Central Missouri Home Health

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Wound Assessment, Documentation, And Photography,” revised 09/01/2024, showed in part the following: - All wounds will be assessed with appropriate documentation within the medical record; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; * During routine visits, the wound will be documented in the wound assessment tool; - The qualified clinician will assess wounds weekly for patients receiving daily wound care performed by the agency; - Reassessments will be documented on the wound assessment tool; * The assessment includes measurement of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the peri wound; * At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound; - Document the following in the medical record; * Wound type (pressure injury, stasis ulcer, abscess, surgical wound, burn, trauma wound); * Location and laterality; * Stage or thickness; * Stage pressure injuries according to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages; * For all other ulcers, document underlying etiology of the ulcer and skin involvement to include limited to breakdown of skin; fat layer exposed; necrosis of muscle; or necrosis of bone; * All other wounds will be described as either partial or full thickness. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Review of the physical therapist (PT) initial start of care assessment dated 03/04/2026, showed in part: - The patient experienced pain in the intragluteal cleft superior with a triangular 4-centimeters (cm) by 9-cm triangular shape pressure sore, stage 1 (one) (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved); - The patient had a stage 1 pressure ulcer of the gluteal superior cleft where pressure from coccyx caused problems. A triangular shape superior is 4-cm across with 9-cm angle; - Plans for next visit include assessment of pressure ulcer on his/her bottom. Review of the plan of care dated 03/04/2026 to 05/02/2026, showed an order for PT to monitor and provide instruction regarding pain control methodologies including non-pharmacologic methods – distraction, positional changes to relieve pressure of bottom; - Skilled nurse (SN) effective 03/08/2026, twice a week for two weeks and then one time a week for six weeks; - SN to provide skilled teaching to prevent pressure ulcers; - SN to instruct patient/caregiver procedure of wound care to coccyx daily and as needed (PRN) after toileting. Cleanse with soap and water and pat dry. Apply skin barrier cream. Review of the physical therapy assistant (PTA) visit dated 03/09/2026, showed the following: - Indicate location patient experiences pain: bottom; - Document other integumentary findings: No open wound. Redness on coccyx and buttocks; - Document communication with other disciplines/individuals involved in case, include appointments along with any changes made to the plan of care (POC) since last visit: Spoke with staff at provider’s office regarding patients’ condition and confusion with medications. Going to get an order for nurse to come out. Review of the skilled nurse visit dated 03/10/2026, showed the following: - Patient reported “my butt hurts”; - Patient rated pain seven out of 10 on a numerical pain scale tool used to quantify pain severity, where 0 is no pain and 10 is the worst imaginable pain; - Wound assessment: * Coccyx, PU stage II (a partial thickness loss of the skin) (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – Partial thickness (a skin injury that extends through the epidermis (outer layer) and into, but not through, the dermis (second layer). Common examples include abrasions, skin tears, and blisters; * Granulation tissue (soft, pink, new, healthy tissue in a healing wound) – intact; * Edges – indistinct; * Exudate (drainage) type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – bright red; * Wound care provided – wound care to coccyx daily, cleansed with soap and water and patted dry. Apply skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/14/2026, showed the following: - Patient rated pain none; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/17/2026, showed the following: - Patient rated pain a five, located on buttock; - Care coordination – orders for Opti foam dressing (bordered foam dressing designed to manage moderate to high-drainage wounds, including pressure injuries, and ulcers) to buttocks; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – part thick; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 100%; * Skin color surrounding wound – bright red; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/19/2026, showed the following: - Patient rated pain a three, located on buttock; - Care coordination – another message left for primary care provider (PCP) orders for Opti foam dressing to buttocks as patient states it is really helping ; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 100%; * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/25/2026, showed the following: - Patient rated pain a zero; - Care coordination – call to PCP requesting orders for Opti foam dressings to buttocks; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken - no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount - none; * Odor - none; * Epithelialization - 100%; * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 04/01/2026, showed the following: - Patient rated pain a zero, located on buttock; - Care coordination – POC discussed with patient; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – yes; * Length x Width x Depth cm – 1.2x0.5x0; * Depth description – partial thickness; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – normal; * Wound care provided – cleansed affected area to coccyx with saline soaked gauze. Patted dry with gauze. Applied barrier cream to affected area on coccyx covered with sacral dressing daily and PRN. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. (The provider failed to complete measurements of the wound when documenting partial thickness). During an interview on 04/14/2026 beginning at 3:47 PM, the administrator stated that he/she would expect wound measurements to be documented and a description of what the area around the wound looks like if it is just a stage 1.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that documentation of the patient’s pressure ulcer was accurate and appropriately authenticated during assessments in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Wound Assessment, Documentation, And Photography,” revised 09/01/2024, showed in part the following: - All wounds will be assessed with appropriate documentation within the medical record; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; and - During routine visits, the wound will be documented in the wound assessment tool. Review of the provider’s undated, Job Title, “Physical Therapist Assistant (PTA) – Home Health,” showed in part the, PTA will complete a progress note for each visit and submit progress notes per provider policy. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Review of the physical therapist (PT) initial start of care assessment dated 03/04/2026, showed in part: - The patient experienced pain in the intragluteal cleft superior with a triangular 4-centimeters (cm) by 9-cm triangular shape pressure sore, stage 1 (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved); - The patient had a stage 1 pressure ulcer of the gluteal superior cleft where pressure from coccyx caused problems. A triangular shape superior is 4-cm across with 9-cm angle; - Plan for next visit included an assessment of pressure ulcer on his/her bottom. Review of the plan of care dated 03/04/2026 to 05/02/2026, showed: - An order for PT to monitor and provide instruction regarding pain control methodologies including non-pharmacologic methods – distraction, positional changes to relieve pressure off bottom; and - Orders were obtained for skilled nursing (SN) and they would instruct the patient/caregiver on daily and as needed wound care to the coccyx - Cleanse with soap and water, pat dry, apply barrier cream. Review of the SN visit dated 03/17/2026 (13 days after the initial assessment) showed: - The patient had a partial thickness (Stage II) pressure ulcer to the coccyx; - Wound care was provided; and - The patient’s goal was for the sore on his/her bottom to heal. Review of the SN visit dated 03/19/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient’s goal was for the sore on his/her bottom to heal. Review of the PTA visit dated 03/19/2026, showed the PTA documented an integumentary assessment that showed no wounds/wound care was not provided this visit. Review of the PTA visit dated 03/23/2026, showed the PTA documented an integumentary assessment that showed no wounds/wound care was not provided this visit. Review of the SN visit dated 03/25/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient’s goal was for the sore on his/her bottom to heal. Review of the PTA visit dated 03/31/2026, showed the PTA documented an integumentary assessment that showed the patient had no wounds/wound care was not provided this visit. Review of the skilled nurse visit dated 04/01/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient’s goal was for the sore on his/her bottom to heal. The PTA failed to accurately document the presence of the pressure ulcer on the patient’s coccyx. During an interview on 04/14/2026 beginning at 3:47 PM, the administrator stated that he/she would expect the PTA to document something about the pressure ulcer in the documentation.”

“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 policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s status and included the current health, psychosocial, functional, and cognitive status in one of six records reviewed (Records/Patients #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Assessment, Initial and Reassessment,” dated 12/01/2025, showed that all patients admitted to the provider will receive an initial assessment. Upon admission and reassessments, the clinician performs an assessment of the patient’s current health status, psychosocial, functional, and cognitive status. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary, dated 03/30/2026, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery, on 04/01/2026 or 04/02/2026, by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Review of the initial, comprehensive nursing assessment documentation, for the visit dated 04/01/2026, showed that: - The patient had an abdominal incision that: * Was covered with a non-removable dressing; and * The skilled nurse (SN) was unable to assess the incision or provide wound care; - A left sacral (tailbone) incision that: * Was covered with a non-removable dressing; and * The skilled nurse (SN) was unable to assess the incision or provide wound care; - A right sacral incision that: * Was covered with a non-removable dressing; * The skilled nurse (SN) was unable to assess the incision or provide wound care; - The patient utilized a back brace; and - The comprehensive assessment visit note failed to contain documentation of: * The condition of the patient’s incisional dressings (i.e., the dressing patency, visible drainage, odor, etc.) and care to be provided by the patient/spouse between SN visits; * Identification of the type of back brace used by the patient, application and removal of the brace, and how long to wear the brace (i.e., continuously, while out of bed, etc.); and * The use of TED hose. During an interview, on 04/07/2026 at 12:55pm, the patient care manager (PCM3) stated that they would expect the clinician to document an assessment of a non-removable dressing including any visible drainage, odor, dressing integrity and the skin surrounding the dressings, the use of a back brace, and TED hose.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure that all medications the patient was taking were current in one of three home visit observation records reviewed (Records/Patients #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Monitoring Medications,” dated 04/01/2026, showed that a drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. The physician will be contacted immediately if any discrepancies between agency information and patient medications are found. The clinician responsible for the drug regimen review will: - Compare the medication list obtained from the facility from which the patient was transferred and/or physician order to actual medications the patient is taking; - Review all medications, including over the counter medications, vitamins, herbs and herbal products, creams and topical ointments, medical marijuana (in states where legalized), and those administered in outpatient settings to identify issues; and - The physician is contacted immediately if any discrepancies between agency (provider) information and patient mediations are found. Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Observation and interview on 04/07/2026 at 11:00 AM, showed the following discrepancies between the provider’s current medication profile (printed on 04/07/2026) and the patient’s home medication bottles: - The provider’s current medication profile showed the patient was to use cholestyramine (used primarily to lower high cholesterol and treat chronic diarrhea related to bile acid malabsorption or itching from biliary obstruction) 4 gram (gm) oral powder daily with 8 ounces of liquid; and - The patient stated that he/she did not take this medication and never took it. During an interview on 04/14/2026 beginning at 2:10 PM, the administrator stated that he/she would expect medications to be reconciled weekly with the medication bottles and medication list in the patient’s home and staff should ask at every visit about any medication changes or physician visits.”

“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 policy review, record review, observation, and interview, the home health provider failed to ensure the plan of care (POC) contained all medications and treatments and patient-specific interventions and education in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 03/01/2026, showed that a plan of care is developed for all patients and updated no less than every 60 days. The POC includes the patient’s medications and treatments, patient specific interventions and education, and measurable outcomes and goals identified by the agency (provider) and patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/31/2026, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Review of the home health certification and POC, dated 04/01/2026, showed that the POC failed to contain orders for: - Wound care orders for the right and left lumbar incisions; - The application and removal of the abdominal binder; - The use of TED hose; and - The plan for staple removal. During an interview on 04/14/2026 at 12:30 PM, the administrator stated that they would expect the plan of care to contain all interventions related to the patient’s care; and the POC failed to contain: - Wound care orders for the incisions on the patient’s right and left lumbar (lower back, the POC did contain orders for a back incision, and the order failed to identify there was more than one incision, and the location of the incisions; - The application and removal of the abdominal binder; - The use of TED hose; and - The plan for staple removal. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/05/2026 with a primary diagnosis of rheumatoid arthritis of multiple sites. The patient had secondary diagnosis of arthritis of the right knee, high blood pressure, diabetes, and dementia. The patient resided in the private residence of his/her sibling. Review of the comprehensive physical therapy start of care assessment, dated 03/05/2026, showed that the patient had diabetes, was not taking insulin, and performing blood sugar testing was not applicable to the patient. Review of the home health certification and plan of care, dated 03/05/2026, showed that: - Physical therapy was to instruct patients on management of diabetes, review appropriate diet, and diabetic foot care. Therapist was to assess lower extremities for presence of lesions on every visit, and instruct on signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar); - When vital signs were obtained, licensed professional was to report vital signs falling outside the following established parameters: FBS 250; and - The POC failed to contain orders for the clinician to monitor the patient’s blood sugar readings. During an interview on 04/14/2026 at 12:45 PM, the administrator stated that: - They would expect an order to monitor blood sugar readings if the POC contained established parameters for the blood sugars; and - The POC failed to contain orders to monitor the patient’s blood sugars.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on policy review, record review, observation, and interviews, the home health provider failed to ensure orders from all physicians or allowed practitioners involved were integrated in the plan of care to assure the coordination of all services and interventions provided to the patient in one of six records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care, From Admit Through Discharge,” dated 12/01/2025, showed that coordination of care with the physician/authorized practitioner will occur at admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/30/2026 and available to the clinician at time of admission via the electronic medical record (EMR), showed that the patient was to perform incision care two to three days after surgery by: - Removing the old dressing after the shower; - Patting the incision dry; - Applying a clean dry gauze dressing secured with tape; - Keeping a dressing over all incisions until drainage ceased; - Leaving non-draining incisions open to air; - Using no ointments or lotions to the incisions; and - Avoiding hot tubs or bathtubs and showering only. During an interview, on 04/07/2026 at 11:35AM, the patient and his/her spouse stated that: - They received written discharge instructions on 03/31/2026 when leaving the hospital; - They showed the documentation they received on 03/31/2026 to the nurse at the time of the admission visit on 04/01/2026; - The admitting nurse looked at the instructions and gave them back to the spouse. Review of the undated hospital discharge instruction document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” given to the patient at discharge from the hospital on 03/31/2026, showed that home care following surgery included: - Front/abdominal dressing: * 48 hours after surgery, remove the abdominal surgical dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply Neosporin (Brand, an antibiotic ointment) over the incision and cover with Band-Aids (brand) or gauze and paper tape; * Replace the front/abdominal dressing daily with fresh Neosporin and Band-Aids/gauze and paper tape until your follow-up appointment; * The staples used to close your abdominal incision will be removed in four weeks; - Back/posterior dressings: * 72 hours after surgery, take your first shower and remove your back dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply only paper tape and gauze for your back/posterior incision; * Do not use ointments to the back/posterior incisions; * If you notice your dressing is saturated, remove the dressing and apply a clean one; * The staples used to close the incisions on your back will be removed at the follow-up appointment in three weeks; - Showering: * You may shower 72 hours after surgery; * Do not rub the incision. Pat the incision gently when drying off; * Do not soak or immerse yourself in a bathtub, pool, or hot tub until the incisions are completely healed. This takes a minimum of six weeks; - Abdominal binder: * The abdominal binder should be always worn until your follow-up appointment; * It may only be removed to shower and change your dressings; * Wear a t-shirt under the binder to avoid skin irritation. Hand wash and air dry if needed; and - The compression stockings/TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) should be worn until your follow-up appointment to help prevent blood clots and reduce leg swelling. Review of the home health certification and plan of care (POC), dated 04/01/2026, showed that: - The skilled nurse (SN) to provide/instruct the client/caregiver on wound care to the abdomen and low back incision daily; - May begin showering two to three days after surgery leaving current dressing in place and removing after shower; - Pat the incision dry with a clean towel, never scrub the incision; - Cover with dry gauze, secure with tape; - The incision may be left open to air when no longer draining; - No ointments to the incisions; - No tub baths, shower only; and - Spouse or adult child to perform wound care in the absence of the SN. Observation and interview on 04/07/2026 at 12:20 PM, showed that: - The patient and spouse reported that they: * Had left the abdominal dressing in place during the patient’s shower on 04/01/2026, patted the dressing dry after the shower, and left the dressing in place. They had not removed the abdominal dressing since the patient came home from the hospital on 03/31/2026; * Were changing the dressing on the patient’s lower back daily by removing the old dressing, applying Neosporin ointment, covering with gauze, and securing with tape; and - Registered nurse (RN)-A called the patient’s physician to clarify the patient’s wound care orders. Review of the physician’s order, dated 04/07/2026, showed that: - Wash the front/abdomen incision gently with clean bath cloth, gently pat dry, and apply Neosporin over the incision using a cotton tipped applicator, cover with a band-aid or gauze, and secure with paper tape; - Allow water to wash over incision while in the shower daily, pat dry and leave open to air if there is no drainage. If it is draining, place dry gauze and secure with paper tape only. Do not apply ointments to back incision. During an interview on 04/08/2026 at 10:25 AM, the admitting skilled nurse (RN-B) stated that: - He/she had access to the physician discharge summary with the referral paperwork; - The patient and his/her spouse had showed him/her the document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” noted the wound care instructions were different than those on the physician discharge summary; and - He/she did not call the physician to clarify the orders as the physician discharge summary was signed by a physician on 03/30/2026. During an interview on 04/07/2026 at 12:55 PM, the patient care manager (PCM-3) stated that they would expect the admitting SN to: - Ask the patient for his/her discharge instructions from the hospital; and - Contact the physician to clarify inconsistencies between the referral paperwork and the paperwork given to the patient at the time of discharge.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure patients received written instructions outlining treatments in one of three home visit observation records reviewed (Records/Patients #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care, From Admit Through Discharge, “ dated 12/01/2025, showed that written information obtained from the plan of care (POC) will be provided to the patient and caregiver outlining the visit schedule, medication schedule and instructions, and treatments to administered by staff or contract workers, including therapy services. Pertinent instructions related to the patient’s care and treatments that the agency will provider, specific to the patient’s needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/30/2026 and available to the clinician at time of admission, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Observation on 04/07/2026 at 11:15 AM, showed that: - A review of the patient’s admission booklet showed the booklet failed to contain written instructions for the care of the patient’s incisions; and - This state agent (SA) observed the skilled nurse (SN) perform wound care: * He/she removed the old dressing from the abdominal wound, and the incision was clean, dry, had no redness, and had well approximated (touching without gaps) edges; * He/she removed the old dressing from the patient’s back exposing the incisions on the lower left and right back; and the incisions were clean, dry, had no redness, and had well approximated edges. During an interview on 04/07/2026 at 11:40 AM, the patient and his/her spouse stated that: - The admission nurse did not provide them with written instructions on the provision of wound care at the time of the admission visit; and - They had been using the written instructions titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” provided to them at discharge from the hospital on 03/31/2026; - The patient had showered on 04/02/2026 with the abdominal bandage in place. He/she did not remove the bandage after the shower. The patient continued to have the same bandage on his/her abdomen that was present at discharge from the hospital 03/31/2026; - The spouse removed the dressing covering the incisions on the patient’s back, applied Neosporin to both back incisions, covered the incisions with dry gauze, and secured in place with paper tape. Review of the undated document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” given to the patient at discharge from the hospital, showed that home care following surgery included: - Front/abdominal dressing: * 48 hours after surgery, remove the abdominal surgical dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply Neosporin (Brand, an antibiotic ointment) over the incision and cover with Band-Aids (Brand) or gauze and paper tape; * Replace the front/abdominal dressing daily with fresh Neosporin and Band-Aids/gauze and paper tape until your follow-up appointment; * The staples used to close your abdominal incision will be removed in four weeks; - Back/posterior dressings: * 72 hours after surgery, take your first shower and remove your back dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply only paper tape and gauze for your back/posterior incision; * Do not use ointments to the back/posterior incisions; * If you notice your dressing is saturated, remove the dressing and apply a clean one; * The staples used to close the incisions on your back will be removed at the follow-up appointment in three weeks; - Showering: * You may shower 72 hours after surgery; * Do not rub the incision. Pat the incision gently when drying off; * Do not soak or immerse yourself in a bathtub, pool, or hot tub until the incisions are completely healed. This takes a minimum of six weeks. Review of the home health certification and POC, dated 04/01/2026, showed that: - The SN was to provide/instruct the client/caregiver on wound care to the abdomen and low back incision daily; - May begin showering two to three days after surgery leaving current dressing in place and removing after shower; - Pat the incision dry with a clean towel, never scrub the incision; - Cover with dry gauze, secure with tape; - The incision may be left open to air when no longer draining; - No ointments to the incisions; - No tub baths, shower only; and - Spouse or adult child to perform wound care in the absence of the SN. During an interview on 04/08/2026 at 10:25 AM, the admitting nurse stated that he/she did not leave written wound care instructions for the patient at the admission visit. The admitting nurse failed to provide written wound care instructions to the patient/caregiver at the time of admission. Without written instructions from the provider, the patient/caregiver had to use the discharge instructions from the hospital to provide wound care in the absence of the SN. The written instructions from the hospital were different from the wound care orders on the patient’s POC. During an interview on 04/07/2026 at 12:55 PM, a patient care manager (PCM-3) stated that they would expect written instructions for the wound care, as it appears on the provider’s plan of care, to be in the patient’s home at the end of the admission visit.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of Missouri statute, policy review, employee file review, and interview, the home health provider failed to ensure that a check of the Employee Disqualification List (EDL) was performed and failed to ensure the Family Care Safety Registry (FCSR) was checked prior to date of first patient contact, in one of six employee files reviewed, (Employee #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” Review of the provider’s policy titled, “Background Checks,” revised 10/01/2025, Policy Number: 2.3.01, showed the following: - All employment offers are contingent upon acceptable background check results. Candidates will not have patient interaction until the search results have been returned and are deemed acceptable; - In Missouri, the EDL must be run through the FCSR prior to hiring a potential employee and checked quarterly for current employees through the Missouri Department of Health and Human Services. Employment may not be continued for current employees whose names appear on the EDL. EMPLOYEE #4: Review of the employee file showed: - Date of hire: 11/24/2025; - The EDL check was received on 04/07/2026 (141 days after hire); and - The FCSR check was received on 04/08/2026 (142 days after hire). During an interview on 04/08/2026 at 12:45 PM, patient care manager 2 stated that the FCSR and EDL on Employee #4 were late.”

“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 policy review, record review, and interview, the home health provider failed to ensure patients were accepted for treatment only when there was a reasonable expectation that the provider could meet the patients’ medical, nursing, rehabilitative, and social needs in the home setting. The provider failed to verify critical factors such as medication availability, required supplies, patient stability, caregiver support, and home safety prior to accepting referrals. This deficient practice resulted in unsafe conditions identified at the initial home visit, requiring emergency department evaluation or hospital transfer in, three of three records reviewed (Records/Patients #1, #2, and #3). The cumulative effect of this deficient practice placed all the patients at risk for unmet care needs and adverse outcomes Findings included: Review of the provider’s policy titled, “Coordination of Care, From Admit through Discharge,” last revised 11/01/2025, showed in part the following: - Admitting only those patients whose health care needs can be met by the agency (provider) and making appropriate referrals to other organizations capable of meeting patient needs when the agency is unable to do so; and - Identifying patient needs through assessment and communication with other health care providers. Review of the provider’s policy titled, “ Acceptance of Patients/Admission Process,” last revised 11/01/2025, showed in part the following: - Patients admitted to home care services must meet admission criteria and have reasonable expectations that needs can be met safely in the home; - The policy required a safe home environment, availability of a capable caregiver if indicated, and confirmation that the agency could meet the patient’s needs; and - If the patient was not accepted, the policy required notification of the physician and referral source. RECORD/PATIENT #1: Record review showed the patient was discharged home from a nursing facility on 02/02/2026 with severe protein-calorie malnutrition, dysphagia (difficulty swallowing), psychiatric illness, and the need for 24-hour supervision. Record review showed the home health nurse conducted a visit on 02/03/2026. There failed to be a completed admission assessment, as the visit was designated a non-admit. However, the coordination note dated 02/03/2026 showed the nurse spent over one hour evaluating the patient in the home, found the patient lethargic and unable to answer questions, and identified that ordered tube-feeding supplies and medications were not available. The note further documented the spouse did not have the appropriate equipment to provide the ordered feedings and that the patient required transport to the hospital. These findings demonstrated the patient’s needs could not be met in the home and reflected that the provider acted on the referral without a reasonable expectation that those patient’s needs could be met. Emergency department documentation dated 02/03/2026 showed the home health nurse advised the patient that he/she required a 24-hour care facility and the spouse could not provide care during working hours. During an interview on 02/09/2026 at 10:18 AM, the registered nurse (RN) whom conducted the initial visit, stated that the patient was lethargic and minimally responsive, no medications were present in the home, the correct feeding supplies were not available, and the spouse did not know how to feed the patient and reported the patient had not received tube feedings since discharge from the nursing facility. There was no referral information attached in the patient record at the time of the visit. The nurse reported he/she had only a diagnosis, medication list, and tube-feeding instructions that were provided by the spouse. The nurse stated that he/she did not receive referral paperwork or coordinated information from the provider prior to the visit. The spouse reported he/she would return to work and expected the home health staff to remain with the patient; however, the nurse explained the provider did not provide 24-hour care. The nurse determined the patient was unsafe and sent the patient to the hospital by ambulance. RECORD/PATIENT #2: Record review showed the patient was discharged home with congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), chronic kidney disease, generalized weakness, and needed assistance with personal care. Referral documentation dated 01/17/2026 showed physician orders for skilled nursing, physical therapy, and occupational therapy services. On 01/19/2026, during the initial assessment, the home health nurse documented the patient was unstable with atrial fibrillation and a heart rate of 135. The patient was instructed to go to the emergency room and the physician was notified. The referral was marked “no admit.” The record lacked evidence of caregiver availability verification, environmental safety review, medication verification, or supply and equipment confirmation prior to acceptance. RECORD/PATIENT #3: Record review showed referral orders dated 10/10/2025 for skilled nursing, physical therapy, and occupational therapy services. On 10/13/2025, the home health nurse documented the patient had been left at the home by facility staff. Upon arrival, the nurse found the home environment unsafe and unclean, with no access to a bathroom and no place for the patient to sleep. EMS was called and the patient was transported to the hospital for social work admission. There was no documentation that the provider verified the home environment or caregiver support prior to acting on the referral. During an interview on 02/09/2026 at 11:13 AM, the administrator stated that the provider required only physician orders for skilled services and a primary care physician to accept the referral. There was no documentation showing referrals were reviewed to verify the patient was appropriate for admission. During an interview on 02/10/2026 at 11:28 AM, the alternate administrator stated that the provider did not have a designated intake person, did not use a referral checklist, and did not verify medications, supplies, equipment, or caregiver availability prior to admission. The admitting nurse determined whether the patient was appropriate for home health services only after arriving at the home. There was no documentation showing referrals were reviewed to verify medications, supplies, caregiver availability, patient stability, or home safety prior to the initial visit.”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Care planning, coordination, quality of care, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 02/13/2028.”