Home Health Care Inc.

“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 severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: G570 at 42 CFR 484.60. The agency failed to provide services in the care plan for 5 of 17 patients (P1, P2, P3, P5, P17), to ensure all requirement were included in the plan of care (POC) for 4 of 17 patients (P1, P2, P7, P14), provide treatments only as ordered by a physician for 1 of 17 patients (P6), ensure POCs were reviewed and signed in their entirety for 3 of 17 patients (P1, P2, P14), ensure prompt notification to physicians when 2 of 17 patients (P1, P2) had a change in condition, provide integration of services provided by the agency and other entities for 2 of 17 patients (P1, P13), provide coordination of care with patients’ representatives for 2 or 17 patients (P1, P7), and failed to provide patient/caregiver written education for 1 of 17 patients (P1). P1 was admitted to the hospital with four pressure injuries and cachexia (significant weight and muscle loss). P2 was admitted to the hospital with bilateral extremity for increased edema. Findings include: Refer to G572: Based on interview and document review the agency failed to provide services indicated in the plan of care for 5 of 17 patients (P1, P2, P3, P5, P17) reviewed for individualized plan of care. Refer to G574: Based on interview and record review, the agency failed to ensure all requirements were included in the plan of care (POC) for 4 of 17 patients (P1, P2, P7, P14) who received home care services. Refer to G580: Based on observation, interview, and document review the agency failed to provide treatments only as ordered by a physician for 1 of 17 patients (P6) reviewed for physician orders. Refer to G588: Based on interview and document review the agency failed to ensure 3 of 17 patients (P1, P2,P14) plans of care (POC) were reviewed and signed in their entirety by their provider every 60 days. Refer to G590: Based on interview and document review the agency failed to promptly inform the physician of changes in condition for 2 of 17 patients (P1, P2) reviewed for change of condition, when P1 was admitted to the hospital with four pressure injuries and cachexia (significant weight and muscle loss) without his physician aware of the wounds and when P2 was admitted to the hospital with bilateral extremity edema, without her physician aware of the increase in edema present for days to weeks, according to hospital records. Refer to G592: Based on interview and document review, the agency failed to revise the plan of care (POC) for 2 of 17 patients (P1, P2) reviewed when there were changes in nutrition and wounds. Refer to G606: Based on interview and document review, the agency failed to integrate services provided by the agency and services provided by other entities were coordinated to evaluate treatment effectiveness and promote patient well-being for 2 of 2 (P1, P13) patients who received services from other medical specialties or care agencies. Refer to G608: Based on interview and document review, the agency failed to involve the patients’ representative in the coordination of care for 2 of 17 patients (P1, P7) when the registered nurse (RN) failed to communicate with P1’s family member, who also served as P1’s personal care assistant (FM/PCA)-C, regarding P1’s declining condition including pressure injuries and when P7’s family member, who also served as her power of attorney (POA) was not contacted regarding her enrollment in home care services and development of her care plan. Refer to G612: Based on interview, and document review the agency failed to provide written education regarding wound care and pertinent instructions related to care and treatment for 1 of 17 patients (P1) reviewed for patient/caregiver education.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on the number and severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: G750 at 42 CFR 484.80. The agency failed to involve the patients’ aides as member of the interdisciplinary team in the coordination of care for 2 of 17 patients (P1, P7), conduct 14-day supervisory visits for patients receiving aide services for 2 of 17 patients (P1, P17), and ensure an onsite supervisory visit was conducted every 60 days for 1 of 1 patient (P15). P1 was admitted to the hospital with four pressure injuries and cachexia (significant weight and muscle loss). Findings include: Refer to G804: Based on interview and document review, the agency failed to involve the patients’ aides as member of the interdisciplinary team in the coordination of care for 2 of 17 patients (P1, P7) when the registered nurse (RN) failed to communicate with P1’s aide who is also P1’s family member, (FM/PCA)-C, regarding P1’s declining condition. P1 was hospitalized with four pressure injuries and cachexia (significant weight and muscle loss). In addition, P7’s aide who is also P17’s family member, FM/PCA-A who also served as her power of attorney (POA) was not contacted regarding her enrollment in home care services and development of her care plan. Refer to G808: Based on interview and document review the agency failed to conduct 14-day supervisory visits for patients receiving aide services for 2 of 17 patients (P1, P17) reviewed. Refer to G814: Based on interview and record review, the agency failed to ensure an onsite supervisory visit was conducted every 60 days for 1 of 1 patient (P15) who received Community First Services and Support (CFSS) without skilled services.”

“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 develop a comprehensive emergency preparedness program (EPP) which addressed the patient population, including persons at risk, with identified needs for required services. Additionally, the EP plan failed to identify the services the agency was able to provide in the event of an emergency. This had the potential to affect all patients receiving services from the agency, as well as other potential patients they may serve in an emergent event. Findings include: A review of the facility profile, found in the agency binder, an identification of geographical areas served by the agency was outlined. The documentation also outlined the services provided by the agency, identified as providing care to the older adult and elderly population, along with those who are physically or mentally disabled. The document identified all clients (patients) were considered vulnerable adults. The document lacked information as to the characteristics of the population served, including potential “at-risk populations” defined as individuals who may need additional response assistance including those who had disabilities, lived in institutionalized settings, were from diverse cultures and racial and ethnic backgrounds, had limited English proficiency or were non-English speaking, lacked transportation, had chronic medical disorders, or had pharmacological dependency. On 10/16/25, at 10:30 a.m., the director of nursing stated there were no further assessments available for review. DON stated she was unaware of this requirement within the emergency preparedness plan.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure an individualized emergency plan was developed for 14 of 17 patients (P1, P2, P3, P4, P5, P6, P7, P9, P10, P11, P12, P13, P16, P17) reviewed who received home care services. P13 P13’s POC for certification period dated 10/2/25-11/30/25, indicated P13 was orientated and had diagnoses of pressure ulcer, diabetes, and end stage renal disease. P13 had activity as tolerated with a walker and wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, lacked indication P13 required a walker and wheelchair for ambulation and did not indicate a safe evacuation destination if needed. P16 P16’s POC for certification dated 9/24/25-11/22/25, indicated P16 was orientated and had diagnoses of pressure ulcer and diabetes. P16 was ambulatory with shortness of breath with minimal exertion and had no durable medical equipment in place. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P16 was chair bound, however lacked indication what medical equipment was needed to evacuate safety. The report further indicated if needed, P16 would evacuate to a shelter of unknown location. P17 P17’s POC for certification period 9/110/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P17 was ambulatory with assistance and required a walker, however lacked indication a wheelchair was needed. The report further indicated if needed, P17 would evacuate to a shelter of unknown location. Findings include: P1’s plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC indicated required assistance and his walker to ambulate. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P1 required assistance to ambulate but lacked required medical equipment to safely ambulate. Further, the report indicated if needed P1 would evacuate to an unidentified outside location. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC indicated she was independent with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P2 was ambulatory with assistance but lacked equipment required for ambulation. The report further indicated if needed P2 would evacuate to a shelter of unknown location. P3’s POC/485 for certification period 7/27/25 to 9/24/25 indicated she had diagnoses of cellulitis (a bacterial infection of the skin) of the right lower leg, stage 4 pressure ulcer (a severe pressure ulcer with complete tissue loss exposing muscle, tendon or bone), of the sacral region, diabetes, chronic kidney disease, pressure ulcer of left buttock, sepsis (serious condition where the body has an extreme reaction to an infection), lymphedema, and depression. P3’s POC indicated she required a walker for ambulation. A facility report titled Emergency Preparedness report dated 10/16/25, indicated she was ambulatory with assistance but lacked indication P3 required a walker for ambulation. The report further indicated if needed, P3 would evacuate to a shelter of unknown location. P4’s POC/485 for certification period 8/27/25 to 10/25/25 indicated she had diagnoses of sinusitis, anxiety, and hypertension (high blood pressure). P4’s POC indicated she was up independently at home with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated she required assistance with ambulation but lacked medical equipment required. The report further indicated if needed, P4 would evacuate to an unidentified outside location. P5’s POC/485 for certification period 9/3/25 to 11/1/25 indicated she had diagnoses of pneumonia, urinary tract infection (UTI), heart failure, diabetes, chronic kidney disease, and dementia. P5’s POC indicated she was independent with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P5 was ambulatory with assistance. The report further indicated if needed, P5 would evacuate to the end of the driveway. P6’s POC/485 for certification period 8/17/25 to 10/15/25, indicated he had diagnoses of cellulitis (a bacterial infection of the skin) of the left lower leg, diabetes, chronic kidney disease, and peripheral vascular disease (a condition where plaque buildup narrows the arteries, reducing blood flow). P6’s POC indicated he required a walker for ambulation. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P6 ambulated with assistance with the use of a walker. The report further indicated if needed, P6 would evacuate to a shelter of unknown location. P7’s POC/485 for certification period 10/1/25 to 11/29/25, indicated she had diagnoses of Alzheimer’s Disease, dementia, and repeated falls. P7’s POC indicated she was on bedrest with bathroom privileges (BRP) and required a wheelchair for mobility. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P7 was chair bound, however lacked indication what medical equipment was needed to evacuate safety. The report further indicated if needed, P7 would evacuate to a shelter of unknown location. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated the individualized emergency plans should be included in the patients’ plan of care (POC). The DON stated she did not see the emergency plans when she viewed several in the EMR system. P9’s plan of care (POC)/485 for certification period 8/17/25 to 10/1525, indicated P9 had diagnoses of type two diabetes (a chronic disease which affects how your body uses sugar) with diabetic peripheral angiopath(y) (a disease which limits blood flow to your legs and feet) without gangrene (tissue death as a result of decreased blood flow), diabetic neuropathy (a loss of sensation in extremities (legs, feet,), essential (primary) hypertension (high blood pressure), and chronic obstructive pulmonary disease (a lung and airway disease which restricts your breathing). P9 was identified as oriented, with forgetfulness and required the use of walker for mobility. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P9 required assistance to ambulate, however, lacked indication of required medical equipment to safely ambulate. The report lacked an identified evacuation location for P9. P10’s plan of care (POC)/485 for certification period 9/10/25 to 11/8/25, indicated P10 had diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting his non-dominant side of the body, osteoarthritis (inflammation of joints-unspecified), and history of falling. P10’s diagnoses listing also included a history of anxiety, and a problem with health literacy (the ability to find, understand, and use information and services to make health-related decisions and actions for themselves and others). P10 was identified as being oriented, but forgetful and depressed. P10’s POC indicated required no assistive devices under the durable medical equipment listing, however, identified “walker” under exercises permitted. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P10 required assistance to ambulate but lacked required medical equipment to do so safely. The report indicated, if needed, P10 would evacuate to a “local shelter” however, no further information was designated as to location of shelter, type of shelter, or mode of transportation to shelter. P11’s plan of care (POC)/485 for certification period 8/6/25 to 10/4/25, indicated P11 had diagnoses of venous insufficiency (chronic and peripheral-a condition which impacts the circulation of the blood), chronic ulcer of the right calf (ongoing wound of the lower leg), type two diabetic neuropathy, acquired absence of the left leg above the knee, and a dependence on a wheelchair. P11’s POC indicated P11 was oriented. The DME section indicated P11 required a walker, however, lacked indication of a wheelchair. The activities permitted section indicated P11 was allowed to be up as tolerated and identified P11 had crutches and a wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P11 was ambulatory with assist, however, lacked indication of need for DME (crutches/walker/wheelchair). Further, the report lacked indication as to where P11 was to evacuate to in the event of an emergency. P12’s plan of care (POC)/485 for certification period 9/18/25 to 11/16/25, indicated P12 had diagnoses of pressure ulcer (also known as a bedsore or decubitus ulcer-are injuries to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (high blood pressure), heart failure, and reduced mobility. P12’s POC indicated P12 could be up as tolerated and identified use of a walker. The POC listed DME, which included a cane, walker, rolling walker and wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P12 required assistance to ambulate but lacked required medical equipment to do so safely. The plan f lacked indication as to where P12 was to evacuate in the event of an emergency. Findings include: P1’s plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC indicated required assistance and his walker to ambulate. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P1 required assistance to ambulate but lacked required medical equipment to safely ambulate. Further, the report indicated if needed P1 would evacuate to an unidentified outside location. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC indicated she was independent with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P2 was ambulatory with assistance but lacked equipment required for ambulation. The report further indicated if needed P2 would evacuate to a shelter of unknown location. P3’s POC/485 for certification period 7/27/25 to 9/24/25 indicated she had diagnoses of cellulitis (a bacterial infection of the skin) of the right lower leg, stage 4 pressure ulcer (a severe pressure ulcer with complete tissue loss exposing muscle, tendon or bone), of the sacral region, diabetes, chronic kidney disease, pressure ulcer of left buttock, sepsis (serious condition where the body has an extreme reaction to an infection), lymphedema, and depression. P3’s POC indicated she required a walker for ambulation. A facility report titled Emergency Preparedness report dated 10/16/25, indicated she was ambulatory with assistance but lacked indication P3 required a walker for ambulation. The report further indicated if needed, P3 would evacuate to a shelter of unknown location. P4’s POC/485 for certification period 8/27/25 to 10/25/25 indicated she had diagnoses of sinusitis, anxiety, and hypertension (high blood pressure). P4’s POC indicated she was up independently at home with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated she required assistance with ambulation but lacked medical equipment required. The report further indicated if needed, P4 would evacuate to an unidentified outside location. P5’s POC/485 for certification period 9/3/25 to 11/1/25 indicated she had diagnoses of pneumonia, urinary tract infection (UTI), heart failure, diabetes, chronic kidney disease, and dementia. P5’s POC indicated she was independent with her walker. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P5 was ambulatory with assistance. The report further indicated if needed, P5 would evacuate to the end of the driveway. P6’s POC/485 for certification period 8/17/25 to 10/15/25, indicated he had diagnoses of cellulitis (a bacterial infection of the skin) of the left lower leg, diabetes, chronic kidney disease, and peripheral vascular disease (a condition where plaque buildup narrows the arteries, reducing blood flow). P6’s POC indicated he required a walker for ambulation. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P6 ambulated with assistance with the use of a walker. The report further indicated if needed, P6 would evacuate to a shelter of unknown location. P7’s POC/485 for certification period 10/1/25 to 11/29/25, indicated she had diagnoses of Alzheimer’s Disease, dementia, and repeated falls. P7’s POC indicated she was on bedrest with bathroom privileges (BRP) and required a wheelchair for mobility. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P7 was chair bound, however lacked indication what medical equipment was needed to evacuate safety. The report further indicated if needed, P7 would evacuate to a shelter of unknown location. P9’s plan of care (POC)/485 for certification period 8/17/25 to 10/1525, indicated P9 had diagnoses of type two diabetes (a chronic disease which affects how your body uses sugar) with diabetic peripheral angiopathy) (a disease which limits blood flow to your legs and feet) without gangrene (tissue death as a result of decreased blood flow), diabetic neuropathy (a loss of sensation in extremities (legs, feet,), essential (primary) hypertension (high blood pressure), and chronic obstructive pulmonary disease (a lung and airway disease which restricts your breathing). P9 was identified as oriented, with forgetfulness and required the use of walker for mobility. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P9 required assistance to ambulate, however, lacked indication of required medical equipment to safely ambulate. The report lacked an identified evacuation location for P9. P10’s plan of care (POC)/485 for certification period 9/10/25 to 11/8/25, indicated P10 had diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting his non-dominant side of the body, osteoarthritis (inflammation of joints-unspecified), and history of falling. P10’s diagnoses listing also included a history of anxiety, and a problem with health literacy (the ability to find, understand, and use information and services to make health-related decisions and actions for themselves and others). P10 was identified as being oriented, but forgetful and depressed. P10’s POC indicated required no assistive devices under the durable medical equipment listing, however, identified “walker” under exercises permitted. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P10 required assistance to ambulate but lacked required medical equipment to do so safely. The report indicated, if needed, P10 would evacuate to a “local shelter” however, no further information was designated as to location of shelter, type of shelter, or mode of transportation to shelter. P11’s plan of care (POC)/485 for certification period 8/6/25 to 10/4/25, indicated P11 had diagnoses of venous insufficiency (chronic and peripheral-a condition which impacts the circulation of the blood), chronic ulcer of the right calf (ongoing wound of the lower leg), type two diabetic neuropathy, acquired absence of the left leg above the knee, and a dependence on a wheelchair. P11’s POC indicated P11 was oriented. The DME section indicated P11 required a walker, however, lacked indication of a wheelchair. The activities permitted section indicated P11 was allowed to be up as tolerated and identified P11 had crutches and a wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P11 was ambulatory with assist, however, lacked indication of need for DME (crutches/walker/wheelchair). Further, the report lacked indication as to where P11 was to evacuate to in the event of an emergency. P12’s plan of care (POC)/485 for certification period 9/18/25 to 11/16/25, indicated P12 had diagnoses of pressure ulcer (also known as a bedsore or decubitus ulcer-are injuries to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (high blood pressure), heart failure, and reduced mobility. P12’s POC indicated P12 could be up as tolerated and identified use of a walker. The POC listed DME, which included a cane, walker, rolling walker and wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P12 required assistance to ambulate but lacked required medical equipment to do so safely. The plan f lacked indication as to where P12 was to evacuate in the event of an emergency. P13’s POC for certification period dated 10/2/25-11/30/25, indicated P13 was orientated and had diagnoses of pressure ulcer, diabetes, and end stage renal disease. P13 had activity as tolerated with a walker and wheelchair. A facility report titled Emergency Preparedness report dated 10/16/25, lacked indication P13 required a walker and wheelchair for ambulation and did not indicate a safe evacuation destination if needed. P16’s POC for certification dated 9/24/25-11/22/25, indicated P16 was orientated and had diagnoses of pressure ulcer and diabetes. P16 was ambulatory with shortness of breath with minimal exertion and had no durable medical equipment in place. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P16 was chair bound, however lacked indication what medical equipment was needed to evacuate safety. The report further indicated if needed, P16 would evacuate to a shelter of unknown location. P17’s POC for certification period 9/110/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. A facility report titled Emergency Preparedness report dated 10/16/25, indicated P17 was ambulatory with assistance and required a walker, however lacked indication a wheelchair was needed. The report further indicated if needed, P17 would evacuate to a shelter of unknown location. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated the individualized emergency plans should be included in the patients’ plan of care (POC). The DON stated she did not see the emergency plans when she viewed several in the EMR system. A policy was requested for completion of the individual patient emergency preparedness plan was requested but not received.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to maintain updated policies and procedures to maintain a system of for medical documentation that secured and maintained the availability of patient information. This had the potential to affect all patients served by the agency. Findings include: A review was completed of the agency Emergency Preparedness Plan. Within the plan, it was identified under the section identified as Medical Records that “Medical records for All [sic] clients will be maintained in the Devero (electronic medical record system for documentation and record storage). The policy further stated “If the system is not accessible, clinicians will use a backup paper system and deliver their documentation to the designated office for secure placement within 24 hours. See attached Devero Emergency Management Plan.” Upon full review of the Emergency Preparedness Plan for the agency, additional policies and procedures related to the Devero system, as well as an additional system identified as Allayah. A document, dated 3/9/20, identified as Homecare Homebase Emergency Downtime was present in the binder, however, this was related to staff notification and running of reports. This did not reflect access of patient information. During interview on 10/16/25, at 10:30 a.m., the director of nursing (DON) stated the current system for documentation was HomeCare HomeBase and identified this had been in place for greater than a year. DON stated in the event of emergency, with computer access impacted, the staff would transition to paper documentation, however, although requested, no further resources related to forms and processes were provided.”

“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 maintain a communication plan within the agency which demonstrated how agency staff would be alerted if there was need for emergent response and provided with instructions as to response. This had the potential to affect all patients served by the agency. Findings include: A review of the agency’s Emergency Preparedness binder was completed. Upon review of the section identified as Communication, it was identified with internal communication within the agency, the agency would maintain a listing of employees, including their contact information and their emergency contact. The policy identified staffing information was maintained within the agency’s electronic medical record (EMR) but did not specify which EMR was within use. The policy went on to state “if the ability to obtain such information is interrupted agency will print an employee list with their contact information and place it in the front of the emergency preparedness manual. The policy also indicates a listing with patient information, including provider contact information, was also to be printed and placed in the front of the binder on Monday. A review of the materiel within the binders identified the facility binder lacked both a staff listing with contact information, as well as patient listings with appropriate information. During interview on 10/16/25, at 10:30 a.m., the director of nursing (DON) identified the staff contact numbers and emergency contact listing was located within the electronic medical record. A hard copy with identified information was to be printed each Monday and placed in the front binder of the emergency preparedness manual. Upon review of the agency emergency preparedness binder, DON acknowledged neither a current, nor outdated listing, of staff and patient information was found in the binder.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to fully develop and maintain an emergency communication plan to allow for ongoing communication between the agency, staff, patients and other partners at the local, county, regional, State, Tribal and Federal levels in the event of an emergency. A review was completed of the agency Emergency Preparedness Plan. The agency plan outlined their primary means of communication during day-to-day operations included the use of telephone and/or cell phone services. The policy further went on to identify in the event cell service or land line phone services were not working, communication would be shared with the use of local media and radio stations. Although the policy identified the use of local news media and radio services, the policy lacked a process to contact the news media and radio stations. The policy lacked phone numbers and key contacts in the event phone services were effective, as well as alternatives for outreach in phone services were down. The policy went on to indicate owners and leadership will be notified immediately if activation of the Emergency Procedure Plan is needed. The policy lacked alternate means of communication with these partners if the phone system is not functioning. The policy identified the possible use of phone, emails, text, or in person notification. The policy went on to indicate communication may change to walkie talkie or 2-way radio communication as requested by local agencies. An interview was completed on 10/16/25, at 10:30 a.m. with director of nursing (DON). DON stated she was unaware if there were walkie-talkies or 2-way radios available for use in the agency. DON stated they had not used them historically., nor had they completed training with them. DON stated the staff contact list was not in the Emergency Preparedness Plan binder, although it was supposed to be updated and placed there routinely on Mondays. Further contact information plans and information was requested for outreach to the local media and radio stations, however, was not received.”

“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 emergency preparedness plan lacked a training and testing program to reflect the risks and effectiveness of their emergency plan. Findings include: A review was completed of the agency Emergency Preparedness Plan. The binder included an assessment, titled All Hazard Vulnerability Assessment-Home Health Care, INC of 1/2/25. An All-Hazard Vulnerability Assessment (HVA) is an assessment completed by the agency to identify areas of vulnerability and the agency’s level of preparedness for the event. The assessment takes into account natural hazards (tornado, severe thunderstorm, blizzard...), information technology hazards (malicious software, data center failure, network based cyber attach...), technological failure (power outage, fuel shortage, information system failure, ...), human hazards (terrorism, civil disturbance...), and hazardous materials (radiologic exposure, chemical exposure, etc...). Within the assessment, the agency considers the probability the event would occur, as well as the agency’s ability to respond. The assessment is then scored using the probability the event would occur, in addition to the agency level of preparedness. This provides the agency with the potential likelihood of the occurrence on a numerical scale, with the greater the number, the higher the likelihood. Upon review, it was identified the agencies greatest risk for vulnerability was that of an information system failure (scored at a level of eight). The next highest risk level identified was with a score of seven, which included: Ice/Snow, Blizzard, Earthquake, Fire, Epidemic/Flu-Disease, Active Shooter, and Transportation Failure. Upon review of the agency Emergency Preparedness Plan binder, it was identified the plan lacked a training plan for upcoming training on the identified vulnerabilities in either an educational format, tabletop, or full-scale exercise. The binder lacked any future plans for training of any sort for upcoming exercises, either identified through the HVA, or with other partners such as the health care coalition, local partners, or any other partners within the area of service. During interview on 10/16/25, at 10:30 a.m., the director of nursing acknowledged the EP binder lacked a training plan for any training, either from the past or planned for the future. DON stated there was a meeting with the Coalition in November. DON stated she was unaware a training plan was required.”

“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 documentation and interview, the facility failed to report all Outcome and Assessment Information Sets (OASIS) data collected in accordance with federal regulations. A review of the total number of records submitted beyond the 30 days between the dates of 1/1/25-10/16/25 was 272, which equaled 100% of submissions. Findings include: On the HHA Error Summary by Agency report period of 1/1/2025-10/16/2025, the agency had an error code of -3330: which identified a record submitted more than 30 days after completion of the new record. The total number of records submitted beyond the 30 days within that period was noted to be 272 out of 272 submissions, which equaled 100% of the submissions submitted. On 10/16/25, at 10:30 a.m. director of nursing (DON) stated she had a report from Centers for Medicaid and Medicare Services (CMS) which indicated they had an error rate of 1.9%. with their submissions of OASIS. DON stated late submissions had occurred when there was a payor source change, at which time the OAISIS document must be backed out and resubmitted. DON stated she received routine reports on OASIS submissions on a weekly to twice weekly basis and followed up with the clinicians. DON stated they previously had been outsourcing the “scrubbing” of OASIS documents but had discontinued that on 9/30/25. Documentation was requested to reflect this, however, DON stated there was no documentation available to reflect this. DON stated was unsure of the effectiveness of this change as it had been less than one month. A secondary report was run for the OASIS submission data for 10/1/25-10/17/25 and reflected there were ten submissions, with ten errors identified for being submitted beyond the 30 days. A request was made to review the report from CMS. On 10/16/25, at 12:54 p.m. the report from CMS, titled Quality Assessments Only (QAO) was provided, and indicated a pass rate of 99.1 %. DON acknowledged this was not reflective of timeliness of submission. DON stated there was not a separate agency policy for OASIS completion and submission. The agency followed the manual for OASIS from CMS (Centers for Medicare and Medicaid).”

“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 document review the agency failed to provide services indicated in the plan of care for 5 of 17 patients (P1, P2, P3, P5, P17) reviewed for individualized plan of care. P17 P17’s plan of care (POC) dated 9/110/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. P17’s private duty POC dated 9/10/25-11/18/25, indicated P17 required patient care assistant (PCA) services up to 12.5 hours a week for assistance with activities of daily living and care due to functional limitations. P17’s electronic medical record (EMR) lacked indication P17 had received PCA services since 9/28/25. P17’s EMR lacked indication P17 had missed any PCA visits or that P17’s provider was notified of missed visits. When interviewed on 10/16/25 at 4:13 p.m., PCA-A stated she and PCA-B both cared for P17. PCA-A stated the hours were being completed, however the visits were not always documented. PCA-A further stated PCA=B and herself were in P17’s home more that the allowed 12.5 hours, however acknowledged there was no documentation to show their time and what cares had been provided. PCA-A acknowledged the hours and cares should be documented. When interviewed on 10/16/25 st 4:27 p.m., the Director of Nursing (DON) stated PCA visits were expected to be documented at the time of the visit to show what cares were provided. If there are missed visits or the hours were not met for the week, the same process would be followed for home health aides and a missed visit note and provider notification should be completed. Furthermore, DON stated aides were not allowed to document missed visits and this was done on the back end with the billing department. If it was determined they were under hours, then they would document a missed visit. DON verified there was no documentation of PCA services for P17 since 9/28/25 and this would need more follow up to determine why this happened. A facility policy titled Home Health Aide Services, no date, directed staff to document all aide services provided under the POC. A facility policy titled Clinical Documentation, no date, directed staff to document services not provided as ordered and the reason for the missed visits to be documented and reported to the patient’s provider. Findings include: P1’s skilled services plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed skilled nursing visits twice weekly. P1’s POC directed to assess/evaluate comorbid conditions including diagnosis list and other conditions that present themselves during the episode to identify changes and intervene to minimize complications. P1’s POC included orders to observe and evaluate integumentary status to identify changes and intervene to minimize complications and provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen, and wound care. It also directed skilled nurse to report significant changes in status to physician for early intervention. P1’s POC also directed for skilled nurse to perform a multifactorial fall risk assessment and implement interventions to avoid falls. P1’s skilled nurse recertification note, dated 9/9/25, indicated P1 lived alone, environmental hazards were assessed, and no community resources were needed at the time of the assessment. It also indicated integumentary of P1 was assessed and no problems were identified, including no pressure ulcers. It indicated a standard mattress was appropriate for P1. Nutritional needs documented as probably inadequate as P1 ate only half of food offered, then also noted no nutritional problems noted. Falls were not assessed, noted as “not applicable”. The assessment indicated no new symptoms were identified associated with P1’s comorbid conditions and no care coordination occurred. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of additional wounds, teaching, or coordination of care. P1’s hospital records indicated he was admitted for disorientation and weakness on 9/30/25. P1 was diagnosed with septic shock, acute on chronic subdural hematomas, and was described as cachectic on arrival. Hospital documents indicated P1 was admitted with pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated P1 did not speak English, had significant cognitive impairment and lived in his apartment alone with 12 hours of PCA services per day, leaving him alone at night. RN-B stated P1 was unable to get out of bed independently, was incontinent of bowel and bladder, and was unable to reposition himself in bed. RN-B stated P1 had “new wounds every week” but RN-B did not document on all of the wounds, rather he left thigh wound on the chart to remind nurses to assess for wounds. RN-B stated he did not inform P1’s primary care physician of each new wound. RN-B stated P1 was dependent on others for care and mobility since he started working with him on 7/28/25. On 10/8/25 at 2:05 p.m., MD-A stated the pressure wounds P1 presented to the hospital with would have taken weeks to months to develop. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s electronic medical record lacked PCA notes regarding skin alterations, report of falls, or communication with the registered nurse (RN). On 10/10/25 at 10:10 a.m., PCA-C stated P1 had “a number of falls in the past few months”. PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. P1’s electronic medical record lacked documentation of P1’s falls or teaching on medication regimen. P2’s initial POC/485 for certification period 7/26/25 to 9/23/25, indicated she had diagnoses of anxiety, chronic kidney disease, diabetes, and infection following a procedure. P2’s POC had orders for skilled nursing once for the first week, three times a week for the second week, then two times per week for two weeks, followed by once weekly nursing visits for six weeks. Physical therapy (PT) was ordered once for the first week, then two times per week for three weeks, followed by once weekly for five weeks. Occupational therapy (OT) was ordered once for the first week, then twice weekly for two weeks, followed by once weekly for six weeks. Home health aide (aide) once weekly for nine weeks. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC directed skilled nursing visits twice weekly and physical therapy visits twice weekly for two weeks, then once weekly for six weeks. P2’s POC orders directed skilled nurse to assess/evaluate comorbid conditions that present themselves during this episode to identify changes and intervene to minimize complications. During an observation on 10/6/25 at 1:00 p.m., P2 reported to RN-B she had a fall earlier in the day while physical therapy was present. P2 stated, “I hope I didn’t break any ribs,” as she held her right hand over her left lateral chest area. She reported her pain was 7 out of 10. P2 also reported bilateral lower legs were more swollen and “weeping some”, leaving her pant legs wet. P2 was wearing a shirt with long sleeves and pants covering her legs. She stated she had to wear special pants that would accommodate the additional swelling. RN-B slightly lifted P2’s left pant leg approximately 2 inches. RN-B stated P2 had 2+ pitting edema (indicating a moderate degree of swelling). RN-B offered to wrap P2’s legs, which P2 declined. RN-B lifted P2’s shift and assessed P2’s post-surgical scar on her abdomen, which was not covered by a dressing. RN-B did not assess P2’s left chest area of pain or her right leg with concerns of edema. RN-B did not assess any other areas of P2’s skin covered by her clothing. A skilled nursing visit note, dated 10/6/25, indicated P2 had pain rated at 7 out of 10, with areas of pain identified as her chest/ribs, abdomen, her left arm and left leg. RN-B documented integumentary (skin, hair, and nails) were assessed, with no problems identified. RN-B documented P2’s cardiovascular system was assessed and was within normal limits (WNL). The 10/6/25 visit note lacked documentation of P2’s increased bilateral extremity edema with weeping. The note lacked coordination of care with P2’s primary care provider. A hospital discharge summary for P2, for hospitalization 10/9/25 to 10/12/25, indicated P2 was referred to the emergency department on 10/8/25 while undergoing a diagnostic test. P2 was admitted for bilateral lower extremity edema. The note indicated P2 reported increasing lower extremity edema over the past several days to weeks. P2 was treated with intravenous (IV) diuretic (medication used to decrease extra fluid) medication. P2’s medical record lacked updates to the physician regarding the surgical wounds and orders to discontinue wound care. P2’s medical record lacked record of aide visits, without notification to the physician. P2’s medical record included a physician’s order, dated 8/17/25, to discontinue aide visits. On 10/6/25 at 1:35 p.m., RN-B stated he did not provide updates to P2’s physician as P2 was able to communicate through her clinic’s website. On 10/16/25 at 9:50 a.m., P2’s physician (MD)-B stated the home care agency had not provided updates on P2’s change in condition related to her increased edema. On 10/16/25 at 11:00 a.m., clinical manager (CM)-C stated the form for the missed aide visits was not completed, when P2 declined the aide visits, subsequently the physician was not informed. P3’s POC/485 for certification period 7/27/25 to 9/24/25 indicated she had diagnoses of cellulitis (a bacterial infection of the skin) of the right lower leg, stage 4 pressure ulcer (a severe pressure ulcer with complete tissue loss exposing muscle, tendon or bone), of the sacral region, diabetes, chronic kidney disease, pressure ulcer of left buttock, sepsis (serious condition where the body has an extreme reaction to an infection), lymphedema, and depression. The POC included orders for skilled nursing four times during the first week, then twice weekly for two weeks, followed by once weekly for six weeks. Physical therapy (PT) was ordered twice weekly for three weeks, then once weekly for six weeks. Occupational therapy (OT) was ordered once weekly for two weeks. PT was ordered to provide therapeutic exercises and soft tissue/joint mobilization designed to restore functional strength and range of motion (ROM). P3’s chart included a coordination note indicating a PT visit was missed on 8/8/25. The note lacked advice or education provided to the patient regarding the impact of the missed visit. The chart lacked evidence the physician was notified of the missed visit. P5’s POC/485 for certification period 9/3/25 to 11/1/25 indicated she had diagnoses of pneumonia, urinary tract infection (UTI), heart failure, diabetes, chronic kidney disease, and dementia. P5’s POC included orders for skilled nursing once for one week, then twice weekly. P5’s POC had orders for physical therapy (PT) once for one week, then twice weekly for three weeks, followed by once weekly for five weeks. P5’s POC had orders for occupational therapy (OT) once weekly for two weeks. P5’s POC had orders for home health aide up for 4 hours per week. Skilled nursing orders included to assess/evaluate comorbid conditions, provide instructions related to management of congestive hear failure, provide wound care to coccyx (tailbone area), assess for fall risks, and diabetic care. PT orders included to evaluate and treat for functional independence. OT orders included to assess and make recommendations for safety modifications in the home. Home health aide orders included assistance with personal care and activities of daily living (ADLs). Coordination notes in P5’s chart indicated the following missed visits, lacking physician notification and education/advice to the patient regarding the impact of the missed visits: 9/5/25 home health aide visit9/5/25 skilled nurse visit9/6/25 OT visit9/9/25 home health aide visit9/13/25 PT visit9/24/25 home health aide visit An undated policy, Skilled Professional Services directed skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, occupational therapy, and medical social services. Skilled professionals must assume responsibility for, but not restricted to the following: Client and caregiver counseling.Client and caregiver education. Preparing clinical notes.Communication with all physicians/allowed non-physician practitioner (NPP) as indicated in the plan of care and other health care practitioners (as appropriate) related to the current plan of care.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on interview, and document review the agency failed to provide written education regarding wound care and pertinent instructions related to care and treatment for 1 of 17 patients (P1) reviewed for patient/caregiver education. Findings include: P1’s skilled services plan of care (POC)/485 for certification periods 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed to perform wound care for skin tears. P1’s POC directed skilled nursing visits twice weekly. Review of P1’s electronic medical record lacked documentation of written information/education provided to family member/personal care assistant (FM/PCA)-C. On 10/8/25 at 10:15 a.m., RN-B stated he had been the RN Case Manager for P1 since 7/28/25. He had never talked to and had never met P1’s FM/PCA-C. RN-B stated P1 spoke Russian and had dementia with significant cognitive impairment. RN-B stated he expected the interpreter, who was present at the visits, to communicate with P1’s FM/PCA-C. On 10/10/25 at 10:10 a.m., FM/PCA-C stated he had never met nor talked to RN-B. FM/PCA-C stated there was no written information left since RN-B assumed care for P1 at the end of July. An undated facility document, Client/Caregiver Education directed clients, and their caregivers or representatives will be provided with information necessary to make decisions and to take responsibility for self-management activities related to their needs. The education and training for clients and families will target the client’s ability to improve outcomes through promotion of health behavior and involvement in their care, treatment, and service decisions. Special instructions included: All clients and caregivers will receive verbal and written instructions as appropriate and as required by regulation in the following areas: · Scope and services provided by the agency and rights and responsibilities as clients and caregivers. · Client disease process, medical regime, medications, and diet. All client and/or caregiver education and instruction, as well as their perceived comprehension and demonstrated competency, as appropriate, will be documented in the client’s record.”

“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 agency failed to develop performance improvement projects (PIPs). Findings include: Review of Quality Assessment Performance Improvement (QAPI) meeting notes for the previous 12 months lacked PIPs. On 10/17/25 at 3:15 p.m., the director of nursing (DON) stated the QAPI committee met quarterly and reviewed trends of infection control, patient outcomes, star ratings, patient satisfaction, and preventable hospitalizations. An undated agency policy, Quality Assessment and Performance Improvement (QAPI) directed the agency will develop, implement, evaluate, and maintain an effective, ongoing agency wide, data driven QAPI program. It directed the agency must conduct performance improvement projects: a. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the agency services and operations. b. The agency must document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects. c. The governing body is responsible for ensuring the following: i) An ongoing program for quality improvement and patient safety is defined, implemented, and maintained. ii) The agency wide assessment and performance improvement efforts address priorities for improved quality of care and client safety. iii) All improvement actions will be evaluated for effectiveness.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on observation, interview, and document review the agency health care professional failed to practice according to the agency’s policies and procedures related to assessing patients, completing documentation of clinical findings, and coordination of care for 3 of 17 patients (P1, P2, P7). Findings include: P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s skilled services plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed skilled nursing visits twice weekly. P1’s POC directed to assess/evaluate comorbid conditions including diagnosis list and other conditions that present themselves during the episode to identify changes and intervene to minimize complications. P1’s POC included orders to observe and evaluate integumentary status to identify changes and intervene to minimize complications and provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen, and wound care. It also directed skilled nurse to report significant changes in status to physician for early intervention. P1’s POC also directed for skilled nurse to perform a multifactorial fall risk assessment and implement interventions to avoid falls. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair, and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of pressure wounds to any areas of P1’s body, interventions to minimize or reduce pressure areas, or concern for lack of caregiver assistance. The note indicated no coordination of care occurred. P1’s hospital records indicated he was admitted for disorientation and weakness on 9/30/25. P1 was diagnosed with septic shock, acute on chronic subdural hematomas, and was described as cachectic on arrival. Hospital documents indicated P1 was admitted on 9/30/25 with pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. P1’s electronic medical record lacked documentation of P1’s falls. On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated when he visited P1 on 9/29/25 P1 had a new wound to his left arm, near his elbow, which he did not document as he could not “keep up with all the wounds”. RN-B stated P1 had “new wounds every week.” RN-B stated he never spoke with P1’s physician since he became the case manager on 7/28/25, as he expected the interpreter to communicate concerns to the physician. RN-B stated no updates, besides the recertification POC were provided to P1’s physician. On 10/8/25 at 10:12 a.m., RN-B stated he completed a full skin assessment of P1 on 9/29/25 where he observed a covered wound to P1’s left arm, but did not remove the dressing to assess the wound. He stated his full skin assessment included P1’s back, buttocks, and heels which he stated were reddened. RN-B stated P1 had no pressure ulcers at the time of the skin assessment on 9/29/25. On 10/8/25 at 2:05 p.m., P1’s medical doctor (MD)-A stated the pressure wounds P1 presented to the hospital with would have taken “weeks to months to develop”. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. MD-A stated someone should have been notifying P1’s physician regarding his condition. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated the RN case manager should have coordinated care with P1’s family member/personal care assistant (FM/PCA)-C and the outside PCA agency. On 10/10/25 at 10:10 a.m., FM/PCA-C stated P1 had “a number of falls in the past few months”. FM/PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. FM/PCA-C stated he had never met nor spoken to RN-B. On 10/10/25 at 1:45 p.m., outside PCA agency representative stated their agency was also providing PCA services to P1 and RN-B had made no attempt to coordinate care with their agency. On 10/17/25 at 11:05 a.m., MD-C stated she had not received updates from the home care agency regarding the extent of the wounds or P1’s falls. MD-C stated she expected the agency to inform her to update her regarding his decline in health. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC directed skilled nursing visits twice weekly and physical therapy visits twice weekly for two weeks, then once weekly for six weeks. P2’s POC directed physical therapy (PT) once weekly, then twice weekly for two weeks, followed by once weekly for six weeks. P2’s POC orders directed skilled nurse to assess/evaluate comorbid conditions that present themselves during this episode to identify changes and intervene to minimize complications. During an observation on 10/6/25 at 1:00 p.m., P2 reported to RN-B she had a fall earlier in the day while physical therapy was present. P2 stated, “I hope I didn’t break any ribs,” as she held her right hand over her left lateral chest area. She reported her pain was 7 out of 10. P2 also reported bilateral lower legs were more swollen and “weeping some”, leaving her pant legs wet. P2 was wearing a shirt with long sleeves and pants covering her legs. She stated she had to wear special pants that would accommodate the additional swelling. RN-B slightly lifted P2’s left pant leg approximately 2 inches. RN-B stated P2 had 2+ pitting edema (indicating a moderate degree of swelling). RN-B offered to wrap P2’s legs, which P2 declined. RN-B did not assess P2’s left chest area of pain or her right leg with concerns of edema. RN-B did not assess any other areas of P2’s skin covered by her clothing. A PT note dated 10/6/25 indicated P2 had a fall and reported mild pain on her left ankle and knee. The note indicated no coordination of care was provided. A skilled nursing visit note, dated 10/6/25, indicated P2 had pain rated at 7 out of 10, with areas of pain identified as her chest/ribs, abdomen, her left arm, and left leg. RN-B documented integumentary (skin, hair, and nails) were assessed, with no problems identified. RN-B documented P2’s cardiovascular system was assessed and was within normal limits (WNL). The 10/6/25 visit note lacked documentation of P2’s increased bilateral extremity edema with weeping. The note indicated no coordination of care was provided. P2’s medical record lacked updates to the physician regarding the surgical wounds and orders to discontinue wound care. On 10/6/25 at 1:35 p.m., RN-B stated he did not provide updates to P2’s physician as P2 was able to communicate through her clinic’s website. He also stated he was unaware of P2’s fall prior to the visit. On 10/9/25 at 12:25 p.m., clinical manager (CM)-B stated documentation for a new wound, the nurse should create a new order with the physician and new interventions in POC, then document the plan and treatment. She sated every wound should be documented and measured with a dressing order and treatment plan. She stated the primary care provider should be updated with changes in patient condition, new wounds, or any concerns with the treatment plan. On 10/9/25 at 1:15 p.m., CM-A stated a head-to-toe skin assessment should be done at every visit and documented, focusing on areas of concern. CM-A stated wound documentation was expected to be completed at each visit, with measurements completed weekly, along with descriptions of each wound. She stated all new wounds should be documented and added to the POC. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated nurses were expected to complete a head-to-toe assessment at every visit and document findings. She stated all wounds should be numbered and measured weekly. On 10/16/25 at 9:50 a.m., P2’s physician/MD-B stated the home care agency reported P2’s fall that occurred on 10/6/25 to her on 10/10/25. She stated the agency had not provided updates on P2’s change in condition related to her increased edema and weeping legs. On 10/16/25 at 10:00 a.m., PTA-A stated P2 fell during her visit on 10/6/25. PTA-A stated she and another staff member assisted P2 up and P2 denied pain. PTA-A stated P2 complained of edema and of her legs weeping. She stated P2 had been reporting increased edema for 1-2 weeks. She stated she did not report the fall or edema concerns to RN-B. PTA-A did not inform the P2’s physician of P2’s edema and weeping legs, and she did not report the fall to the physician until 10/10/25. PTA-A stated P2 was “on top of her care”, using the application to communicate with her physician. On 10/17/25 at 2:15 p.m., the DON stated all falls should be documented. She stated coordination of care with physicians was necessary for falls, incidents, and changes in patient condition. P7’s POC/485 for certification period 10/1/25 to 11/29/25, indicated she had Alzheimer’s Disease, dementia, and repeated falls. The POC directed the skilled nurse to observe and assess the patient and instruct family/caregivers in proper management techniques related to the disease process. P7’s POC directed skilled nursing visits once weekly for the first week, three times the following week, then twice weekly for three weeks, and once weekly for the last four weeks. Review of P7’s admission agreement, dated 10/1/25, indicated P7 signed for consent to treatment and authorization to pay benefits, authorization to initiate home care, her rights and responsibilities, grievance and complaint process, and arbitration agreement. During an observation on 10/10/25 at 11:00 a.m., P7 appeared disoriented and confused. P7 was cooperative and required several prompts and verbal cues from the nurse providing wound care. P7 asked the nurse repeated questions. On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated the staff must coordinate care with patients’ family and their caregivers if the patient has cognitive impairment. On 10/16/25 at 9:40 a.m., RN-F stated she completed the home care admission assessment and had P7 sign for enrollment in home care services on 10/1/25. RN-F stated P7 had “extreme dementia” and there were no family members or patient representatives present. RN-F stated she spoke with the assisted living facility nurse to establish a plan of care and determine P7’s preferences. On 10/17/25 at 11:35 a.m., FM-A who was P7’s power of attorney (POA) stated she was unaware P7 was receiving home care services and was not contacted by the home care agency. FM-A stated she should have been contacted regarding the enrollment in home care services and coordination of care. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated for patients who have dementia, the family or POA was typically contacted by the intake department to set up a time to meet and should be called if they are not present at the time of the home care admission assessment. She stated patients’ level of cognitive impairment was determined by an assessment. An undated facility policy, Coordination of Client Services directed the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and included communication with physicians. Agency will integrate services, whether services are provided directly or under arrangement, to assure the identification of client needs and factors that could affect client safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordination of care will include dealing with multiple programs for the complex clients. Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan. Documentation must address the coordination activities, and any training and education provided to the client and caregivers. Involvement of the care team must be apparent in the record either in an electronic health record or a paper document. How and when communication happens must be documented. Coordination will include providers of care who are not part of the agency assisted living staff, outpatient wound clinics or privately hired caregivers. An undated policy, Skilled Professional Services directed skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, occupational therapy, and medical social services. Special instructions: Skilled professionals must assume responsibility for, but not restricted to the following: Client and caregiver counseling. Client and caregiver education. Preparing clinical notes. Communication with all physicians/allowed non-physician practitioner (NPP) as indicated in the plan of care and other health care practitioners (as appropriate) related to the current plan of care. An undated policy, Clinical Documentation, directed staff to complete a separate note for each visit and additional pertinent to the patients care or condition would be documented in a progress note or flow sheet. Furthermore, documentation of telephone or other communication will be documented in the clinical progress notes or other interagency communication form.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on interview and documentation review, the agency failed to obtain the patient’s legal representative’s signature when enrolling 1 of 17 patients (P7) in home care services, not informing them of rights and responsibilities. Findings include: A review of P7’s Admission Agreement, dated 10/1/25, indicated P7 signed her name to enroll in home care services and acknowledging her rights and responsibilities. An admission assessment, dated 10/1/25, indicated P7 was alert, forgetful, confused, and oriented to person only. Another section of the same note indicated P7 required considerable assistance in routine situations, was not alert and oriented, had a memory deficit where she was unable to recall the last 24 hours, and failed to recognize familiar persons and places. P7’s level of cognitive impairment was documented as “severe impairment”. P7’s plan of care (POC)/485 for certification period 10/1/25 to 11/29/25, indicated she had Alzheimer’s Disease, dementia, and repeated falls. During an observation on 10/10/25 at 11:00 a.m., P7 appeared disoriented and confused. P7 was cooperative and required several prompts and verbal cues from the nurse providing wound care. P7 asked the nurse repeated questions. On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated the staff must coordinate care with patients’ family and their caregivers if the patient has cognitive impairment. On 10/16/25 at 9:40 a.m., RN-F stated she completed the home care admission assessment and had P7 sign for enrollment in home care services on 10/1/25. RN-F stated P7 had “extreme dementia” and there were no family members or patient representatives present, and information was reviewed with the assisted living nurse. On 10/17/25 at 11:35 a.m., FM-A who was P7’s power of attorney (POA) stated she was unaware P7 was receiving home care services and was not contacted by the home care agency. FM-A stated she should have been contacted regarding the enrollment in home care services and coordination of care. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated for patients who have dementia, the family or POA was typically contacted by the intake department to set up a time to meet and should be called if they are not present at the time of the home care admission assessment. She stated patients’ level of cognitive impairment was determined by an assessment. A facility document, Home Care Bill of Rights policy, dated 5/14/24, directed Clients and their representatives will be informed of their rights as a consumer of home care services prior to the start of care. The agency will provide verbal notice of the client’s rights and responsibilities in the person’s primary or preferred language and in a manner the client/representative understands, free of charge, with the use of competent interpreter if necessary, no later than the completion of the second visit from a skilled professional. Special instructions included: · A designated Registered Nurse/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 treatment is initiated. The following will be included in this notice: Written notice of the client’s rights and responsibilities under this rule, and the agency’s transfer and discharge policies. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. · The agency will obtain the client’s or legal representative’s signature confirming that they have received a copy of the notice of rights and responsibilities. · In the event that the client is unable to make decisions, the Home Care Bill of Rights shall be given to the client’s representative or legal guardian. The reason the client is unable to acknowledge receipt of the Home Care Bill of Rights shall be documented. The client/caregiver shall be advised orally and in writing of their right to voice grievances/complaints and the method of contacting the agency if dissatisfied. · The agency will document that verbal discussion of rights took place, and that the client and/or representative was able to confirm their understanding of the rights. It is an expectation that clients/representatives will be able to confirm that they received information about their rights and responsibilities and the agency’s transfer and discharge policies. They will acknowledge that this information was presented in a language they understood and in a manner that accommodated any disability they have.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview, document review the agency failed to conduct a comprehensive assessment with accurate reflection of patient status for 1 of 17 patients (P1) reviewed for comprehensive assessment. Findings include: A registered nurse (RN) recertification visit note, dated 9/9/25, for skilled services, indicated P1 lived alone, environmental hazards were assessed, and no community resources were needed at the time of the assessment. It also indicated integumentary of P1 was assessed and no problems were identified, including no pressure ulcers. It indicated a standard mattress was appropriate for P1. Nutritional needs documented as probably inadequate as P1 ate only half of food offered, then also noted no nutritional problems noted. Falls were not assessed, noted as “not applicable”. The assessment indicated no new symptoms were identified associated with P1’s comorbid conditions and no care coordination occurred. Two wounds were listed on the visit note: one on the left cheek and one on the left thigh. Transfer assistance was listed as independent and assist of 1 or 2. P1’s plan of care (POC)/485 for 9/13/25 to 11/11/25, indicated P1 had heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair, and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of pressure wounds to any areas of P1’s body, interventions to minimize or reduce pressure areas, or concern for lack of caregiver assistance. Hospital documents indicated P1 was admitted on 9/30/25 with pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated P1 did not speak English, had significant cognitive impairment, and lived in his apartment alone with 12 hours of PCA services per day, leaving him alone at night. RN-B stated P1 was unable to get out of bed independently, was incontinent of bowel and bladder, and was unable to reposition himself in bed. RN-B stated P1 had “new wounds every week.” RN-B stated P1 was dependent on others for care and mobility since he started working with him on 7/28/25. On 10/8/25 at 2:05 p.m., medical doctor (MD)-A stated the pressure wounds P1 presented to the hospital with would have taken “weeks to months to develop”. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. On 10/10/25 at 10:10 a.m., P1’s family member/personal care assistance (FM/PCA)-C stated P1 had several falls in his apartment due to attempting to pull himself up from the toilet, using the towel bar in his bathroom. FM/PCA-C affirmed there were periods of time where P1 was left alone in his apartment. On 10/17/25 at 12:23 p.m., clinical manager (CM)-C stated she was asked to contact the care coordinator of P1’s benefits to request additional PCA hours to be authorized during the week of June 23rd. She stated no additional hours were added to P1’s care. An undated facility document, Client Reassessment/Update of Comprehensive Assessment directed The Comprehensive Assessment will be updated and revised as often as the client’s condition warrants due to major decline or improvement in health status. 1. The assessment will identify the problems, needs, and strengths of the client and the care the family can provide. The initial and ongoing assessments include consideration of the following: a. Specific individualized client needs pertinent to the care or service being provided. c. Involvement of family friends, and other individuals or organizations. d. Appropriateness of the level of care provided by the family or support system to safely meet the client needs. e. Condition of the home and surrounding environment and identified safety needs within the home setting. h. Ability/willingness of the client/family to assume responsibility for healthcare needs. 10. Client needs and the availability and adequacy of family and support systems will be considered in the care planning process.”

“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 requirements were included in the plan of care (POC) for 4 of 17 patients (P1, P2, P7, P14) who received home care services. P1’s plan of care (POC)/485 for certification periods 7/15/25 to 9/12/25 and for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed to perform wound care for skin tears. P1 required skilled nursing twice weekly and only used a walker for durable medical equipment (DME). P1’s POC indicated he had a do not resuscitate order. P1’s medications were omitted from the POC for certification period 9/13/25 to 11/11/25. P1’s medical record lacked a signed physician order regarding resuscitation. P1’s hospital notes indicated he was a full code. P1’s admission physical therapy assessment dated 5/16/25, indicated P1 used a rolling walker, wheelchair, a bedside commode, an elevated toilet seat, and a tub chair. P1’s recertification nursing assessment dated 7/11/25, indicated P1 used a multi-wheeled walker and wheelchair. P1’s recertification nursing assessment dated 9/9/25, indicated P1 used a multi-wheeled walker for ambulation. The note lacked identifying any additional DME. P2’s POC/485 for certification period 7/26/25 to 9/23/25, indicated P2 had diagnoses of chronic kidney disease, diabetes, anxiety and an infection following a procedure. P2’s POC directed wound care to pack strip into wound, cover and secure with tape. P2’s POC did not specify the strip to be used in the wound care process. The POC indicated P2 only had a walker for DME. P2’s admission nursing assessment dated 7/26/25, indicated P2 had a walker, tub chair, bed side commode, and an elevated toilet seat for DME. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated P2 had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC only included a walker for DME. P2’s recertification nursing assessment dated 9/22/25, indicated P2 only had a walker for DME. On 10/6/25 at 1:20 p.m., P2 stated she continued to use the walker, tub chair, and elevated toilet set. P7’s POC/485 for certification period 10/1/25 to 11/29/25, indicated she had Alzheimer’s Disease, dementia, and repeated falls. P7’s POC indicated she had no advance directives. On 10/17/25 at 11:35 a.m., FM-A who was P7’s power of attorney (POA) stated P7 should be listed as do not resuscitate. P7’s Provider Order for Life-Sustaining Treatment (POLST), dated 4/24/24, directed do not attempt resuscitation. On 10/8/25 at 10:12 a.m., RN-B stated DME and medical supplies were not typically included on the patients’ POC. On 10/8/25 at 1:45 p.m., RN-C stated DME and medical supplies were not necessary to be included in the POC unless the patient was on Medicare. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated DME and medical supplies should be on the POC. She stated there may have been some confusion about how things were billed out of the electronic medical record system. On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated DME and supplies should be included in the POC. On 10/16/25 at 9:40 a.m., registered nurse (RN)-F stated she completed the admission for P7. She stated, “If I’m unable to obtain a physical copy, I put them at a full code”, when asked about determining code status. A facility document Plan of Care policy, dated 5/14/24 directed home care services are furnished under the supervision and direction of the client’s physician/allowed non-physician practitioner (NPP). The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary, but at least every sixty (60) days. The Plan of Care shall be completed in full to include: m. Medications, treatments, and procedures. n. Medical supplies and equipment required. o. Any safety measures to protect against injury. At the time of certification and recertification, a written summary of the client’s current status and the services being provided are submitted with the plan of care for review. The summary shall include but is not limited to: changes in clients physical or psychosocial condition, client response to care/services and outcome of care and services. 10. Professional staff shall promptly alert the physician/allowed non-physician practitioner (NPP) to any changes that suggest a need to alter the Plan of Care. 11. Verbal/telephone orders shall be obtained from the client’s physician/allowed non-physician practitioner (NPP) for changes in the Plan of Care (refer to the Physician Orders policy). P14 P14’s POC dated 8/7/25-10/5/25, indicated P14 was orientated and had diagnoses of pressure ulcer of left buttock, heart failure, and diabetes. P14 required skilled nursing once a week and did not use durable medical equipment (DME). P14’s recertification nursing assessment dated 8/4/25, indicated P14 required a rolling walker and wheelchair for mobility.”

“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 document review the agency failed to provide treatments only as ordered by a physician for 1 of 17 patients (P6) reviewed for physician orders. Findings include: During an observation of P6’s wound care on 10/10/25 at 9:00 a.m., registered nurse (RN)-E completed the wound care as ordered, followed by wrapping the right lower leg in an ACE wrap (elastic bandage used to provide compression). On 10/10/25 at 9:30 a.m., RN-E stated she had been applying the ACE wrap since P6 was started on home care services. RN-E stated she was unsure whether there was a physician’s order for the ACE wrap. RN-E stated wound care must follow physician orders. P6’s plan of care (POC)/485 for certification period 8/17/25 to 10/15/25, indicated he had diagnoses of cellulitis (a bacterial infection of the skin) of the left lower leg, diabetes, chronic kidney disease, and peripheral vascular disease (a condition where plaque buildup narrows the arteries, reducing blood flow). P6’s POC directed skilled nurse visits three times weekly to include wound care. Wound care orders to the right lateral (outer edge) foot were to cleanse with mild soap and water, apply betadine moistened gauze to wound bed, cover with ABD pad (an absorbent gauze pad), and secure with kerlix (rolled gauze) and tape. P6’s POC and electronic medical record lacked physician orders for an ACE wrap. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated interventions require a physician’s order, including the use of an ACE wrap. An undated facility document, Physician/Allowed Non-Physician Practitioner (NPP) Orders policy directed all medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP).”

“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 document review the agency failed to ensure 3 of 17 patients (P1, P2,P14) plans of care (POC) were reviewed and signed in their entirety by their provider every 60 days. Findings include: P1’s plan of care (POC)/485 for certification period 9/13/25 to 11/11/25 for skilled care, indicated P1 had diagnoses of heart failure, atrial fibrillation (a heart rhythm disorder), dementia, depression, cardiomyopathy (problem with the heart muscle making it harder to pump blood to the rest of the body), pulmonary embolism (a blood clot that has traveled to the lung), chronic pain, and history of falls. P1 required skilled nursing twice weekly. Furthermore, P1’s skilled care POC in his medical record only included pages 1,2 and 3. P1’s electronic medical record (EMR) lacked indication the physician had reviewed or signed pages 4 and 5 of P1’s POC. P1’s POC for certification period 8/15/25 to 10/13/25 for private duty care, indicated P1 had diagnoses of dementia, pulmonary embolism, cardiomyopathy, atrial fibrillation, and heart failure. P1 required up to 40 hours weekly of personal care assistant (PCA) to assist with personal care and activities of daily living (ADLs). P1 required one nursing visit. Furthermore, P1’s non-skilled POC in his EMR only included pages 1 and 2. P1’s EMR lacked indication the physician had reviewed or signed page 3 of P1’s POC. P2’s POC/485 for certification period 7/26/25 to 9/23/25, indicated P2 had diagnoses of anxiety, chronic kidney disease, and diabetes. P2 required skilled nursing once weekly for one week, then three times weekly for one week, then twice weekly for two weeks, followed by once weekly for six weeks. Physical therapy (PT) once weekly for one week, twice weekly for three weeks, followed by once weekly for six weeks. Occupational therapy (OT) once weekly for one week, then twice weekly for two weeks, followed by once weekly for six weeks. Home health aide once weekly for nine weeks. Furthermore, P2’s POC only had signatures on pages 1 and 7 of her seven page POC. P2’s EMR lacked indication the provider had reviewed or signed pages 2,3,4,5, and 6 of P14’s POC. P14’s POC dated 8/7/25-10/5/25, indicated P14 was orientated and had diagnoses of pressure ulcer of left buttock, heart failure, and diabetes. P14 required skilled nursing once a week. Furthermore, P14’s POC had only the first two pages signed from the provider. P14’s electronic medical record (EMR) lacked indication the provider had reviewed or signed pages 3 and 4 of P14’s POC. P141’s physician signed POC dated 8/7/25-10/5/25, was requested however was not received. When interviewed on 10/16/25 at 4:21 p.m., the Director of Nursing (DON) stated the agency recently changed document managers and realized the day prior not all of the pages were being send back, so not all of the signed pages were available. DON further stated medical records was notified and they are trying to figure out why there were missing pages. DON further acknowledged all signed pages should be available. An agency policy titled Plan of Care revised 5/14/24, directed staff to ensure the total plan of care shall be reviewed by the attending provider and agency personnel as often as the client’s condition requires, but at least 60 days.”

“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 document review the agency failed to promptly inform the physician of changes in condition for 2 of 17 patients (P1, P2) reviewed for change of condition, when P1 was admitted to the hospital with four pressure injuries and cachexia (significant weight and muscle loss) without his physician aware of the wounds and when P2 was admitted to the hospital with bilateral extremity edema, without her physician aware of the increase in edema present for days to weeks, according to hospital records. Findings include: P1’s plan of care (POC)/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s skilled services plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed skilled nursing visits twice weekly. P1’s POC directed to assess/evaluate comorbid conditions including diagnosis list and other conditions that present themselves during the episode to identify changes and intervene to minimize complications. P1’s POC included orders to observe and evaluate integumentary status to identify changes and intervene to minimize complications and provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen, and wound care. It also directed skilled nurse to report significant changes in status to physician for early intervention. P1’s POC also directed for skilled nurse to perform a multifactorial fall risk assessment and implement interventions to avoid falls. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair, and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of pressure wounds to any areas of P1’s body, interventions to minimize or reduce pressure areas, or concern for lack of caregiver assistance. The note indicated no coordination of care occurred. P1’s hospital records indicated he was admitted for disorientation and weakness on 9/30/25. P1 was diagnosed with septic shock, acute on chronic subdural hematomas, and was described as cachectic on arrival. Hospital documents indicated P1 was admitted on 9/30/25 with pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated when he visited P1 on 9/29/25 P1 had a new wound to his left arm, near his elbow, which he did not document as he could not “keep up with all the wounds”. RN-B stated P1 had “new wounds every week.” RN-B stated he never spoke with P1’s physician since he became the case manager on 7/28/25, as he expected the interpreter to communicate concerns to the physician. RN-B stated no updates, besides the recertification POC were provided to P1’s physician. On 10/8/25 at 10:12 a.m., RN-B stated he completed a full skin assessment of P1 on 9/29/25 where he observed a covered wound to P1’s left arm, but did not remove the dressing to assess the wound. He stated his full skin assessment included P1’s back, buttocks, and heels which he stated were reddened. RN-B stated P1 had no pressure ulcers at the time of the skin assessment on 9/29/25. On 10/8/25 at 2:05 p.m., P1’s medical doctor (MD)-A stated the pressure wounds P1 presented to the hospital with would have taken “weeks to months to develop”. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. MD-A stated someone should have been notifying P1’s physician regarding his condition. On 10/17/25 at 11:05 a.m., MD-C stated she had not received updates from the home care agency regarding the extent of the wounds or P1’s falls. MD-C stated she expected the agency to inform her to update her regarding his decline in health. P1’s electronic medical record lacked documentation of P1’s falls. P1’s electronic medical record lacked PCA notes regarding skin alterations, report of falls, or communication with the registered nurse (RN). On 10/10/25 at 10:10 a.m., the PCA who was also P1’s family member (FM/PCA)-C stated P1 had “a number of falls in the past few months”. FM/PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. FM/PCA -C stated the electronic medical record system in use by the agency did not allow for him to document any falls or skin concerns. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC directed skilled nursing visits twice weekly and physical therapy visits twice weekly for two weeks, then once weekly for six weeks. P2’s POC directed physical therapy (PT) once weekly, then twice weekly for two weeks, followed by once weekly for six weeks. P2’s POC orders directed skilled nurse to assess/evaluate comorbid conditions that present themselves during this episode to identify changes and intervene to minimize complications. During an observation on 10/6/25 at 1:00 p.m., P2 reported to RN-B she had a fall earlier in the day while physical therapy was present. P2 stated, “I hope I didn’t break any ribs,” as she held her right hand over her left lateral chest area. She reported her pain was 7 out of 10. P2 also reported bilateral lower legs were more swollen and “weeping some”, leaving her pant legs wet. P2 was wearing a shirt with long sleeves and pants covering her legs. She stated she had to wear special pants that would accommodate the additional swelling. RN-B slightly lifted P2’s left pant leg approximately 2 inches. RN-B stated P2 had 2+ pitting edema (indicating a moderate degree of swelling). RN-B offered to wrap P2’s legs, which P2 declined. RN-B did not assess P2’s left chest area of pain or her right leg with concerns of edema. RN-B did not assess any other areas of P2’s skin covered by her clothing. A PT note dated 10/6/25 indicated P2 had a fall and reported mild pain on her left ankle and knee. The note indicated no coordination of care was provided. A skilled nursing visit note, dated 10/6/25, indicated P2 had pain rated at 7 out of 10, with areas of pain identified as her chest/ribs, abdomen, her left arm, and left leg. RN-B documented integumentary (skin, hair, and nails) were assessed, with no problems identified. RN-B documented P2’s cardiovascular system was assessed and was within normal limits (WNL). The 10/6/25 visit note lacked documentation of P2’s increased bilateral extremity edema with weeping. The note indicated no coordination of care was provided. A hospital discharge summary for P2, for hospitalization 10/9/25 to 10/12/25, indicated P2 was referred to the emergency department on 10/8/25 while undergoing a diagnostic test. P2 was admitted for bilateral lower extremity edema. The note indicated P2 reported increasing lower extremity edema over the past several days to weeks. P2 was treated with intravenous (IV) diuretic (medication used to decrease extra fluid) medication. P2’s medical record lacked updates to the physician regarding the surgical wounds and orders to discontinue wound care. On 10/6/25 at 1:35 p.m., RN-B stated he did not provide updates to P2’s physician as P2 was able to communicate through her clinic’s website. On 10/16/25 at 10:00 a.m., PTA-A stated P2 fell during her visit on 10/6/25. PTA-A stated she and another staff member assisted P2 up and P2 denied pain. PTA-A stated P2 complained of edema and of her legs weeping. She stated P2 had been reporting increased edema for 1-2 weeks. She stated she did not report the fall or edema concerns to RN-B. PTA-A did not inform the P2’s physician of P2’s edema and weeping legs, and she did not report the fall to the physician until 10/10/25. PTA-A stated P2 was “on top of her care”, using the application to communicate with her physician. On 10/16/25 at 9:50 a.m., P2’s physician/MD-B stated the home care agency reported P2’s fall that occurred on 10/6/25 to her on 10/10/25. She stated the agency had not provided updates on P2’s change in condition related to her increased edema and weeping legs. On 10/9/25 at 12:52 p.m., clinical manager (CM)-B stated the primary care provider should be updated with changes in patient condition, new wounds, or any concerns with the treatment plan. On 10/14/25 at 11:20 a.m., CM-C stated the physician should be called if patients have a fall, a new wound, or a change in condition. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated coordination of care with physicians was necessary for falls, incidents, and changes in patient condition. An undated facility document, Coordination of Client Services policy directed the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and included communication with physicians.”

“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 document review, the agency failed to revise the plan of care (POC) for 2 of 17 patients (P1, P2) reviewed when there were changes in nutrition and wounds. Findings include: P1’s skilled services plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed skilled nursing visits twice weekly. P1’s POC directed to assess/evaluate comorbid conditions including diagnosis list and other conditions that present themselves during the episode to identify changes and intervene to minimize complications. P1’s POC included orders to observe and evaluate integumentary status to identify changes and intervene to minimize complications and provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen, and wound care. P1’s POC also directed for skilled nurse to perform a multifactorial fall risk assessment and implement interventions to avoid falls. P1’s skilled nurse recertification note, dated 9/9/25, indicated P1 lived alone, environmental hazards were assessed, and no community resources were needed at the time of the assessment. It also indicated integumentary of P1 was assessed and no problems were identified, including no pressure ulcers. It indicated a standard mattress was appropriate for P1. Nutritional needs documented as probably inadequate as P1 ate only half of food offered, then also noted no nutritional problems noted. Falls were not assessed, noted as “not applicable”. The note indicated P1 lived alone and had caregiver ability to support him 24/7. The assessment indicated no new symptoms were identified associated with P1’s comorbid conditions and no care coordination occurred. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of additional wounds. P1’s electronic medical record lacked updates to his POC that accurately reflected the changes to his skin condition and falls. P1’s hospital records indicated he was admitted for disorientation and weakness on 9/30/25. P1 was diagnosed with septic shock, acute on chronic subdural hematomas, and was described as cachectic on arrival. Hospital documents indicated P1 was admitted with pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated P1 did not speak English, had significant cognitive impairment and lived in his apartment alone with 12 hours of PCA services per day, leaving him alone at night. RN-B stated P1 was unable to get out of bed independently, was incontinent of bowel and bladder, and was unable to reposition himself in bed. RN-B stated P1 had “new wounds every week” but RN-B did not document on all of the wounds, rather he left thigh wound on the chart to remind nurses to assess for wounds. RN-B stated he did not inform P1’s primary care physician of each new wound. RN-B stated P1 was dependent on others for care and mobility since he started working with him on 7/28/25. On 10/8/25 at 2:05 p.m., MD-A stated the pressure wounds P1 presented to the hospital with would have taken weeks to months to develop. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. On 10/10/25 at 10:10 a.m., family member who served as P1’s PCA (FM/PCA) stated P1 had “a number of falls in the past few months”. FM/PCA stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. P2’s initial POC/485 for certification period 7/26/25 to 9/23/25, indicated she had diagnoses of anxiety, chronic kidney disease, diabetes, and infection following a procedure. P2’s POC had orders for skilled nursing once for the first week, three times a week for the second week, then two times per week for two weeks, followed by once weekly nursing visits for six weeks. The POC directed skilled nurse to perform/teach wound care to abdomen, midline surgical incision: cleanse with normal saline (NS) via syringe, pack strip into wound, cover and secure with tape. Using clean/aseptic technique, change dressing every day and as needed. A recertification skilled nurse visit note, dated 9/22/25, indicated P2’s integumentary (skin, hair, and nails) was assessed, with no problems identified. Further it indicated the RN did not assess P2’s abdominal wound as P2 completed the wound care. P2’s POC/485 for certification period 9/24/25 to 11/22/25, indicated she had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC directed skilled nursing visits twice weekly. The POC directed skilled nurse to perform/teach wound care to incision/suture site, cover with abdominal gauze pad (ABD), clean/aseptic technique. Change dressing daily and as needed. During an observation on 10/6/25 at 1:00 p.m., RN-B lifted P2’s shift and assessed P2’s post-surgical scar on her abdomen, which was not covered by a dressing. Skin appeared intact. A skilled nursing visit note, dated 10/6/25, indicated P2’s integumentary (skin, hair, and nails) was assessed, with no problems identified. P2’s medical record lacked updates to her POC to care for her abdominal wounds. On 10/9/25 at 1:15 p.m., clinical manager (CM)-A stated new wounds required an update to the provider, followed by updating the POC with interventions for the wound. On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated the registered nurse is responsible to update the POC. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated the POC should be updated every sixty days, based on assessment of the patient. An agency policy, dated 5/14/24, Plan of Care directed home care services are furnished under the supervision and direction of the client’s physician/allowed non-physician practitioner (NPP). The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary, but at least every sixty (60) days. At the time of certification and recertification, a written summary of the client’s current status and the services being provided are submitted with the plan of care for review. The summary shall include but is not limited to: changes in clients physical or psychosocial condition, client response to care/services and outcome of care and services.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and document review, the agency failed to integrate services provided by the agency and services provided by other entities were coordinated to evaluate treatment effectiveness and promote patient well-being for 2 of 2 (P1, P13) patients who received services from other medical specialties or care agencies. P13’s POC for certification period 10/2/25-11/30/25, indicated P13 was orientated and had diagnoses of pressure ulcer on the right buttock stage 2, diabetes, and end stage renal disease. P13’s admission oasis assessment dated 10/2/25, indicated P13 was cognitively intact and had diagnoses of pressure wound of right buttock, kidney failure, and diabetes. P13 had PCA services and dialysis treatments (a treatment to filter the blood when kidneys did not function) in place, however the assessment lacked where and what agency provided these services. P13’s electronic medical record (EMR) lacked indication of contact information, scheduling or where P13 received dialysis and PCA services. When interviewed on 10/16/25 at 2:45 p.m., registered nurse (RN)-G stated R13 was seen on Monday, Wednesday and Fridays for wound care. RN-G stated P13 was a high risk for skin breakdown and was admitted with wounds. RN-G was not aware P13 received PCA services from another agency. RN-G was aware of R13’s dialysis fistula and stated R13 had dialysis treatments a few times a week but wasn’t sure where. RN-G stated they were not sure how communication would happen between dialysis facility and the home care agency, but there wouldn’t be any communication with dialysis unless there was some sort of emergency. If medication changes were made in dialysis; RN-G thought the dialysis facility would call the home care office. When interviewed on 10/16/25 at 4:27 p.m., the Director of Nursing (DON) expected staff to document any services provided by another agency if known. If a patient identified they have a PCA, staff should document the agency used and contact information. DON stated the same would be for dialysis. If a patient received dialysis care, staff should document their schedule and where they go. DON verified P13’s EMR did not indicate what agency PCA services were through or when and where dialysis completed. DON stated this was important to know and document this this information as staff were expected to communicate and coordinate cares. An undated facility document, Coordination of Client Services policy directed the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and included communication with physicians. It indicated the purpose of the policy included: To coordinate care delivery to meet individual client needs. To involve the client, their representative (if any), and caregivers in the coordination activities. To assure that the efforts of agency personnel effectively complement one another and support the objectives outlined in the Plan of Care. To modify the plan to reflect needs or changes identified by members of the team and avoid duplication of services. To determine the continuation of services and/or future plans for care. Special instructions included: Agency will integrate services, whether services are provided directly or under arrangement, to assure the identification of client needs and factors that could affect client safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordination of care will include dealing with multiple programs for the complex clients. Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan. Documentation must address the coordination activities and any training and education provided to the client and caregivers. Involvement of the care team must be apparent in the record either in an electronic health record or a paper document. How and when communication happens must be documented. Coordination will include providers of care who are not part of the agency assisted living staff, outpatient wound clinics or privately hired caregivers. Findings include: P1’s skilled services plan of care (POC)/485’s for certification periods 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed to perform wound care for skin tears. P1’s POC directed skilled nursing visits twice weekly. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s aide care plan directed the PCA to assist P1 with stand-by assistance for ambulation, shower, dressing, and fall risk. The care plan also directed the PCA to prepare meals, laundry and complete errands for P1. P1’s electronic medical record lacked documentation indicating care was coordinated with P1’s PCA services from this agency or the other PCA agency involved, P1’s care coordinator through his insurance company who managed his PCA services, or any other staff within the agency to consider options for additional supervision, home modifications, or medical equipment to relieve pressure and mitigate risk of falls. On 10/8/25 at 10:15 a.m., RN-B stated P1 had “bad dementia”, only spoke Russian, lived alone, received PCA services from 9:00 a.m. to 9:00 p.m. every day, leaving him home alone at night. He stated P1 was unable to get out of bed without assistance. RN-B stated P1 had “new wounds every week”. RN-B stated he stated he was not sure which agency P1’s PCA services were through. He stated, “They (PCA’s) don’t necessarily have a nurse to report to.” On 10/9/25 at 12:25 p.m., the insurance care coordinator (ICC) stated she had been assigned to P1 since July 2025 and had never received any communication from RN-B regarding P1’s care needs or concerns. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated the RN case manager should have coordinated care with PCA-C and the outside PCA agency. On 10/10/25 at 10:10 a.m., PCA-C stated P1 had “a number of falls in the past few months”, sometimes P1 would fall from attempting to use the towel bar in his bathroom to stand up. PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. PCA-C stated P1 sat in his recliner for extended periods of time causing pressure to his heels and tailbone area. He stated P1’s tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. PCA-C stated he never spoke with RN-B regarding PCA-C’s wounds or falls. On 10/10/25 at 1:45 p.m., outside PCA agency representative stated RN-B had made no attempt to coordinate care with their agency. An undated facility document, Coordination of Client Services policy directed the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and included communication with physicians. It indicated the purpose of the policy included: To coordinate care delivery to meet individual client needs. To involve the client, their representative (if any), and caregivers in the coordination activities. To assure that the efforts of agency personnel effectively complement one another and support the objectives outlined in the Plan of Care. To modify the plan to reflect needs or changes identified by members of the team and avoid duplication of services. To determine the continuation of services and/or future plans for care. Special instructions included: Agency will integrate services, whether services are provided directly or under arrangement, to assure the identification of client needs and factors that could affect client safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordination of care will include dealing with multiple programs for the complex clients. Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and change in the plan. Documentation must address the coordination activities and any training and education provided to the client and caregivers. Involvement of the care team must be apparent in the record either in an electronic health record or a paper document. How and when communication happens must be documented. Coordination will include providers of care who are not part of the agency assisted living staff, outpatient wound clinics or privately hired caregivers.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on interview and document review, the agency failed to involve the patients’ representative in the coordination of care for 2 of 17 patients (P1, P7) when the registered nurse (RN) failed to communicate with P1’s family member, who also served as P1’s personal care assistant (FM/PCA)-C, regarding P1’s declining condition including pressure injuries and when P7’s family member, who also served as her power of attorney (POA) was not contacted regarding her enrollment in home care services and development of her care plan. Findings Include: P1’s skilled services plan of care (POC)/485 for certification periods 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed to perform wound care for skin tears. P1’s POC directed skilled nursing visits twice weekly. On 10/8/25 at 10:15 a.m., RN-B stated he had been the RN Case Manager for P1 since 7/28/25. He had never talked to and had never met P1’s family member/personal care assistant (FM/PCA)-C. RN-B stated P1 spoke Russian and had dementia with significant cognitive impairment. RN-B stated he expected the interpreter, who was present at the visits, to communicate with P1’s FM/PCA-C. On 10/10/25 at 10:10 a.m., FM-B stated he had never met nor talked to RN-B. P7’s POC/485 for certification period 10/1/25 to 11/29/25, indicated she had Alzheimer’s Disease, dementia, and repeated falls. The POC directed the skilled nurse to observe and assess the patient and instruct family/caregivers in proper management techniques related to the disease process. P7’s POC directed skilled nursing visits once weekly for the first week, three times the following week, then twice weekly for three weeks, and once weekly for the last four weeks. An admission assessment, dated 10/1/25, indicated P7 was alert, forgetful, confused, and oriented to person only. Another section of the same note indicated P7 required considerable assistance in routine situations, was not alert and oriented, had a memory deficit where she was unable to recall the last 24 hours, and failed to recognize familiar persons and places. P7’s level of cognitive impairment was documented as “severe impairment”. During an observation on 10/10/25 at 11:00 a.m., P7 appeared disoriented and confused. P7 was cooperative and required several prompts and verbal cues from the nurse providing wound care. P7 asked the nurse repeated questions. On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated the staff must coordinate care with patients’ family and their caregivers if the patient has cognitive impairment. On 10/16/25 at 9:40 a.m., RN-F stated she completed the home care admission assessment and had P7 sign for enrollment in home care services on 10/1/25. RN-F stated P7 had “extreme dementia” and there were no family members or patient representatives present. RN-F stated she spoke with the assisted living facility nurse to establish a plan of care and determine P7’s preferences. On 10/17/25 at 11:35 a.m., family member (FM)-A who was P7’s power of attorney (POA) stated she was unaware P7 was receiving home care services and was not contacted by the home care agency. FM-A stated she should have been contacted regarding the enrollment in home care services and coordination of care. On 10/17/25 at 2:15 p.m., the director of nursing (DON) stated for patients who have dementia, the family or POA was typically contacted by the intake department to set up a time to meet and should be called if they are not present at the time of the home care admission assessment. She stated patients’ level of cognitive impairment was determined by an assessment. An undated facility document, Coordination of Client Services directed the agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. Special Instructions included: The client, representative, and caregivers will participate by identifying what they want to achieve and what they feel comfortable doing. This will be built into the plan. Information provided to clients must be verbally and in writing and the agency documentation will also clarify what the plan is and who was informed.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, interview and document review the agency failed to complete clinical notes for 3 of 17 patients (P1, P2, P5) reviewed for completion of clinical notes. Findings include: P1’s skilled services plan of care (POC)/485 for certification period 9/13/25 to 11/11/25, indicated P1 had diagnoses of heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. P1’s POC directed to perform wound care for skin tears. P1’s POC directed skilled nursing visits twice weekly to observe and evaluate integumentary status to identify changes and intervene to minimize complications. P1’s POC also directed for skilled nurse to perform a multifactorial fall risk assessment and implement interventions to avoid falls. P1’s skilled nurse visit note, dated 9/29/25, indicated the registered nurse (RN) completed and integumentary (skin, hair, and nails) assessment and documented bruising. The RN documented one wound on P1’s left anterior (front) thigh, measuring 2 centimeters (cm) x 1 cm x 0 cm. The note lacked documentation of pressure wounds to any areas of P1’s body, interventions to minimize or reduce pressure areas, or concern for lack of caregiver assistance. P1’s hospital records indicated he was admitted for disorientation and weakness on 9/30/25. P1 was diagnosed with septic shock, acute on chronic subdural hematomas, and was described as cachectic on arrival. P1 had pressure wounds to his coccyx (tailbone area) at stage 2-3 (partial to full skin thickness, right malleolus (ankle) stage 2-3, and unstageable (due to non-viable tissue) bilateral heels. P1’s electronic medical record lacked documentation of P1’s falls. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s electronic medical record lacked PCA notes regarding skin alterations, report of falls, or communication with the registered nurse (RN). On 10/6/25 at 1:35 p.m., registered nurse (RN)-B stated when he visited P1 on 9/29/25 P1 had a new wound to his left arm, near his elbow, which he did not document as he could not “keep up with all the wounds”. RN-B stated P1 had “new wounds every week.” He stated he left the left upper thigh wound in the chart and used it as a reminder to check for new skin tears with each visit, and the left thigh wound was almost healed. RN-B stated P1 used to have a wound on his backside that had since healed. On 10/8/25 at 10:12 a.m., RN-B stated he completed a full skin assessment of P1 on 9/29/25 where he observed a covered wound to P1’s left arm, but did not remove the dressing to assess the wound. He stated his full skin assessment included P1’s back, buttocks, and heels which he stated were reddened. RN-B stated P1 had no pressure ulcers at the time of the skin assessment on 9/29/25. On 10/8/25 at 2:05 p.m., MD-A stated the pressure wounds P1 presented to the hospital with would have taken “weeks to months to develop”. She also stated, “These are not insignificant wounds.” MD-A stated P1 lived alone with 11 hours per day of personal care assistant (PCA) care. MD-A stated there were “big gaps in care”. On 10/10/25 at 10:10 a.m., family member/personal care assistant (FM/PCA)-C, stated P1 had “a number of falls in the past few months”. FM/PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. FM/PCA-C stated the electronic medical record system in use by the agency did not allow for him to document any falls or skin concerns. During an observation on 10/6/25 at 1:00 p.m., P2 reported to RN-B she had a fall earlier in the day while physical therapy was present. P2 stated, “I hope I didn’t break any ribs,” as she held her right hand over her left lateral chest area. She reported her pain was 7 out of 10. P2 also reported bilateral lower legs were more swollen and “weeping some”, leaving her pant legs wet. P2 was wearing a shirt with long sleeves and pants covering her legs. She stated she had to wear special pants that would accommodate the additional swelling. RN-B slightly lifted P2’s left pant leg approximately 2 inches. RN-B stated P2 had 2+ pitting edema (indicating a moderate degree of swelling). RN-B offered to wrap P2’s legs, which P2 declined. RN-B lifted P2’s shift and assessed P2’s post-surgical scar on her abdomen, which was not covered by a dressing. RN-B did not assess P2’s left chest area of pain or her right leg with concerns of edema. RN-B did not assess any other areas of P2’s skin covered by her clothing. A skilled nursing visit note, dated 10/6/25, indicated P2 had pain rated at 7 out of 10, with areas of pain identified as her chest/ribs, abdomen, her left arm, and left leg. RN-B documented integumentary (skin, hair, and nails) were assessed, with no problems identified. RN-B documented P2’s cardiovascular system was assessed and was within normal limits (WNL). The 10/6/25 visit note lacked documentation of P2’s increased bilateral extremity edema with weeping. P2’s PCO/485 for certification period 9/24/25 to 11/22/25, indicated P2 had diagnoses of chronic kidney disease, diabetes, and anxiety. P2’s POC directed skilled nursing visits twice weekly and physical therapy visits twice weekly for two weeks, then weekly for six weeks. P2’s POC orders directed skilled nurse to assess/evaluate comorbid conditions that present themselves during this episode to identify changes and intervene to minimize complications. During an observation on 10/9/25 at 4:30 p.m., as RN removed P5’s stockings, a small bandage was present on P5’s left shin. P5 stated HHA-A placed the bandage over the wound after she assisted P5 with her shower earlier that afternoon. P5’s POC/485 for certification period 9/3/25 to 11/1/25 indicated she had diagnoses of pneumonia, urinary tract infection (UTI), heart failure, diabetes, chronic kidney disease, and dementia. P5’s POC included orders for skilled nursing once for one week, then twice weekly. P5’s POC had orders for physical therapy (PT) once for one week, then twice weekly for three weeks, followed by once weekly for five weeks. P5’s POC had orders for occupational therapy (OT) once weekly for two weeks. P5’s POC had orders for home health aide up for 4 hours per week. Skilled nursing orders included to assess/evaluate comorbid conditions, provide instructions related to management of congestive heart failure, provide wound care to coccyx (tailbone area), assess for fall risks, and diabetic care. PT orders included to evaluate and treat for functional independence. OT orders included to assess and make recommendations for safety modifications in the home. Home health aide (HHA) orders included assistance with personal care and activities of daily living (ADLs). P5’s HHA visit note, dated 10/9/25, lacked documentation of a skin tear. P5’s chart lacked documentation HHA-A communicated P5’s skin tear to the RN. On 10/17/25 at 11:09 a.m., HHA-A stated the aides are unable to document any changes or observations they make with patients in their electronic medical record (EMR). She stated they needed to call or text the RN responsible for the care of each patient. HHA-A stated P5 had a new skin tear that was covered by a bandage on 10/9/25 but she did not inform the RN about the skin tear. On 10/9/25 at 12:25 p.m., clinical manager (CM)-B stated documentation for a new wound, the nurse should create a new order with the physician and new interventions in POC, then document the plan and treatment. She sated every wound should be documented and measured with a dressing order and treatment plan. On 10/9/25 at 1:15 p.m., CM-A stated a head-to-toe skin assessment should be done at every visit and documented, focusing on areas of concern. CM-A stated wound documentation was expected to be completed at each visit, with measurements completed weekly, along with descriptions of each wound. She stated all new wounds should be documented and added to the POC. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated nurses were expected to complete a head-to-toe assessment at every visit and document findings. She stated all wounds should be numbered and measured weekly. On 10/17/25 at 2:15 p.m., the DON stated all falls should be documented. She stated the electronic medical record system only allowed for the PCA to document by exception and did not allow for them to add any notes. She stated the PCA’s should be calling their supervisor or RN directly to verbally report any falls, skin observations, or other concerns. An undated facility document, Clinical Record Content/Medical Record Retention directed clinical records are legal documents containing comprehensive, accurate, and organized information concerning the client’s health and emotional status, treatments, and services rendered by the registered nurses and other health care team members. When care is provided, documentation in the clinical record shall reflect the client’s physical condition, psychosocial status, safety measures to protect the client from injury, and medical care provided, as applicable from admission to discharge. Documentation shall establish that effective interchange, reporting, and coordination of client care does occur. An undated policy, Skilled Professional Services directed skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, occupational therapy, and medical social services. Special instructions: Skilled professionals must assume responsibility for but not restricted to the following: Preparing clinical notes. An undated policy, Home Health Aide Services indicated all home health aide services will be documented in the client record, home health aides must document each visit at the time care is provided and submit documentation to the agency within seven days.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on interview and document review, the agency failed to involve the patients’ aides as member of the interdisciplinary team in the coordination of care for 2 of 17 patients (P1, P7) when the registered nurse (RN) failed to communicate with P1’s aide who is also P1’s family member, (FM/PCA)-C, regarding P1’s declining condition. P1 was hospitalized with four pressure injuries and cachexia (significant weight and muscle loss). In addition, P7’s aide who is also P17’s family member, FM/PCA-A who also served as her power of attorney (POA) was not contacted regarding her enrollment in home care services and development of her care plan. P17 P17’s plan of care (POC) for certification perios 9/110/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. P17’s private duty POC dated 9/10/25-11/18/25, indicated P17 required patient care assistant (PCA) services up to 12.5 hours a week for assistance with activities of daily living and care due to functional limitations. P17’s electronic medical record lacked indication P17 had any skin alterations. An observation on 10/15/25 at 12:00 p.m., P17 was observed during their home visit with registered nurse (RN)-A. P17 had a bandage on their right wrist/forearm. P17 stated about a week ago, she bumped her arm on the wheelchair and PCA-A cleaned it up and dressed it. P17’s wheelchair had wash clothes taped to both side arms of the chair. RN-A removed the dressing and obtained wound measurements before replacing with a new bandage. When interviewed on 10/15/25 at 12:45 p.m., RN-A stated she was not aware of P17’s skin tear before the visit today and did not think it was there last week. RN-A verified there was no communication found in P17’s EMR about the skin tear. RN-A stated usually if the PCAs saw a skin concern, it would be reported to the nurse. RN-A further stated PCA-A was also a family member who was a nurse, so they just took care of it. When interviewed on 10/16/25 at 4:13 p.m., PCA-A stated they did not communicate P17’s skin tear to the nurse when it was discovered, PCA-A acknowledged she should have let them know about it when it happened. An agency policy for PCA services was requested however was not provided. An agency policy titled Home Health Aide Services directed HHA staff will be under the direct supervision of an agency RN or therapist. The policy further directed staff to recognize and report any changes in skin condition. An agency policy titled Clinical Documentation, no date, directed staff to complete a separate note for each visit and additional pertinent to the patients care or condition would be documented in a progress note or flow sheet. Furthermore, documentation of telephone or other communication will be documented in the clinical progress notes or other interagency communication form. P1’s plan of care (POC)/485, for skilled care, for certification period 9/13/25 to 11/11/25, indicated P1 had heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. The POC also indicated P1 used a walker, was forgetful, and had a history of falls. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistant (PCA) up to 40 hours per week. P1’s aide care plan directed the PCA to assist P1 with stand-by assistance for ambulation, shower, dressing, and fall risk. The care plan also directed the PCA to prepare meals, laundry and complete errands for P1. P1’s electronic medical record lacked PCA notes regarding skin alterations, report of falls, or communication with the registered nurse (RN). On 10/10/25 at 10:10 a.m., PCA-C stated P1 had “a number of falls in the past few months” and P1 experienced several falls when attempting to use the towel bar in his bathroom to stand up. PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. PCA-C stated P1 sat in his recliner for extended periods of time causing pressure to his heels and tailbone area. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. He stated the RN was making wound care visits twice weekly for P1, therefore PCA-C did not feel it was necessary to update RN-B. PCA-C stated the agency’s charting system did not allow PCA’s to document anything that was not on the care plan. PCA-C stated he had never spoken to and had never met RN-B. On 10/8/25 at 10:15 a.m., RN-B stated he had never talked to and had never met PCA-C, further he stated he was not sure which agency P1’s PCA services were through. He stated, “They (PCA’s) don’t necessarily have a nurse to report to.” On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated PCA’s were expected to report change in skin condition and falls to the RN and to their supervisor. On 10/17/25 at 2:15 p.m., The director of nursing (DON) stated the aides should be calling their supervisor or RN directly to report concerns regarding patients. She stated the electronic medical record system in use only allowed the PCAs to document by exception.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and document review the agency failed to conduct 14-day supervisory visits for patients receiving aide services for 2 of 17 patients (P1, P17) reviewed. P9’s plan of care (POC)/485 with a certification period of 6/18/25 to 8/16/25, identified P9 had type 2 diabetes (a chronic condition which occurs when the body cannot use insulin effectively, leading to high blood sugars) with diabetic peripheral angiopathy without gangrene (a condition where the blood vessels are affected by diabetes, but there is no evidence of gangrene-a condition when the body tissues die due to lack of blood flow). P9 was also identified as having primary hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD-a lung condition caused by damage to the airways that limits air flow). P9 was identified as being oriented, but forgetful. The POC orders indicated P9 was to receive skilled nurse visits (SNV) every two weeks, as well as home health aide (HHA) visits three times a week. P9’s POC dated 8/17/25 to 10/15/25, indicated the diagnoses and level of orientation remained unchanged. P9’s orders continued for SNV every two weeks, with HHA visits three times a week. A review of the SNV notes identified a HHA supervisory visit was lacking between the date of 7/17/25 and the date of 8/13/25. A care coordination note identified the patient refused visit for 7/29/25, however, lacked any indication of attempting to schedule a visit in follow up to complete the HHA supervision visit. A review of the SNV supervisory frequency between 9/25/25 and 10/14/25 identified a gap of 19 days between HHA supervisory visits. During visit on 10/16/25, at 3:30 p.m., the director of nursing (DON) stated supervisory visits of patients receiving skilled care services were to be completed every 14 days. If a skilled nurse visit was cancelled, it was her expectation it would be rescheduled. DON stated supervisory visits are to be completed every 14 days. DON stated a frequency of greater than 14 days would be out of compliance. A facility policy, Home Health Supervision, updated 5/14/24, identified when skilled services were being provided to a client (patient), a registered nurse/therapist must make a supervisory visit to the client’s (patient’s) residence no less frequently than every 14 days. HHA supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to the following elements: following the client’s plan of care for completion of tasks assigned to the HHA; maintaining open communication process with the client, representative, caregivers, and family; demonstrating competency with assigned tasks; reporting changes in the client’s condition; and honoring client’s rights. P17’s POC for certification period 9/110/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. P17’s private duty POC dated 9/10/25-11/18/25, indicated P17 required patient care assistant (PCA) services up to 12.5 hours a week for assistance with activities of daily living and care due to functional limitations. P17’s electronic medical record lacked indication supervisory visits were completed every 14 days. When interviewed on 10/15/25 at 12:45 p.m., RN-A verified P17 received PCA services through the agency as well as nursing and therapy services. RN-A stated she did not supervise P17’s PCA and the only time supervision was completed was at the time of recertification. P1’s plan of care (POC)/485, for skilled care, with a certification period of 7/15/25 to 9/12/25 and POC/485 for 9/13/25 to 11/11/25, indicated P1 had heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. The POC orders indicated P1 was to receive skilled nurse visits twice weekly. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistance (PCA) up to 40 hours per week. P1’s electronic medical record lacked indication supervisory visits were completed every 14 days. A registered nurse (RN) visit note, dated 8/13/25, indicated supervision of PCA was conducted with “a new PCA” who was not PCA-C. Review of skilled nurse visit notes dated 7/11/25 to 10/6/25 lacked documentation of PCA supervisory visits. On 10/8/25 at 10:15 a.m., RN-B stated he had never talked to and had never met PCA-C, further he stated he was not sure which agency P1’s PCA services were through. He stated, “They (PCA’s) don’t necessarily have a nurse to report to.” On 10/9/25 at 12:52 p.m., clinical manager (CM)-B stated PCAs and home health aides must be supervised every 14 days when open to skilled services. She stated if they were not open to skilled services, the nurse would conduct a supervisory visit with every recertification visit/every 60 days. On 10/9/25 at 1:50 p.m., the director of nursing (DON) stated PCAs received supervision by the RN every 14 days when they were also open to skilled care, noting the supervision could be indirect. On 10/10/25 at 10:10 a.m., PCA-C, who is also P1’s family member (FM)-B, stated he was the PCA for P1, employed by the home health agency. PCA-C stated he had never spoken to and had never met RN-B. On 10/14/25 at 11:20 a.m., CM-C stated supervisory visits for those clients receiving only PCA services (non-skilled services) should be after the initial 14 days, and then every 60 days. She stated supervisory visits for clients open to skilled services who also received home health aide or PCA services should be every 14 days. Findings include: P1’s plan of care (POC)/485, for skilled care, for certification period 9/13/25 to 11/11/25, indicated P1 had heart failure, dementia, pleural effusion (condition where fluid accumulates in the area between the lungs and chest wall, cardiomyopathy (group of weakened or thickened heart muscles), and chronic pain. The POC also indicated P1 used a walker, was forgetful, and had a history of falls. P1’s POC/485, for private duty care, with a certification period 8/15/25 to 10/13/25, indicated P1 had dementia, pulmonary embolism (blood clot in the lungs), cardiomyopathy, heart failure, and chronic pain. The POC orders indicated P1 was to receive skilled nursing once for one week, and personal care assistant (PCA) up to 40 hours per week. P1’s aide care plan dated 8/15/25 directed the PCA to assist P1 with stand-by assistance for ambulation, shower, dressing, and fall risk. The care plan also directed the PCA to prepare meals, laundry, and complete errands for P1. P1’s electronic medical record lacked PCA notes regarding skin alterations, report of falls, or communication with the registered nurse (RN). On 10/10/25 at 10:10 a.m., PCA-C stated P1 had “a number of falls in the past few months” and P1 experienced several falls when attempting to use the towel bar in his bathroom to stand up. PCA-C stated P1 had several wounds from falling and bumping his elbows into things such as the edge of the table. PCA-C stated P1 sat in his recliner for extended periods of time causing pressure to his heels and tailbone area. He stated the tailbone wound was present for about 6 weeks and the heel wounds were present for a few months. He stated the RN was making wound care visits twice weekly for P1, therefore PCA-C did not feel it was necessary to update RN-B. PCA-C stated the agency’s charting system did not allow PCA’s to document anything that was not on the care plan. PCA-C stated he had never spoken to and had never met RN-B. On 10/8/25 at 10:15 a.m., RN-B stated he had never talked to and had never met PCA-C, further he stated he was not sure which agency P1’s PCA services were through. He stated, “They (PCA’s) don’t necessarily have a nurse to report to.” On 10/14/25 at 11:20 a.m., clinical manager (CM)-C stated PCA’s were expected to report change in skin condition and falls to the RN and to their supervisor. On 10/17/25 at 2:15 p.m., The director of nursing (DON) stated the aides should be calling their supervisor or RN directly to report concerns regarding patients. She stated the electronic medical record system in use only allowed the PCAs to document by exception. P17’s plan of care (POC) for certification periods 9/10/25-11/8/25, indicated P17 was orientated and had diagnoses of femur fracture, chronic kidney disease and a history of falls. P17 required a wheelchair and walker for ambulation assistance. P17’s private duty POC dated 9/10/25-11/18/25, indicated P17 required patient care assistant (PCA) services up to 12.5 hours a week for assistance with activities of daily living and care due to functional limitations. P17’s electronic medical record lacked indication P17 had any skin alterations. An observation on 10/15/25 at 12:00 p.m., P17 was observed during their home visit with registered nurse (RN)-A. P17 had a bandage on their right wrist/forearm. P17 stated about a week ago, she bumped her arm on the wheelchair and PCA-A cleaned it up and dressed it. P17’s wheelchair had wash clothes taped to both side arms of the chair. RN-A removed the dressing and obtained wound measurements before replacing with a new bandage. When interviewed on 10/15/25 at 12:45 p.m., RN-A stated she was not aware of P17’s skin tear before the visit today and did not think it was there last week. RN-A verified there was no communication found in P17’s EMR about the skin tear. RN-A stated usually if the PCAs saw a skin concern, it would be reported to the nurse. RN-A further stated PCA-A was also a family member who was a nurse, so they just took care of it. When interviewed on 10/16/25 at 4:13 p.m., PCA-A stated they did not communicate P17’s skin tear to the nurse when it was discovered, PCA-A acknowledged she should have let them know about it when it happened. An agency policy for PCA services was requested however was not provided. An agency policy titled Home Health Aide Services directed HHA staff will be under the direct supervision of an agency RN or therapist. The policy further directed staff to recognize and report any changes in skin condition. An agency policy titled Clinical Documentation, no date, directed staff to complete a separate note for each visit and additional pertinent to the patients care or condition would be documented in a progress note or flow sheet. Furthermore, documentation of telephone or other communication will be documented in the clinical progress notes or other interagency communication form.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure an onsite supervisory visit was conducted every 60 days for 1 of 1 patient (P15) who received Community First Services and Support (CFSS) without skilled services. Findings include: P15’s unskilled plan of care (POC) for certification period 9/19/25-11/17/25, indicated P15 was orientated and had diagnoses of diabetes, vascular disease, and heart disease. P15 used a walker or cane for ambulation. Furthermore, P15 required CFSS up to 66.5 hours a week and homemaking up to 3 hours a week for 9 weeks. P15’s nursing recertification note dated 7/17/25, indicated there was no change in frequency/duration of medications or treatments. Furthermore, a supervisory function was performed during this recertification. P15’s nursing recertification note dated 9/16/25, indicated there was no change in frequency/duration of medications or treatments. However, no supervisory functions were performed as it was documented as not applicable to P15’s care. No communication occurred with other disciplines involved in P15’s care. P15’s electronic medical record (EMR) lacked indication a supervisory visit was completed between 7/17/25 and 10/15/25. When interviewed on 10/15/25 at 12:45 p.m., registered nurse (RN)-A stated supervisory visits for unskilled services were completed every 60 days with the recertification assessment. When interviewed on 10/15/25 at 1:50 p.m., the Director of Nursing (DON) expected staff to complete a supervisory visit for unskilled services every 60 days, unless skilled services were also ordered. An agency policy titled Home Health Aide Supervision revised 5/14/24, directed skilled staff must make a supervisory visit to the client’s residence at least once every 60 days. The aide does not need to be present.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: During observation, interview and record review, the agency failed to ensure staff were following accepted standards of infection control practices during home care observation visits for 3 of 7 residents (P8, P9, P12). Agency staff failed to utilize personal protective equipment (PPE) such as a barrier against potential infectious disease exposure of their supply/workbags that were placed directly on furniture and/or carpet. P8 P8’s start of care (SOC) to the agency was 10/26/24, with diagnoses of cerebral infarction (stroke), generalized weakness, and cognitive communication deficit. P8’s plan of care (POC) had certification dates of 10/26/24 to 12/24/24. During observation on 12/3/24 at 10:00 a.m., Occupation therapist (OT)-A entered P8 home with backpack bag and walked up stairs to living room of P8 home. OT-A placed backpack bag on the carpet in front of the couch where OT-A sat. No barrier was used between the backpack bag and the carpet. During interview with OT-A on 12/3/24 at 10:30 a.m., OT-A verified she did not use a barrier between her backpack bag and the carpet. “I did not put a barrier on the ground to set my bag on top of. Should be done [it] for infection control. I haven’t done that since Covid. I don’t have barriers in my bag.” P12 P12’s SOC to the agency was 11/19/24 with diagnoses of left knee replacement, pulmonary hypertension, chronic kidney disease, anemia morbid obesity, and long-term use of anticoagulants. P12’s plan of care (POC) had certification dates of 11/19/24 to 1/17/25. During home care observation with home health aide (HHA)-A on 12/4/24 at 9:40 a.m., upon entrance to P12 apartment, HHA-A placed her work bag on the seat of a chair without use of a barrier. During interview with HHA-A on 12/4/24 at 10:15 a.m., HHA-A verified she did not place work bag on top of a barrier when placing it on the chair for visit. HHA-A stated, “[I have] never been told by agency that my bag needs to be on top of a barrier”. During interview with director of nursing (DON) on 12/4/24 at 12:02 p.m., DON stated expectation of all home care staff is to use barriers between their work bags and the surfaces that they are rested on when in the residents’ home. “We have bag barriers we give to all of the staff that do home visits. Bags are to be set on that. Soap and paper towels are also provided”. And “[bags] never should go on the floor. Not on couch or fabric chairs either”. Undated policy titled, Nursing Bag identifies, “When in a client’s home, place a waterproof disposable barrier on a clean and dry surface then place the bag down on the barrier.” P9’s start of care (SOC) was 11/29/24. P9’s plan of care (POC) for certification period 11/29/24 to 1/27/25 included diagnoses of hypertension and left sided hemiplegia (paralysis) following cerebral infarction (stroke). The POC indicated one skilled nurse visit one time per week for nine weeks, one physical therapy visit for one week, one occupational therapy visit for one week and one speech therapy visit for one week. During observation on 12/3/24 at 10:00 a.m., registered nurse (RN)-D placed her nursing supply backpack directly on the living room floor next to P9’s chair. No barrier was placed under RN-D’s bag. When interviewed on 12/4/24 at 12:30 p.m., RN-D indicated she had used barriers for her bag when Covid was an issue but was never given anymore from the office when she ran out.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: During observation, interview and record review, the agency failed to identify and update all prescription and non-prescription medications for 2 o7 patients (P6, P10) reviewed during home visits. Findings include: P6’s start of care (SOC) to the agency was 12/16/22 with diagnoses of Alzheimer’s disease, peripheral vascular disease, hypertension, and identified a language barrier. P6’s plan of care (POC) had certification dates of 10/6/24 to 12/4/24. The POC identified orders as, “Skilled nurse to review medication profile and reconcile medications as needed. Skilled nurse may instruct and reinforce medication teaching related to use of medications to treat disease process. Skilled nurse may fill medi-planner per current medication orders/profile QWK (every week).” During review of P6’s plan of care (POC) with certification dates of 10/6/22 to 12/4/24, downloaded 12/2/24, and P6’s updated medication list downloaded 12/3/24, identified Alendronate 70 milligram (MG) tablet to be taken weekly with order start date of 4/22/24. During home care observation with registered nurse (RN)-E on 12/2/24 at 3:00 p.m., visit was conducted with Vietnamese interpreter (VI) due to language barrier. RN-E reviewed medication bottles in the home that P6 provided for review. Two prescription bottles were present in the home but not on P6 POC and electronic medical record (EMR). Medications were: “Vitamin D3 50 micrograms (MCG) 2000UI (international units) tablets with frequency as ‘QD’ (daily)”. This bottle stated it was last refilled by pharmacy on 10/23/24. “Loratadine 10 milligram (MG) tablets” with frequency as QD. This bottle stated it was last refilled by pharmacy on 11/26/24. RN-E Stated, “we don’t fill [P6] weekly med box with Alendronate”. RN-E Stated she did not know why. RN-E reviewed P6 clinic after visit summary dated 9/11/24 that was in the home and verified the Vitamin D3 and Loratadine were on it but not on the agency’s P6 medication list. Also, “I expect the med list [in P6] EMR to be updated and current, which it was not regarding the Vitamin D3 and Loratadine.” RN-E stated, “[agency] should have updated the med list from after visit summaries and review [them with provider]. “ During interview with VI during home visit, VI stated, “I visit [P6] weekly, and the home care nurse sets up [P6’s] meds. [P6] has been on the Vitamin D3 and Loratadine for several months. I know the home care nurse sets them up [in the med planner] and calls them in [to pharmacy] for refills when [agency nurse] is here. [Agency nurse] sets up all of [P6] meds.” During interview with director of nursing (DON) on 12/3/24 at 12:45 p.m., DON verified P6 medication list in EMR downloaded on 12/3/24 was accurate and up to date. DON stated the Alendronate 70 mg tablet order was on P6 POC and EMR and was expected to be set up by agency nurse weekly per orders. “Fosamax is supposed to be set up by us. Any changes including medications should be reflected in the med list there (pointing to P6 EMR)”. DON stated the Vitamin D3 and Loratadine were expected to be reconciled to current EMR and were not. DON stated,” If there are meds in the home that are being set up by us, we need to have them on the med list in the EMR”. DON stated she was unable to download P6’s after visit summary dated 9/11/24. Review of undated policy titled Medication Set Up Policy identified expectation of “The medication list is current and updated with physician/ allowed non-physician practitioner (NPP) orders as changes occur. The medications are reviewed at each visit to determine if there are new or changed medications. This includes over the counter medications.” Also, “The nurse must always read the pharmacy labels carefully whether he/she is filling a med-planner or administering the medication. The nurse should then compare the medication labels to the 485 (POC), checklist, and/or MAR before administering the medication or filling the med-planner.” In addition, “Medication reconciliation will be completed at each visit.” P10’s plan of care (POC) for certification period 10/24/24 to 12/22/24, indicated P10’s start of care (SOC) was 10/24/24, and diagnosis included displaced intertroch fracture of the left femur (broken hip), atrial fibrillation (A Fib), depression, and constipation. The POC included a comprehensive medication list. During skilled nurse visit on 12/3/24 at 11:00 a.m., P10 denied any recent medication changes. Registered nurse (RN)-A discussed P10s difficulty sleeping and pain. P10 stated she was utilizing Tylenol for pain relief. RN-A asked if P10 was using any Voltaran cream. P10 denied use, but did have the cream sitting next to her. Neither Tylenol nor Voltaran cream were on the POC. Additional medications not on the POC were found in P10s home during medication review. Calcium Polycarbophil (Fiber) 625 mg tabs, fluticasone (Flonase) 50 mcg/act nasal spray, omeprazole (Prilosec) 40 mg capsule, trazodone (Desyrel) 50 mg tab. P10 stated she has been taking all of these medications since prior to admission to home care services. During interview on 12/3/24 at 11:15 a.m., RN-A stated a comprehensive review of medications should have been completed at SOC. RN-A stated she does not complete SOC visits for the agency so was unsure of the exact process. RN-A stated she asks about new medications at each home visit and would add medications to the POC if needed. During interview on 12/4/24 at 8:16 a.m., RN-B confirmed she was a SOC nurse for the agency, but did not remember P10’s SOC specifically. RN-B stated the normal process for medication reconciliation at SOC was to review the orders prior to the visit, review orders with medication in the home, then follow up with the provider with any differences or questions. During interview on 10/4/24 at 10:19 a.m., assistant director of nursing (ADON) confirmed it is policy that a complete medication reconciliation should be completed at every SOC visit. All medications in the home should be reviewed and provider should be updated with questions or discrepancies. The differences and clarification should be documented in the patient’s medical record. She stated this was important for a number of reasons, including watching for interactions, ensuring all providers are aware of all medications the patient is taking, and to ensure an updated medication list is in the patient’s home. Facility policy titled Medication Reconciliation dated 5/13/24, included a complete medication reconciliation should be completed at start of care and include all prescription, over the counter, and as needed medications. The policy included this was important to prevent potential mediation errors and to assure clients are receiving all necessary medications, to prevent hospitalization due to adverse effects and non-adherence.”

“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 observation, interview and document review, the agency failed to include all durable medical equipment (DME) on 1 of 7 patient’s (P7) plan of care (POC) reviewed during home visits. P7’s POC with certification period 10/4/24 to 12/2/24 indicated a start of care on 8/5/24. P7’s POC included diagnoses of chronic respiratory failure, severe obesity (overweight), chronic pain, and hypertension (high blood pressure). P7’s section on the POC that indicated DME and supplies was filled out with “none.” P7’s physical therapy assessment completed during 7/19/24 hospital admission included P7 had grab bars, wheelchair, handicap tub with removable bench, and 2-wheel walker in the home. P7’s home care occupational therapy evaluation completed 8/7/24, included DME available for P7 as multi-wheeled walker, wheelchair and tub chair. During home visit on 12/2/24 at 1:48 p.m., P7 worked with physical therapist (PT)-A while using a front wheel walker. P7 had a wheelchair in her living room and spoke of using it when going out for appointments. During interview on 12/4/24 at 8:48 a.m., PT-A stated the DME section was usually filled out during start of care. PT-A did confirm P7 had DME in the home which included a walker, lift chair, tub bench and wheelchair. During interview on 12/4/24 at 10:19 a.m., assistant director of nursing (ADON) stated any medical equipment used in the home should have been included on the POC. She confirmed P7’s POC listed “none” for DME and P7’s admission summary stated P7 had a walker. She stated it was important to include all DME on the POC so clinicians and providers would have known what was available for use by the patient. Agency policy titled Plan of Care dated 5/14/24, included the plan of care needed to include all home medical equipment and assistive devices.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure catheter insertion was provided within standards of practice for 1 of 3 (P1) patients reviewed for catheter insertion. RN-A met resistance when inserting an indwelling urinary catheter and could not inflate the balloon to capacity. P1 presented to the emergency room with pain. Findings include: Indwelling Urinary Catheter Insertion and Maintenance retrieved from CAUTI 104 (cdc.gov), https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf indicated Many nurses and other clinicians have to relearn “proper” technique, working environments does not resemble learning environment, inserting clinicians should receive competency-based training and be able to demonstrate indwelling catheter insertion competency. Practices should be observed and monitored in real world settings after initial training. Proper Indwelling Catheter Use to Prevent CAUTIs retrieved from https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2019/11000/proper_indwelling_catheter_use_to_prevent_cautis.5.aspx indicated insert the catheter approximately to the bifurcation from the tip of the catheter (see Picturing indwelling catheter placement). Stop advancement if resistance is met and notify the physician. Next, insert the catheter until urine is returned. Inflate the balloon slowly using the prefilled syringe. Pull gently on the catheter until resistance is felt. P1’s Home Health Certification and Plan of Care, dated 3/26/24, for certification period 3/28/24 through 5/26/24, with an addendum added on 4/18/24 indicated he had orders to change his foley catheter every 30 days. A visit note, dated 4/18/24 indicated P1 had a visit from registered nurse (RN)-A. The visit note lacked interventions conducted at the visit. The visit note indicated P1 had no pain, and the genitourinary system was assessed. An After Visit Summary, dated 4/19/24, for P1 when he presented to the emergency room for catheter malfunction. The after-visit summary indicated it appeared the indwelling urinary catheter was not fully advanced before the balloon was inflated. The catheter was removed in the emergency room and replaced. During an interview on 4/24/24 at 12:29 a.m., RN-A stated she changed P1’s foley catheter on 4/18/24. RN-A stated she encountered resistance and was only able to insert seven cubic centimeters (cc) of sterile water in the balloon because P1 complained of discomfort. RN-A stated she told the nurse in the building to monitor the urine flow and call her with any questions. RN-A stated she was never asked to demonstrate her skill ability with foley catheter insertion when she started at the agency about one year ago. During an interview on 4/25/24 at 11:41 a.m., P1 stated he was aware the home care nurse had difficulty placing his foley catheter on 4/18/24. P1 stated when the nurse tried to fill the balloon, it caused him “terrific pain”. P1 stated when he woke in the middle of the night in pain, after having the catheter placed by the home health nurse earlier that day and requested to go to the emergency room. During an interview on 4/25/24 at 2:25 p.m., the director of clinical services stated there was not a completed competency for inserting foley catheters for RN-A. The director of clinical services stated she expected RN-A would have included documentation of the interventions and difficulties she had on P1’s visit note. An undated facility document, Competency Evaluation of Home Care Staff, directed the agency will establish a program that allows for objective, measurable, assessment of the person’s ability to perform required activities. The assessment will verify and focus on the individual staff knowledge and skill appropriate to assigned responsibilities, communication skills, and the ability to respond to client needs within their scope of responsibility. Competencies will address: age/type of client, scope of services offered by the agency, high risk procedures, new procedures/technologies, and areas identified in performance improvement process. The competency evaluations will be completed by individuals who have the knowledge and skills to assess performance and ability. All competencies will be documented, and actions will be taken when opportunities for improvement are identified. An undated facility document, Urinary Catheter Insertion - Straight or Indwelling Catheter procedure directed advance catheter until urine begins to flow out end. Approximately seven to nine inches in adults. Inflate balloon: Caution, if the client complains of sudden pain, the catheter may be in the urethra. Withdraw the solution and advance catheter further, then repeat procedure. Documentation in the clinical record: a. Type and size of catheter inserted. b. Date and time of catheter insertion. c. Urine return and characteristics, color, and odor, if any. d. Amount of urine prior to residual catheterization. e. Any difficulties or discomfort. f. Teaching provided and client/caregiver response. g. The client’s tolerance of the procedure.”