Breakthrough Healthcare Limited Liability Company

“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 admission booklet review, record review, complaint log review, observation, and interview, the home health provider violated the patients’ rights when the provider failed to ensure: - Patients participated in their plan of care (G0434); - Patients received all services in the plan of care (POC) (G0436); - Patients received proper written notice in advance of reducing or terminating ongoing care (G0442); and - The documentation of patient complaints (G0484). The cumulative effect of these deficient practices had 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, administrator job description review, and interview, the home health provider failed to ensure the administrator was responsible for the day-to-day operations of the home health agency (G0948). The cumulative effect of these deficient systemic practices resulted in the provider’s inability to ensure their patients care needs would be met.”

“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 two Conditions of Participation: Patient rights, 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 07/30/2028.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on admission booklet review, record review, and interview, the home health provider failed to ensure that patients were informed about changes in the care to be furnished in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the admission booklet, provided to all patients at the time of admission to service, showed that the patient had the right to participate in, be informed about, and consent to or refuse care in advance of and during treatment, where appropriate, with respect to any changes in the care to be furnished. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/12/2025. The patient was recertified on 04/11/2026 with a primary diagnosis of dementia (decline in mental capacity). The patient had a secondary diagnosis of a gastrostomy tube (G-tube, a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication). The patient resided in his/her own home with the assistance of his/her spouse. Review of the plan of care (POC), dated 04/11/2026, showed that skilled nursing visits were to be three times per week. Review of the interim order, dated 05/16/2026, showed that skilled nursing visits were decreased to one time per week. Review of the clinical record showed that the record failed to contain documentation that the patient and caregiver were notified of, and/or participated in, the decision to decrease skilled nursing visits to one time weekly. During an interview, on 07/29/2026, the patient’s spouse stated that: - The weeks of 05/20/2026 and 05/27/2026, the nurse failed to show up for visits, and failed to make visits three times each week; and - When he/she called the nurse to discuss the missed visits, the nurse failed to call him/her back or make a visit. During an interview, on 07/30/2026, the administrator stated that: - The clinician provided visits as ordered; - They expect clinicians to discuss and document changes in the POC with the patient; and - He/she was unable to locate documentation that the patient/spouse had been notified of the decrease in nursing visits.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on admission booklet review, record review, and interview, the home health provider failed to ensure patients received all services outlined in the plan of care (POC) in two of three records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all of the provider’s patients. Findings included: Review of the admission booklet, provided to all patients at the time of admission to service, showed that the patient had the right to receive all services outlined in the POC. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/12/2025. The patient was recertified on 04/11/2026 with a primary diagnosis of dementia (decline in mental capacity). The patient had a secondary diagnosis of a gastrostomy tube (G-tube, a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication). The patient resided in his/her own home with the assistance of his/her spouse. Review of the POC, dated 04/11/2026, showed that: - The nurse was to perform pressure ulcer care to the G-tube site every other day (qod). - The nurse may teach patient/caregiver to perform wound care. Review of the nursing documentation showed that the nurse performed wound care on, but not limited to: - 04/11/2026, 04/14/2026 (every other day (qod) would have been 04/13/2026); - 04/16/2026, 04/18/2026, 04/21/2026 (qod would have been 04/20/2026); - 04/23/2026 04/25/2026, 04/28/2026 (qod would have been 04/27/2026); - 04/30/2026, 05/02/2026, 05/05/2026 (qod would have been 05/04/2026); - The patient’s caregiver received instruction on the performance of wound care in the absence of the skilled nurse; - The clinical record failed to contain documentation that the patient/caregiver was performing the wound care in the SN absence; and - The nurse performed wound care outside the ordered every other day frequency. During an interview on 07/30/2026, at 10:00 AM, the administrator stated that: - They expect clinicians to follow the POC; and - The POC for this patient was inaccurate, the wound care order should have been written for three times per week. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/20/2026 with a primary diagnosis of heart failure (CHF, a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses including, but not limited to, lymphedema (a condition in which extra fluid builds up in tissue and causes swelling) and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland). The patient resided in his/her own home with the assistance of his/her spouse. Review of the initial POC, dated 07/20/2026, showed that the patient was to receive nursing visits two times during the week of 07/20/2026. Home visit observation with the administrator present, on 07/28/2026, showed that: - Upon arrival to the home, the patient’s spouse asked the administrator about the nursing visit schedule. The patient stated that: * He/she understood nursing was to visit two times per week on the week of 07/20/2026; * He/she had received the initial nursing visit on 07/20/2026; and * The nurse failed to return to the home for the second visit the week of 07/20/2026; - The administrator called the visiting nurse, the nurse confirmed that he/she had not made a second visit because he/she was too busy; and - The administrator stated that the visiting nurse had not notified him/her of the missed visit. During an interview on 07/30/2026, at 10:00 AM, the administrator stated that: - The nurse should call the office when he/she is unable to make a visit, so the visit can be rescheduled; - The nurse failed to report the missed visit; - They had a process to run reports to check for missed visits; and - They had not had time to run the report for the past week.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on admission booklet review, record review, and interview, the home health provider failed to ensure that patients received proper written notice in advance of the provider reducing or terminating ongoing care in one of three records reviewed (Record/Patient #2). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the admission booklet, provided to all patients at the time of admission to service, showed that the patient had the right to receive proper written notice in advance of the provider reducing or terminating ongoing care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 04/02/2026. The patient was recertified on 06/01/2026 with a primary diagnosis of a wound on the right foot. The patient resided in his/her own home with the assistance of an aide. The patient was scheduled for surgery on 06/17/2026 for debridement (the medical removal of dead, damaged, or infected tissue) and possible amputation (surgical removal of a part of the body) of part of his/her foot. The surgery was cancelled. Review of the POC dated 06/01/2026 showed that the nurse was to perform wound care to the patient’s right foot every other day. The nurse cleansed with wound cleanser, applied Aquacel AG (a special bandage that kills germs and traps moisture), covered with an ABD pad (abdominal pad, a thick, highly absorbent dressing used to cover large wounds and manage heavy drainage), wrapped with gauze, and secured with tape. Review of the interim order, dated 06/16/2026, showed that the patient was to receive nursing visits one time per week for one week, two times per week for five weeks, and then one time per week. Review of the visit documentation for the dates of: - 07/03/2026 and 07/07/2026, the nurse documented discharge planning was discussed with the patient; however, the documentation failed to contain details of what planning occurred; and - 07/14/2026 showed the documentation failed to contain information on discharge planning. On 07/15/2026, a non-visit OASIS (Outcome and Assessment Information Set; a standardized data collection tool) discharge was performed. The documentation showed that the patient’s aide would be performing his/her wound care. The discharge failed to contain documentation that: - The aide had received training on and demonstrated proficiency of the wound care procedure; - The aide was acting within his/her scope of practice in performing wound care; and - The patient had access to prescription wound care supplies. During an interview on 07/29/2026 at 11:20 AM, the patient stated that: - He/she had a nurse coming to change the patient’s wound dressing; and - All of a sudden, the nurse stopped coming. The nurse failed to come to the house and failed to call; - The patient called the office and was notified that he/she had used up all of his/her visits for the year; - He/she, with the assistance of his/her aide, was performing his/her wound care every two to three days to conserve supplies; and - He/she was still waiting for a date for debridement of the wound or amputation of part of his/her foot. During an interview on 07/30/2026, at 10:00 AM, the administrator stated that: - They would expect discharge planning documentation to contain specific information regarding the patient’s discharge; - He/she was unable to locate additional documentation showing what was planned for the patient’s discharge.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on admission booklet review, complaint log review, observation, and interview, the home health provider failed to ensure the acceptance of patient complaints in two of three records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the admission booklet, provided to all patients at the time of admission to service, showed that if a patient felt the provider’s staff had failed to follow its policies or had in any way denied the patient his/her rights, the patient should: - Notify the clinical manager by phone from 08:00 AM to 04:30 PM, Monday through Friday; - Submit a complaint in writing by mail; or - Notify the administrator, listed in the patient rights section of the booklet, by phone or in writing. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/12/2025. The patient was recertified on 04/11/2026 with a primary diagnosis of dementia (decline in mental capacity). The patient had a secondary diagnosis of a gastrostomy tube (G-tube, a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication). The patient resided in his/her own home with the assistance of his/her spouse. During an interview on 07/29/2026 at 11:20 AM, the patient’s spouse stated that: - His/her spouse had received services from the provider for several years; - Over the last six months or so, the services had changed; - Nurses would miss visits, arrive late for visits, and fail to call; - Supplies would be delivered late or not at all; - The nurses failed to visit three times a week for the weeks of 06/13/2026 and 06/20/2026; - He/she had called the nurse multiple times and the nurse failed to return his/her phone calls; and - He/she did not call the office as he/she usually coordinated visits with the nurse. Review of the complaint/grievance log showed that the log failed to contain documentation of the spouse’s complaint regarding late or missing nursing visits and supply issues. During an interview on 07/29/2026 at 4:00 PM, the administrator stated that they: - Had a process in which the staff were to have patients use a protected health information (PHI) application on their work phones. Clinicians were to use the application for scheduling and coordination of services. This application provided transcripts of clinician contacts to the office staff to assist with coordination of care; and - Were unaware that the nurse was not using the application to communicate with his/her patients. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/20/2026 with a primary diagnosis of congestive heart failure (CHF, a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses including, but not limited to, lymphedema (a condition in which extra fluid builds up in tissue and causes swelling) and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland). The patient resided in his/her own home with the assistance of his/her spouse. Home visit observation on 07/28/2026, at 2:00 PM, showed that: - The administrator accompanied the state agent on the home visit observation; - Upon arrival to the home, the patient’s spouse asked the home health administrator about the nursing visit schedule. The patient stated that he/she understood nursing was to visit two times per week during the week of 07/20/2026. He/she had received the initial nursing visit on 07/20/2026, and the nurse failed to return to the home for the second visit; - The administrator called the visiting nurse, the nurse confirmed that he/she had not made a second visit because he/she was too busy; and - The administrator stated that the visiting nurse had not notified him/her of the missed visit; - The physical therapist asked the patient for his/her folder (left in the patient’s home at time of admission), The patient and spouse stated that the admitting nurse failed to leave the provider’s folder in the home; - The administrator asked the patient/spouse whether they had attempted to contact the office about the missed visit; - The patient and spouse stated that they did not know whom to call, they did not know the name of the provider, and they did not have the provider’s information available in their home; - The administrator asked to see the patient’s folder, and it was confirmed that there was no folder in the home; - Review of the visits provided to the patient showed that the nursing start-of-care visit and the physical therapy evaluation visits were performed 07/20/2026; and - The administrator left an admission folder in the patient’s home at the end of the observation visit.”

“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 comprehensive assessment accurately reflected the patient’s status at the time of assessment in two of three 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 undated policy titled, “Comprehensive Assessment of Patients,” showed that the OASIS (Outcome and Assessment Information Set) data collected must accurately reflect the patient’s status at the time of assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/12/2025. The patient was recertified on 04/11/2026 with a primary diagnosis of dementia (decline in mental capacity). The patient had a secondary diagnosis of a gastrostomy tube (G-tube, a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication). The patient resided in his/her own home with the assistance of his/her spouse. Review of the plan of care dated 04/11/2026 showed that the patient/caregiver would achieve optimal wound healing without further signs or symptoms of infection or complications, and that the wound healed. Review of the non-visit discharge OASIS (Outcome and Assessment Information Set; a standardized data collection tool) comprehensive assessment documentation, dated 06/09/2026, showed that the patient was discharged from services with goals met. During an interview on 07/29/2026 at 11:20 AM, the patient’s spouse stated that he/she had requested discharge from the provider due to service-related issues. During an interview on 07/28/2026 at 4:00 PM, the administrator stated that: - The patient’s spouse had requested discharge from the provider; - The OASIS documentation showed that the patient was discharged from the provider with their goals met; and - The OASIS visit documentation failed to accurately show that the patient requested discharge from the provider’s services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 04/02/2026. The patient was recertified on 06/01/2026 with a primary diagnosis of a wound on the right foot. The patient resided in his/her own home with the assistance of an aide. Review of the nursing OASIS comprehensive assessment, dated 05/31/2026, showed that the patient had no pain. Review of the plan of care dated 06/01/2026 showed that the patient: - Took oxycodone-acetaminophen (an opioid medication used to treat severe pain) every eight hours as needed and duloxetine (a medication used to treat nerve pain) two times per day for pain management; - Orders to call the physician for pain greater than six on a zero (0) to 10 high (0-10 high) scale; and - Narcan nasal inhalant as needed for opioid overdose. During an interview on 07/29/2026 at 11:20 AM, the patient stated that: - He/she experienced severe, chronic pain associated with the wound on his/her foot: and - He/she had occasional periods when he/she was pain-free but never had an entirely pain-free day. Review of nursing documentation for visits dated 06/02/2026, 06/06/2026, and 06/16/2026, showed the patient experienced pain rated from three to 10 on a 0-10 high scale. During an interview on 07/30/2026 at 10:00 AM, the administrator stated that: - The patient experienced chronic pain, and - The OASIS comprehensive documentation failed to accurately reflect the patient’s pain status at the time of assessment.”

“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, and interview, the home health provider failed to ensure the plan of care (POC) contained patient specific interventions in two of three records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Planning,” showed that the POC shall include, but not limited to: - Orders for therapy services; and - Patient-specific interventions and education. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 04/02/2026. The patient was recertified on 06/01/2026 with a primary diagnosis of a wound on the right foot. The patient had, among other conditions, a secondary diagnosis of diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in his/her own home with the assistance of an aide. The patient was scheduled for surgery on 06/17/2026 for debridement (the medical removal of dead, damaged, or infected tissue) and possible amputation (removal) of part of his/her foot. Review of the comprehensive nursing visit documentation, dated 05/31/2026, showed that the patient: - Monitored his/her blood sugars, and had a fasting blood sugar range of 108-117 using his/her glucometer (a machine used to monitor the level of sugar in the blood); and - Received wound care to his/her right foot daily by cleansing with wound cleanser, applying Aquacel AG (a special bandage that kills germs and traps moisture), covering with an ABD pad (abdominal pad, a thick, highly absorbent dressing used to cover large wounds and manage heavy drainage), wrapping with gauze, and securing with tape. Review of the POC, dated 06/01/2026, showed that the document failed to contain: - The patient’s glucometer as a medical supply; - Orders to assess the patient’s blood sugars at each visit; and - Wound care orders for the wound on the patient’s right foot. During an interview on 07/30/2026, at 10:00 AM, the administrator stated that: - They would expect the POC to contain orders for the individualized assessments, interventions, and supply needs of the patient; - The POC failed to contain the patient’s glucometer, orders to assess the patient’s blood sugars, and wound care orders for the patient’s right foot. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/20/2026 with a primary diagnosis of heart failure (CHF, a decrease in the ability of the heart to pump blood). The patient had secondary diagnoses including, but not limited to, lymphedema (a condition in which extra fluid builds up in tissue and causes swelling) and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland). The patient resided in his/her own home with the assistance of his/her spouse. Review of the referral paperwork showed SN (Skilled Nurse), PT (Physical Therapy), and OT (Occupational Therapy) were to evaluate and treat. Review of the initial, nursing comprehensive assessment documentation, dated 07/20/2026, showed that the patient had: - An indwelling catheter (a sterile tube placed into the bladder to drain urine); - No identified problems with his/her skin integrity, no unhealed pressure/status/surgical wounds; and - Non-pitting edema of ankles and feet. Review of the plan of care (POC) dated 07/20/2026 showed that the POC failed to contain interventions and orders for: - OT to evaluate and treat; and - Interventions and assessments to manage the patient’s CHF. During an interview on 07/30/2026 at 10:00 AM, the administrator stated that: - They would expect interventions to assess and manage the patient’s CHF to be on the POC; and - They had not noticed the order for OT to evaluate and treat on the patient’s referral paperwork.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on current survey findings, administrator job description review, and interview, the home health provider failed to ensure the administrator was responsible for the day-to-day operations of the home health agency. 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 two Conditions of Participation: - §484.50 Condition of Participation: Patient Rights; and - §484.105 Condition of Participation: Organization and administration of services. Review of the administrator job description, revised 04/28/2021, showed in part that the administrator’s job functions included, but were not limited to: - Promotion of interdepartmental cooperation and communication; - Oversight of care delivery and patient outcomes to ensure that care met the patient’s needs; - To monitor and take reasonable steps to ensure: * Patient rights are exercised; * Compliance with applicable Federal, State, and local laws and professional standards are maintained; and * Compliance with the patient’s plan of care. During an interview on 07/30/2026 at 10:00 AM, the administrator stated that: - Most of the issues found during this survey were related to just one employee, and he/she had suspended that employee pending the results of this survey; - They had hired a clinical manager and case manager; and - Both new hires would begin training the following week.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure skilled professional services were provided in an acceptable manner and as ordered by the physician (G0710). The systemic effect of this deficient practice has the potential to affect all the patients served by the provider.”

“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: Skilled Professional 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 03/02/2028.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated 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 skilled professional services were provided in an acceptable manner and as ordered by the physician in two of three sampled patients (Records/Patients #1 and #3) and four additional patients (Records/Patients #4, #5, #6 and #7). This deficient practice has the potential to affect all patients on service with the home health provider. Review of the provider’s undated policy titled, “Physician Orders/Plan of Care,” showed in part that the policy is to ensure care is under the direction of a physician, and the physician should receive reports with any need to alter the plan of care. Review of the provider’s undated policy titled, “Patient Conduct, Responsibility, and Rights,” showed in part that the patient had a right to be admitted only if the agency had the ability to provide safe and effective care at the intensity needed. Example #1: RECORD/PATIENT #1: Review of the admission records showed that the patient had been on service previously with the provider. The patient was admitted to home health services for the most recent episode on 01/21/2026 with a primary diagnosis of unhealed stage 2 sacral wound (Stage II Pressure Injury - A partial thickness loss of the skin). Upon admission, the nurse was ordered to visit the patient weekly. Review of a plan of care summary showed, on 01/19/2026, the nurse (SN) was to perform wound care daily to the right lower buttock wound (wound #3). Review of an interim order dated 01/22/2026, showed the SN visit frequency was changed to daily for ulcer care to the left buttock. Review of all available nurse visit notes showed no SN visits on 01/23/2026, 01/24/2026, 01/25/2026, 01/26/2026, 01/27/2026, and 01/28/2026. There was a missed visit note entered on 01/26/2026 for inclement weather. During a nurse visit dated 01/29/2026, the nurse documented that wound #3 (right lower buttock) had serosanguineous drainage (a thin, red discharge composed of serum and blood) and “no odor” was documented. Review of all nurse visit notes showed no SN visits on 01/30/2026, 01/31/2026, 02/01/2026, 02/02/2026, 02/03/2026, and 02/04/2026. During the next nursing visit completed 02/05/2026, the nurse assessed wound #3 with “moderate odor”. Review of the nurse visit note showed the nurse coordinated with the physician regarding wound drainage, with no documentation that the physician was made aware of the new onset of wound odor. Review of a communication noted dated 02/10/2026 showed that “(the patient) was admitted to (a hospital). Admitted on 02/05/2026”. RECORD/PATIENT #3: Review of the admission assessment, completed on 10/03/2025 by registered nurse (RN)-A, showed the patient was admitted to service on 10/03/2025 with a primary diagnosis of polycythemia (an abnormal increase in red blood cells). Review of the discharge summary from 01/18/2026 showed that the patient was discharged with goals met. Review of the plan of care showed the patient was to receive nurse visits weekly. All coordination notes and notification to the physician regarding missed visits were requested from the administrator on 02/10/2026 at 1:40 PM. Review of the nurse visit notes showed the patient received no weekly nurse visits the week of 01/11/2026. All available coordination/notification notes and interim orders showed no communication that the plan of care was not followed the week of 01/11/2026. During interviews on 02/10/2026 at 12:50 PM and 1:30 PM, and on 02/11/2026 at 10:22 AM and 11:42 AM, the administrator stated that Patient #3 was completely “forgot about” and had a missed visit. The nurse, (RN-A), assigned to that patient was disciplined and educated about following the plan or care and visit schedule. Example #2: During an interview with Physical Therapist (PT-A) on 02/11/2026 at 12:10 PM, he/she stated that: - He/she had worked for the provider on a PRN (as needed) basis for two years; - When asked if he/she was available to visit patients, “I am leaving on vacation for two weeks starting Sunday (02/15/2026), I have no patients assigned”; and - When asked if there were delays in the initiation of therapy after it was ordered, he/she stated that he/she worked full-time for another provider and was not available every day, “sometimes visits have to be delayed and rescheduled because of my availability”. During an interview on 02/11/2026 at 10:48 AM, RN-A stated that: - He/she worked full-time for the provider for a year as an RN case manager; - When asked if he/she received any patient complaints about missing or delayed therapy visits, he/she stated, “multiple patients have complained about a delay in getting therapy started, (Patient #4, #5, #6 and #7) all complained about delays in therapy and home health visits”; and - He/she was aware that the director of nurses recently resigned, unaware that the therapy clinical manager was no longer employed, and that the administrator took over the role of clinical manager. During interviews on 02/10/2026 at 12:50PM and 1:30 PM, and on 02/11/2026 at 10:22 AM and 11:42 AM, the administrator stated that: - The provider had problems with missed visits starting December 19, 2025, when they contracted with a new quality assurance (QA) company. He/she assumed the QA company would track missed visits and notify him/her and they did not; - Patient #3 was completely “forgot about” and had missed visits. The nurse (RN-A) assigned to that patient was disciplined and educated about following the plan or care and visit schedule; - The (previous) director of nurses discovered the issue with missed visits on 01/06/2026. The problem with missed visits were addressed with a new system of reporting at that time. A system was started with a new case management form that was turned into the previous director of nursing on Wednesdays, the case management forms are unavailable. This system along with new missed visit practices were educated on during a weekly Wednesday meeting that occurred on 01/14/2025 with additional training on 02/04/2025; and - The missed visit issue has not been written into a performance improvement plan (PIP) or tracked in the provider’s quality assessment and performance improvement plan (QAPI) since it just occurred. Review of the provider’s complaint log showed four entries in February of 2026. The concerns were as follows: - “Therapy schedule, lack of communication” (Complaint from Patient #4); - “Missed visit and poor communication” (Complaint from Patient #5); - Unhappy with therapy and wound care “going with another provider” (Complaint from Patient #6); and - Complaint about wound care supplies (Complaint from Patient #7). On 02/11/2025 at 1:15 PM, the administrator provided a missed visit report on nursing and therapy from 01/01/2025 through 02/11/2025. Review of the missed visit report, during that period, showed 118 missed visits. The administrator stated that the reason for the missed visits was not generated on the report and could be from patient refusal, etc.”