Sedum Home Health, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on policy review, review of the home health provider’s current patient rights information, and interview, the provider failed to ensure the provider’s patient rights information contained the following: - Written notice of the patient’s rights and responsibilities and the provider’s transfer and discharge policies to a patient-selected representative within 4 (four) business days of the initial evaluation visit (G422); - The right to be advised of the state toll free home health telephone hot line hours of operation (G444); - The name address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides (G446); - The home health may only transfer or discharge the patient from the home health if the home health advises the patient, the representative, the physician or allowed practitioner issuing orders for the home health plan of care, and the patient’s primary care practitioner that a discharge for cause is being considered (G464); - The home health may only transfer or discharge the patient from the home health if the home health provides the patient and representative with contact information for other agencies or providers who may be able to provide care (G468); - The home health may only transfer or discharge the patient from the home health if the home health documents the problem(s) and efforts made to resolve the problem(s) and enter the documentation into the clinical record (G470); - The right to have complaints investigated, including but not limited to, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the home health agency (provider) (G478); and - The patient’s right to have access to the patient rights information that was provided in a language and manner that is accessible and timely to (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act and (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations(G490). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.”

“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, home visit observation, and interview, the home health provider failed to: - Ensure an individualized plan of care (POC) included relevant physicians who were providing home health orders (G574); - Ensure all patient care orders, including verbal orders, were recorded in the plan of care (G576); - Ensure the individualized POC was reviewed and revised by the physician responsible for the home health plan of care and the HHA (home health agency) no less frequently than every 60 days (G588); - Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patients (G604); and - Ensure the coordination of care to meet the patient’s needs (G608). The cumulative effect of these deficient practices has the potential to affect all the patients on service.”

“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 current survey findings, policy review, clinical manager job description review, home visit observation, and interview, the home health provider failed to ensure: - The coordination of patient care (G962); and - The administrator and clinical manager provided oversight assuring the development, implementation, and updating of the individualized plan of care (G0968). The cumulative effect of these systemic practices resulted in the provider’s inability to ensure the patient’s care needs would be met.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on policy review, review of the home health provider’s emergency preparedness (EP) plan, and interview, the provider failed to document the review and update of their emergency preparedness plan every two years. This deficient practice has the potential to affect the safety of all the patients served by the provider. Findings included: Review of the home health provider’s undated policy titled, “Policies and Procedures and an Emergency Preparedness Plan,” showed in part: - An EP plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation; - The plan uses the term “all-hazard” to address all types of incidents; - An incident is an occurrence, caused either by humans or by a natural phenomenon, which requires or may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and/or the environment; - The hazard vulnerability analysis tool is designed so agencies (providers) can evaluate their level of risk and preparedness for a variety of hazardous events; - A hazard vulnerability assessment is usually the first step in emergency planning for an organization; and - The policy failed to include guidelines for how frequently the provider should review the emergency plan. Review of the provider’s current EP plan and all-hazards risk assessment showed the provider failed to document the date of the last EP plan review and failed to document a date of review for the all-hazard risk assessment. During an interview on 02/27/2025 at 11:10 AM, the administrator stated that the last all-hazard risk assessment was completed for the EP plan at the end of last year and all of the provider’s policies were reviewed by the governing body on 12/30/2024. The state agent (SA) was presented with the governing body minute notes from 12/30/2024, that showed “Reviewed the organization’s policies and procedures. The body recommended the organization to review the most current CoP (conditions of participation) by the CMS (Centers for Medicare and Medicaid Services)”. The minute notes failed to show the EP Plan had been reviewed.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on policy review, review of the home health provider’s emergency preparedness (EP) plan, and interview, the provider failed to develop and implement an emergency communication plan that included the names and contact information of the contracted therapy employees. This deficient practice has the potential to affect all the patient’s served by the provider. Findings included: Review of the home health provider’s undated policy titled, “Policies and Procedures and an Emergency Preparedness Plan”, showed in part: - An EP plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation; - “The purpose: To follow-up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency”; - “Based on the emergency plan, the agency (provider) include, but are not limited to, the procedures to follow-up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency”; and - In case of emergency, the emergency operations plan shall be activated by the administrator/clinical manager using telephone calls, text messages, or email alerts. Review of the providers EP plan showed a staff phone tree with employee names and phone numbers that failed to contain the contract therapy names and numbers. During an interview on 02/27/2025 at 11:10 AM the administrator stated that the staff phone tree list had been updated and provided the new list.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on policy review, review of the home health provider’s emergency preparedness (EP) plan, and interview, the provider failed to include contact information for FEMA (Federal emergency management agency) in their emergency preparedness plan. This deficient practice has the potential to affect all the patient’s served by the provider. Findings included: Review of the home health provider’s undated policy titled, “Policies and Procedures and an Emergency Preparedness Plan,” showed in part: - An EP plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation; and - In case of emergency, the emergency operations plan shall be activated by the administrator/clinical manager using telephone calls, text messages, or email alerts. Review of the provider’s EP plan failed to include the contact information for FEMA. During an interview on 02/27/2025 at 11:10 AM, the administrator stated that the emergency plan had been updated to include FEMA. The update failed to include the contact information for FEMA.”

“Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This Standard is not met as evidenced by: Based on policy review, review of the home health provider’s current patient rights information, and interview, the provider failed to ensure patients were informed of the right to have access to patient rights information that was provided in a language and manner that is accessible and timely to (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act and (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This deficient practice has the potential to affect all the patients who have disabilities or limited English on service with the provider. Findings included: Review of the provider’s undated policy titled, “Patient Bill of Rights,” showed: - The agency (provider) will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show patients were informed of the right to have access to patient rights information that was provided in a language and manner that is accessible and timely to (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act and (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. Review of the home health provider’s current patient rights information in their admission folder failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she had corrected the missing information.”

“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, clinical record review, and interview, the home health provider failed to maintain professional standards according to their provider policy when wound measurements were not performed/documented in the clinical record in, one of four applicable records (Record/Patient #5). This deficient practice has the potential to affect all the wound care patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Wound Care Protocol and Policy,” showed in part: - Wounds will be measured at the initial start of care and per plan of care (POC); - If there is a change in wound condition, nursing must report to the physician wound status within 24 hours; and - All changes in wound status must be documented in skilled nursing notes and uploaded to the electronic medical record. RECORD/PATIENT #5: Review of the POC dated 09/13/2024 to 11/11/2024, showed in part: - Patient admitted to home health services on 09/13/2024; - Diagnoses included, but not limited to, open wound of right buttock, open wound of left buttock, and other sites of candidiasis (a fungal infection typically on the skin or mucous membranes caused by candida); - Skilled nurse (SN) two times weekly for observation and assessment of wound healing status, measure wound weekly. Review of the SN start of care (SOC) visit note dated 09/13/2024, showed in part, under the integumentary (skin) status section: The patient had superficial wounds to the testicular area, bilateral buttock, and coccyx. The note failed to show any wound measurements documented. Review of the SN visit notes dated 09/17/2024, 09/20/2024, 09/24/2024, 09/27/2024, 10/01/2024, 10/04/2024, 10/08/2024, 10/11/2024, 10/15/2024, and 10/18/2025 failed to show any wound measurements documented. Review of a physician order dated 10/18/2024, showed it was okay to discharge the patient on 10/23/2024 due to wound was healed. During an interview on 02/27/2025 at 12:51 PM, the administrator stated that: - He/she did not have any wound measurements; - The wound was a fungus; - There was no wound on admission. It started on the 18th; and - A new proposed wound policy had been written.”

“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 three Conditions of Participation: Patient Rights, Care Planning, Coordination of Services, and Quality of Care and Organization and Administration of Services, 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 03/04/2027.”

“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 all documented entries included appropriate authentication that included, an accurate signature date of a skilled nursing visit and clinician signature with the times in which the communication log documentation was completed, in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Service Policies Nursing Services,” showed, nursing functions included in part, prepare clinical and progress notes and maintain records related to the provision of nursing service that meets legal requirements and agency (provider) policy. Review of the provider’s undated policy titled, “Nursing Documentation,” showed in part: - The agency will ensure accurate documentation of nursing services; and - Documentation will be filed in the medical record within 48 hours of visit completion. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/17/2025 with primary diagnosis of pneumothorax (a collapsed lung and occurs when air leaks into the space between your lung and chest wall); - The patient resided at home alone; - Skilled nurse visit note on 01/20/2025 showed, “Patient administers (his/her) medications, not sure if (he/she) is very compliant with it but patient does what (he/she) wants to do, does not listen to anyone;” and - A patient communication log was provided to the state agent (SA) on 02/27/2025, that showed, “Notified (named) registered nurse (RN0 with (named) nurse practitioner (NP) that patient complained of pain during visit but stated (he/she) is not taking anything because (he/she) has had pain for years.” The date listed showed 01/21/2025 (one day after the skilled nurse visit). The communication log failed to show a timestamp with date, time, and signature of the clinician that entered the note. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a long-term condition that happens when the heart can’t pump blood well enough to give the body what it needs); - The patient resided at home with his/her spouse; - A skilled nurse visit note showed a visit date of 11/05/2024 (before the admission) and was signed and dated by the licensed practical nurse (LPN) on 11/04/2024 (one day prior to the date of the visit); and - A paper document titled “Med-Pass Supervisory Visit Record,” dated 01/10/2025, showed an LPN supervisory visit that was conducted by the administrator over the phone with the patient. The patient’s signature section had “conducted over the phone” written in it, the employee signature section was left blank, the supervisor’s signature section was signed by the administrator, and there was no documentation of the time. During an interview on 02/25/2025 at 12:10 PM, the administrator stated that: - The LPN visit note from 11/05/2024 was from the patient’s previous certification period; - The patient had been on service for 2 (two) years but since (he/she) was a patient of (named payer source), each authorization period the patient gets a new admission for that authorized period of time; - The LPN dated the visit note the day prior in error; and - He/she was not aware that all patients were required to follow the same regulations regardless of the payer source. RECORD/PATIENT #4: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/03/2024 with primary diagnosis of type 2 (two) diabetes mellitus (a group of diseases that results in too much sugar in the blood) with foot ulcer (a complication from diabetes and uncontrolled blood sugars); - The patient resided at home with his/her spouse; - Skilled nurse visit note on 01/04/2025 showed, “patient expressed sharp pain to right lateral foot wound with touch;” - A patient communication log was provided to the SA on 02/27/2025, that showed, “Notified (named) RN with (named) NP of patient’s complain of sharp pain with touch to right lateral wound.” The date listed showed 01/04/2025. The communication log failed to show a timestamp with date, time, and signature of the clinician that entered the note; - Skilled nurse visit note on 01/06/2025 showed, “Patient expressed sharp pain to right lateral foot wound with touch. Patient declined taking medication prior to wound dressing change (The plan of care and medication profile failed to show any pain medication listed. The clinical record failed to show an order for pain medication); and - A patient communication log was provided to the SA on 02/27/2025, that showed, “Notified (named) RN with (named) NP of patient’s complain of sharp pain with touch to right lateral wound. I suggested taking pain medication prior to treatment but patient declined, no pain medication ordered at this time.” The date listed showed 01/06/2025. The communication log failed to show a timestamp with date, time, and signature of the clinician that entered the note. During an interview on 03/04/2025 at 10:10 AM, the administrator stated that: - The patient communication logs did not show timestamps with the date and time that the entries were made; and - He/she would contact the electronic medical record (EMR) company to find out how to get the date and time that patient communication logs were entered.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on policy review, review of the home health provider’s current patient rights information, and interview, the provider failed to include the written notice of the patient’s rights and responsibilities and the home health agency’s (provider’s) transfer and discharge policies to a patient-selected representative within 4 (four) business days of the initial evaluation visit. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Patient Bill of Rights,” showed: - The agency (provider) will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show the patient’s right to have written notice of their rights and the provider’s transfer and discharge policies given to a patient selected representative within 4 business days of the initial evaluation visit. Review of the home health provider’s current admission folder provided to the patient during the initial visit showed the current patient rights information failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she stated that things were worded differently. He/she had corrected the missing information.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on policy review, review of the home health provider’s current patient rights information, and interview, the provider failed to provide written notice of the state toll free home health hotline number correct hours of operation. This deficient practice has the potential to affect the patients served by the provider. Findings included: Review of the providers undated policy titled, “Patient Bill of Rights,” showed the hotline hours incorrectly listed as 24 hours a day, seven days a week. Review of the patient rights listed in the admission folder/binder, showed: - On the cover of one-piece, the hotline hours as Monday through Friday 8:00 AM o 5:00 PM (correct hours are 8:00 AM to 7:00 PM); - On page four the hotline hours were listed as regular business hours; - On page eight the hotline hours were listed as 24 hours, seven days a week; - On page 11 the hotline phone number was listed but failed to list any hours; -In the patient rights and responsibilities portion of the fastener folder, item number 30 showed 24 hours, 7 days a week; and -The admission folder/binder failed to contain the home health hotline hours of operation (8:00 AM to 7:00 PM, seven days a week). During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the hotline hours were incorrect, and the hours had been corrected.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on review of the home health provider’s current patient rights information and interview, the provider failed to include the name, address, and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the home health provider’s current patient rights information failed to show Livanta listed as the current QIO and showed KEPRO incorrectly listed. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the QIO listed was incorrect and he/she had corrected the QIO.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on policy review, review of the home health provider’s current patient rights information, and interview, the provider failed to include that the provider must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Patient Bill of Rights,” showed: - The agency (provider) will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show the provider must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, when a discharge for cause is being considered. Review of the home health provider’s current patient rights information in their admission folder failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she had corrected the missing information.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on policy review, review of the home health provider’s patient rights information, and interview the home health provider failed to include the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first provide the patient and representative with contact information for other providers who may be able to provide care. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Patient Bill of Rights,” showed: - The agency (provider) will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show the patient’s right to be informed that, before the provider could discharge a patient for cause, they must first provide the patient and representative with contact information for other providers who may be able to provide care. Review of the home health provider’s current patient rights information in their admission folder failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she had corrected the missing information.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on policy review, review of the home health providers patient rights information, and interview, the provider failed to include the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records. This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the providers undated policy titled, “Patient Bill of Rights,” showed: - The agency (provider) will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show the patient’s right to be informed that, before the provider can discharge a patient for cause, they must first document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records. Review of the home health provider’s current patient rights information in their admission folder failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she had corrected the missing information.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, review of the home health provider’s patient rights information, and interview, the provider failed to ensure patients were informed of the right to have complaints investigated, including but not limited to, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the home health agency (provider). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Patient Bill of Rights,” showed: - The agency will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment; and - The policy failed to show the patient’s right to be informed of the right to have complaints investigated, including but not limited to, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the home health agency. Review of the home health provider’s current patient rights information in their admission folder failed to include this patient right. During an interview on 02/27/2025 at 1:00 PM, the administrator stated that the missing information was worded differently. He/she had corrected the missing information.”

“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, home visit observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a long-term condition that happens when the heart can’t pump blood well enough to give the body what it needs); and - The patient resided at home with his/her spouse. On 02/25/2025 at 8:45 AM, during the home visit observation with LPN (Licensed Practical Nurse), showed: - The patient’s medication list had Spironolactone Oral Tablet 25 MG (milligram) take one tablet every morning for accumulation of fluid; and - The LPN reported that the Spironolactone was put on hold on 12/04/2024 and completely discontinued on 02/11/2025 (The medication profile was never updated with the changes). During an interview on 02/27/2025 at 11:40 AM, the Administrator stated that: - The nurse reviewed the patient’s visit notes from the ER (emergency room) and follow-up note with the cardiologist and filled the patient’s pill box based on the changes that were noted in the records sent home with the patient; and - No orders were entered in the patient’s clinical record; and - The patient’s medication list should accurately reflect the patient’s medications. Findings included: Review of the provider’s undated policy titled, “Medication Reconciliation,” showed in part: - At time of admission, the admitting RN (registered nurse), PT (physical therapist), or SLP (speech/language pathologist) will create and document a complete list of medications that the patient is taking at home; - Any discrepancies will be reconciled be a RN with the patient’s physician; - Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; - Medications ordered while the patient is receiving care will be compared to the medication list/profile; and - The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 02/12/2025 with a principal diagnosis of an unspecified open wound of the left lower leg with SN (skilled nursing) visits two times weekly to, in part, provide wound care and for observation/assessment of medication compliance and response. The patient lived in their own home with a child as their caregiver. Review of the current medication profile supplied by the provider showed, in part: empagliflozin 10mg (milligram) tablet, take one tablet once daily for HFrEF (heart failure with reduce ejection fraction- the heart muscle does not pump blood as effectively as it should). Review of the POC (plan of care) dated 02/15/2025-04/15/2025 showed, in part, empagliflozin 10mg tablet, take one tablet once daily for HFrEF. Further review of the clinical record showed the patient had SN visits three times since admission (02/18/2025, 02/21/2025 and 02/24/2025) and the omission of the patient taking the empagliflozin failed to be identified. On 02/25/2025 at 10:00AM, following the home visit observation with the PT, the following medication discrepancies were noted when a medication reconciliation was done with the caregiver who filled the patient’s medication planner: - The patient failed to be taking the empagliflozin 10mg tablet once daily; and - Had not taken it since admission. Per interview conducted with the caregiver who filled the medication planner during the home visit observation, he/she stated that: - The patient failed to be taking the empagliflozin; - The patient hadn’t taken any since admission; and - No one had informed him/her to do otherwise. Per interview conducted with PT-A during the home visit observation, he/she stated that he/she doesn’t do a medication reconciliation “per say”, he/she just asked if there were any medication changes and would notify the nurse if there were. On 02/25/2025 at 10:00AM, following the home visit observation with the PT (physical therapist), the following medication discrepancies were noted when a medication reconciliation was done with the caregiver who filled the patient’s medication planner: - The patient failed to be taking the empagliflozin 10mg tablet once daily; and - Had not taken it since admission. Per interview conducted with the caregiver who filled the medication planner during the home visit observation, he/she stated that: - The patient failed to be taking the empagliflozin; - The patient hadn’t taken any since admission; and - No one had informed him/her to do otherwise. Per interview conducted with PT-A during the home visit observation, he/she stated that he/she doesn’t do a medication reconciliation “per say”, he/she just asked if there were any medication changes and would notify the nurse if there were. Findings included: Review of the provider’s undated policy titled, “Medication Reconciliation,” showed in part: - At time of admission, the admitting registered nurse (RN), physical therapist (PT), or speech/language pathologist (SLP) will create and document a complete list of medications that the patient is taking at home; - Any discrepancies will be reconciled be a RN with the patient’s physician; - Discrepancies include duplications, omissions, changes, contraindications, and/or unclear information; - Medications ordered while the patient is receiving care will be compared to the medication list/profile; and - The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient resided at home with his/her spouse. On 02/25/2025 at 8:45 AM, during the home visit observation with LPN (Licensed Practical Nurse), showed: - The patient’s medication list had Spironolactone Oral Tablet 25 MG (milligram) take one tablet every morning for accumulation of fluid; and - The LPN reported that the Spironolactone was put on hold on 12/04/2024 and completely discontinued on 02/11/2025 (The medication profile was never updated with the changes). During an interview on 02/27/2025 at 11:40 AM, the Administrator stated that: - The nurse reviewed the patient’s visit notes from the ER (emergency room) and follow-up note with the cardiologist and filled the patient’s pill box based on the changes that were noted in the records sent home with the patient; and - No orders were entered in the patient’s clinical record; and - The patient’s medication list should accurately reflect the patient’s medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 02/12/2025 with a principal diagnosis of an unspecified open wound of the left lower leg with SN (skilled nursing) visits two times weekly to, in part, provide wound care and for observation/assessment of medication compliance and response. The patient lived in their own home with a child as their caregiver. Review of the current medication profile supplied by the provider showed, in part: empagliflozin 10mg (milligram) tablet, take one tablet once daily for HFrEF (heart failure with reduce ejection fraction- the heart muscle does not pump blood as effectively as it should). Review of the POC (plan of care) dated 02/15/2025-04/15/2025 showed, in part, empagliflozin 10mg tablet, take one tablet once daily for HFrEF. Further review of the clinical record showed the patient had SN visits three times since admission (02/18/2025, 02/21/2025 and 02/24/2025) and the omission of the patient taking the empagliflozin failed to be identified. On 02/25/2025 at 10:00AM, following the home visit observation with the PT, the following medication discrepancies were noted when a medication reconciliation was done with the caregiver who filled the patient’s medication planner: - The patient failed to be taking the empagliflozin 10mg tablet once daily; and - Had not taken it since admission. Per interview conducted with the caregiver who filled the medication planner during the home visit observation, he/she stated that: - The patient failed to be taking the empagliflozin; - The patient hadn’t taken any since admission; and - No one had informed him/her to do otherwise. Per interview conducted with PT-A during the home visit observation, he/she stated that he/she doesn’t do a medication reconciliation “per say”, he/she just asked if there were any medication changes and would notify the nurse if there were. On 02/25/2025 at 10:00AM, following the home visit observation with the PT (physical therapist), the following medication discrepancies were noted when a medication reconciliation was done with the caregiver who filled the patient’s medication planner: - The patient failed to be taking the empagliflozin 10mg tablet once daily; and - Had not taken it since admission. Per interview conducted with the caregiver who filled the medication planner during the home visit observation, he/she stated that: - The patient failed to be taking the empagliflozin; - The patient hadn’t taken any since admission; and - No one had informed him/her to do otherwise. Per interview conducted with PT-A during the home visit observation, he/she stated that he/she doesn’t do a medication reconciliation “per say”, he/she just asked if there were any medication changes and would notify the nurse if there were.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure a comprehensive assessment was updated and revised no less frequently than the last 5 (five) days of every 60 days, in one of one applicable record reviewed (Record/Patient #2). This deficient practice has the potential to adversely affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care- CMS #485 and Physician Orders,” showed in part: - At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient for a subsequent episode; and - Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); - The patient resided at home with his/her spouse; - The patient’s start of care comprehensive assessment was completed on 11/15/2024; - The patient was seen every other week by the licensed practical nurse (LPN) for medication management and pill planner fill; and - The patient did not receive a comprehensive assessment at the end of the initial 60-day episode from the start of care date. During an interview on 02/25/2025 at 11:50 AM, the administrator stated that: - The patient was a “non-bundled” Veteran (VA) patient on service for pill planner fill every 2 (two) weeks; and - He/she was not aware that all patients were required to follow the same regulations regardless of the payer source.”

“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, home visit observation, and interview, the home health provider failed to ensure an individualized plan of care (POC) included all relevant physicians that were providing home health orders, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients on served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care- CMS #485 and Physician Orders,” showed in part, the plan of care is established in writing by the physician, agency staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long-term needs. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part: - Coordination of agency’s (provider’s) internal resources include, assuring all involved staff members are aware of the patient’s plan of care and making patient information available to all staff; - Care will be coordinated with other involved external organizations; - Communication with other individuals or organizations involved in the patient’s care when significant changes occur in the patient’s overall care; and - Share relevant information to facilitate appropriate continuity and care coordination. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); and - The patient resided at home with his/her spouse. Observation on 02/25/2025 at 8:45 AM, with the licensed practical nurse (LPN), showed: - The patient informed the LPN that he/she went to the (named) clinic to have labs drawn, but they did not have an order and were unable to draw the labs; - The LPN informed the patient that the cardiologist ordered the labs to be drawn and would have to go to the cardiologist for the lab draw if the (named) clinic did not receive an order; - The LPN reviewed the patient’s office visit note from his/her follow-up with the cardiology clinic and obtained the name and phone number of the provider that ordered the labs during that follow-up; - An office assistant at the cardiology clinic informed the LPN of the name of the patient’s cardiologist as it was different from the nurse practitioner that had seen the patient during the follow-up; and - The plan of care failed to show the name and contact information for a cardiologist. During an interview on 02/25/2025 at 11:50 AM, the administrator stated that: - The patient was referred by (named provider) for pill planner fill every 2 (two) weeks; - The patient’s primary care provider was the only physician on the plan of care; and - He/she would put other physician’s names and contact information on the plan of care if they were aware of the other physicians and received orders from them.”

“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 policy review, record review, and interview, the home health provider failed to ensure that all patient care orders, including verbal orders, were recorded in the plan of care (POC), in one of five full 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 undated policy titled, “Plan of Care – CMS #485 and Physician Orders,” showed in part: - Skilled nursing and other home health services will be in accordance with the plan of care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources; - The POC is established in writing by the physician, the provider’s staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long-term needs; - The POC includes, in part: * Types of services and equipment required; * Frequency of visits and duration; * Expected goals or outcomes to be achieved; - If a physician refers a patient under a plan of care that cannot be completed until an evaluation visit, the physician is consulted to approve additions or modifications to the original plan; - Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency and duration; and - The therapist and other provider personnel participate in developing the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/12/2025 with a principal diagnosis of an unspecified open wound of the left lower leg with skilled nursing (SN) visits two times weekly to, in part, provide wound care and for observation/assessment of medication compliance and response. The patient lived in their own home with a child as their caregiver. Review of the referral records dated, “02/12/2025 at 9:08:52 AM,” showed in part, SN and physical therapy (PT). Review of the POC dated 02/15/2025 to 04/15/2025, failed to show an order for PT and include a visit frequency and an established treatment plan. Review of a PT evaluation dated 02/20/2025, showed PT orders for 1w1, 2w3,1w1 (once a week for the first week, twice a week for the next three weeks, then once a week for one more week, goals and interventions. The POC failed to show the PT orders. During an interview on 02/27/2025 at 1:10 PM, the administrator stated that: The therapy treatment plan was usually added to the POC, but things happen.”

“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 policy review, record review, and interview, the provider failed to ensure that the individualized plan of care was reviewed and revised by the physician responsible for the home health plan of care and the HHA (home health agency) no less frequently than every sixty (60) days, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care- CMS #485 and Physician Orders,” showed in part: - At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient for a subsequent episode; - Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode; and - The total plan of care will be reviewed and signed by the attending physician and agency (provider) personnel involved in the patients care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); - The patient resided at home with his/her spouse; - The patient’s plan of care showed a certification period of 11/15/2025 to 05/09/2025; and - The clinical record failed to include a plan of care that was reviewed/revised at the end of the initial 60-day episode from the start of care date. During an interview on 02/25/2025 at 11:50 AM, the administrator stated that: - The patient was a “non-bundled” Veteran (VA) patient on service for pill planner fill every 2 (two) weeks; - The certification period was authorization period that was approved by the VA for the pill planner fill; and - He/she was not aware that all patients were required to follow the same regulations regardless of the payer source.”

“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, and interview, the home health provider failed to integrate orders from all physicians involved in the plan of care, to assure coordination of all services and interventions were provided to the patient in, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care- CMS #485 and Physician Orders,” showed in part, the plan of care is established in writing by the physician, agency (provider) staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long-term needs. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part: - Coordination of agency’s internal resources include, assuring all involved staff members are aware of the patient’s plan of care and making patient information available to all staff; - Care will be coordinated with other involved external organizations; - Communication with other individuals or organizations involved in the patient’s care when significant changes occur in the patient’s overall care; and - Share relevant information to facilitate appropriate continuity and care coordination. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); - The patient resided at home with his/her spouse; - Skilled nursing visit on 12/31/2024 showed, “Empagliflozin (an antidiabetic medication) and spironolactone (diuretic) which were on hold since 12/04/2024, until follow-up labs and instructions by the provider” was noted in the comment section; - The clinical record failed to show orders for the medications being on hold; - Skilled nurse visit on 02/11/2025, showed the licensed practical nurse (LPN) contacted the cardiologist’s office and left a voicemail regarding the medications that were on hold. The LPN received a return call and spoke with the nurse. The nurse stated that, “the doctor wants (the patient) to resume bumetanide (diuretic) and empagliflozin and discontinue the spironolactone and to repeat labs in one week after taking empagliflozin;” and - The clinical record failed to show any orders received for the medications and labs. During an interview on 02/25/2025 at 11:50 AM, the administrator stated that: - There were no orders in the clinical record; and - He/she agreed that the clinical record should have been updated with the medication changes.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on policy review, record review, home visit observation, and interview the home health provider failed to ensure the coordination of care met the patient’s needs in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the coordination of care and services for all the patients on service with the provider. Findings included: Review of the provider’s undated policy titled, “Service Policies Nursing Services,” showed in part: - The registered nurse (RN) gives direct care, teaches, and supervises others in aspects of patient care, is responsible for assessing patient needs and for planning patient care; - The RN is responsible for maintaining communication with licensed practical nurse (LPN) relative to patient status and ongoing plan of care; and - Professional Nursing (Registered Nurse) functions include in part, coordination of services. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part: - Coordination of agency’s (provider’s) internal resources include, assuring all involved staff members are aware of the patient’s plan of care and making patient information available to all staff; - Care will be coordinated with other involved external organizations; - Communication with other individuals or organizations involved in the patient’s care when significant changes occur in the patient’s overall care; and - Share relevant information to facilitate appropriate continuity and care coordination. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); and - The patient resided at home with his/her spouse. Observation on 02/25/2025 at 8:45 AM, with the LPN, showed: - The patient informed the LPN that he/she went to the (named) clinic to have labs drawn, but they did not have an order and were unable to draw the labs; - The LPN informed the patient that the cardiologist ordered the labs to be drawn and would have to go to the cardiologist for the lab draw if the (named) clinic did not receive an order; - The LPN left a voicemail with the cardiologist office regarding the patient not being able to get labs drawn the week prior due to the (named) clinic not having an order to draw them; and - The clinical record failed to show coordination of care between 02/11/2025 and 02/25/2025 regarding the patient’s lab, resulting in the patient’s labs not getting drawn until 02/28/2025. During an interview on 02/25/2025 at 12:10 PM, the administrator stated that: - The home health did not draw labs; - The patient’s had to go to the (named) clinic for lab draws; - The (named) clinic did not have the order because it was ordered by an outside cardiologist; and - He/she was not sure about the medication changes and the labs needed but was going to be checking into and would update the state agent (SA) as information became available.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observation and interview, the home health provider failed to ensure staff provided the patient and/or caregiver with a copy of written instructions outlining the patient’s medication schedule/instruction, including the medication name, dosage, and frequency in, one of three home visit observations (Record/Patient #3). This deficient practice has the potential to adversely affect the knowledge of self-care and provider expectations in all the patients served by the provider. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/12/2025 with a principal diagnosis of an unspecified open wound of the left lower leg with skilled nursing (SN) visits two times weekly to, in part, provide wound care and for observation/assessment of medication compliance and response. The patient lived in their own home with a child as their caregiver. Observation on 02/25/2025 at 10:00 AM with physical therapist (PT)-A, showed the home folder failed to contain a medication list from the current episode of care. (There was a medication list from a prior admission/episode of care that was no longer relevant/accurate). Per interview conducted during the home visit observation, PT-A stated that he/she: - Did not do a medication reconciliation “per se”; and - Would ask if there were any changes in the medications and notify the nurse if there were any changes. Per interview conducted during the home visit observation, the patient’s caregiver stated that: - He/she filled the medication planner; and - That he/she did not have a medication list and just went by the medication bottles. During an interview on 02/27/2025 1:15 PM, the administrator stated that he/she went over the patient’s medications in depth on admission with the caregiver. (He/she failed to comment if a medication list was supplied to the patient for this episode of care).”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on survey findings, policy review, job description review, record review, home visit observation, and interview, the clinical manager failed to provide oversight of patient care services that included, coordinating care with the LPN (licensed practical nurse), in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the current survey findings showed the provider failed to meet compliance for three Conditions of Participation: -§484.50 Condition of Participation: Patient Rights; -§484.60 Condition of Participation: Care planning, coordination of services, and quality of care; and -§484.105 Condition of Participation: Organization and administrations of services. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part, the Director of Clinical Services and/or Nursing Supervisor communicates with staff daily to discuss changes in the patient’s condition, the plan of care, and physician’s orders. Review of the provider’s job description titled, “Director of Clinical Services/Clinical Manager,” dated 01/30/2019, showed in part: - Coordinated interdisciplinary team services; - Assures ongoing assessment of patient/family needs and implementation of interdisciplinary team plan of care; and - Ensures compliance with federal, state, accrediting bodies, local, and agency (provider) policies and all patient care aspects of the agency. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); and - The patient resided at home with his/her spouse; - Skilled nursing visit on 12/31/2024 showed, “Empagliflozin (an antidiabetic medication) and spironolactone (diuretic) which were on hold since 12/04/2024, until follow-up labs and instructions by the provider” was noted in the comment section; - The clinical record failed to show orders for the medications being on hold; - Skilled nurse visit on 02/11/2025 showed the licensed practical nurse (LPN) contacted the cardiologist’s office and left a voicemail regarding the medications that were on hold. The LPN received a return call and spoke with the nurse. The nurse stated that, “the doctor wants (the patient) to resume bumentadine (diuretic) and empagliflozin and discontinue spironolactone and to repeat labs in one week after taking the empagliflozin;” - The clinical record failed to show any orders received for the medications and labs; and - The clinical record failed to show coordination of care between the LPN and the clinical manager regarding the medication changes and the labs. Observation on 02/25/2025 at 8:45 AM with the LPN, showed: - The patient informed the LPN that he/she went to the (named) clinic to have labs drawn but they did not have an order and were unable to draw the labs; - The LPN informed the patient that the cardiologist ordered the labs to be drawn and would have to go to the cardiologist for the lab draw if the (named) clinic didn’t get an order; - The patient’s medication list had spironolactone oral tablet 25 milligram (mg) take one tablet every morning for accumulation of fluid; and - The LPN reported that the spironolactone was discontinued on 02/11/2025 (The medication profile failed to be updated with the changes); - The LPN left a voicemail with the cardiologist office regarding the patient not being able to get labs drawn the week prior due to the (named) clinic not having an order to draw them; and - The clinical record failed to show coordination of care between 02/11/2025 and 02/25/2025 regarding the patient’s lab, resulting in the patient’s labs not getting drawn until 02/28/2025. During an interview on 02/25/2025 at 12:10 PM, the administrator/clinical manager stated that: - The home health did not draw labs; - The patient’s had to go to the (named) clinic for lab draws; - The (named) clinic did not have the order because it was ordered by an outside cardiologist; and - He/she was not sure about the medication changes and the labs needed, but was going to be checking into and would update the state agent (SA) as information became available.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on survey findings, policy review, job description review, record review, and interview, the clinical manager failed to provide oversight of patient care services that included, assuring the development, implementation, and updates of the individualized plan of care, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the current survey findings showed the provider failed to meet compliance for three Conditions of Participation: -§484.50 Condition of Participation: Patient Rights; -§484.60 Condition of Participation: Care planning, coordination of services, and quality of care; and -§484.105 Condition of Participation: Organization and administrations of services. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part, the Director of Clinical Services and/or Nursing Supervisor communicates with staff daily to discuss changes in the patient’s condition, the plan of care, and physician’s orders. Review of the provider’s job description titled, “Director of Clinical Services/Clinical Manager,” dated 01/30/2019, showed in part: - Oversees staffing and visit assignments; - Ensures that patients plan of care are developed, implemented and evaluated; - Assures ongoing assessment of patient/family needs and implementation of interdisciplinary team plan of care; and - Ensures compliance with federal, state, accrediting bodies, local, and agency (provider) policies and all patient care aspects of the agency. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); - The patient resided at home with his/her spouse; - The patient’s plan of care showed a certification period of 11/15/2025 to 05/09/2025; - Skilled nurse visit note on 12/03/2024 showed the patient had a blood pressure of reading of 71/40 (normal = 120/80, low considered below 90/60) on the right arm and a reading of 68/42 on left arm. The LPN contacted the primary care physician, and the patient was recommended to go to the emergency room (ER) for low blood pressure; - Skilled nurse visit note on 12/06/2024 showed “patient went to (named) ER on 12/04/24 regarding low blood pressure. Received a call from (named provider) for new change of medications; bumetanide (diuretic) 1 milligram (mg) tablet: take one tablet by mouth every morning as needed for fluid retention, take only when gain greater than three pounds in 24 hours, hold spironolactone (diuretic) 25 mgs and hold empagliflozin an antidiabetic agent) until follow-up labs and instructions from provider” was written in the comment section; - The clinical manager failed to ensure that the plan of care was reviewed/revised with the patient’s change in condition and/or at least every 60 days. During an interview on 02/25/2025 at 11:50 AM, the administrator stated that: - The patient was a “non-bundled” Veteran (VA) patient on service for pill planner fill every 2 (two) weeks; - The certification period was the authorization period that was approved by the VA for the pill planner fill; and - He/she was not aware that all patients were required to follow the same regulations regardless of the payer source.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on policy review, record review, and interview the provider failed to ensure that clinical records included all interventions and responses to those interventions, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Physician Orders- Verbal Orders,” showed in part: - Orders for patient care are obtained from the physician, either verbally or in writing; - Verbal orders taken by a licensed practical nurse (LPN) must be approved by a registered nurse (RN) prior to implementing order and cosigned by RN prior to submitting to physician for signature; - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order; - A record of this order is documented on a physician’s supplemental order form; and - A copy will remain in the patient’s record until the signed order is returned and a copy will be placed in the tracking file. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 11/15/2024 with primary diagnosis of heart failure (a decrease in the ability of the heart to pump blood); - The patient resided at home with his/her spouse; - Skilled nurse visit note on 12/06/2024 showed “patient went to (named) emergency room (ER) on 12/04/24 regarding low blood pressure. Received a call from (named provider) for new change of medications; bumetanide (diuretic)1 milligram (mg) tablet: take one tablet by mouth every morning as needed for fluid retention, take only when gain greater than three pounds in 24 hours, hold spironolactone (diuretic) 25 mgs and hold empagliflozin (an antidiabetic agent) until follow-up labs and instructions from provider” was written in the comment section; - The clinical record failed to show orders for the medications changes; - Skilled nurse visit on 02/11/2025 showed the licensed practical nurse (LPN) contacted the cardiologist’s office and left a voicemail regarding medications that were on hold. The LPN received a return call and spoke with the nurse. The nurse stated that, “the doctor wants (the patient) to resume bumetanide and empagliflozin and discontinue spironolactone and to repeat labs in one week after taking the empagliflozin;” and - The clinical record failed to show orders for the medication changes and labs. During an interview on 02/25/2025 at 12:10 PM, the administrator/clinical manager stated that: - There were no orders in the clinical record for the medication changes and labs; and - He/she was not sure about the medication changes and the labs needed, but was going to be checking into and would update the state agent (SA) as information became available.”