Aplus Health Care LLC

“Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for basis and scope, 42 CFR § 484.1 at G0325. The agency failed to ensure primary engagement in providing skilled nursing and other therapeutic services and meet Condition of Participation requirements. See G510, G570, G640, G848, G940, and G1008. See G510: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Comprehensive Assessments of Patients, 42 CFR § 484.55 at G0510. The agency failed to ensure comprehensive assessments were individualized to the patient and/or completed. See G528, G530, G538 G540, and G550. See G570: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for care planning, coordination and quality of care at 42 CFR § 484.60 at G0570. The agency failed to ensure patients’ care plans were individualized and included the care and services necessary to meet patients’ needs. See G572, G574, G576, and G588. See G640: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Quality assessment/performance improvement, 42 CFR § 484.65 at G0640. The agency failed to implement, evaluate and maintain a Quality Assessment Process Improvement (QAPI) program. See G642, G644, G646, G656, and G660. See G848: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Organization and administration of services, 42 CFR § 484.100 at G0848. The agency failed to ensure their comprehensive home care licensure was active. See G860. See G940: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Organization and administration of services, 42 CFR § 484.105 at G0940. The agency had skilled nursing services available and lacked at least one additional therapeutic service available for current and future patients the agency may admit. See G982. See G1008: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for clinical records, 42 CFR § 484.110 at G1008. The agency failed to ensure accurate and complete medical records were available to ensure safe care was delivered. See G1012, G1016, G1022, and G1026.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Comprehensive Assessments of Patients, 42 CFR § 484.55 at G0510. The agency failed to ensure comprehensive assessments were individualized to the patient and/or completed. See G528, G530, G538 G540, and G550. Findings include: See G528: Based on interview and document review the agency failed to conduct a comprehensive assessment that accurately reflected the health status for 1 of 3 patients (P3) reviewed who received skilled services. See G530: Based on interview and document review the agency failed to ensure the patient’s goals were accurately reflected in the comprehensive assessment for 1 of 3 patients (P3) who received skilled services. See G538: Based on interviews and document review the agency failed to ensure caregiver information was included in the comprehensive assessment for 1 of 3 patients (P3) who received skilled services. See G540: Based on interview and document review the agency failed to ensure the patient representative was included in the comprehensive assessment for 1 of 3 patients who received skilled services. See G550: Based on interview and document review the agency failed to ensure a comprehensive discharge assessment was completed for 1 of 2 patients (P3) who received skilled services and discharged from the facility.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for care planning, coordination and quality of care at 42 CFR § 484.60 at G0570. The agency failed to ensure patients’ care plans were individualized and included the care and services necessary to meet patients’ needs. See G572, G574, G576, and G588. Findings include: See G572: Based on interview and document review the agency failed to ensure 2 of 3 (P1, P3) patients reviewed received care consistent with the providers orders listed in the plan of care (POC). See G574: Based on interview and document review, the agency failed to ensure patient’s plan of care included all required components in the patient’s individualized care plans for 3 of 3 patients (P2, P3, P1) reviewed for skilled services. See G576: Based on interview, and document review the agency failed to ensure all patient care orders, were part of the plan of care (POC) for of 2 of 3 patients (P3, P1) reviewed for skilled nursing services. See G588: Based on interview and document review the agency failed to ensure the Plan of Care was reviewed and signed by the provider for 1 of 3 patients (P3) reviewed who received skilled services.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Quality assessment/performance improvement, 42 CFR § 484.65 at G0640. The agency failed to implement, evaluate and maintain a Quality Assessment Process Improvement (QAPI) program. See G642, G644, G646, G656, and G660. See G642: Based on interview and document review, the agency failed to establish a process to measure, analyze and track quality indicators. This had the potential to affect all patients who received home care services. See G644: Based on interview and document review, the agency failed to utilize quality data to identify opportunities for improvement. This had the potential to affect all patients who received home care services. See G646: Based on interview and document review, the agency failed to implement, measure and track performance improvement activities. This had the potential to affect all patients who received home care services. See G656: Based on interview and document review, the agency failed to implement, measure and track performance improvement activities. This had the potential to affect all patients who received home care services. See G660: Based on interview and document review the agency failed to ensure an ongoing quality assurance performance improvement program was implemented and maintained. This had the potential to affect all patients who received home care services.”

“Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Organization and administration of services, 42 CFR § 484.100 at G0848. The agency failed to ensure their comprehensive home care licensure was active. See G860. See G860: Based on interview and document review the agency failed to ensure they were licensed in accordance with the state licensing authority. This had the potential to impact all patients who received home care services.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for Organization and administration of services, 42 CFR § 484.105 at G0940. The agency had skilled nursing services available and lacked at least one additional therapeutic service available for current and future patients the agency may admit. See G982. Refer to G982: Based on interview and document review, the agency failed to ensure one other skilled service was provided along with skilled nursing services. This had the potential to impact P1 and all future patients who received skilled home care services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation for clinical records, 42 CFR § 484.110 at G1008. The agency failed to ensure accurate and complete medical records were available to ensure safe care was delivered. See G1012, G1016, G1022, and G1026. See G1012: Based on interview and record review, the agency failed to ensure medical records included the most recent comprehensive assessments for 1 of 3 patients and clinical notes for 3 of 3 patients (P3, P1, and P2) reviewed who received skilled services. See G1016: Based on interview and document review the facility failed to ensure patient’s goals were included in the plan of care (POC) and had documented progress towards achieving them for 1 of 1 patient (P3) who reviewed who received skilled services. See G1022: Based on interview and record review the agency failed to ensure a completed discharge summary was completed for 1 of 2 residents (R3) reviewed for skilled services and was discharged. See G1026: Based on interview and document review, the agency failed to ensure complete clinical records were retained for 5 years after patient discharged for 1 of 2 patients (R3) reviewed for skilled services who discharged.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to ensure 5 of 8 employees (PCA-A, PCA-B, ADON, DON, and administrator) received ongoing emergency preparedness training at least every 2 years. Findings include: Personal care assistant (PCA)-A’s date of hire 10/31/23. No training on the EP program was on file since hire. PCA-B’s date of hire was 9/4/24. No training on the EP program was on file since hire. The assistant director of nursing (ADON)’s had no ongoing training on the EP program on file. The director of nursing (DON)’s date of hire was 11/2/21. No training on the EP program was on file since hire. The administrator had no ongoing training on the EP program on file. During an interview on 5/15/26 at 2:20 p.m., the DON stated staff were trained upon hire and yearly. Documentation of ongoing training was requested and not provided. The facility’s undated EP program training policy was requested and not provided.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure they conducted emergency preparedness exercises annually which involved different scenarios to test their emergency plan. Findings include: The agency’s two most recent exercises dated 3/3/25 and 3/18/26, identified table-top severe weather exercises were done for both years. During an interview and document review on 5/15/26 at 2:20 p.m., the director of nursing (DON) reviewed the emergency preparedness documents and verified the previous two exercises were similar scenarios. The DON reviewed the facility risk assessment for other high-risk situations and stated those included power outage, flooding, civil unrest and fire, however, no testing was done of the other high risk areas. The DON stated she would expect the high-risk area exercises to rotate so everyone knows how to respond to a variety of situations. A copy of the emergency preparedness testing policy was requested and not provided.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to report all OASIS data collected in accordance with federal regulations for 2 of 3 patients (P3, P1) reviewed for skilled care. The total number of records submitted beyond the 30 days was 3, which equaled 3.37% of the submissions submitted. Findings include: P1’s POC for certification period 3/27/26 through 5/25/26, identified P1 required one skilled nursing visit every other week. P1’s start of care - further visits planned OASIS dated 3/27/26, identified it was not submitted. The Home Health Agency (HHA) error report for a period of 1/1/25-12/31/25, indicated the agency had an error code of -330: records submission late. The description included submissions were more than 30 days late. P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3 required skilled nursing 12 hours a day for 60 days. P3’s recertification OASIS assessment dated 10/1/25, indicated it was not transmitted. P3’s discharge OASIS assessment dated 11/1/25, indicated it was not transmitted. When interviewed on 5/15/26 at 2:20 p.m., the Director of Nursing (DON) verified the OASIS assessments for P3 and P1 were not submitted at all and should have been. DON was traveling when P1’s was supposed to be submitted and may have been when P3’s should have been as well. DON expected all OASIS assessments to be submitted timely. An agency policy on timeliness of OASIS admissions was not provided.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure a discharge summary was completed for 1 of 1 patients (P3) reviewed who received skilled services and was discharged. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 required skilled nursing 12 hours a day for 60 days. P3’s discharge comprehensive assessment dated 11/1/25, indicated P3 discharged from the agency on 11/1/25. P3’s electronic medical record and paper medical record lacked indication a discharge summary was completed. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) confirmed P3’s discharged, however was not sure if it was in November or December. DON verified there was no discharge summary for P3. DON expected a discharge summary to be completed as it was important to pass on to P3’s provider or other agencies involved in their care. An agency policy titled Client Discharge Process, no date did not provide direction for completion of a DC summary.”

“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 ensure 2 of 3 (P1, P3) patients reviewed received care consistent with the providers orders listed in the plan of care (POC). Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3 had diagnoses of chronic respiratory failure, brain injury and paraplegia (inability to move all extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s POC for certification period 8/3/25-10/1/25, indicated P3 had diagnoses of chronic respiratory failure, brain injury and paraplegia (inability to move all extremities). P3 required skilled nursing 12 hours a day for 60 days. A review of P3’s skilled nursing notes showed the following: -for 11/2025, skilled nursing visit notes were documented for 1 day leaving 29 skilled nursing visits unaccounted for. -for 10/2025, skilled nursing visit notes were documented for 16 days leaving 15 skilled nursing visits unaccounted for. -for 9/2025, skilled nursing visit notes were documented for 17 days leaving 13 skilled nursing visits unaccounted for. -for 8/2025, skilled nursing visit notes were documented for 10 days leaving 21 skilled nursing visits unaccounted for. P3’s electronic medical record (EMR) and paper medical record lacked indication of any missed visit notes or P3’s provider was updated. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON confirmed there were no missed visit notes in P1 or P3’s medical record. DON stated she did not think P1 was a current patient as no cares had been provided. DON assumed P1 didn’t want home care, and staff should have communicated to the provider and suggest a discharge. DON was unaware of staff still trying to connect with P1 to set up a visit and expected documentation to reflect the attempts as well as to inform the provider. For P3, DON further stated there were times when the agency may not have had staff to complete a visit and the family would then care for the patient. When the agency did not have staff to send, a note was not required. DON stated she was not sure why there was no documentation or if it was one of those times where there was no staff. DON would need to look into it. No further information was provided. An agency policy titled Clinical Documentation Policy no date, directed staff to complete a separate note for each visit provided. Furthermore, the progress note may be used to document any other communication with provider or person involved in patient’s care. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying condition with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing one time every two weeks for 60 days. P1’s medical record for the above certification period had zero skilled nursing visits and lacked notification to P1’s provider of the missed visits. On 5/14/26 at 12:50 p.m., a phone call was placed to P1’s phone number on file, and when the phone was answered the person hung up after introduction. On 5/14/26 at 12:51 p.m., a phone call was placed to P1’s emergency contact, a voicemail was left with call back instructions, and no return call was received.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to establish a process to measure, analyze and track quality indicators. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment process improvement (QAPI) program. including data and performance improvement projects was requested, however wasn’t received. The agency’s Minutes of Meeting of Professional Advisory Board dated 4/19/26, indicated a meeting was held. The meeting minutes indicated the administrator, Director of Nursing (DON), physical therapist (PT)-A, the alternate administrator (AA), and contracted consultant (CC) attended. The meeting agenda consisted of marketing strategies, an update of the Medicare PCR, and when to schedule the 2025-2026 meetings. Details of the meeting minutes directed QAPI to meet and address the issues found in the Medicare revisit survey. When interviewed on 5/15/26 at 12:43 p.m., the owner of the contracted physical therapy agency stated they did not know who PT-A was. Furthermore, PT-A had not worked for the company. When interviewed 5/15/26 1:08 p.m., acting administrator stated he hadn’t been with the company for long and wasn’t sure about any quality program or initiatives. Requested contents of quality program and stated the meeting minutes were what he was able to provide and would need to look into the rest. No further information was provided. When interviewed on 5/15/26 at 2:10 p.m. the DON stated she had been involved in quality meetings but there had not been any for a long time. DON was not sure how the agency tracked quality and said if a patient or family had concerns, staff would work to solve the complaints. DON reviewed the meeting minutes received and stated there was no meeting in April of 2026 and it looked like that was a mistake. Furthermore, the DON stated she was not aware of the physical therapist who was listed as attending and said that wasn’t correct either. An agency policy title Quality Management no date, directed the agency will develop a continuous quality program that will measure and assess performance to determine improvement activities.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to utilize quality data to identify opportunities for improvement. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment process improvement (QAPI) program including data and performance improvement plan was requested, however was not received. When interviewed on 5/15/26 1:08 p.m., acting administrator stated he hadn’t been with the company for long and wasn’t sure about any quality program or initiatives. Requested contents of QAPI program and stated the meeting minutes were what he was able to provide and would need to look into the rest. No further information was provided. When interviewed on 5/15/26 at 2:10 p.m. the Director of Nursing (DON) stated she had been involved in quality meetings but there had not been any for a long time. DON was not sure how the agency tracked quality data and said if a patient or family had concerns, they would work to solve the complaints. DON reviewed the meeting minutes received and stated there was no meeting in April of 2026 and it looked like that was a mistake. Furthermore, the DON stated she was not aware of the physical therapist who was listed as attending and said that wasn’t correct either. An agency policy title Quality Management no date, directed the agency will develop a continuous quality program that will measure and assess performance to determine improvement activities.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to identify performance improvement activities. This had the potential to affect all patients who received home care services. Findings include: The agency’s quality assessment process improvement (QAPI) program including data and performance improvement plan was requested, however was not received. The agency’s Minutes of Meeting of Professional Advisory Board dated 4/19/26, indicated a meeting was held. The meeting minutes indicated the administrator, Director of Nursing (DON), physical therapist (PT)-A, the alternate administrator (AA), and contracted consultant (CC) attended. The meeting agenda consisted of marketing strategies, an update of the Medicare PCR, and when to schedule the 2025-2026 meetings. Details of the meeting minutes directed QAPI to meet and address the issues found in the Medicare revisit survey however lacked any plan or process to implement or track improvements. When interviewed on 5/15/26 1:08 p.m., acting administrator stated he hadn’t been with the company for long and wasn’t sure about any quality program or initiatives. Requested contents of QAPI program and stated the meeting minutes were what he was able to provide and would need to look into the rest. When interviewed on 5/15/26 at 2:10 p.m. the Director of Nursing (DON) stated she had been involved in quality meetings but there had not been any for a long time. DON was not sure how the agency tracked quality data and said if a patient or family had concerns, they would work to solve the complaints. DON was not aware of any performance activities in place. DON reviewed the meeting minutes received and stated there was no meeting in April of 2026 and it looked like that was a mistake. Furthermore, the DON stated she was not aware of the physical therapist who was listed as attending and said that wasn’t correct either. An agency policy title Quality Management no date, directed the agency will develop a continuous quality program that will measure and assess performance to determine improvement activities.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and document review the agency failed to ensure an ongoing quality assurance performance improvement program was implemented and maintained. This had the potential to affect all patients who received home care services. Findings include: The agency’s QAPI program, including data and performance improvement plan, was requested however, was not received. The agency’s Minutes of Meeting of Professional Advisory Board dated 4/19/26, indicated a meeting was held. The meeting minutes indicated the administrator, Director of Nursing (DON), physical therapist (PT)-A, the alternate administrator (AA), and contracted consultant (CC) attended. The meeting agenda consisted of marketing strategies, an update of the Medicare PCR, and when to schedule the 2025-2026 meetings. Details of the meeting minutes directed QAPI to meet and address the issues found in the Medicare revisit survey. When interviewed on 5/15/26 1:08 p.m., acting administrator stated he hadn’t been with the company for long and wasn’t sure about any quality program or initiatives. Requested contents of QAPI program and stated the meeting minutes were what he was able to provide and would need to look into the rest. When interviewed on 5/15/26 at 2:10 p.m. the Director of Nursing (DON) stated she had been involved in quality meetings but there had not been any for a long time. DON was not sure how the agency tracked quality data and said if a patient or family had concerns, they would work to solve the complaints. DON was not aware of any performance activities in place. DON reviewed the meeting minutes received and stated there was no meeting in April of 2026 and it looked like that was a mistake. DON said it had been at least a year since a meeting was held. Furthermore, the DON stated she was not aware of the physical therapist who was listed as attending and said that wasn’t correct either. An agency policy title Quality Management no date, directed the agency will develop a continuous quality program that will measure and assess performance to determine improvement activities.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure infection control education was provided yearly for 5 of 5 staff members (patient care assistant (PCA)-A, PCA-B, PCA-C, Assistant Director of Nursing (ADON) and Director of Nursing (DON), reviewed for education. Findings includ PCA-A’s employee file was reviewed and lacked indication yearly education for infection control was completed. PCA-A’s yearly education for infection control was requested however was not received. PCA-B’s employee file was reviewed and lacked indication yearly education for infection control was completed. PCA-B’s yearly education for infection control was requested however was not received. PCA-C’s employee file was reviewed and lacked indication yearly education for infection control was completed. PCA-C’s- yearly education for infection control was requested however was not received. ADON’s employee file was reviewed and lacked indication yearly education for infection control was completed. ADON’s yearly education for infection control was requested however was not received. DON’s employee file was reviewed and lacked indication yearly education for infection control was completed. DON’s yearly education for infection control was requested however was not received. When interviewed on 5/15/26 at 2:10 p.m., the DON verified PCA-A, PCA-B, PCA-C, ADON and DON’s employee file did not include yearly education for infection control. DON stated there was an online education program called Educare, however did not have access to the program. DON thought infection control education was completed in that system and would provide however no further information was provided. An agency policy titled Annual Training Requirements no date, directed staff to complete annual infection control training.”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on interview and document review the agency failed to ensure they were licensed in accordance with the state licensing authority. This had the potential to impact all patients who received home care services. Findings include: An email correspondence with the state authority (SA) on 5/13/26 at 3:51 p.m., indicated the agency had not submitted a license renewal application or payment for their comprehensive home care license that expired 3/2/2026. An observation on 5/14/26 at 9:00 a.m., the agency had their Minnesota Comprehensive Home Care License displayed on the wall behind the desk in the main office. The license had an expiration date of 3/2/26. When interviewed on 5/14/26 at 9:41 a.m., the acting administrator (AA) stated they were not sure how to start the re-licensure process and stated the Administrator was supposed to complete that weeks ago, before traveling out of the country. AA was not aware it had not been started and stated it should have been taken care of. An agency policy on licensure was not provided.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure one other skilled service was provided along with skilled nursing services. This had the potential to impact P1 and all future patients who received skilled home care services. Findings include: A review of personal care assistant (PCA)-A’s employee file on 5/14/26, lacked indication of home health aide (HHA) certification or continuing education needed for a HHA. A review of PCA-B’s employee file on5/14/26, lacked indication of HHA certification or continuing education needed for a HHA. A review of PCA-C’s employee file on5/14/26, lacked indication of HHA certification or continuing education needed for a HHA. When interviewed on 5/16/26 at 2:10 p.m., the Director of Nursing (DON) believed the therapy agency was contracted to provide PT, OT and ST services if needed. DON was not aware of any confusion with the contract and was not aware the therapy agency only provided PT services. DON stated they have never used any of the contracted therapy’s services that she was aware of. DON confirmed non licensed home care staff were PCAs and were not home health aides (HHA)s. DON stated many use the term interchangeably, however the PCA staff did not have the training to provide HHA services. DON further stated she had taken a “train the trainer” course and could provide education to become HHA’s but had not. An agency policy titled Agency Objectives no date, directed the agency to provide a coordinated team approach to therapeutic and rehabilitative services using skilled nursing, HHA, medical social services, PT, OT, and ST. The agency’s Contracting Services Contract Business Associate Agreement dated 8/1/23, identified an agreement between the contracted physical therapy clinic and the agency, for the clinic to provide physical, occupational and/or speech therapy. The agreement was signed by the agency’s administrator dated 8/2/23, and an illegible signature dated 8/1/23, above the line titled HIPAA Business Associate Agreement. During a phone call to the contracted physical therapy clinic on 5/14/26, at 9:06 a.m., the owner stated there was no contract in place with the agency and he had owned the facility for over two years. Additionally, the clinic has never provided occupational or speech therapy services, only physical therapy. During a follow up phone call on 5/15/26 at 4:11 p.m., the clinic administrator stated she had worked with the clinic’s previous owner and current owner. The clinic was never contacted by the agency for service during 2023 to the present date, nor provided services with the agency. Lastly, no billing between the clinic and the agency had occurred. In 2024, the clinic had removed their home care and telehealth insurance, so home care services were not allowed on their license in over two years anyway.”

“Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA’s policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure complete clinical records were retained for 5 years after patient discharged for 1 of 2 patients (R3) reviewed for skilled services who discharged. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck) and required tube feeding for nutrition. P3 required skilled nursing 12 hours a day for 60 days. P3’s Discharge Comprehensive Assessment dated 11/1/25, indicated P3 discharged on 11/1/25. P3’s medical and paper medical was reviewed and lacked indication admission paperwork was completed. This included lack of signed Bill of Rights and signed service plans for all certification periods from the time of admission through discharge. When interviewed on 5/14/26, the contracted consultant (CC) stated P3’s most recent admission should all be in the electronic medical record (EMR) as the agency had transitioned to that at that time. However, some of the admitting documents and other signed documents were not found P3’s EMR. CC stated she would need to talk to nursing to figure out where they would be. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) was not able to find P3’s missing service plans and admission information. DON stated there may be other paper medical records, but was not sure. DON explained the agency recently moved and some records may be in storage but was not sure. No further information was provided. An agency policy titled Clinical Records/Record retention no date, directed the agency to retain clinical records for 5 years after discharge.”

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure the OASIS privacy notice was provided to 1 of 3 patients (P3) reviewed who recieved skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s electronic medical record (EMR) lacked indication P3 received the privacy notice for OASIS data collected. P3’s paper medical record lacked indication P3 received the privacy notice for OASIS data collected. 8/14/23-12/31/25. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) verified P3’s medical record did not contain P3’s admission information, including the OASIS privacy notice and was not sure why. DON stated they should be included in P3’s paper chart but could not find them. DON expected all admission documents to be explained to and signed at the time of admission by the patient or family representative. An agency policy title Admission Policy no date, directed staff to complete the physical assessment and other additional documents as required during the admission process.”

“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 document review the agency failed to ensure a signature was obtained confirming a copy of the notice of patient rights and responsibilities was provided to 1 of 3 patients (P3) reviewed who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s electronic medical record (EMR) lacked indication of signed Home Care Bill of Rights notice. P3’s paper medical record lacked indication of signed Home Care Bill of Rights for P3’s admission 8/14/23-12/31/25. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) verified P3’s medical record did not contain P3’s signed bill of rights and was not sure why. DON stated they should be included in P3’s paper chart but could not find them. DON expected all admission documents to be explained to and signed at the time of admission by the patient or family representative. An agency policy title Admission Policy no date, directed staff to obtain clients signature on Home Care Bill of Rights.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure the right to lodge a complaint against the agency was provided to 1 of 3 patients (P3) reviewed who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s electronic medical record (EMR) lacked indication P3 was provided notice of the right to lodge a complaint against the agency was provided. P3’s paper medical record lacked indication lacked indication P3 was provided notice of the right to lodge a complaint against the agency was provided. P3’s admission 8/14/23-12/31/25. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) verified P3’s medical record did not contain P3’s admission information including the right to make a complaint against the agency and was not sure why. DON stated the documents should be included in P3’s paper chart but could not find them. DON expected all admission documents to be explained to and signed at the time of admission by the patient or family representative. An agency policy title Admission Policy no date, directed staff to obtain clients signature on Home Care Bill of Rights and responsibilities.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure 2 of 3 patients (P1, P3) reviewed who received skilled services were informed of and agreed upon care services provided by the agency. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s electronic medical record (EMR) lacked indication of any signed service agreements. P3’s paper medical record lacked indication of signed service agreements for P3’s admission 8/14/23-12/31/25. When interviewed on 58/14/26 at 11:59 a.m., the contracting consultant (CC) was unable to find any signed service agreements in P3’s EMR and stated there should be a paper chart somewhere. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) verified P3’s medical record did not contain P3’s service agreements and was not sure why. DON stated they should be included in P3’s paper chart but could not find them. Furthermore, DON thought P1’s service agreement was signed, however acknowledged she was in a rush during P1’s assessment and missed it as she was leaving out of the country soon after the initial assessment was completed. An agency policy titled Client Admission Process no date, directed staff to review the plan for services, treatment and care with the client and caregiver and obtain the signature on the service plan. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying condition with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing one time every two weeks for 60 days. P1’s Service Agreement dated 3/27/26, identified P1 had not signed the consent for services.”

“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 interview and document review the agency failed to conduct a comprehensive assessment that accurately reflected the health status for 1 of 3 patients (P3) reviewed who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, had a tracheostomy (surgical airway in the neck for breathing) brain injury, was a quadriplegia (inability to move any extremities) and was in a comatose state. Furthermore, P3 was prescribed 14 medications and required tube feed for nutrition. P3 required skilled nursing 12 hours a day for 60 days. P3’s comprehensive reassessment dated 10/1/25, indicated the following: -P3’s prognosis was poor and showed a risk of hospitalization due to a decline in mental, emotional or behavioral status. The applicable risk of taking more than 5 medications was not checked. -P3’s caregivers were unable/willing to provide care or assist with activities of daily living (ADL)s, however, was safely able to care for P3 and managed P3’s tracheostomy and tube feeding. -P3 denied pain, however a non-verbal pain scale was not used. -P3’s size and type of tracheostomy was not documented. -P3’s gastrostomy tube (surgical tube placed in stomach for feeding) and formula was not documented. -P3’s nutritional health screen section placed P3 at a low nutritional risk indicating P3 had oral and dental problems which made eating difficult. However, other risks such taking more than 3 medications, or having a diagnosis which affects the type of food eaten were not checked. P3 did not have a weight or height recorded so it was unknown if P3 had weight loss concerns related to tube feeding and comatose state. -P3’s fall risk assessment indicated a low risk for falls. However, the applicable choices of taking more than 4 medications, and cognitive impairment were not marked. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) confirmed P3 was comatose, completely dependent, had a tracheostomy and tube feeding. DON verified the assessment was lacking in areas. DON expected the assessments to be accurate to the health status of the patient. This was important because it then flowed into the patients care plan that showed what was needed to care for the patient. An agency policy titled Comprehensive Client Assessment no date, indicated a thorough and accurate assessment with the clients’ immediate needs will be completed by a registered nurse upon admission, during reassessment and as needed.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure the patient’s goals were accurately reflected in the comprehensive assessment for 1 of 3 patients (P3) who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. Furthermore, P3 was prescribed 14 medications and required tube feed for nutrition. P3 required skilled nursing 12 hours a day for 60 days. P3’s comprehensive reassessment dated 10/1/25, indicated P3 had the following health goals: -P3 will receive assistance needed during certification period. However, there was no mention of how this will be measured or interventions needing to be in place. -P3 will remain compliant with medication safety during certification period. However, there was no mention of how this will be measured or interventions in place. -P3 will remain have assistance with ADLs with assistance of home health aide. However, no home health aide services were ordered. -P3/caregiver will demonstrate effective pain control measures within (blank). This goal was not completed. -P3 will be urinary tract infection free within (blank) This goal was not completed -P3/caregiver will be independent in tube feeding within (blank). This goal was not completed. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) confirmed P3’s goals and assessments were not complete. DON further explained often a template was used as a starting point but should have been completed. DON expected the goals and interventions to be complete. An agency policy titled Comprehensive Client Assessment no date, indicated a thorough and accurate assessment of the clients’ immediate needs will be completed by a registered nurse upon admission, during reassessment and as needed”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on interviews and document review the agency failed to ensure caregiver information was included in the comprehensive assessment for 1 of 3 patients (P3) who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck) and required tube feeding for nutritinon. P3 required skilled nursing 12 hours a day for 60 days. P3’s comprehensive reassessment dated 10/1/25, indicated P3 was totally dependent. P3’s caretakers were unable/willing to provide care and assistance. However, P3’s caretakers managed the tracheostomy and tube feeding. P3’s assessment lacked indication of who the care takers were or a schedule of availability. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) stated P3 was cared by family when the nurse was not there. DON expected this information to be included P3’s comprehensive assessment as it was important to understand who cared for them on a day-to-day basis. An agency policy titled Comprehensive Client Assessment no date, indicated a thorough and accurate assessment of the clients’ immediate needs will be completed by a registered nurse upon admission, during reassessment and as needed.”

“The patient’s representative (if any); CFR(s): 484.55(c)(7) The patient’s representative (if any); This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure the patient representative was included in the comprehensive assessment for 1 of 3 patients who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck) and required tube feeding for nutritinon. P3 required skilled nursing 12 hours a day for 60 days. P3’s comprehensive reassessment dated 10/1/25, indicated P3 was totally dependent and in a comatose state. P3’s comprehensive reassessment lacked identification of P3’s representative or decision maker. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) stated P3 was cared by family when the nurse was not there. DON stated thP3’s representative should be included P3’s comprehensive assessment as it was important to understand who was in charge of making decisions. An agency policy titled Comprehensive Client Assessment no date, indicated a thorough and accurate assessment of the clients’ immediate needs will be completed by a registered nurse upon admission, during reassessment and as needed.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure a comprehensive discharge assessment was completed for 1 of 2 patients (P3) who received skilled services and discharged from the facility. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 required skilled nursing 12 hours a day for 60 days. P3’s discharge comprehensive assessment dated 11/1/25, indicated P3 discharged from the agency on 11/1/25. The assessment was incomplete and lacked documentation in several areas. Furthermore, P3’s discharge assessment did not include a summary of P3’s progress in meeting goals. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) confirmed P3’s discharge assessment was not completed and lacked a summary of P3’s goals. DON was not sure where P3 discharged to or the timeline. DON expected the discharge assessment to be complete and include if patient goals were met or how they progressed. An agency policy titled Client Discharge Process no date, directed the nurse shall treatment/goals have been met or if unmet, the patient is provided other home care services in the patient’s area. An agency policy titled Comprehensive Client Assessment no date, indicated a thorough and accurate assessment of the clients’ immediate needs will be completed by a registered nurse upon admission, during reassessment and as needed.”

“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 document review, the agency failed to ensure patient’s plan of care included all required components in the patient’s individualized care plans for 3 of 3 patients (P2, P3, P1) reviewed for skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck). P3 required skilled nursing 12 hours a day for 60 days. P3’s POC lacked the following required information: -Gastrostomy tube size. -Tracheostomy size. -durable medical equipment (DME) required for P3’s g-tube, tube feeding and tracheostomy cares. -individual and specific interventions with measurable outcomes and goals. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified the missing items in P3’s POC. DON stated a template was often used however was not filled out and that was why there were blank spaces. DON was not sure why the specifics of the g-tube, tracheostomy and tube feed was not included in P3’s care plan. DON verified P2’s missing items and stated, “I don’t see any of it”. P2’s POC should have included tube feed equipment, ventilator and tracheostomy supplies. DON verified P1’s POC verified the wrong patient’s name was included in the demographic section and had several missing medications missing. DON wasn’t sure how another resident’s information had gotten into P1’s POC and would need to investigate that. DON expected all patients to have the correct information, medications, treatments and supplies listed in the POC so accurate care can be provided. An agency policy titled Nursing Care Plans no date, directed nursing to develop a care plan to assure coordination and continuity of skilled care delivery for patients who received skilled care. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying condition with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing one time every two weeks for 60 days. P1’s POC Clinical Summary identified he was paralyzed; however, this was not listed in the diagnosis section. P1’s POC Patient Demographics listed a different patient’s name and description. The incorrect Patient Demographics described a female patient who was able to bathe independently, required reminders for toilet transfers, and ambulated with a one-handed device. On 5/14/26 at 12:50 p.m., a phone call was placed to P1’s phone number on file, and when the phone was answered the person hung up after introduction. On 5/14/26 at 12:51 p.m., a phone call was placed to P1’s emergency contact, a voice message was left with call back instructions, and no return call was received. On 5/15/26 at 9:04 a.m., a phone call was placed to P1’s physician listed on the POC and the secretary identified they did not have a provider by that name. On 5/15/26 at 9:17 a.m., another phone number was located on-line for the clinic listed on P1’s POC. The voicemail prompt indicated the clinic was open. A voice message was left with call back instructions. No return call was received.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview, and document review the agency failed to ensure all patient care orders, were part of the plan of care (POC) for of 2 of 3 patients (P3, P1) reviewed for skilled nursing services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck). P3 required skilled nursing 12 hours a day for 60 days. P3’s POC lacked the following required information: -provider orders for tube feed formula, rate and amount administered daily. -Gastrostomy tube (f-tube, tube leading into stomach for tube feeding) cares. -Tracheostomy cares. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified the P3’s and P2’s POC did not include orders for tube feeding, g-tube or tracheostomy cares. DON was not sure why the orders had not been included. DON verified P1’s POC had several missing medication orders missing. DON wasn’t sure why and would need to investigate. DON expected all patients to have the correct orders for medications, treatments and supplies listed in the POC so accurate care can be provided. An agency policy titled Nursing Care Plans no date, directed nursing to develop a care plan to assure coordination and continuity of skilled care delivery for patients who received skilled care. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying conditions with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing once every two weeks for 60 days. P1’s Current Medications list dated 5/13/26, from the primary care clinic listed on the POC identified: Acetaminophen 500 mg by mouth every 6 hours as neededArtificial Tear solution eye drops 4 times per dayBlood glucose monitoring supplies with device kit 3 times per dayLancet device 3 times dailyGlucose blood in vitro strips 2 times per dayVitamin D3 2,000-unit tablet by mouth once dailyTED stockings (elastic bandages) as neededJardiance 25 mg tablet by mouth dailyFexofenadine 60 mg tablet by mouth 2 times per dayFinasteride 5 mg tablet by mouth dailyHydrocortisone 2.5% external ointment apply to affected area dailyNifedipine 30 mg tablet by mouth dailyPantoprazole 40 mg tablet by mouth dailyRosuvastatin 40 mg tablet by mouth dailySenokot S 8.6 mg-50 mg 2 tablets by mouth dailyMinerin Creme skin protectant apply external 3 times per dayTamsulosin 0.4 mg capsule by mouth dailyTerbinafine 1% external cream apply once daily to skin for 14 daysTrazodone 50 mg tablet, take one-half tablet by mouth at bedtime.P1’s POC Medications section for certification period 3/27/26 through 5/27/26, identified only the medications above numbered 1, 8, 9, 10, 12, 14 and 17 were listed. Twelve of P1’s current medications were not reconciled with the home care POC.”

“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 the Plan of Care was reviewed and signed by the provider for 1 of 3 patients (P3) reviewed who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, P3 was comatose, P3 had chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. P3’s signed POC for certification period 10/2/25-11/30/25, was requested however was not received. P3’s POC for certification period 8/3/25-10/1/25, was requested however was not received. P3’s POC for certification period 6/4/25-8/2/25, was requested however was not received. P3’s electronic medical record (EMR) and paper medical record lacked indication P3 had a signed POC since 12/5/24. When interviewed on 5/14/26 at 11:59 a.m., the contracted consultant (CC) was not able to P3’s signed POCs in the EMR. CC stated the POCs were sent electronically through the EMR and sent back when signed. CC further stated P3’s signed POC’s may be in P3’s paper chart but she wasn’t sure. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified P3 did not have signed POCs in their paper medical record. DON stated the process was to send electronically through the EMR. DON further stated they should have been sent to the provider to be signed. The agency used to have a health unit coordinator (HUC) who would do this but wasn’t sure when she worked last or if she worked during this time period. An agency policy titled Nursing Care Plans no date, directed the patient care plans will be periodically reviewed, evaluated, and revised based on the patients’ health. The policy however did not direct how often they are signed by the provider.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on interview and document review, the agency failed to implement, measure and track performance improvement activities. This had the potential to affect all patients who received home care services. Findings include: he agency’s quality assessment process improvement (QAPI) program including data and performance improvement plan was requested, however was not received. The agency’s Minutes of Meeting of Professional Advisory Board dated 4/19/26, indicated a meeting was held. The meeting minutes indicated the administrator, Director of Nursing (DON), physical therapist (PT)-A, the alternate administrator (AA), and contracted consultant (CC) attended. The meeting agenda consisted of marketing strategies, an update of the Medicare PCR, and when to schedule the 2025-2026 meetings. Details of the meeting minutes directed QAPI to meet and address the issues found in the Medicare revisit survey. However, did not include a detailed performance improvement plan. When interviewed on 5/15/26 1:08 p.m., acting administrator stated he hadn’t been with the company for long and wasn’t sure about any quality program or initiatives. Requested contents of QAPI program and stated the meeting minutes were what he was able to provide and would need to look into the rest. No further information was provided. When interviewed on 5/15/26 at 2:10 p.m. the Director of Nursing (DON) stated she had been involved in quality meetings but there had not been any for a long time. DON was not sure how the agency tracked quality data and said if a patient or family had concerns, they would work to solve the complaints. DON was not aware of any performance activities in place. DON reviewed the meeting minutes received and stated there was no meeting in April of 2026 and it looked like that was a mistake. Furthermore, the DON stated she was not aware of the physical therapist who was listed as attending and said that wasn’t correct either. An agency policy title Quality Management no date, directed the agency will develop a continuous quality program that will measure and assess performance to determine improvement activities.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure clinical notes were prepared for 2 of 3 patients (P3, P1) reviewed who received skilled services. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3 was comatose and had diagnoses of chronic respiratory failure, brain injury and was a quadriplegia (inability to move any extremities). P3 required skilled nursing 12 hours a day for 60 days. A review of P3’s skilled nursing notes for certification period 10/2/25-11/30/25, indicated skilled notes were not completed for 44 of the 60 days. P3’s electronic medical record and paper medical record lacked indication of any missed visit notes. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified P3’s missing clinical notes and P3 and P1 had no missed visit notes. DON stated staff were educated to complete notes each shift. If notes were not completed, staff would not get paid. DON further stated if there were no agency staff to do the shift, the family would provide care. If family provided care, there would be no visit note or missed visit note as the patient or family signed a document saying they would cover if the agency was not able to staff the shift. If there was a visit, the DON expected staff to document a note. An agency policy titled Clinica Records/Medical Record Retention no date, directed staff to maintain a clinical record that accurately details home care services including clinical notes. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying conditions with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing once every two weeks for 60 days. P1’s medical record for the above certification period lacked documentation of any visits or skilled nursing visits.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure medical records included the most recent comprehensive assessments for 1 of 3 patients and clinical notes for 3 of 3 patients (P3, P1, and P2) reviewed who received skilled services. Findings include: P3 P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck) and required tube feeding for nutrition. P3 required skilled nursing 12 hours a day for 60 days. A review of P3’s electronic and paper medical record lacked the following assessment and clinical note documentation: -P3’s discharge comprehensive assessment dated 11/1/25, indicated P3 discharged from the agency on 11/1/25. The assessment was incomplete, not signed, and lacked documentation in several areas. - P3’s skilled nursing notes for certification period 10/2/25-11/30/25, indicated skilled visit notes or missed visit notes were not completed for 44 of the 60 days. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified the missing items in P3’s, P2’s and P1’s medical record. DON expected all patients to have the correct information and for medical records to be complete. An agency policy titled Clinical Documentation no date, directed the agency to document all cares and treatments for each visit of service. An agency policy titled Clinical Records/Medical Record Retention no date, directed the agency to provide a clinical record that contains any pertinent past and current findings in accordance to professional standards is maintained for every patient who received services. P1’s POC for certification period 3/27/26 through 5/27/26, indicated the start of care was on 3/27/26. P1 had diagnoses of diabetes due to underlying conditions with diabetic chronic kidney disease, osteoarthritis and spinal stenosis (narrowing of one or more spaces within the spinal canal). P1 required skilled nursing once every two weeks for 60 days. P1’s medical record for the above certification period lacked documentation of any visits or skilled nursing visits and lacked notification to P1’s provider of the missed visits. P2’s POC for certification period 12/8/24 through 2/3/25, indicated the start of care was on 12/6/24. P1 had diagnoses of dependency on ventilator status, cancer, anemia, and chronic kidney disease stage 3. P2 required skilled nursing services 24 hours daily for 60 days. P2’s POC for certification period 2/4/25 through 4/4/25, identified it was sent to the physician on 2/21/25, and no response was received. P2’s Skilled Nursing Visit Notes identified services were completed on 60 out of 60 days of the certification period without a physician’s order.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on interview and document review the facility failed to ensure patient’s goals were included in the plan of care (POC) and had documented progress towards achieving them for 1 of 1 patient (P3) who reviewed who received skilled services. Findings include: P3’s POC for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 had a tracheostomy (surgical airway in the neck) and required tube feeding for nutrition. P3 required skilled nursing 12 hours a day for 60 days. P3’s POC included the following goals: P3’s comprehensive discharge assessment dated 11/1/26, was not fully completed. Identified goals for P3 were incomplete and lacked indication of progress made to achieve them. P3’s comprehensive reassessment dated 10/1/25, indicated P3 had the following health goals: -P3 will remain have assistance with ADLs with assistance of home health aide. However, no home health aide services were ordered. -P3/caregiver will demonstrate effective pain control measures within (blank). This goal was not completed. -P3 will be urinary tract infection free within (blank) This goal was not completed -P3/caregiver will be independent in tube feeding within (blank). This goal was not completed. When interviewed on 5/15/26 at 2:10 p.m., the Director of Nursing (DON) verified P3’s comprehensive assessments had incomplete goals and lacked any progress towards them for discharge. DON stated a template was often used for the goals and had not filled out. That was why there were blank spaces and incomplete goals. DON stated complete assessments and plan of care was important to ensure the patient was making progress or was stable. DON expected these to be documented and completed. An agency policy titled Clinical Records/Medical Records Retention no date, directed the agency to maintain medical records that accurately detail each client’s status. Documentation was required to establish effective interchange, reporting and coordination of client care has occurred.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review the agency failed to ensure a completed discharge summary was completed for 1 of 2 residents (R3) reviewed for skilled services and was discharged. Findings include: P3’s plan of care (POC) for certification period 10/2/25-11/30/25, indicated P3’s start of care was on 8/14/23. P3 had chronic respiratory failure, brain injury, was a quadriplegia (inability to move any extremities) and in a comatose state. P3 required skilled nursing 12 hours a day for 60 days. P3’s discharge comprehensive assessment dated 11/1/25, indicated P3 discharged from the agency on 11/1/25. P3’s electronic medical record and paper medical record lacked indication a discharge summary was completed. When interviewed on 5/15/26 at 2:10 p.m., the Director of nursing (DON) confirmed P3’s discharged, however was not sure if it was in November or December. DON verified there was no discharge summary for P3. DON expected a discharge summary to be completed as it was important to pass on to P3’s provider or other agencies involved in their care. An agency policy titled Clinical Records/Medical Records no date, directed the agency to maintain a clinical record for every client receiving home care services and should include a discharge summary.”