. He reported another fall without injury after his knees buckled while trying to self-transfer. P1 self-administered his testosterone injections weekly. He used a wheelchair in his home with pivot transfers. He denied depression. He was a smoker. He denied anxiety and dizziness. He reported numbness and tingling in his fingers and occasionally in his toes. He experienced tremors bilaterally in his lower extremities. His skin was clean, dry, and intact. He reported bladder elimination was adequate and regular bowel movements. He reported clonus (an abnormal, rhythmic, involuntary muscle contraction and relaxation usually after a stretch of a muscle). The note did not indicate licensed practical nurse (LPN) communicated her findings with the registered nurse (RN) or P1’s provider to update P1’s plan of care (POC). Under the heading Plan/Coordination/Checklist (LPN)-A checked the boxes that the patient/caregiver consulted and in agreement with recommended changes and care was coordinated with the Physician and the skilled nurse. No documentation of what was communicated or any changes. P1’s nursing visit note dated 4/1/26 did not indicate P1 had been in the hospital. No vital signs were documented. He was seen for weekly skilled nursing visits, in good spirits, and talkative. P1 continued to have hypotension and hypertension fluctuation. Lisinopril was on hold until further notice. He reported another fall without injury this week after his knees buckled while trying to self-transfer. P1 self-administered his testosterone injections weekly. He used wheelchair in his home, pivot transfers. He denied depression and anxiety. He was a smoker. He experienced numbness and tingling fingers. Occasional numbness and tingling in toes. He experienced tremors in his lower extremities bilaterally. Skin was warm, dry, and intact (WDI). He reported bladder elimination adequate and regular bowel movements. He reported clonus tremors. Under the heading Plan/Coordination/Checklist (LPN)-A checked the boxes that the patient/caregiver consulted and in agreement with recommended changes and care was coordinated with the Physician and the skilled nurse. No documentation of what was communicated or any changes. P1’s hospital admission note dated 4/20/26 indicated P1 presented to the emergency department (ED) not feeling well for approximately four days. His skin had been more yellow. He had no urine when a foley catheter was attempted. He had burgundy red stools noted in his incontinent brief. P1 was intubated and sedated. His abdomen was large and extended. His skin was jaundice (yellow), bruising on his upper extremities and face. His admitting diagnosis was sepsis. P1’s hospital death record indicated he passed away 4/21/26 at 5:56 p.m. His discharge diagnosis was acute gastrointestinal bleed, hemorrhagic shock (severe blood loss causing inadequate oxygen to tissues and organs) and alcoholic cirrhosis. Upon interview on 5/5/26 at 10:45 a.m. registered nurse (RN)-B stated was not aware that P1’s POC had not been updated since she stepped down as director of nursing (DON) in August of 2025. She stated she was not responsible for P1 and was not sure which RN should have been updating his POC. Upon interview on 5/5/26 at 1:40 p.m. licensed practical nurse (LPN)-A denied reaching out to P1’s provider on either of her visits. She stated her understanding was that the RN who cased managed would read her notes and notify the provider and change the POC if needed. An HHA policy titled Medical Supervision undated indicated the physician will be contacted when any of the following occurs: -Conditional changes. -Expected response to treatment or medication changes. -Laboratory results are received, upon physician’s request, otherwise only abnormal results. -Caregiver support or home environment changes.”

“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 interview and record review the home health agency (HHA) failed to revise the plan of care for patient change of status for 2 of 7 (P1 and P3) patients reviewed for updated comprehensive assessments. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25 indicated P1 had diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing every other week for health status monitoring and medication set-up. P1’s activities permitted were use of a walker, cane, and a wheelchair for ambulation. His DME and supplies were a bath bench, cane, walker, wheelchair and grab bars. His safety measures were fall precautions/transfer safety, universal precautions, proper use of assistive devices. There were no interventions for his safety precautions. P1’s hospital admission/discharge summary dated 3/25/26 indicated P1 was a high fall risk, he had a past medical history of alcohol use disorder, chronic neck and back pain, neuropathy, malnutrition, hypertension, and tobacco us. He reportedly fell due to syncope with orthostatic hypotension (dizziness upon standing due to decreased blood pressure). P1 had weakness and was dehydrated. There was no discharge orders as P1 left the hospital against medical advice (AMA). P1’s skilled visit note summary dated 5/11/26 indicated he had a nursing visit on 3/4/26 and not again until 4/1/26. P1’s skilled visit note dated 3/4/26 indicated his blood pressure was 164/89 normal range (90-120/60-80). His pain level was 9/10 in his back. General notes indicated P1 was seen for weekly skilled nursing visit, in good spirits and talkative. Client continued to have hypotension and hypertension fluctuation. His Lisinopril (blood pressure medication) was on hold until further notice. He reported another fall without injury after his knees buckled while trying to self-transfer. P1 self-administered his testosterone injections weekly. He used a wheelchair in his home with pivot transfers. He denied depression. He was a smoker. He denied anxiety and dizziness. Client reported numbness and tingling in his fingers and occasionally in his toes. He experienced tremors bilaterally in his lower extremities. His skin was clean, dry, and intact. He reported bladder elimination was adequate and regular bowel movements. He reported clonus (an abnormal, rhythmic, involuntary muscle contraction and relaxation usually after a stretch of a muscle). The note did not indicate licensed practical nurse (LPN) communicated her findings with the registered nurse (RN) or P1’s provider to update P1’s plan of care (POC). Under the heading Plan/Coordination/Checklist (LPN)-A checked the boxes that the patient/caregiver consulted and in agreement with recommended changes and care was coordinated with the Physician and the skilled nurse. No documentation of what was communicated or any changes. P1’s nursing visit note dated 4/1/26 did not indicate P1 had been in the hospital. No vital signs were documented. Client was seen for weekly skilled nursing visits, in good spirits, and talkative. Client continues to have hypotension and hypertension fluctuation. Lisinopril on hold until further notice. He reported another fall without injury this week after his knees buckled while trying to self-transfer. Client self admin testosterone injections weekly. He used wheelchair in his home, pivot transfers, P1 denies depression, anxiety, and dizziness. He reported experiencing numbness and tingling in fingers. Occasional numbness and tingling in toes. P1 experienced tremors in his lower extremities bilaterally. Skin is warm, dry, and intact (WDI). He reported bladder elimination and regular bowel movements. He reported clonus tremors. Under the heading Plan/Coordination/Checklist (LPN)-A checked the boxes that the patient/caregiver consulted and in agreement with recommended changes and care was coordinated with the Physician and the skilled nurse. No documentation of what was communicated or any changes. Upon record review from 8/1/25 – 5/11/26 P1 did not have any updated assessments in his medical record. Therefore, there were no updates to his plan of care from his hospital stay of 3/25/26 – 3/27/26 for his high fall risk, alcohol use, pain, malnutrition, dehydration, tobacco use, and orthostatic hypotension. P1’s hospital admission note dated 4/20/26 indicated P1 presented to the emergency department (ED) not feeling well for approximately four days. His skin had been more yellow. He had no urine when a foley catheter was attempted. He had burgundy red stools noted in his depends. P1 was intubated and sedated. Abdomen was large and extended. His skin was jaundice (yellow), bruising on his upper extremities and face. His admitting diagnosis was sepsis. P1’s hospital death record indicated he passed away 4/21/26 at 5:56 p.m. His discharge diagnosis was acute gastrointestinal bleed, hemorrhagic shock (severe blood loss causing inadequate to oxygen to tissues and organs) and alcoholic cirrhosis. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s medications were listed as: Metoprolol Succinate Oral Tablet extended Release by mouth 50 MG 1 & 1/2 tabs. Tab(s) – daily at bedtime Warfarin Sodium Oral Tablets per INR results Cholecalciferol Oral Capsule 10000 UNIT 1 capsule daily Vitamin B12 Oral tablet extended release 100 mcg 1 tablet daily Vitamin E Blend 400 UNIT 1 capsule daily Topiramate oral tablet 25 mg 1 tablet twice daily P3’s clinic consultation note dated indicated P3 was in the hospital from 3/16/26 – 3/25/26 for acute or chronic congestive heart failure (CHF) and atrial fibrillation (heart arrhythmia of the upper chambers) He required aggressive IV diuresis (excessive urination). He was to continue with aspirin 81 milligrams(mg) per day, Diclofenac Gel, APAP (acetaminophen) 500 mg as needed Spiro lactone (diuretic) 25 mg. His furosemide (diuretic) was changed to Bumetanide (diuretic) and Atorvastin (for high cholesterol) was changed to Rosuvastatin (the dosage was not indicated on the consultation report). The consultation indicated that the HHA was informed via phone to (LPN)-A and then the consultation was faxed to the HHA. Upon record review of P3’s records dated 3/26/26 – 5/11/26 P3 did not have any updated assessments in his medical record. The aspirin, Diclofenac Gel, acetaminophen, Spirolactone, furosemide, bumetanide and the Atorvastin were not in his record as changes identified. Upon interview on 5/5/26 at 10:45 a.m. registered nurse (RN)-B stated was not aware that P1’s POC had not been updated since she stepped down as director of nursing (DON) in August of 2025. With any changes the physician should be notified and the plan of care updated. She stated she was not responsible for P1 and was not sure which RN should have been updating his POC. She stated she completed recertification visit 4/3/26, however noticed she did not have authorization, so she discharged him on 4/14/26. She was not aware that P3 had a hospitalization. Upon interview on 5/5/26 at 1:40 p.m. licensed practical nurse (LPN)-A denied reaching out to P1’s provider on either of her visits. She stated her understanding was that the RN who cased managed would read her notes and notify the provider and change the POC if needed. An HHA policy titled Care Plans undated indicated The Care Plan shall be reviewed, evaluated and revised (minimally every 62 days and as needed) based upon the client’s health status and/or environment, ongoing client assessments, caregiver support systems and effectiveness of interventions in achieving progress toward goals. All updated entries must be signed and dated by the Registered Nurse or Therapist. The Care Plan shall include, but not be limited to, the following: Nursing diagnosis(es)/problems and needs identified. Reasonable, measurable, and realistic nursing, therapy, social service, client, and/or caregiver goals.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to assure communication with all physicians involved in the plan of care was being conducted for 3 of 7 patients (P2, P7, & P8) reviewed for communication with all physicians who were receiving home health services. Findings include: P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. Upon interview on 5/4/26 at 4:02 p.m. P2 stated the agency had not provided her with nursing visits since last February. She stated she has a primary care provider and a psychiatrist. The psychiatrist orders her injections. She was not certain whether the agency had been updating her psychiatrist or not. Upon interview on 5/12/26 at 1:47 p.m. P2’s Psychiatrist stated she had never been notified by P2’s HHA. P2 was already on the Invega injections when she started treating her and had the HHA in place. Her expectation was that the agency would notify her that P2 had missed visits because the dosage of her medication maybe needed to be changed due to going without it for some time. P7’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P7’s diagnoses were Paranoid Schizophrenia, nicotine dependence, and insomnia. P7 required skilled nursing visits for assessment of pain and mental health status along with monthly aripiprazole injections (antipsychotic used to treat Schizophrenia). P7 was oriented. He ambulated with a cane without any restrictions. Upon interview on 5/7/26 at 2:30 p.m. P7 stated he had a “real doctor” and a “mental health” doctor. He was not certain which physician ordered which of his medications. He stated his nurse took care of that. Upon interview on 5/7/26 at 4:00 p.m. (RN)-A stated he was aware that P7 had a psychiatrist and P8 had a Gastroenterologist and an Oncologist, but he had not never communicated with them, nor has he added those providers to the HHA’s medical chart because he was not aware that was required. He thought he was only to communicate with the PCP’s. P8’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P8’s diagnoses were hereditary Hemochromatosis (the body stores too much iron) and hereditary and idiopathic neuropathies (nerve damage from no known cause). He required weekly skilled nursing visits for assessments of mental health, general health, pain, fall risk, skin integrity, bowel and bladder and medication management. Upon observation on 5/7/26 at 3:45 p.m. registered nurse (RN)-A was setting-up P8’s medications. P8 mentioned to (RN)-A that he was confused about reordering his medications and could not remember one of his medications came from his Gastroenterologist or his PCP. P8 also mentioned an upcoming appointment with his Oncologist. Upon interview on 5/5/26 at 10:45 a.m. registered nurse, (RN)-B stated the agency only notifies the clients primary care providers (PCPs) and the PCP’s were responsible for communicating with other specialists the clients may see. An HHA policy titled Coordination of Client Services dated 11/1994 indicated: To ensure that services are coordinated between members of the interdisciplinary team.All personnel furnishing services maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care.To ensure that appropriate, quality care is being provided to clients.To establish that effective interchange, reporting, and coordination of client care does occur.To assure that TLC Home Care of the Twin Cities personnel efforts effectively complement one another and support the objectives outlined in the Plan of Care.To evaluate eligibility for care. To evaluate adequacy of treatment and effect of services provided.To determine continuation and future plans for care.To provide the attending physician with an ongoing assessment of the client and response to services provided.To identify potential or actual client abuse and/or neglect.To ensure continuity of care.Care conferences will be held to establish interchange, reporting and coordinated evaluation between all disciplines involved in the client’s care.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedules for 6 of 7 patients (P1, P2, P3, P4, P7 & P8) reviewed for scheduling. Findings include: P1’s plan of care (POC)/485 for certification periods 6/2/25 to 7/31/25, indicated P1 had diagnoses were alcoholic cirrhosis of liver with ascites (significant scarring of the liver causing build-up of fluid in the abdomen) P1 required skilled nursing visits every other week for health status monitoring and medication set-up. Upon interview on 5/5/26 at 8:40 P1’s family member (FM)-A stated she did know when the nurses were going to visit her husband, she did not understand English well. The nurses would text message P1. She noted he had not been seen in weeks and did not have a schedule or the HHA contact information in her home. P1 could not interview as he passed away 4/21/26. P2’s POC/485 for certification period 8/2/25 – 9/30/25, indicated P2’s diagnoses were Schizophrenia and cocaine abuse. P2’s POC indicated she was required to have monthly skilled nursing visits for an Invega injection (antipsychotic medication to treat Schizophrenia) and assessment of pain and mental status. Upon interview on 5/4/26 at 4:02 p.m. P2 stated she had never had a schedule “locked in” at the HHA. She expressed that may be the reason she had not had a visit since the end of February and missed her Invega injections (anti-psychotic) injection. P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). Upon interview on 5/5/26 at 1:23 p.m. P3’s (FM)-B stated she did not have a nursing schedule in the home. The nurse would text P3 when she was going to see him. (FM)-B stated he did have missed visits prior to his hospitalization. P3 was unable to interview as he passed away on 5/13/26. P4’s POC/485 for certification period 4/6/26 – 6/5/26 indicated P4’s diagnoses were Multiple Sclerosis (disabling autoimmune disease of the central nervous system) and Type 2 diabetes mellitus with hyperglycemia (increased blood sugar levels). P4 required weekly skilled nursing visits for assessment of general health, skin, pain, mood, vital signs, and edema. She required medication set-up and compliance monitoring and administration of an Avonex injection (medication for Multiple Sclerosis). Upon interview on 5/5/26 at 2:27 p.m. P4’s family member (FM)-C stated there was not a visit schedule in the home. P4 had missed visits from the agency and when that occurs (FM)-C was an unlicensed care giver and set-up P4’s medications and gave her an injection for her multiple sclerosis. P7’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P7’s diagnoses were Paranoid Schizophrenia, nicotine dependence, and insomnia. P7 required skilled nursing visits for assessment of pain and mental health status along with monthly aripiprazole injections (antipsychotic used to treat Schizophrenia). Upon observation and interview on 5/7/26 at 3:15 p.m. (RN)-A was setting-up P7’s medications. P7 did not have a visit schedule in his home. He stated the nurses call him before they come to see him, he was not certain what day or how often he was seen. P8’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P8’s diagnoses were hereditary Hemochromatosis (the body stores too much iron) and hereditary and idiopathic neuropathies (nerve damage from no known cause). He required weekly skilled nursing visits for assessments of mental health, general health, pain, fall risk, skin integrity, bowel and bladder and medication management. Upon observation and interview on 5/7/26 at 3:45 p.m. (RN)-A was setting-up P8’s medications. P8 did not have a visit schedule in his home. P8 stated his nursing visits occur weekly, give or take a day or two, the staff always called before arriving. Upon interview on 5/5/26 at 8:32 a.m. Registered nurse (RN)-C stated the HHA has never had a formal scheduling system. The nurse case managers set up and complete their own visits when they have availability. Upon interview on 5/6/26 at 10:00 a.m. the Administrator stated the nurses were responsible for their own schedules and they should leave the patient a note of their next visit. Upon interview on 5/6/26 at 11:02 a.m. the Administrator in training stated when he started at the agency about three weeks ago, he texted messages to all the nurses asking what patient they saw and when they saw them. He did not do anything further with the information. Upon interview on 5/7/26 at 4:00 p.m. (RN)-A stated he made his own schedule and since many of the clients were mentally ill, they forget about their visits, so he calls all patients prior to his visits. An HHA policy regarding visits was requested, however none was received.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on interview and document review, the facility failed to perform actions aimed at performance improvement and tracking performance following those actions. This had the opportunity to affect all 40 patients. Findings include: The agency lacked actions taken aimed at performance improvement and a system to track outcomes to ensure improvements were sustained. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and was “not sure” what the quality assessment performance improvement (QAPI) program was. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated RN-B and RN-D managed the quality assurance and met every three to six months and the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated, “I don’t know if we really had an official QAPI program.” She stated subjects were addressed as they arose and created a spreadsheet at one point to track medical records and authorizations and the agency did not currently have a DON. The agency Quality Assurance/Improvement policy, dated 10/1996, directed the agency shall maintain a planned systemic organization wide approach to designing, measuring, assessing and improving its performance. Outcome measurements of the performance improvements will be monitored on a continuous basis and all results will be reported at least annually to the advisory board.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation, interview and document review the agency failed to provide patient education for 1 of 3 patients (P6) reviewed for patient education. Findings include: P6’s Plan of Care/Certification dated 4/16/26 to 6/14/26 indicated P6 was on a diabetic diet with corresponding medications to manage her diabetes. P6’s orders and goals included a verbal order dated 4/15/26 with no specific information, the frequency and duration were identified as every other week to assess and eval every other month for recertification. Observation and Assessment included vital signs monitoring of respiratory, gastrointestinal, cardiopulmonary, and integumentary status. Pain management, endocrine, neurological, and renal/genitourinary status. To provide observation and assessment patient/caregiver ability to manage diabetes and care. Observation and assessment of medication compliance, response, set-up medications, and order refills. The goal was to be free of exacerbation of those areas. P6 identified she wanted to lose weight. Review of P6’s medical records lacked documentation of patient education in any area identified in P6’s plan of care/certification. During an observation on 5/8/26, at 10:00 a.m., registered nurse (RN)-A failed to provide education during P6’s visit. During an interview on 5/8/26, at 10:30 a.m., P6 stated the agency nurses have not provided education during her visits, and she had no printed educational material in her home. During an interview on 5/8/26, at 10:40 a.m., RN-A stated he did not provide education to his patients as they were “mostly mental health clients”. During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON). During an interview on 5/8/26, at 12:18 p.m., the owner stated they have not had a DON since September 2025. During an interview on 5/12/26, at 10:05 a.m., the administrator stated their DON stepped down in September of 2025 and had not been replaced. An agency policy related to patient education was requested but not received.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on interview and document review the agency failed to appoint the administrator for the agency. This had the opportunity to affect all 40 patients. Findings include: The agency’s organizational chart, undated, indicated the administrator was the administrator. During an interview on 5/8/26, at 12:18 p.m., the owner stated he was the only member of the governing body. He stated the administrator was the administrator but was only in a consulting role and the administrator in training, was still in training. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025. The agency was going through a transition and the administrator in training was still learning. She was unaware of the process to appoint a new administrator. The agency job description for the administrator directed the administrator is responsible to plan, develop and direct all aspects of the agency’s operation. The agency Appointment of Administrator policy, dated 7/20/17, directed the governing body will appoint a qualified administrator per local, state and federal regulations. A qualified person is authorized in writing to act in the absence of the administrator. To provide organization and direction for the agencies ongoing functions; to maintain ongoing liaison among the governing body, the group of professional personnel and the staff. The document included appointment of a person who no longer works for the agency. In case of temporary absence (in excess of 21 days) the duties of the administrator will be assumed by the appointed alternate, and the Department of Health Services, Licensing and Certification unit shall be notified in writing. A vacancy in this position will be filled within 60 days. The agency Governing Body policy, dated 7/200, directed the governing body shall assume full legal authority and responsibility for the operation of the agency. The duties and responsibilities of the governing body shall include: to appoint a qualified administrator. The agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure the administrator was responsible for the day-to-day operations. This had the opportunity to affect all 40 patients. Findings include: The agency’s organizational chart, undated, indicated the administrator was the administrator. During an interview on 5/8/26, at 12:18 p.m., the owner stated he was the only member of the governing body. He stated the administrator was the administrator but was only in a consulting role and the administrator in training, was still in training. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025. The agency was going through a transition and the administrator in training was still learning. She was no longer involved with day-to-day operations of the agency. The agency job description for the administrator directed the administrator is responsible to plan, develop and direct all aspects of the agency’s operation. The agency Appointment of Administrator policy, dated 7/20/17, directed the governing body will appoint a qualified administrator per local, state and federal regulations. A qualified person is authorized in writing to act in the absence of the administrator. To provide organization and direction for the agencies ongoing functions; to maintain ongoing liaison among the governing body, the group of professional personnel and the staff. The document included appointment of a person who no longer works for the agency. In case of temporary absence (in excess of 21 days) the duties of the administrator will be assumed by the appointed alternate, and the Department of Health Services, Licensing and Certification unit shall be notified in writing. A vacancy in this position will be filled within 60 days. The agency Governing Body policy, dated 7/200, directed the governing body shall assume full legal authority and responsibility for the operation of the agency. The duties and responsibilities of the governing body shall include to appoint a qualified administrator. The agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure clinical manager was available at all times. This had the opportunity to affect all 40 patients. Findings include: On 5/8/26, at 6:58 a.m., a call was placed to the agency to determine if a clinical manager was available. During an interview on 5/8/26, at 7:00 a.m., the administrator in training stated, “We have nurses but it’s after hours.” He stated he did not know who on-call was, but it was probably registered nurse (RN)-B. There was not an RN on-call schedule that he was aware of and didn’t know the agency was required to provide this service. He stated the clients should call their case manager if they needed something but wasn’t sure they were expected to answer their phones 24 hours a day, 7 days a week. During an interview on 5/8/26, at 9:38 a.m., RN-D stated clients and personal care assistants (PCA) have called her directly when they have had concerns after business hours or they call the office. “There used to be someone on call for the agency. That would be a question for RN-B.” During an interview on 5/8/26, at 10:30 a.m., P6 stated she was not sure if the agency provided after-hours availability or a number to call. During an interview on 5/8/26, at 10:40 a.m., RN-A stated RN-B was on call for clinical needs after normal business hours, but he did not know. During an interview on 5/8/26, at 12:00 p.m., RN-B stated she stepped down from the director of nursing position “last spring” (2025) and was not sure if the agency had a clinical manager on call after normal business hours. During an interview on 5/8/26, at 12:18 p.m., the owner stated, “All the nurses are on call for their patients.” During an interview on 5/12/26, at 3:18 p.m., RN-C stated she was not aware of a clinical manager on call after hours and she herself was not on-call for after-hour patient needs. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she had stepped down from her position in March 2025 but has been consulting with the agency as she able. The DON stepped down from her position in September 2025. The agency was “going through a transition” and the phones were all directed to the administrator in training. The agency Provision for 24 Hour RN Availability policy, dated 10/1996, directed hours of operation are 9:00 a.m. to 5:00 p.m., Monday through Friday. A RN shall be accessible 24 hours per day by telephone and/or pager at all times to meet client needs. The RN will be available to make a home visit if necessary. The nursing supervisor or designee will develop the on-call scheduleThe on-call nurse must be available at all times by pager or telephone and must communicate availability to the answering service.The on-call nurse shall respond to all messages in a timely manner. In an emergency situation, the nurse will direct the client to call 911. The nurse may also direct the client to call his/her physician. The on-call nurse shall be available for home visits if the client’s condition requires a visit.All calls are documented on an activity log. This log is available to the clinical record review committee for its review and comments.Information pertinent to a specific client’s care must be documented in the client’s chart on a progress record and/or flow sheet.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure a qualified pre-designated person, authorized in writing by the administrator and governing body, was available to assume the administrator’s responsibilities. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:18 p.m., the owner stated he was the only member of the governing body. He stated the administrator was the administrator but was only in a consulting role and the administrator in training, was still in training. During an interview on 5/12/26, at 10:05 a.m., the administrator stated she stepped down from her position in March 2025. The agency was going through a transition and the administrator in training was still learning. The agency Appointment of Administrator policy, dated 7/20/17, directed in case of temporary absence (in excess of 21 days) the duties of the administrator will be assumed by the appointed alternate, and the Department of Health Services, Licensing and Certification unit shall be notified in writing. A vacancy in this position will be filled within 60 days. Delegation of authority was requested by the agency but was not received.”

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on interview and document review the agency failed to make patient and personnel assignments and provide oversight by the clinical manager. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/7/26, at 9:30 a.m., the administrator in training stated he did know the visit schedule as the nurses made their own schedules and he had no way to know which clients were being seen each day without calling each of them. During an interview on 5/8/26, at 9:38 am., RN-D stated the nurses made their own visit schedules. During an interview on 5/8/26, at 10:40 a.m., RN-A stated he worked for the home health agency part-time and made his own schedule. During an interview on 5/8/26, at 12:00 p.m., RN-B stated she was no longer the director of nursing (DON) and had stepped down from the position in September 2025. She changed to part-time employment with the agency and made her own visit schedule. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated the agency did not currently have a DON. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the agency did not currently have a DON and hadn’t had a DON since September 2025. A schedule of nursing visits was requested but not received. The agency Director of Nursing Job Description, dated 2007, directed the DON is responsible to carry out day-to-day client care operations within the organization. Major areas of accountability: Plan, direct and participate in delivery of professional services to home care clientsParticipate in the organizations strategic planning activitiesThe agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares. The director of patient services will be responsible for the day-to-day direction, implementation, coordination and improvement of patient care. This person will be available at all times during operating hours.The director of patient services will authorize, in writing, a designated home health RN to carry out delegated responsibilities in the absence of the administrator or director of patient services.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on interview and document review the agency failed to provide oversight in coordinating patient care. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and had stepped down from the position in September 2025. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated the agency did not currently have a DON and each RN managed their patients independently. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the agency did not currently have a DON and hadn’t had a DON since September 2025. The agency Director of Nursing Job Description, dated 2007, directed the DON is responsible to carry out day-to-day client care operations within the organization. Major areas of accountability: Plan, direct and participate in delivery of professional services to home care clientsParticipate in the organizations strategic planning activitiesCoordinate services to meet client needs from the time of a new referral through the initial at home intake visitProvide consultation to staff regarding home care nursing treatmentsMaintain liaison with attending physiciansCoordinate referrals to other community agencies as appropriateThe agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares. The director of patient services will be responsible for the day-to-day direction, implementation, coordination and improvement of patient care. This person will be available at all times during operating hours.The director of patient services will authorize, in writing, a designated home health RN to carry out delegated responsibilities in the absence of the administrator or director of patient services.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on interview and document review the agency failed to provide oversight in assuring patient needs are continually assessed. This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and had stepped down from the position in September 2025. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated the agency did not currently have a DON and each RN managed their patients independently. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the agency did not currently have a DON and hadn’t had a DON since September 2025. The agency Director of Nursing Job Description, dated 2007, directed the DON is responsible to carry out day-to-day client care operations within the organization. Major areas of accountability: Plan, direct and participate in delivery of professional services to home care clientsProvide consultation to staff regarding home care nursing treatmentsMaintain liaison with attending physiciansCoordinate referrals to other community agencies as appropriateThe agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares. The director of patient services will be responsible for the day-to-day direction, implementation, coordination and improvement of patient care. This person will be available at all times during operating hours.The director of patient services will authorize, in writing, a designated home health RN to carry out delegated responsibilities in the absence of the administrator or director of patient services.”

“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 interview and document review the agency failed to ensure implementation of the patients’ plans of care (POC). This had the opportunity to affect all 40 patients. Findings include: During an interview on 5/8/26, at 12:00 p.m., registered nurse (RN)-B stated she was no longer the director of nursing (DON) and had stepped down from the position in September 2025. During an interview on 5/8/26, at 12:18 p.m., the agency owner stated the agency did not currently have a DON and each RN managed their patients independently. During an interview on 5/12/26, at 10:05 a.m., the administrator stated the agency did not currently have a DON and hadn’t had a DON since September 2025. The agency Director of Nursing Job Description, dated 2007, directed the DON is responsible to carry out day-to-day client care operations within the organization. Major areas of accountability: Plan, direct and participate in delivery of professional services to home care clientsProvide consultation to staff regarding home care nursing treatmentsMaintain liaison with attending physiciansCoordinate referrals to other community agencies as appropriateThe agency Administrative Structure policy, dated 11/1994, directed agency will provide a defined administrative structure to establish lines of authority for the delegation of responsibility and communication concerning the delivery of patient cares. The director of patient services will be responsible for the day-to-day direction, implementation, coordination and improvement of patient care. This person will be available at all times during operating hours.The director of patient services will authorize, in writing, a designated home health RN to carry out delegated responsibilities in the absence of the administrator or director of patient services.”

“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 interview and record review the home health agency (HHA) failed to accurately document clinical records for 2 of 7 patients (P3 and P7) reviewed for clinical records content. Findings include: P3’s POC/485 for certification period 3/4/26 – 5/2/26, indicated P3’s only diagnosis was Type 2 diabetes mellitus without complications. P3 was oriented with no restrictions. His prognosis was good. P3 required skilled nursing weekly visits for blood glucose levels and diabetic compliance, International Normalized Ratio (INR) checks for dosing of Warfarin (blood thinner). P3’s discharge summary dated 4/14/26 indicated P3 was discharged from the agency to home. His reason for discharge was his authorization had expired. His services were skilled nursing. P3’s nursing visit note dated 4/3/26 at 8:40 a.m., indicated patient was seen for general health assessment. He was talkative, pleasant, and cooperative, denied dizziness and chest pain. He experiences numbness and tingling bilaterally in his lower extremities. Skin was clear, dry, and intact. He reported urine elimination adequate. He will have a BM every 1-3 days, denied diarrhea and constipation. No changes in diet, no alcohol or tobacco intake, no injuries, or changes. No falls, no bruising. He checked BG daily. His INR was 2.7 on 4/03/26. Client had 2 mg Warfarin tabs on hand. He was to take 1.5 tablets Monday’s and Fridays. Two tablets all other days. His next INR in 2 weeks 04/16/2026. There was no documentation of a discharge for P3. During interview on 5/5/26 at 10:45 a.m. registered nurse (RN)-B stated she made a visit to see P3 on 4/3/26. She told P3 the agency could no longer see him because they did not have authorization, and he would need to be seen in his clinic for his next INR draw on 4/16/26 and Warfarin dosing. (RN)-B did not complete P3’s discharge at the time of his visit. She asked the surveyor during the interview if she should discharge P3. She back dated a discharge to 4/16/26 in the HHA’s software system. At a later interview on 5/12/26 at 11:11 a.m., she stated she had made the discharge date 4/14/26 because that would be the date, he would miss a visit with the agency. P3’s discharge summary was signed by (RN)-B on 5/5/26 during the survey process and was not sent to the provider. P7’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P7’s diagnoses were Paranoid Schizophrenia, nicotine dependence, and insomnia. P7 required skilled nursing visits for assessment of pain and mental health status along with monthly aripiprazole injections (antipsychotic used to treat Schizophrenia). Record review on 5/5/26 indicated P7’s recertification was due on 5/5/26. During interview on 5/6/26 at 1:12 p.m., the Administrator in training stated he reached out (RN)-A, and he would be completing his skilled nursing visit on 5/7/26 at 2:00 p.m., and it was okay for the surveyor to shadow the visit. During interview on 5/11/26 at 10:49 a.m. the Administrator in training stated he thought the recertification assessments had a window to be completed so it was alright for a nurse to open another visit in the system to make the dates align even if the patient was not seen on that exact day, but the agency would not bill for those visits. During interview on 5/11/26 at 3:15 p.m., RN-A stated he only had a visit with P7 on 5/7/26, however he charted his assessment on 5/5/26. He stated it was okay to have a few days off to make the assessment dates correct. An HHA policy titled Clinical Record Review with a revision date of 6/1999 indicated the HHA evaluated patient records to ensure that document was complete, accurate, and timely.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to document the dates of medication set-up, name of the medication, quantity of dose, time to be administered, route of administration, and the name of the staff completing the medication set-up at the time of the set-up for 3 of 3 patients (P6, P7, & P8) reviewed for HHA services including medication set-up. Findings include: P7’s Plan of Care POC/485 for certification period 5/5/26 – 7/3/26 indicated P7’s diagnoses were Paranoid Schizophrenia, nicotine dependence, and insomnia. P7 required skilled nursing visits for assessment of pain and mental health status along with monthly aripiprazole injections (antipsychotic used to treat Schizophrenia) and medication set-up. P7 was oriented. He ambulated with a cane without any restrictions. His prognosis was good. Upon observation on 5/7/26 at 2:00 p.m. registered nurse (RN)-A was setting-up P7’s medications. P7’s medications were kept in an unlocked medication box. (RN)-A did not follow a medication list or use an electronic list of medications. No documentation was made at the time of the set-up. He set up P7’s medications according to the instructions on the medication bottles. P7’s nursing visit notes dated 4/30/26 and 5/7/26 lacked any evidence of documentation of the dates of medication set-up, name of the medication, quantity of dose, time to be administered, route of administration, and the name of the staff completing the medication set-up at the time of the set-up Upon observation on 5/7/26 at 3:15 p.m. registered nurse (RN)-A was setting-up P7’s medications. P8’s medications were kept in an unlocked medication box. (RN)-A did not follow a medication list or use an electronic list of medications. No documentation was made at the time of the set-up. He set up P8’s medications according to the instructions on the medication bottles. P8’s nursing visit notes dated 5/1/26 and 5/7/26 lacked any evidence of documentation of the dates of medication set-up, name of the medication, quantity of dose, time to be administered, route of administration, and the name of the staff completing the medication set-up at the time of the set-up P8’s POC/485 for certification period 5/5/26 – 7/3/26 indicated P8’s diagnoses were hereditary Hemochromatosis (the body stores too much iron) and hereditary and idiopathic neuropathies (nerve damage from no known cause). He required weekly skilled nursing visits for assessments of mental health, general health, pain, fall risk, skin integrity, bowel and bladder and medication management. P8’s functional limitations were endurance and ambulation. P8 was independent at home with the use of a cane. He was oriented, forgetful, and depressed. Upon observation on 5/7/26 at 3:45 p.m. registered nurse (RN)-A was setting-up P8’s medications. P8’s medications were kept in an unlocked medication box. (RN)-A did not follow a medication list or use an electronic list of medications. No documentation was made at the time of the set-up. He set up P8’s medications according to the instructions on the medication bottles. Upon interview on 5/7/26 at 4:00 p.m. (RN)- A stated he was not aware that medications needed to be documented at the time of set-up. He stated neither P7 nor P8 had many medication changes, so the bottles from the pharmacy were correct. P6’s POC/485 for certification period 4/16/26 through 6/14/26 indicated P6’s diagnosis was bipolar disorder. P6 required skilled nursing visits weekly for observation and assessment medication compliance, response set up medications, order refills, and ability to manage diabetes. P6 was oriented and ambulated independently. Upon observation on 5/8/26 at 10:00 a.m., RN-A set up P6’s medications. P6’s medications were kept in a plastic tray. RN-A did not reference a medication profile or physician’s orders. He set up P6’s oral medications according to directions on the labels on the prescription bottles, including two medications not listed on plan of care: spironolactone (a diuretic medication) 12.5 milligrams (mg) and sacubitril-valsartan 24-26 mg (a combination medication for heart failure). RN-A explained to P6 the ferrous sulfate (iron) was not set up due to insurance coverage issues at the pharmacy. He did not document each medication as it was set up in P6’s weekly medication box. He did not observe P6’s injectable medications: Insulin Glargine (a long-acting insulin), Insulin Lispro (a short acting insulin, dose dependent on blood sugar readings), or Mounjaro (diabetic medication) or ask her about her blood sugar. Miralax (laxative medication) was observed on P6’s counter. P6’s nursing visit notes, dated 5/1/26 and 5/8/26, lacked evidence of documentation of the dates of the medication set up, names of the medications, quantity/dose of medication, time to be administered and staff who completed medication set up. The visit notes lacked indication ferrous sulfate was not set up and did not indicate medications that lacked physician orders were set up. The visit notes also lacked coordination with physicians. During an interview with P6 on 5/8/26, at 10:30 a.m., she stated she did not think RN-A knew she was diabetic and has never asked about her blood sugars, how much insulin she is taking, or observed her injectable medications. She stated she had been taking the Miralax for constipation and could not recall how long she had been taking it. During an interview with RN-A on 5/8/26, at 10:40 a.m., RN-A stated he did not document the medication set up, but “probably should” and did not ask P6 about her blood sugars and insulin management because she was independent with self-administration of those tasks. He stated he did not ask for P6 if she was taking acetaminophen and was not aware she was taking Miralax, as needed for constipation. Upon interview on 5/11/26 at 10:49 a.m. the Administrator (in-training) stated he was not aware that medications required specific documentation at the time of the set-up, however, would make a system change at the HHA. An HHA policy requesting medication set-up was requested, however none was provided.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure one or more qualified individuals; licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse provided oversight of all patient care services and personnel when the administrator was fulling the duties of the clinical manager. Findings included: The HHA’s organizational chart dated 1/1/25 indicated registered nurse (RN)-B as the director of nursing (clinical manager). The Administrators credentials were Masters or Public Health, MPH. During the survey entrance on 11/19/25 at 10:45 a.m. the administrative assistant (AA)-A identified registered (RN)-B as the clinical manager and stated she would on vacation and could not be reached until 11/24/25. She stated the contact person would be the administrator. Upon interview on 11/24/25 at 8:30 a.m. RN-B stated she was no longer the clinical manager and had stepped down 4/2025. Since April until present she had a part-time position at the home health agency. Upon interview on 11/24/25 at 10:30 a.m. the Administrator stated RN-B had stepped back from her clinical manager role 4/2025. Between the two of them they have been managing the day to day functioning of the HHA. RN-B has kept on a part-time status at the HHA as she had another job. The Administrator who lives in California stated she covered as clinic manager when RN-B was absent. The clinical manager position had been posted, but not yet filled. The Administrator stated she was not a nurse. A policy regarding the clinical manager was requested however none was provided.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on observation and interview the facility failed to appropriately discharge 2 of 3 patients (P1 and P2) reviewed for discharges. The home health agency (HHA) did not notify the patient’s healthcare providers or healthcare professionals that P1 and P2 were being discharged. Findings include: P1’s Home Health Plan of Care and Certification for certification period 6/20/25 – 8/18/25 indicated P1’s diagnoses were Autistic disorder and unspecified intellectual disabilities. P1’s mental status was oriented, forgetful, and depressed. P1 was ordered to have skilled nursing every other week to observe and assess vital signs and to monitor respiratory status, gastrointestinal status, cardiopulmonary status, integumentary status, pain management, endocrine status, neurological status, renal/genitourinary status, observe and assess mental status and to observe and assess medication compliance, response, set-up medications and assist with ordering medications. P1’s last skilled nursing visit note dated 8/21/25 indicated P1 lived alone in a condominium. He was oriented, but forgetful. He attended a day program five days a week. P1 had a history of seizure activity. He would have absent seizures that lead to grand mal seizures. He reported having difficulty starting urine stream. He needed assistance with medication regimen related to self-care deficit. P1’s medications were filled for two weeks. Registered nurse (RN)-A documented she was not able to accommodate P1’s requests to have his medications filled on Tuesday or Thursday mornings. She notified the scheduling staff at the HHA. Email correspondence from the HHA administrative assistant to the Administrator and the director of nursing (DON) dated 10/6/25 at 2:42 p.m. indicated P1’s outside case manager (CM) called the HHA because she was told by RN-A that P1’s visits were passed along to another nurse. She was wondering who the nurse was and how to contact them. The assistance looked in P1’s file and found there was no primary nurse assigned to P1. The assistant reached out to RN-A that another agency will see P1 and for RN-A to discharge him. Upon interview on 11/19/25 at 10:45 a.m. P1’s CM -A stated on 10/7/25 P1 notified her that he had not had his seizure medication in a few days, and he was unable to get a refill on his own. The CM assisted him to get the medication. P1 told the CM-A that he had been discharged from the agency. The CM called the agency and was told RN-A was unable was to see P1 and another agency nurse would be completing his nursing visits. When the HHA looked up the nurse who was supposed to be seeing P1 the agency revealed there was not a nurse scheduled for P1, and the HHA did not have one so P1 would need to be discharged. CM-A called P1’s county case worker (CW)-A to ask if P1 had a new HHA and was told he did not. CM-A stated when the HHA told her they needed to discharge. The agency failed to provide any discharge information to a new HHA or the case management team. Upon interview on 11/19/25 at 12:27 p.m. RN-A stated she had completed nursing visits for P1, however due to scheduling conflicts she was unable to see him after the 8/21/25 visit. She was given the name of another HHA nurse who would see P1. RN-A was not aware that P1 had not been seen and did not recall being asked to discharge him. Upon interview on 11/19/25 at 1:15 p.m. P1 stated he was not receiving any nursing services in home and had not seen a nurse since summertime and currently was not seeing a nurse. He stated was told by the nurse that he was discharged, and his day program had been assisting him with his medications. Upon interview on 11/19/25 at 2:14 p.m. administrative assistant (AA)-A stated P1 must have been discharged because he was on the nursing schedule. She did not know a discharge date. Upon interview on 11/24/25 at 8:30 RN-B (the former director of nursing) stated she had stepped down from her role as director of nursing (DON) and all she knew about P1 was that he was difficult to get a hold of. She thought P1’s discharge was completed through the HHA and P1 had another agency. Upon interview on 11/24/25 at 10:30 a.m. the Administrator stated she believed P1 had been discharged from the agency. She stated the case manager should be making sure all components of the discharge are completed along with the notifications of missed visits to the provider as they are taking place. P1’s Primary Care Physician did not respond to an interview request. P2’s Home Health Plan of care and Certification for certification period 11/9/25 – 1/7/26 indicated P2’s diagnoses were low back pain, polyps of the colon, diabetes mellitus due to an underlying condition with hyperosmolarity but without nonketotic hyperglycemic-hyperosmolar coma (a severe complication of type 2 diabetes defined by extremely high blood sugar levels, where coma did not occur). P1 was oriented and forgetful. P1 was ordered to have weekly skilled nursing visits to assess/monitor general health, mood, set-up meds and monitor compliance. P2’s discharge summary dated 11/11/25 indicated P2 was discharged to her home the discharge reason was the nurse was unable to contact P2 throughout the months of October and November. The summary indicated P2 had been progressing toward her goals. Documentation under the title patient and/or family post discharge instructions indicated P2 was hospitalized (no dates indicated). RN-A requested HHA office staff obtain a discharge summary from the hospital, but did not receive any response from the office staff. The discharge summary did not have the providers signature and did not indicate if the document was faxed to the provider and when in the spaces provided. In addition, the note did not indicate any discharge planning measures or goals. Upon interview on 11/20/25 at 9:20 a.m. RN-A stated P2 had been in and out of the hospital. She stated the practice of the HHA was when the HHA is unable to see the patients for any reason when the certifications become due the agency is required to discharge the patients. She did not provide any discharge planning because the discharge was not planned. Upon interview on 11/20/25 at 2:24 p.m. P2’s primary care providers certified medical assistant (CMA) stated the last correspondence the clinic had with the HHA was a recertification fax on 9/9/25. There was no communication with the clinic regarding missed visits, discharge planning or an actual discharge. Upon interview on 11/20/25 at 8:30 a.m. RN-B stated she was not aware whether P2 was still a patient or not since she stepped down from the director of nursing position, she had not been tracking discharges. An agency policy titled Policy on Client Discharged undated indicated: Clients will be discharged from services when requests were not within the scope of the agency’s resources, policies, and procedures. the HHA’s discharge criteria included the following: 1. The client has reached the optimum rehabilitative potential. 2. The client refuses services or requests that services be discontinued. 3. The client expires. 4. The client 18 years and older enters an inpatient facility for greater than a 24-hour time. If there are no significant changes in the Plan of Treatment, the discharge procedure may be waived at the discretion of the Director of Nursing or designee. 5. The client’s service needs change requiring a referral to another provider. 6. The client’s service needs cannot be met by the agency’s resources. 7. The services are terminated by the client’s physician through written order. 8. The client’s responsible party refuses to comply with the provisions of the Plan of Care jeopardizing the health, safety and welfare of the client, caregiver, and/or agency staff. 9. The client is non-complaint with supervision. If the PCA/Aide/Homemaker is a family member and is non-complaint with supervision. 10. There is no payer for services.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to complete a comprehensive assessment including the Outcome and Assessment Information Set (Oasis) within two days of discharge for 1 of 3 patients (P1) reviewed for discharge. Based on interview and record review the home health agency (HHA) failed to complete a comprehensive assessment including the Outcome and Assessment Information Set (Oasis) within two days of discharge for 1 of 3 patients (P1) reviewed for discharge. Findings include: P1’s Home Health Plan of Care and Certification for certification period 6/20/25 – 8/18/25 indicated P1’s diagnoses were autistic disorder and unspecified intellectual disabilities. P1’s mental status was oriented, forgetful, and depressed. P1 was ordered to have skilled nursing every other week to observe and assess vital signs and to monitor respiratory status, gastrointestinal status, cardiopulmonary status, integumentary status, pain management, endocrine status, neurological status, renal/genitourinary status, observe and assess mental status and to observe and assess medication compliance, response, set-up medications and assist with ordering medications. P1’s last skilled nursing visit note dated 8/21/25 indicated P1 lived alone in a condominium. He was oriented, but forgetful. He attended a day program five days a week. P1 had a history of seizure activity. He would have absent seizures that lead to grand mal seizures. He reported having difficulty starting urine stream. He needed assistance with medication regimen related to self-care deficit. P1’s medications were filled for two weeks. Registered nurse (RN)-A documented she was not able to accommodate P1’s requests to have his medications filled on Tuesday or Thursday mornings. She notified the scheduling staff at the HHA. Email correspondence from the HHA administrative assistant to the Administrator and the director of nursing (DON) dated 10/6/25 at 2:42 p.m. indicated P1’s outside case manager (CM) called the HHA because she was told by RN-A that P1’s visits were passed along to another nurse. She was wondering who the nurse was and how to contact them. The assistance looked in P1’s file and found there was no primary nurse assigned to P1. The assistant reached out to RN-A that another agency will see P1 and for RN-A to discharge him. P1’s medical record dated 10/9/25– 11/19/25 did not indicate a comprehensive assessment or OASIS was completed by the HHA. Email correspondence dated 11/19/25 at 2:56 p.m. from the HHA administrator indicated P1 was transferred to another agency. In a subsequent email 11/19/25 at 3:33 p.m. she indicated P1’s case manager reached out to the HHA to let them they were transferring him to a new agency as the agency nurse was unable to reach him to schedule nursing visits. She indicated she would follow-up with an HHA nurse to get his discharge completed. Upon interview on 11/19/25 at 10:45 a.m. P1’s CM stated on 10/7/25 P1 notified her that he had not had his seizure medication in a few days, and he was unable to get a refill on his own. The CM assisted him to get the medication. P1 told the CM that he had been discharged from the agency. The CM called the agency and was told RN-A was unable was to see P1 and another agency nurse would be completing his nursing visits. When the HHA looked up the nurse who was supposed to be seeing P1 the agency revealed there was not a nurse scheduled for P1, and the HHA did not have one so P1 would need to be discharged. Upon interview on 11/19/25 at 12:27 p.m. RN-A stated she had completed nursing visits for P1, however due to scheduling conflicts she was unable to see him after the 8/21/25 visit. She was given the name of another HHA nurse who would see P1. RN-A was not aware that P1 had not been seen and did not recall being asked to discharge him. An HHA policy on Oasis requirements was requested, however the agency sent the agencies submission reports and direction for exporting Oasis documents.”