VNA of Western NY Chha

“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 review of clinical records, agency policy and procedure, and staff interviews, for one (1) of five (5) patients (Patient #1), the clinical record lacks documented evidence that the Notice of Medicare Non-Coverage was provided to the patient before being discharged from the agency. Failure to complete the Notice of Medicare Non-Coverage form with the patient prior to discharge has the potential to result in negative patient outcomes. The agency failed to provide the patient with a Notice of Medicare Non-Coverage form prior to discharge as evidenced by the following: Patient #1 – This 74-year-old patient with diagnoses of pressure ulcer right hip, unstageable, unspecified open wound, left thigh, and Alzheimer’s disease was admitted to the home care agency on 08/23/2025. Review of the Discharge-Transfer Summary Report dated 09/03/2025 revealed the following: - Episode Status: Discharged - Episode End Date: 09/03/2025 The clinical record lacks documented evidence that the Notice of Medicare Non-Coverage was discussed and provided to the patient before the patient was discharged from the agency. In an email dated 11/20/2025 at 04:13 PM, the Chief Quality and Safety Officer stated, “I am not able to locate it.” Additionally, during interview on 12/09/2025 at 09:48 AM, the Chief Quality and Safety Officer stated they could not find a notice of non-coverage. Additionally, the Chief Quality and Safety Officer stated they are not sure if the patient was notified of the intent to discharge at the 09/03/2025 visit discharge. Lastly, the Chief Quality and Safety Officer stated that the agency leaves a calendar in the patient’s home that specifies the number of visits they plan on doing so the patient should have been aware that the 09/03/2025 visit was the last planned 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 review of patient care records, agency policy and procedure, and interview with agency staff for two (2) of five (5) patient records (Patient #’s 1 and 3), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. This was cited in Event #: Review of the agency’s policy entitled “Initial Assessment/Reassessment” effective 07/22/2022 revealed the following: “3. The care provider will gather information which will include at least the following: A. A comprehensive assessment of the patient’s health status and needs…” Patient #1 – This 74-year-old patient with diagnoses of pressure ulcer right hip, unstageable, unspecified open wound, left thigh, and Alzheimer’s disease was admitted to the home care agency on 08/23/2025. Review of the Annual Visit (patient referral) dated 08/22/2025 revealed the patient’s physician documented the following: - The patient has a post along the right hip that the patient’s wife wanted checked out. There is a 1.2 centimeter by 8-millimeter painless ulcer along the patient’s right hip; - Exam reveals a 1.2 centimeter by 8-millimeter painless ulcer along the right hip. There is a rim of erythema with central eschar without exudates; and - Assessment #6: Pressure ulcer of right hip. Plan per below: Mupirocin 2% to affected area(s) three times daily. Order: Home Care. Review of the Home Health Certification and Plan of Care for certification period 08/23/2025 to 10/21/2025 revealed the following orders: - Patient has pressure ulcer on the right hip that is non stageable due to nonviable tissue and a trauma wound to the left posterior thigh; wife will learn wound care; - Skilled nurse to perform skin assessment; Instruct patient/caregiver on skin assessment; - Skilled nurse to perform/teach wound care to right hip non stageable pressure ulcer due to nonviable tissue and trauma/skin tear to left posterior thigh. Cleanse with wound cleanser, hydrogel to wound bed, and cover with gentle boarder foam dressing. Clean/aseptic technique. Skilled Nurse to teach wife to perform wound care two (2) times per week; and - Skilled Nurse one (1) time per week for three (3) weeks. Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission dated 08/23/2025 lacks documented evidence of an assessment of the non-stageable right hip pressure ulcer and left posterior thigh trauma wound that provides a complete picture of the wound status since admission and reflects the patient’s current wound assessment. The Skilled Nurse failed to perform a complete assessment of the patient’s wounds. During interview on 11/20/2025 at 10:08 AM, the Registered Nurse stated at the initial visit they would have just assessed the wound and demonstrated the wound care to the patient’s care giver. The Registered nurse stated that the teaching of the wound care would have happened at the subsequent visit. Additionally, the Registered Nurse stated that they would have assessed the receptiveness of the caregiver at the initial visit as well. Patient #3 – This 82-year-old patient with diagnoses of left femur fracture, pressure ulcer of the sacral region, and Type 2 diabetes was admitted to the home care agency on 09/22/2025. Review of the Home Health Certification and Plan of Care for certification period 09/22/2025 to 11/20/2025 revealed the following orders: - Stage II on right sacrum (0.6 by 0.4 by 0.2; no unit of measurement specified), no drainage or signs/symptoms of infection. Stage I on left sacrum, non-blanching. Family currently applying barrier cream to both areas and leaving open to air. Wound photos obtained and uploaded to chart, per protocol, and - Physical therapist to perform skin assessment. Review of the PT (Physical Therapy) OASIS (Outcome and Assessment Information Set) Admission dated 09/22/2025 revealed the Physical Therapist documented the patient has a Stage II on their right sacrum (0.6 by 0.4 by 0.2; no unit of measurement specified), no drainage or signs/symptoms of infection. Stage I on left sacrum, non-blanching. Family currently applying barrier cream to both areas and leaving open to air. Wound photos obtained and uploaded to chart, per protocol. There is a lack of documented evidence of wound measurements and a comprehensive assessment of the left sacral wound. The Physical Therapist failed to perform a complete assessment of the patient’s wounds. During interview on 12/08/2025 at 02:07 PM, the Physical Therapist stated that she did not obtain wound measurements for the left sacral wound because it was not an open area. The Physical Therapist stated that to the best of their knowledge they assessed, cleaned, and photographed the wounds. Additionally, the Physical Therapist stated they referred in nursing, who started the next day, to manage the patient’s wounds.”

“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 review of clinical records and interview with staff, for one (1) of five (5) patients (Patient #3), the agency failed to review and/or revise the Plan of Care in accordance with patient needs. Failure to review and/or revise the Plan of Care in accordance with patient needs, places patients at risk for unmet needs and poor quality of care. Patient #3 – This 82-year-old patient with diagnoses of left femur fracture, pressure ulcer of the sacral region, and Type 2 diabetes was admitted to the home care agency on 09/22/2025. Review of the Home Health Certification and Plan of Care for certification period 09/22/2025 to 11/20/2025 revealed an order for SN (Skilled Nurse) one (1) time a week for one (1) week, and two (2) times a week for two (2) weeks. Review of the Physician Order dated 09/24/2025 revealed the following: Coccyx Stage II pressure ulcer, 100% non-granulation tissue, moderate drainage. 1. Cleanse wound with vashe moistened gauze for 5 minutes. 2. Pat dry. 3. Apply collagen to wound bed. 4. Cover with bordered foam dressing. Secure with transparent draping, two (2) times per week and as needed for soiling or dislodged dressing. Using clean aseptic technique. 5. Educate patient/caregiver on pressure relief over the area. Review of the Client Coordination Note Report dated 10/01/2025 revealed the agency received a telephone call from the patient’s friend cancelling all visits for 10/02/2025 because the patient was admitted to the hospital. Review of the Client Coordination Note Report dated 10/08/2025 revealed the patient was discharged from the hospital on 10/08/2025 and was transferred to subacute rehab. On 12/08/2025 at 02:30 PM, the surveyor requested the discharge summary from the sub-acute rehab stay and none was provided. Review of the patient care record revealed the Registered Nurse completed a resumption of care on 11/15/2025. Review of the Resumption of Care Orders dated 11/15/2025 lacked documented evidence of an updated nursing frequency (the previous nursing frequency would have ended week three, 10/05/2025 to 10/11/2025, as stated in the initial Home Health Certification and Plan of Care for certification period 09/22/2025 to 11/20/2025). The agency failed to review and/or revise the Plan of Care in accordance with patient needs. During interview on 12/09/2025 at 09:15 AM, the Registered Nurse stated they are not sure what happened there. The Registered Nurse stated that it appears as though the initial nursing frequency would have ended the week the patient went in to the hospital and would have needed to be updated at the resumption of care visit that took place on 11/15/2025.”

“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 review of clinical records and interview with staff, for four (4) of five (5) patients (Patient #s: 2, 3, 4, and 5), the agency failed to provide care in accordance with the written Plan of Care. Failure to ensure patient care is provided in accordance with the written Plan of Care has the potential for unmet patient needs, care being provided that is inconsistent with the physician’s intentions, and possible negative outcomes. The agency failed to ensure services were provided in accordance with the written Plan of Care as evidenced by: Patient #3 – This 82-year-old patient with diagnoses of left femur fracture, pressure ulcer of the sacral region, and Type 2 diabetes was admitted to the home care agency on 09/22/2025. Review of the Physician Order dated 09/24/2025 revealed the following order: Coccyx Stage II pressure ulcer, non-granulation tissue, moderate drainage. 1. Cleanse wound with vashe moistened gauze for five (5) minutes. 2. Pat dry. 3. Apply collagen to wound bed. 4. Cover with bordered foam dressing. Using aseptic technique. 5. Educate patient/caregiver on pressure relief over the area. Review of the RN (Registered Nurse) Subsequent Visit dated 09/29/2025 revealed the Registered Nurse documented they cleansed the patient’s sacrum with warm soapy water, patted the wound dry, and applied protective ointment. The Registered Nurse failed to perform wound care as ordered. During interview on 12/05/2025 at 09:18 AM, the Registered Nurse stated the new wound supplies were delivered to the patient’s house on 09/27/2025. The Registered Nurse stated that they are not quite sure why the documentation says they did the old wound care because that should not have been the case. The Registered Nurse stated that they had the supplies, but that the family had been using barrier cream all along. Patient #5 – This 77-year-old patient with diagnoses of unstageable pressure ulcer right heel, Stage II pressure ulcer right buttock, and Type II diabetes mellitus with diabetic polyneuropathy was admitted to the home care agency on 10/16/2025. Review of the Home Health Certification and Plan of Care for certification period 10/16/2025 to 12/14/2025 revealed the following orders: - SN (Skilled Nurse) two (2) times per week for one (1) week and three (3) times a week for three (3) weeks; - Stage II pressure injury to right buttock and unstageable pressure ulcer to right heel; and - Skilled Nurse to perform/teach pressure ulcer care to buttock. Cleanse with vashe soak for three (3) to five (5) minutes. Apply Santyl to wound bed and cover with foam dressing three (3) times weekly and as needed. Unstageable pressure injury to right heel. Apply betadine to wound bed and cover with abdominal pad and wrap in rolled gauze daily. A. Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Visit dated 10/16/2025 revealed the Registered Nurse completed wound care as ordered. Review of the RN (Registered Nurse) Subsequent Visit dated 10/18/2025 revealed the Registered Nurse documented the patient and daughter declined wound care due to no available supplies in the home. The Skilled Nurse failed to perform wound care as ordered. During interview on 12/05/2025 at 01:27 PM, the Director of Clinical Operations stated that the first supply order was delivered on 10/20/2025 and the breakdown that caused the supply delay occurred at the start of care. B. Review of the Coordination Note dated 10/21/2025 revealed the Licensed Practical Nurse attempted to call the patient to schedule a visit and was unable to get an answer or leave a voicemail. The Licensed Practical Nurse notified the physician of the canceled visit. Review of the Coordination Note dated 10/25/2025 revealed the Registered Nurse documented the following: - Daughter will do wound care today (Saturday – 10/25/2025) (this did not meet the ordered frequency for nursing/wound care); - Requested Monday (10/27/2025) visit be moved to Tuesday (10/28/2025); and - Confirmed for Tuesday (10/28/20225) and Thursday (10/30/2025) next week for nursing (this did not meet the ordered frequency for nursing/wound care); The Registered Nurse failed to provide nursing services as per the plan of care. During interview on 12/05/2025 at 09:00 AM, The Registered Nurse stated wound care was not done on the 18th because the daughter declined it. The Registered Nurse stated that no visit was made on the 21st because they could not get ahold of the patient. The Registered Nurse stated no visit was done on the 22nd. Additionally, the Registered Nurse stated that no visit was done on the 23rd because the daughter was not there. Lastly, the Registered Nurse stated that they did not notify the doctor of the missed visits and the inability to complete wound care as ordered. Patient #4 – This 68-year patient with the diagnoses of amyotrophic lateral sclerosis and dysphagia was admitted to the home care agency on 09/15/2025. Review of the Add On Discipline order dated 10/17/2025 revealed the following order: Skilled Nurse for administration of bladder instillation/irrigation with 60-100 cubic centimeters of normal saline as needed (no indication specified). Review of the RN (Registered Nurse) High Risk Subsequent Visit dated 10/23/2025 revealed the Registered Nurse documented that they instilled 30 milliliters of normal saline and they instructed the daughter and client on irrigation. The Registered Nurse failed to perform bladder irrigation as ordered. During interview on 12/08/2025 at 01:15 PM, the Registered Nurse stated that they typically documented that they instilled thirty milliliters’ times 2 and that would add up to the ordered amount of 60. The Registered Nurse stated that on this day they may have forgotten to specify the times two in their documentation. Patient #2 – This 49-year-old patient with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft, and chronic combined systolic and diastolic heart failure was admitted to the home care agency on 10/02/2025. Review of the Physician Order dated 10/16/2025 revealed Skilled Nursing one (1) week one (1) effective 10/20/2025. Review of the clinical record from 10/02/2025 to 12/05/2025 lacked documented evidence that a skilled nurse visit was completed the week of 10/19/205 to 10/25/2025. During an interview on 12/05/2025 at 01:02/PM, the Registered Nurse stated that they messed up and should have changed the visit from a RN11 (Subsequent Visit) to a RN18 (Discharge from agency Visit). The Registered Nurse continued to state that originally the patient was to be seen by the physician on 12/12/2025 or 12/13/2025, and the plan was to discharge after the physician visit, but the patient did not want to pay the co-pay and that is why the patient was discharged on the 12/15/2025.”

“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 a review of clinical records, agency policy and procedure and staff interviews, it was determined in one (1) of one (1) patients (Patients # 3), requiring a resumption of care assessment, that the comprehensive assessment for the resumption of care was not of sufficient scope to ensure all patient needs are identified. Specifically, the patient’s wound was not measured during the resumption of care visit. Failure to ensure the comprehensive assessment is complete has the potential for the patient to receive inappropriate care. The agency failed to ensure the resumption of care comprehensive assessments was complete as evidenced by the following: Patient #3- This 68-year-old patient with diagnoses that include encounter for attention to cystostomy, benign prostatic hyperplasia with lower urinary tract symptoms and schizophrenia was admitted to the home care agency on 01/16/2025. The patient was hospitalized on 05/21/2025 for treatment of a newly developed wound on the left posterior leg and discharged home on 05/28/25. Review of the agency policy entitled Initial Assessment/Reassessment effective 05/2025 revealed “The care provider will gather information which will include at least the following: A. A comprehensive assessment of the patient’s health status and needs.” Review of the RN Resumption of Care Visit Note dated 05/29/2025 revealed the Registered Nurse (RN) documented that the chief reason the patient has been referred to home care is for wound care, and that the wound would be managed by nursing. The RN further documented that a picture of the wound was obtained and that the wound was unstageable due to slough covering the wound bed. The wound assessment revealed no measurements of the wound were taken on that visit because the RN “forgot to measure.” During interview on 06/11/2025 at 11:28 AM the RN stated, “I know I measured it.” The RN further stated that the RN did not see that the measurements were documented in the clinical record. The VNA Manager stated that the visit was a co-visit with the RN and the VNA Manager and that the VNA Manager also believed that the RN obtained wound measurements. Upon further review of the record, the VNA Manager verified that no wound measurements are documented in the clinical record on that date of the visit.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record reviews and staff interviews, the agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed. This is evident for one (1) of one (1) clinical records reviewed that required transmission (Patient #5). Failure to ensure that all completed Outcome and Assessment Information Set assessments are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days has the potential for negative patient outcomes. The agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days as evidenced by: Pre-survey the “Home Health Agency Error Summary Report” on 03/03/2025 revealed the agency has 477 (four hundred seventy-seven) late submissions of the Outcome and Assessment Information Set assessments (M0090) from 01/01/2024 to 12/31/2024. Patient #5 – This 79-year-old patient with the diagnoses of heart disease of native coronary artery, chronic obstructive pulmonary disease, and chronic kidney disease was admitted to the home care agency on 11/20/2024. Review of the Registered Nurse Outcome and Assessment Information Set Start of Care completed by the Registered Nurse revealed the Outcome and Assessment Information Set Assessment (M0090) was completed on 11/20/2024. Review of the Home Health Agency Error Submission Report provided by the agency on 03/05/2025 at 12:45 revealed the patient’s Outcome and Assessment Information Set Assessment (M0090) was submitted on 12/31/2024, 41 (forty-one) days after the assessment was complete. During interview on 03/10/2025 at 11:14 AM, the Director of Operations stated the clinical documentation team reviews the Outcome and Assessment Information Set Assessments prior to submission and did not know why it was submitted late. The agency is working on implementing a better workflow to ensure this does not recur.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on clinical record review and staff interview for five (5) of seventeen (17) patients (Patient #’s: 5, 10, 12, 13, and 14), requiring updates to the comprehensive assessment based on a major change in the patient’s health status, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. HV Patient #12- This 69-year-old patient with the diagnoses of chronic obstructive pulmonary disease with exacerbation, hypertension and anxiety was admitted to the home care agency on 02/24/2025. During an observational home visit on 03/04/2025 at 03:15 PM, the patient reported they were taking miralax for constipation. Review of the Home Health Certification and Plan of Care for 02/24/2025 to 04/24/2025 lacks an order for miralax. Review of the Licensed Practical Nurse Subsequent Visit Noted dated 03/04/2025 revealed the following assessment: Meds reconciled, no discrepancies noted. Review of the clinical record lacks documentation that there was follow-up with the physician regarding the medication the patient reported taking. During interview on 03/07/2025 at 12:32 PM, the Licensed Practical Nurse stated they forgot and that there was no follow-up with the physician regarding the specified medication. The agency failed to ensure comprehensive assessments based on major changes in the patient’s health status were of sufficient scope to identify current patient needs as evidenced by: Patient #14 – This 41-year-old patient with the diagnoses of infection following a procedure, bacteremia, and staphylococcus as the cause of disease was admitted to the home care agency on 06/25/2024. Review of the Registered Nurse Subsequent Visit Note dated 07/05/2024 revealed “Patient complaining of increased pain at wound site, as well as green drainage from wound, as well as bloody drainage. Patient also has been having persistent nausea and vomiting over several days. At visit, this writer didn’t see any green drainage from wound, but did note a moderate amount of bloody drainage. Due to all of these symptoms, this writer made recommendation that patient go to emergency room, as it seems wound has become infected. Patient declined, wanted medical doctor called first. Call placed to (medical doctor), spoke to Registered Nurse and reported above to her. Registered Nurse from office to call patient and make recommendations.” Review of the Registered Nurse Infusion Subsequent Visit Note dated 07/06/2024 lacks documented evidence the Registered Nurse followed up on the patient’s symptoms and whether the patient received a call from the physician. During interview on 03/07/2025 at 12:12 PM, the Registered Nurse, IV (intravenous) and Pediatric Team Manager stated there is no documented evidence the Registered Nurse follow-up with the patient or physician. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, chronic obstructive pulmonary disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. A. Review of Coordination Note completed by Registered Nurse on 12/03/2024 at 10:39AM revealed the following: “Patient and caregiver are both agreeable to skilled nursing discharge this date. They are still hoping to have Physical Therapy and Occupational Therapy evaluations with the goals of getting the patient back on her stair glide so she can get out of her bedroom again. She hasn’t left the bedroom for many months.” Review of the clinical record lacks documented evidence the Registered Nurse followed up on the patient’s continued need for Physical Therapy and Occupational Therapy, and delay in start of therapy services. During interview on 03/10/2025 at 09:43AM, the Registered Nurse stated that they did not follow up because they knew the services were ordered, and Occupational and Physical therapy would come when they could. B. Review of Coordination Note completed by Occupational Therapist on 12/06/2024 at 04:41AM revealed the following: “Her husband stated that before she went on hospice which she is no longer on she had portable oxygen making it much easier for her to complete tasks. Patient’s husband is also overwhelmed as a caregiver. This Occupational Therapist mentioned maybe talking to a social worker to find additional resources. Patient states that he’s overwhelmed with the patient constantly asking about food and the menu. Patient said that he’s overwhelmed with making all the meals, but he does get it done. This Occupational Therapist discussed signing up for meals on wheels. Patient’s caregiver said that they like to keep the doors locked and the meals on wheels people in the past have come too early. This Occupational Therapist suggested that they leave out an insulated cooler out on the stoop so that he can bring meals in when he is ready. Caregiver stated that’s possibly a good idea and he will look into it further.’ Review of the clinical record lacks documented evidence the Occupational Therapist followed up on the patient’s potential need for portable oxygen as well as a social services referral. During interview on 03/10/2025 at 09:58AM, the Director of Branch Operations stated being unable to speak for the Occupational Therapist as to whether any follow up was completed but did confirm that there is no documented evidence of follow up in the patient’s record. Patient #10 - This 57-year-old patient with the diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the agency on 04/17/2017. A. Review of the Licensed Practical Nurse Subsequent Visit Note dated 01/22/2025 revealed the Licensed Practical Nurse documented the “patient to have cysto [cystoscopy] this afternoon.” Review of the Licensed Practical Nurse Subsequent Visit Note dated 01/24/2025 revealed the Licensed Practical Nurse documented “patient cysto [cystoscopy] yesterday showed 3 large bladder stones. Patient scheduled for removal of these Feb. 11th.” Review of the clinical record lacks documented evidence the Registered Nurse followed up with the patient or patient’s physician regarding the cystoscopy, bladder stones and removal of bladder stones. During interview on 03/10/2025 at 10:51 AM, the Registered Nurse stated being unable to recall if the Registered Nurse followed up with the patient or physician. B. Review of the Licensed Practical Nurse Subsequent Visit Note dated 03/10/2025 revealed the Licensed Practical Nurse documented “bactrim will be added to patient’s allergies moving forward…this notation sent to case manager via email.” The clinical record lacks documented evidence of the patient’s allergy to the medication. During interview on 03/10/2025 at 10:49 AM, the Registered Nurse stated that the allergy should have been added to the patient’s record and was not. Patient #13- This 78-year-old with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the agency on 09/10/2024. Review of the Registered Nurse Subsequent Visit Note dated 09/19/2024 revealed the Registered Nurse documented the following: - Vital Sign Alert: Blood Pressure 154/62 - Comments: System phone call to physician office. Reported elevated blood pressure. Patient denies headache, dizziness, lightheadedness. Informed physician that we requested patient to keep record of blood pressures at home. Chart set up. Receptionist put message into the record for the physician. Review of the Registered Nurse Discharge from Agency Visit Note dated 09/24/2024 lacks documented evidence the Registered Nurse followed up on the patient’s high blood pressure and whether the nurse or patient received a call back from the physician. During interview on 03/06/2025 at 04:11 PM, the Director of Clinical Operations stated there is no documented evidence the Registered Nurse follow-up with the physician.”

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on review of clinical records, agency policies and procedures, and interviews with staff, for one (1) of seventeen (17) patients (Patient #17 ), the agency failed to ensure a legal representative (an individual who has been legally designated or appointed as the patient’s health care decision maker), a power of attorney for health care decision-making, or a designated health care agent are provided written notice of the patient’s rights and responsibilities. Failure to provide written notice of the patient’s rights and responsibilities to all patients or their proxies, has the potential for negative patient outcomes. The agency failed to ensure a legal representative (an individual who has been legally designated or appointed as the patient’s health care decision maker), a power of attorney for health care decision-making, or a designated health care agent are provided written notice of the patient’s rights and responsibilities as evidenced by: Review of the agency policy entitled “Initial Assessment/ Reassessment” effective 07/22/2022 revealed the following: 2. On an initial visit, prior to providing any services, the care provider will review and complete with the patient the following information. For a resumption of care visit, the care provider will assure that the patient has the following information from the initial visit: E. Information regarding Advanced Directives. Ask the patient if they have a current Advance Directive. Leave information regarding Advanced Directives with the patient and obtain a copy of any current Advance Directive. Patient #17- This 71-year-old patient with the diagnoses of unspecified fracture of the right femur, subs for closed fracture with routine healing, unspecified alzheimer’s disease, and dementia in other disease classified elsewhere, unspecified severity without behaviors/ psychosis/ mood disturbance/ anxiety was admitted to the home care agency on 05/26/2024. Review of the History and Physical dated 05/04/2024 revealed the physician documented the following: Capacity: Patient lacks capacity for medical decision making. Review of the Patient Agreement dated 05/26/2024 revealed the patient’s spouse signed the agreement for the patient. Review of the Home Health Certification and Plan of Care for 05/26/2024 to 07/24/2024 revealed the patient’s advanced directives include a Health Care Proxy. Review of the clinical record lacks documentation indicating who is the patient’s Health Care Proxy. During interview on 03/07/2025 at 2:47 PM, the Physical Therapist stated that at the admission visit, the patient’s spouse said he was the patient’s Health Care Proxy. The Physical Therapist stated they did not see a completed Health Care Proxy before allowing the patient’s spouse to sign the paperwork.”

“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 review of clinical records, agency policy and procedure, and staff interviews, for one (1) of seventeen (17) patients (Patient #13), the clinical record lacks documented evidence that the Notice of Medicare Non-Coverage (NOMNC) was provided to the patient before being discharged from the agency. Failure to complete the Notice of Medicare Non-Coverage form with the patient prior to discharge has the potential to result in negative patient outcomes. The agency failed to provide the patient with a Notice of Medicare Non-Coverage form prior to discharge as evidenced by the following: Patient #13- This 78-year-old patient with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the home care agency on 09/10/2024. Review of the Discharge-Transfer Summary Report dated 09/24/2024 revealed the following: - Episode Status: Discharged - Episode End Date: 09/24/2024 The clinical record lacks documented evidence that the Notice of Medicare Non-Coverage (NOMNC) was discussed and provided to the patient before the patient was discharged from the agency. During interview on 03/06/2025 at 03:49 PM, the Director of Clinical Operations stated the Notice of Medicare Non-Coverage was not done and is not in the clinical record.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for four (4) of seventeen (17) patients (Patient #s: 1, 3, 5 and 13 ) the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the Start of Care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the Start of Care as evidenced by: Patient #1 – This 35-year-old patient with the diagnoses of aftercare following surgery for neoplasm, neoplasm of unspecified behavior of other specified sites, and malignant neoplasm of unspecified testis was admitted to the home care agency on 02/25/2025. Review of the Physical Therapy Outcome Assessment and Information Set Admission Note dated 02/2/52025 revealed “Consults also placed for Skilled Nursing, Occupational Therapy, Medical Social Work, and Registered Dietician.” Review of the clinical record revealed the Registered Dietician provided the first visit on 03/06/2025, nine (9) days after the start of care. During interview on 03/07/2025 at 11:40 AM, the Physical Therapist stated the Registered Dietician consult was submitted late, it was an oversight. Patient #3 – This 91-year-old patient with the diagnoses of influenza, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine was admitted to the home care agency on 02/18/2025. Review of the Home Health Certification and Plan of Care for 02/18/2025 to 04/18/2025 revealed the order for Speech Therapy effective 02/23/2025 once a week for one week. Review of the clinical record revealed the Speech Therapist provided the first visit on 03/06/2025, 11(eleven) days after the order was placed and 16 (sixteen) days after the start of care. During interview on 03/07/2025 at 11:05 AM, the Director of Quality Improvement stated there is no documentation to explain the delay. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, chronic obstructive pulmonary disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. A. Review of the referral orders on 11/15/2024 revealed: “Skilled Nurse: assessment, medication/disease management/education, assess needs, Physical Therapy/Occupational Therapy: Evaluate and treat.” Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the order for Physical Therapy effective 12/15/2024 once a week for one week. Review of the clinical record revealed the Physical Therapist provided the first visit on 12/16/2024, one (1) day after the order was placed and twenty-six (26) days after the start of care. During interview on 3/10/2024 at 9:26AM the Director of Branch Operations confirmed that Physical Therapy was ordered on the initial referral at start of care and was unaware of any explanation for the delay in the start of care of the service. The Director of Branch Operations further confirmed that the expectation is the initial Physical Therapy visit should have occurred within five (5) days of the referral order. B. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the order for Occupational Therapy effective 12/01/2024 once a week for one week. Review of the clinical record revealed the Occupational Therapist provided the first visit on 12/05/2024, four (4) days after the order was placed and fifteen (15) days after the start of care. During interview on 3/10/2024 at 09:26AM the Director of Branch Operations confirmed that Occupational Therapy was ordered on the initial referral at start of care and was unaware of any explanation for the delay in the start of care of the service. The Director of Branch Operations further confirmed that the expectation is the initial occupational therapy visit should have occurred within five (5) days of the referral order. Patient #13- This 78-year-old patient with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the agency on 09/10/2024. Review of the Client Care Coordination Referral Note dated 09/07/2024 revealed “Facility discharge date: 09/08/2024…Physical Therapy to evaluate and treat.” Review of the Physical Therapy Add-On Evaluation Visit Report dated 09/19/2024 revealed that the Physical Therapist’s initial visit with the patient occurred on 09/19/2024 and that the Physical Therapist determined that the patient did not qualify for Physical Therapy. Review of the Home Health Certification and Plan of Care for certification period 09/10/2024 to 11/08/2024 revealed the following order: “Frequency/ Duration of Visits: Physical Therapy; effective 09/15/2024; one (1) visit for one (1) week.” Review of the clinical record lacks documentation explaining why Physical Therapy services were delayed until 09/19/2024, nine (9) days after the patient was discharged from the facility. During interview on 03/06/2025 at 03:16 PM, the Registered Nurse stated they were unable to recall the reason for the delay in Physical Therapy services, and why the order was changed to the week of 09/15/2024. Additionally, there was no documentation in the record to explain the delay.”

“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 review of patient care records, and interview with agency staff for sixteen (16) of seventeen (17) patient records (Patient #’s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 17), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. HV Patient #10- This 57-year-old patient with the diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the home care agency on 04/17/2017. A. Review of the Registered Nurse Recertification Without Skill Visit Note dated 01/03/2025 revealed the Registered Nurse documented patient’s mother as an emergency contact. During an observational home visit on 03/07/2025 at 10:40 AM, the patient stated that the patient’s mother died a year ago. During interview on 03/10/2025 at 10:08 AM, the Registered Nurse stated they were unaware that the patient’s mother died and was no longer available as an emergency contact or caregiver. B. Review of the Registered Nurse Recertification Without Skill Visit Note dated 01/03/2025 revealed the Registered Nurse documented, Indicate Genitourinary Assessment: (Mark all that apply): Indwelling/Suprapubic Catheter. Review of the Home Health Certificate and Plan of Care for 01/05/2024 to 03/05/2025 revealed an order for “Skilled Nurse to perform observation and assessment of genitourinary status and intervene to minimize complications of disease process. Skilled Nurse to provide instruction, regarding management of disease process including pathophysiology, nutrition/fluid requirements, and medication regimen.” Review of the clinical record lacks documentation indicating which physician manages the indwelling/suprapubic catheter. During interview on 03/10/2025 at 10:27 AM, the Registered Nurse stated that the patient’s indwelling/suprapubic catheter is managed monthly by the urologist, and this should have been included in the medical orders. C. Review of the Registered Nurse Recertification Without Skill Visit Note dated 01/03/2025 revealed the Registered Nurse documented patient is unable to leave home without assistance. During an observational home visit on 03/10/2025 at 10:36 AM, the patient stated that they own a mobility van that was modified to accommodate a wheelchair, and the patient is able to independently drive self to work. Review of the clinical record lacks documented evidence of the patient’s ability to leave home without assistance. During interview on 03/10/2025 at 10:06 AM, the Manager Branch Office stated they believe the patient drives independently. During interview on 03/10/2025 at 10:06 AM, the Director Branch Operations stated the patient works outside of the home. During interview on 03/10/2025 at 10:07 AM, the Registered Nurse stated there is no documentation indicating who accompanies the patient to appointments and is unable to recall who is responsible for accompanying the patient. D. Review of the Home Health Certification and Plan of Care from 01/05/2025 to 03/05/2025 revealed an order for the licensed professional to report vital signs falling outside the following established parameters…”O2 (oxygen) less than 92.” Review of the Registered Nurse Recertification Without Skill Visit Note dated 01/03/2025 lacks an assessment of the patient’s oxygen level. During interview on 03/10/2025 at 10:03 AM, the Registered Nurse stated they were unable to recall the patient’s oxygen level during the visit. Additionally, the Registered Nurse stated that it is the agency’s expectation that oxygen levels are monitored if there are parameters to notify the physician. E. Review of the clinical record lacks documented evidence the patient’s immunization status was assessed. During interview on 03/10/2025 at 10:12 AM, the Registered Nurse stated the patient’s immunization status was not discussed during the nursing visit. F. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/10/2025 at 10:12 AM, the Registered Nurse stated palliative care needs were not discussed during the nursing visit. Patient #8 - This 19-year-old patient with the diagnoses of acute leukemia of unspecified cell type not achieve remission, encounter for antineoplastic chemotherapy, and other acute pancreatitis without necrosis or infection was admitted to the home care agency on 12/23/2024. A. Review of the Home Health Certification and Plan of Care for 02/21/2025 to 04/21/2025 revealed an order for licensed professional to report vital signs falling outside the following established parameters… “O2 (oxygen) less than 92.” Review of the Registered Nurse Infusion Outcome and Assessment Information Set Admission Note dated 12/23/2024 and the Registered Nurse Infusion Subsequent Visit Note dated 03/05/2025 lack documented evidence that the patient’s oxygen level was assessed. During interview on 03/06/2025 at 02:51 PM, the Registered Nurse stated the oxygen level was not assessed during the visits, however, it is expected that oxygen is monitored if there are parameters to notify the physician. B. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/06/2025 at 02:27 PM, the Registered Nurse stated they were unable to recall if the patient’s immunization status was assessed or documented during the nursing assessment. C. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/06/2025 at 02:27 PM, the Registered Nurse was unable to recall if the patient’s need for palliative care was assessed or documented during the nursing assessment. Patient #13- This 78-year-old patient with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the home care agency on 09/10/2024. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/06/2025 at 03:31 PM, the Director of Clinical Operations stated the clinician is expected to ask the patient and document the patient’s immunization status. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/06/2025 at 03:27 PM, the Director of Clinical Operations stated the patient’s need for palliative care was not documented during the nursing assessment. Patient #11- This 73- year- old patient with the diagnoses encounter for surgical aftercare following surgery on digestive system, diverticuli of the intestines, part unspecified, with perforation and abscess without bleed, and retention of urine, unspecified was admitted to the home care agency on 02/08/2025. A. Review of the clinical record lacks documented evidence the patient’s pneumonia immunization status was assessed. During interview on 03/07/2025 at 01:01 PM, the Registered Nurse stated that the patient’s pneumonia immunization status was not reviewed. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 01:01 PM, the Registered Nurse stated that potential palliative care needs were not discussed with the patient. C. Review of the Registered Nurse Outcome Assessment and Information Set Visit Report dated 02/08/2025 revealed the Registered Nurse documented the following: “Respiratory: Indicate other respiratory issue: Sleep apnea- Utilizes CPAP (continuous positive airway pressure).” Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 lacks an order for continuous positive airway pressure. During interview on 03/07/2025 at 01:19 PM, the Registered Nurse stated that continuous positive airway pressure should be on the Plan of Care, but it is not. D. Review of the Registered Nurse Outcome Assessment and Information Set Visit Report dated 02/08/2025 revealed the Registered Nurse documented the following: “Narrative: Gait is unsteady with rolling walker.” Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 lacks an order for a rolling walker. During interview on 03/07/2025 at 01:25 PM, the Registered Nurse stated that the patient does use a rolling walker, and there should be an order for it. E. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 revealed the order for “Repatha sureclick 140 milligrams/per milliliter subcutaneous pen injector; subcutaneously; 1 milliliter; every other week; for hyperlipidemia; administered by patient every two (2) weeks.” Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 lacks an order for a sharps container. During interview on 03/07/2025 at 01:23 PM, the Registered Nurse stated that sharps management was not discussed. There should be an order for the sharps container. Patient #2 - This 72- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of right artificial knee joint, and essential primary hypertension was admitted to the home care agency on 02/19/2025. A. Review of the clinical record lacks documented evidence the patient’s pneumonia immunization status was assessed. During interview on 03/07/2025 at 2:10 PM, the Branch Manager stated that the clinician did not document the patient’s pneumonia immunization status. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 2:11 PM, the Branch Manager stated that the clinician did not assess the patient’s need for palliative care. C. Review of the “Medicine Consult Note” (Referral to agency) dated 02/17/2025 revealed the Physician’s Assistant recommended the following treatment: “Deep Vein Thrombosis Prophylaxis: Thrombo- Embolic Deterrent (TED) Stockings.” Review of the Home Health Certification and Plan of Care for 02/19/2025 to 04/19/2025 lacks an order for Thrombo- Embolic Deterrent Stockings. During interview on 03/07/2025 at 2:24 PM, the Branch Manager stated the clinician did not document Thrombo- Embolic Deterrent Stockings under Durable Medical Equipment on the Plan of Care, so it is unclear whether the patient is using them. Patient #17- This 71- year- old patient with the diagnoses of unspecified fracture of the right femur, subs for closed fracture with routine healing, unspecified alzheimer’s disease, and dementia in other disease classified elsewhere, unspecified severity without behaviors/ psychosis/ mood disturbance/ anxiety was admitted to the home care agency on 05/26/2024. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 02:38 PM, the Physical Therapist stated that they did not ask the patient about the pneumonia vaccine. Additionally, the Physical Therapist stated that it is required to ask about influenza vaccination between October and April, and since the patient was admitted in May, the Physical Therapist did not ask if the patient had the influenza vaccine. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 02:39 PM, the Physical Therapist stated they briefly thought of palliative care for this patient, but the patient was ordered for restorative physical therapy, so possible palliative care needs were not discussed. Patient #4 – This 62- year -old patient with the diagnoses of type 2 diabetes mellitus with foot ulcer, non- pressure chronic ulcer other part left foot, cutaneous abscess of right foot, and acquired absence of right great toe was admitted to the home care agency on 10/19/2024. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 11:25 AM, the Registered Nurse stated it was assessed but was not documented in the visit note. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 11:25 AM, the Registered Nurse stated there was no assessment of palliative care needs. Patient #12- This 69-year-old patient with the diagnoses of chronic obstructive pulmonary disease with exacerbation, hypertension and anxiety was admitted to the home care agency on 02/24/2025. A. Review of the clinical record lacks documented evidence the patient’s immunization status was assessed. During interview on 03/07/2025 at 12:28 PM, the Registered Nurse stated the immunization status was assessed but not documented. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 12:28PM, the Registered Nurse stated there was no assessment of palliative care needs. Patient #15- This 91- year -old patient with the diagnoses of pressure ulcer of right heel stage 3, peripheral vascular disease, venous insufficiency, and paroxysmal atrial fibrillation was admitted to the home care agency on 05/20/2023. A. Review of the clinical record lacks documented evidence the patient’s pneumonia immunization was assessed. During interview on 03/07/2025 at 10:46 AM, the Registered Nurse stated the pneumonia immunization status was not assessed. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 10:46 AM, the Registered Nurse stated they were not aware the palliative care needs were to be assessed. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, chronic obstructive pulmonary disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/10/2025 at 09:25AM, the Registered Nurse confirmed that an assessment for the need of palliative care was not completed. Patient #9 – This 69-year-old male with the diagnoses of status post left total knee replacement on 02/25/2025 and hypertension was admitted to the home care agency on 02/26/2025. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/7/2025 at 04:10PM, the Physical Therapist confirmed that an assessment for the need for palliative care was not completed. The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs as evidenced by: Patient #1 – This 35-year-old patient with the diagnoses of aftercare following surgery for neoplasm, neoplasm of unspecified behavior of other specified sites, and malignant neoplasm of unspecified testis was admitted to the home care agency on 02/25/2025. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 11:47 AM, the Physical Therapist stated it was assessed but not documented in the visit note. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 11:47 AM, the Physical Therapist stated they did not document an assessment of palliative care needs. Patient #3 – This 91-year-old patient with the diagnoses of influenza, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine was admitted to the home care agency on 02/18/2025. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 11:08 AM, the Registered Nurse stated it was assessed but not documented. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 11:09AM, the Registered Nurse stated they did not document an assessment of palliative care needs. Patient #6 – This 95-year-old patient with the diagnoses of heart failure and hypertension was admitted to the home care agency on 02/26/2025. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 10:48 AM, the Registered Nurse stated the immunization status was not documented. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 10:48 AM, the Registered Nurse stated it was assessed but not documented, the Registered Nurse thought she was only supposed to document if palliative care was needed. Patient #14 – This 41-year-old patient with the diagnoses of infection following a procedure, bacteremia, and staphylococcus as the cause of disease was admitted to the home care agency on 06/25/2024. A. Review of the clinical record lacks documented evidence the patient’s immunization was assessed. During interview on 03/07/2025 at 12:16 PM, the Director of Operations stated the immunization status was not documented. B. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 12:17 PM, the Director of Operations stated it was not documented. Patient #7 – This 59-year-old patient with the diagnoses of malignant neoplasm of small intestine, iron deficiency anemia, and encounter for adjustment of ventricular assist device was admitted to the home care agency on 02/19/2025. Review of the clinical record lacks documented evidence the patient’s need for palliative care was assessed. During interview on 03/07/2025 at 10:37 AM, the Registered Nurse stated the patient did not need palliative care services but did not document that in the record.”

“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 review of clinical records, agency policy and procedure, and interviews with agency staff, for eleven (11) of seventeen (17) patients (Patient #s: 2, 3, 4, 5, 6, 8, 9, 11, 12, 15, and 17) the clinical record lacked documented evidence of a complete review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. Patient #4 – This 62- year -old patient with the diagnoses of type 2 diabetes mellitus with foot ulcer, non- pressure chronic ulcer other part left foot, cutaneous abscess of right foot, and acquired absence of right great toe was admitted to the home care agency on 10/19/2024. Review of the Home Health Certification and Plan of Care for 10/19/2024 to 12/27/2024 revealed the following orders: - ammonium lactate 12 percent (%) lotion apply to feet daily - cholecalciferol (vitamin D3) 50 mcg(micrograms) by mouth 1 capsule daily - ferrous sulfate 325 mg (milligrams) 1 tablet daily -fluticasone propionate 50 mcg nasal spray suspension 2 (two) spray 2 (two) times daily -linezolid 600 mg 1 tablet 2 times daily -pantoprazole 20 mg tablet 1 tablet daily Review of Hospital Discharge Medication List dated 10/18/2024 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 11:30 AM, the Registered Nurse stated being unsure of having any discussion with physician regarding the identified discrepancies. B. Review of the Home Health Certification and Plan of Care for 10/19/2024 to 12/27/2024 revealed the order for ammonium lactate 12 percent (%) lotion apply to feet daily. Review of Hospital Discharge Medication List dated 10/18/2024 revealed an order for ammonium lactate 12 percent (%) lotion apply to feet daily 2 times daily. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 11:30 AM, the Registered Nurse was unsure of having any discussion with physician regarding the identified discrepancy. Patient #12- This 69-year-old patient with the diagnoses of chronic obstructive pulmonary disease with exacerbation, hypertension and anxiety was admitted to the home care agency on 02/24/2025. Review of the facility discharge medication list dated 02/20/2025 revealed the following orders: - ipratropium-albuterol 0.5 mg-2.5 mg (milligrams) 3 mls (milliliters) inhalation solution every 4 (four) hours as needed for chronic obstructive pulmonary disease (COPD) -tylenol 325 mg every 6 (six) hours as needed for pain Review of the Home Health Certification and Plan of Care for 02/24/2025 to 02/24/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 12:25 PM, the Registered Nurse stated the physician was contacted but this was not documented. Patient #15- This 91- year -old patient with the diagnoses of pressure ulcer of right heel stage 3, peripheral vascular disease, venous insufficiency, and paroxysmal atrial fibrillation was admitted to the home care agency on 05/20/2023. Review of the Home Health Certification and Plan of Care for 05/20/2023 to 07/18/2023 revealed the following orders: - melatonin 3 mg 1 capsule at bedtime - metoprolol succinate extended release 100 mg tablet 1 tablet twice a day - nitrofurantoin macrocystal 100 mg capsule 1 capsule twice a day Review of the referral to the agency dated 05/17/2023 lacks orders for the medications. Review of the clinical record lacks documented evidence of the discrepancy and follow-up clarification with the physician. During interview on 03/07/2025 at 01:28 PM, the Registered Nurse Quality Manager stated the medications on the plan of care did not match the referral to the agency. The agency failed to ensure a complete review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns as evidenced by: Review of the undated “Medication Reconciliation” training revealed the following: Physical Therapy Process: - At start of care, documented in the clinical summary who assists the patient with medications, overt issues, and any education provided, Registered Nurse referral. - This documentation will go to the Drug Regimen Review nurse. - Clinical Documentation Improvement will review Drug Regimen Review nurse documentation and edit as appropriate for your review/acceptance as you will have received an email with the Drug Regimen Review nurse information. - The Drug Regimen Review nurse will complete the review of the patient’s drug regimen using homecare homebase system and will document findings in a coordination note and electronically mail the findings to you, the Physical Therapist. Review of the “Therapist Process for Medication Review” updated 04/05/2023 revealed “If there is an issue with reconciliation at start of care (medications in home and medications on most recent medication list from medical doctor or facility discharge summary with referral to now match) – the provider/medical doctor must be called. Issues explained and in response to these – any new orders or a current/correct medication list must be faxed over or called in to branch office nurse or central intake nurse. It is the responsibility of the therapist to follow up on receipt of any faxed orders.” Review of the “Medication Reconciliation Process” dated 07/13/2022 revealed “Medication reconciliation at start of care and resumption of care involves the process of comparing medications in the home… to the medication list from the physician or the discharge instruction sheet… clarify and verify with the physician any discrepancies with a medication, dose, route, or frequency.” Patient #3 – This 91-year-old patient with the diagnoses of influenza, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine was admitted to the home care agency on 02/18/2025. Review of the hospital discharge dated 02/17/2025 revealed the order for nitroglycerin (nitrostat 0.4 milligram sublingual tablet) 1 tablet sublingual every five (5) minutes as needed for chest pain. Review of the Home Health Certification and Plan of Care for 02/18/2025 to 04/18/2025 lacks an order for the nitrostat. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/07/2025 at 11:03 AM, the Registered Nurse stated the nitrostat was not ordered. Patient #6 – This 95-year-old patient with the diagnoses of heart failure and hypertension was admitted to the home care agency on 02/26/2025. Review of the hospital discharge dated 02/24/2025 revealed the order for albuterol 90 micrograms/actuation inhaler two puffs, four (4) times daily. Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 lacks an order for albuterol. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 10:46 AM, the Registered Nurse stated they did call the physician but did not specify discussing albuterol. Patient #9 – This 69-year-old patient with the diagnoses of status post left total knee replacement on 02/25/2025 and hypertension was admitted to the healthcare agency on 02/26/2025. A. Review of the After Visit Summary dated 02/25/2025 revealed the order: tylenol take 2 (two) tablets (650 milligrams total) by mouth every six (6) hours for 10 (ten) days. Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 revealed the order: tylenol 325 milligrams tablet 2 (two) tablets every 6 (six) hours orally as needed for pain. Review of the Total Knee Replacement Postop instructions dated 02/25/2025, revealed the order: tylenol: 2 (two) tablets every 6 (six) hours around the clock for one (1) week, then can take as needed. Review of the clinical record lacks documented evidence the Physical Therapist or Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/07/2025 at 04:15PM, the Physical Therapist stated being unable to recall seeing the medication instructions in the discharge summary at the patient’s home, so they did not add to medication list or clarify with physician. B. Review of the After Visit Summary dated 02/25/2025, the medication list revealed the order: aspirin take 1 tablet (81mg total) by mouth in the morning and 1 tablet (81mg total) by mouth before bedtime. Do all this for 14 (fourteen) days. Take one tablet twice daily for 14 days then once daily for 4 weeks. Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 revealed the order for aspirin 81 milligram tablet, delayed release 1 tablet two (2) times daily orally for prevention. Review of the Total Knee Replacement Postop instructions dated 02/25/2025 revealed the order for aspirin 81 milligram tablet twice a day for two (2) weeks, then once per day for four (4) more weeks. Review of the clinical record lacks documented evidence the Physical Therapist or Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/07/2025 at 04:15PM, the Physical Therapist stated being unable to recall seeing the medication instructions in the discharge summary at the patient’s home, so they did not add to medication list or clarify with physician. C. Review of the After Visit Summary dated 02/25/2025 revealed the order for oxycodone 5 milligram immediate release tablet. Take 1 tablet (5 milligrams total) by mouth every four (4) hours if needed for severe pain (pain scale 7-10) for up to seven (7) days. Max amount daily: 30 milligrams. Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 revealed the order for oxycodone 5mg tablet 1 tablet every five (5) hours orally as needed for pain. Review of the Total Knee Replacement Postop instructions dated 02/25/2025, the medications on discharge revealed the order for oxycodone1 tablet every four to six (4-6) hours as needed for breakthrough pain. Review of the clinical record lacks documented evidence the Physical Therapist or Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/07/2025 at 04:15PM, the Physical Therapist stated being unable to recall seeing the medication instructions in the discharge summary at the patient’s home, so they did not add to medication list or clarify with physician. D. Review of the After Visit Summary dated 02/25/2025, the medication list revealed the order for tramadol 50 milligram tablet. Take 1 tablet (50mg total) by mouth every six (6) hours for seven (7) days. Max daily amount 200 milligrams. Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 revealed the order for tramadol 50 milligrams tablet 1 tablet every six (6) hours orally as needed for pain. Review of the Total Knee Replacement Postop instructions dated 02/25/2025 revealed the order for tramadol: 1 pill every six (6) hours around the clock for one (1) week, then as needed. Review of the clinical record lacks documented evidence the Physical Therapist or Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/07/2025 at 04:15PM, the Physical Therapist stated being unable to recall seeing the medication instructions in the discharge summary at the patient’s home, so they did not add to medication list or clarify with physician. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, chronic obstructive pulmonary disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. A. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the order for tylenol 325 milligram tablet every 6 (six) hours as needed for pain. Review of the primary care physician note within the referral revealed “internal medicine progress note – telephone visit” dated 11/14/2024, the current outpatient medication list lacks orders for tylenol. Review of the clinical record lacks documented evidence the Registered Nurse discussed the medication discrepancy with the physician. During interview on 3/10/2025 at 09:32AM, the Registered Nurse stated recalling a phone discussion about the medication with the nurse at patient’s primary care office, but did not document it. B. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed orders for miralax 17gram oral powder packet daily and as needed for constipation. Review of the primary care physician note within the referral “internal medicine progress note – telephone visit” dated 11/14/2024 lacks an order for the medication. Review of the clinical record lacks documented evidence the Registered Nurse discussed the medication discrepancy with the physician. During interview on 3/10/2025 at 09:32AM, the Registered Nurse stated recalling a phone discussion about the medication with the nurse at patient’s primary care office, but did not document it. C. Review of the physician order dated 11/21/2024 at 12:39 PM revealed “per faxed medication list patient to resume trazadone, buspar, Lexapro, vitamin B12, and duoneb (as needed).” Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 lacks orders for the medications. Review of clinical record lacks documented evidence the Registered Nurse contacted the patient and/or patient spouse to discuss medication discrepancy and resumption of medication. During interview on 03/10/2025 at 09:27AM the Registered Nurse stated being unable to remember if the Registered Nurse placed a call to follow up with patient or spouse after receiving clarification orders regarding the medication discrepancy. During interview on 03/10/2025 at 09:28AM the Director of Branch Operations confirmed that it is the agency’s expectation that there is medication reconciliation follow up with documentation. Patient #11- This 73- year- old patient with the diagnoses of encounter for surgical aftercare following surgery on digestive system, diverticuli of the intestines, part unspecified, with perforation and abscess without bleed, and retention of urine, unspecified was admitted to the home care agency on 02/08/2025. A. Review of the Discharge Summary dated 02/07/2025 revealed the following medications: - coq10, oral, daily; - hyoscyamine0.125 milligrams sublingual tablet; 0.125 milligrams = one (1) tablet; as needed every six (6) hours; sublingual; - macrobid 100 milligrams oral capsule; 100 milligrams = one (1) capsule; oral; twice daily; - simethicone 20 milligrams/ per 0.3 milliliters oral suspension; 80 milligrams- 1.2 milliliters; as needed at bedtime; - sucralfate 1 gram, oral. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 lacks documented evidence of orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 01:15 PM, the Registered Nurse stated the medications were likely not present in the patient’s home at the time of the visit, medications are not added to the Plan of Care until physically seen in the home. The Registered Nurse further stated that a medication reconciliation is done at each visit, then any changes are addressed with the physician to be added to the Plan of Care. B. Review of the Discharge Summary dated 02/07/2025 revealed the following orders: - caltrate 600+ D oral tablet; one (1) tablet; oral; twice daily; - famotidine 20 milligram oral tablet; 20 milligrams= one (1) tablet; oral; daily; - high potency vitamin D3 25 micrograms (1000 international units) oral capsule; 25 micrograms= one (1) capsule; oral; twice daily; - repatha 140 milligrams; subcutaneous; every month; - vitamin B12 1000 microgram oral tablet; 1000 micrograms = one (1) tablet; oral; twice daily. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 revealed the following orders: - caltrate with vitamin D3 600 milligrams- 20 micrograms (800 Unit) tablet; oral; two (2) tablets; two (2) times daily; - famotidine 40 milligram tablet; by mouth; one (1) tablet; daily; - D3 DOTS 50 micrograms (2000 international units) tablet; oral; one (1) tablet; daily; - repatha sureclick 140 milligrams/ per milliliter subcutaneous pen injector; subcutaneous; one (1) milliliter; every other week; - mecobalamin (vitamin B12) 2500 microgram chewable tablet; oral; one (1) tablet; daily: Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 01:18 PM, the Registered Nurse stated that each of these medications and doses were reviewed with the physician, but they failed to document the phone call. C. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 revealed the following orders: - alprazolam 0.5 milligram tablet; oral; one (1) tablet; as directed; take thirty (30) minutes prior to magnetic resonance imaging (MRI); - saline nasal 0.65% spray aerosol; each nostril; one (1) spray; every four (4) hours/ as needed for dryness. Review of the Discharge Summary dated 02/07/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 01:18 PM, the Registered Nurse stated that each of these medications were reviewed with the physician, but they failed to document the phone call. D. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 revealed the following medication order: - miralax 17 gram/ per dose oral powder; oral; 17 grams; daily. The order lacks directions to stir and dissolve in any four (4) to eight (8) ounces of beverage, then drink as directed by the manufacturer. The order lacks instructions on how to reconstitute the medication. During interview on 03/07/2025 at 01:13 PM, the Registered Nurse stated the reconstitution directions should be included in the order but were omitted. E. Review of the Physician Order to Schedule a Resumption of Care Visit dated 02/28/2025 revealed the following list of discharge medications: - calcium- vitamin D (caltrate 600+ D oral tablet); one (1) tablet; oral; twice daily; - famotidine 20 milligram oral tablet; one (1) tablet; oral; every day. Review of the Discharge Medication list lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. F. Review of the Physician Orders for Resumption of Care dated 03/01/2025 revealed the following orders: - caltrate with vitamin D3 600 milligrams- 20 micrograms (800 Unit); two (2) tablets; two (2) times daily; oral; Start/ End: 02/08/2025; - famotidine 40 milligram tablet; one (1) tablet; daily; oral; Start/ End: 02/08/2025; - miralax 17 gram/ per dose oral powder; oral; 17 grams; daily; Start/ End: 02/08/2025; - saline nasal 0.65% spray aerosol; each nostril; one (1) spray; every four (4) hours/ as needed for dryness; Start/ End: 02/08/2025. Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 lacks orders for the medications. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 01:44 PM, the Registered Nurse stated that these medications were already listed in the record and the Registered Nurse did not alter these medications. Additionally, the Registered Nurse stated they focused on the new medications and did not closely review the existing medications. G. Review of the Physician Order to Schedule a Resumption of Care Visit dated 02/28/2025 revealed the following discharge medication: - fluconazole 100 milligram oral tablet; one (1) tablet; oral; every day for five (5) days; Review of the Physician Orders for Resumption of Care dated 03/01/2025 revealed the following order medication order: - fluconazole 100 milligram tablet; one (1) tablet; daily; oral; Start/ End: 03/01/2025. The order lacks an end date. During interview on 03/07/2025 at 01:40 PM, the Registered Nurse stated that they forgot to enter the end date. H. Review of the Physician Order to Schedule a Resumption of Care Visit dated 02/28/2025 revealed the following discharge medication: - albuterol (equivalent to proair) 90 microgram/ per inhalation aerosol; two (2) inhalations; once daily. Review of the Physician Orders for Resumption of Care dated 03/01/2025 revealed the following order medication order: - Ventolin 90 microgram/ actuation aerosol inhaler; two (2) puffs; four (4) times daily/ as needed; inhalation; Start/ End: 02/08/2025. During interview on 03/07/2025 at 01:50 PM, the Registered Nurse stated that the correct order was for albuterol, it was changed, the ventolin was discontinued. Furthermore, the Registered Nurse stated that the medications were discussed with the physician but not documented. Patient #17- This 71- year- old patient with the diagnoses of unspecified fracture of the right femur, subs for closed fracture with routine healing, unspecified alzheimer’s disease, and dementia in other disease classified elsewhere, unspecified severity without behaviors/ psychosis/ mood disturbance/ anxiety was admitted to the home care agency on 05/26/2024. Review of the Transfer/ Discharge Report (from Sub- Acute Rehabilitation Facility) dated 05/20/2025 revealed the following medication orders: - aspirin 81milligram oral tablet delayed release; 81 milligrams; give one (1) tablet by mouth two (2) times daily for deep vein thrombosis prophylaxis until 05/31/2024; - loperamide hydrochloride oral tablet 2 milligrams; give one (1) tablet by mouth every six (6) hours as needed for loose stools; do not exceed six (6) doses in twenty- four (24) hours; - milk of magnesia suspension 1200 milligrams/ per 15 milliliters; give thirty (30) milliliters by mouth every twenty- four (24) hours as needed for constipation; - bisacodyl suppository; insert 10 milligrams rectally every twenty- four (24) hours as needed for constipation; - fleet enema 7-19 grams/ per 118 milliliters; insert one (1) applicatorful rectally every twenty- four (24) hours as needed for constipation; - acetaminophen oral tablet 325 milligrams; give two (2) tablets by mouth every six (6) hours as needed for pain or temp over 101; two (2) tablets= 650 milligrams; max dose 3000 milligrams per twenty- four (24) hours; - tramadol hydrochloride oral tablet 50 milligrams; give one (1) tablet by mouth every six (6) hours as needed for pain; - tylenol oral tablet 325 milligrams; give two (2) tablets by mouth every six (6) hours as needed for pain. Review of the Home Health Certification and Plan of Care for certification period 05/26/2024 to 07/24/2024 revealed an order for aspirin 81 milligram tablet, delayed release; one (1) tablet daily for blood clot prevention. The Home Health Certification and Plan of Care lacks documented evidence of orders for loperamide, milk of magnesia. Bisacodyl, fleet enema, tramadol or as needed acetaminophen/tylenol. Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancies. During interview on 03/07/2025 at 02:40PM, the Physical Therapist stated that all the medications were reviewed with the physician, but each medication discussed was not documented. Additionally, at 02:48 PM, the Director of Clinical Operations stated the bowel medications and as needed acetaminophens were standing orders at the Sub-Acute Rehabilitation facility that were stopped at the patient’s discharge home. Patient #2- This 72- year- old patient with diagnoses that include aftercare following joint replacement surgery, presence of right artificial knee joint, and essential primary hypertension was admitted to the home care agency on 02/19/2025. Review of the Registered Nurse Outcome Assessment and Information Set Visit Report dated 02/19/2025 revealed the Physical Therapist documented the following: “Therapy Assessment/ Plan: Telephone call to the physician, the Physical Therapist was directed to a confidential nursing voicemail. The Physical Therapist left a message that the patient did not receive celecoxib from the pharmacy, although it is listed on the discharge summary medication list, the call back number was provided.” Review of the Client Coordination Note Report dated 02/20/2025 revealed the Physical Therapist documented the following: “Note Type: Clinical Significant Medication Issue; Note: Briefly describe the medication issue and follow up: The patient was not given the celecoxib from the pharmacy although it is listed on the discharge summary. Phone call placed with the physician and left a voicemail discussion the medication issue. Call back number provided. Awaiting call back. Was medication follow-up completed by midnight the next calendar day? To be determined.” Review of the clinical record lacks documented evidence of resolution of this medication discrepancy. During interview on 03/07/2025 at 02:19 PM, the Branch Manager stated that there is no further documented follow- up on the medication issue.”

“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 review of clinical records and staff interviews for five (5) of seventeen (17) patients (Patient #s: 5, 8, 9, 10, and 16) the agency failed to develop individualized Plans of Care that are complete and accurate and address the total needs of the patients. Failure to ensure comprehensive individualized plans of care are developed has the potential for unmet patient needs. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, Chronic Obstructive Pulmonary Disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. A. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the following orders for diabetes management: Skilled Nurse to instruct patient about diabetes management to include diet, skin care, Blood Glucose Testing Trulicity 3 milligrams/0.5 milliliters subcutaneous pen injector, 3 milligrams injection weekly every Tuesday for diabetes. Review of the clinical record lacks documented evidence that an order was obtained for glucometer testing strips, needles for subcutaneous injection, and sharps container. During interview on 03/10/2025 at 09:35AM, the Registered Nurse stated the necessary supplies were within the home and confirmed that the orders should have been in the medical record but were not. B. Review of the Physician Order dated 11/21/2024 revealed the following order: ipratropium 0.5 milligrams - albuterol 3 milligrams/3milliliter nebulization solution. Inhale one (1) nebule via nebulizer four times daily as needed for chronic obstructive pulmonary disease. Review of the clinical record lacks documented evidence that an order was obtained for a nebulizer and supplies. During interview on 03/10/2025 at 09:28AM, the Registered Nurse confirmed that an order was not obtained for the required medical equipment. C. Review of Occupational Therapy Recertification with Skill Visit Note dated 01/14/2025 revealed that through utilization of the fall risk assessment tool completed the occupational therapist determined the patient is at risk for falls. Review of the Home Health Certification and Plan of Care for 01/19/2025 to 03/19/2025 revealed the following safety measures: diabetic precautions, oxygen precautions, and universal precautions. It is not documented on the plan of care that the patient is a fall risk. During interview on 03/10/2025 at 09:57AM, the Director of Branch operations confirmed that the plan of care did not include that patient is at risk for falls or on fall precautions and that it should have been documented as a safety measure. Patient #9 – This 69-year-old patient with the diagnoses of status post left total knee replacement on 2/25/2025 and hypertension was admitted to the home care agency on 02/26/2025. Review of the After Visit Summary dated 02/25/2025, the total knee replacement postop discharge instructions revealed: “Dos: Wear your compression stockings until your follow up appointment. Remove at night and reapply in the morning.” Review of the Home Health Certification and Plan of Care for 02/26/2025 to 04/26/2025 lacks orders for compression stockings. During interview on 03/07/2025 at 04:12PM the Physical Therapist states she cannot remember whether the discharge instructions included orders for compression stockings and confirmed that if it was listed in discharge instructions it is expected to be noted in the plan of care but does not see it documented. HV Patient #10 - This 57-year-old patient with the diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the agency on 04/17/2017. A. During observational home visit on 03/07/2025 at 10:25 AM, the surveyor observed the Home Health Aide transfer the patient from the wheelchair to the bed using a slide board. Review of the Licensed Practical Nurse Subsequent Visit Note dated 01/20/2025 revealed the Licensed Practical Nurse documented the patient “was assisted out of bed 15-20 minutes later to his bedside commode with the use of his slide board.” Review of the clinical record from 01/05/2025 (most recent recertification period) to 03/10/2025 (last day of survey) lacks an order for a slide board. During interview on 03/10/2025 at 10:25 AM, the Registered Nurse stated the patient uses a slide board to transfer from the wheelchair to bed and it should have been included on the medical orders. B. During an observational home visit on 03/07/2025 at 10:29 AM, the surveyor observed the Home Health Aide put thrombo-embolus deterrent (ted) stockings on the patient’s lower legs. Review of the clinical record from 01/05/2025 (most recent recertification period) to 03/10/2025 (last day of survey lacks an order for the ted stockings, including the amount of compression and instructions for application. During interview on 03/10/2025 at 10:36 AM, the Registered Nurse stated the patient wears ted stockings. Additionally, the Registered Nurse stated that there should be an order for the ted stockings. C. Review of the Home Health Certification and Plan of Care for 01/05/2025 to 03/05/2025 revealed the following: - Diagnosis of Type 2 diabetes mellitus without complications… - An order for “Skilled Nurse to instruct patient about diabetes management to include diet, skin care, blood glucose testing prn [as needed]”… - Durable medical equipment- glucometer, lancets and test strips. Review of the clinical record from 01/05/2025 (most recent recertification period) to 03/10/2025 (last day of survey lacks an order that includes the blood sugar parameters that are to be reported to the physician. During interview on 03/10/2025 at 10:15 AM, the Registered Nurse stated parameters stating when to contact the physician should have been included in the orders. Patient #8- This 19-year-old patient with the diagnoses of acute leukemia of unspecified cell type not achieve remission, encounter for antineoplastic chemotherapy, and other acute pancreatitis without necrosis or infection was admitted to the agency on 12/23/2024. A. Review of the Registered Nurse Infusion Recertification Visit dated 02/17/2025 revealed the Registered Nurse documented the following: 2. Attention to mediport IV access for site care and line maintenance…Cleansed site area with chlorhexidine solution applicator using back and forth scrubbing motion for 30 seconds. Allowed site area to dry completely, then inserted huber needle. Ensured 20G x ¾ in huber needle placement by validating positive blood return, then flushed and labs drawn per lab note. Deaccesed. Review of the Home Health Certificate and Plan of Care for 02/21/2025 to 04/21/2025 lacks an order that includes the size of the huber needle to be used for the mediport access. During interview on 03/06/2025 at 02:13 PM, the Registered Nurse stated there are different sizes of huber needles. Additionally, the order should have included the size of the huber needle. B. Review of the Home Health Certification and Plan of Care for 02/21/2025 to 04/21/2025 revealed an order for Lantus Solostar Units-100 Insulin 100 unit/milliliter (3 milliliter) subcutaneous pen blood glucose monitoring before meals three times a day and 3 units Lispro 100 unit/ milliliter every meal three times a day. Initiate with steroid therapy and report blood glucose results daily to determine when blood glucose monitoring and insulin can be held. Review of the clinical record lacks documented evidence an order was obtained for diabetic glucometer and testing supplies. During interview on 03/06/2025 at 02:17 PM, the Registered Nurse stated that the glucometer and testing supplies were not included because the patient was not currently prescribed a steroid and did not need to take Lantus. The agency failed to develop individualized Plans of Care that are complete and accurate and address the total needs of the patients as evidenced by: Patient #16 – This 71-year-old patient with the diagnoses of venous insufficiency, lymphedema, and chronic ulcer of the left lower leg with fat layer exposed was admitted to the home care agency on 06/05/2022. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed the following: “The patient has an allergy to adhesive glue... Skilled Nurse to perform/teach wound care to left upper leg measures 12 centimeters x 7 centimeters x 0.2 centimeters, thigh wound orders: cleanse with vashe, apply santyl, then hydrofera blue, then foam. Change three (3) times a week. Left buttocks measures 8 centimeters x 6 centimeters x 0.1 centimeters left buttock wound: apply triad, apply foam, change three (3) times a week using clean/aseptic technique.’ The order lacks documentation stating what is used for securing the wound dressing to the patient. During interview on 03/07/2025 at 09:47 AM, the Registered Nurse stated they were using tegaderm to secure the dressing, but it was not included on the plan of care.”

“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 clinical record review and staff interview, three (3) of seventeen (17) patient records (Patient #’s: 5, 10, and 16) lacked evidence an order was obtained to update the Plan of Care to reflect the patient’s status. Failure to obtain an order to update the Plan of Care has the potential for agency staff to act on inaccurate and incomplete information, and places patient health and welfare at risk. The agency failed to ensure that an order was obtained to update the Plan of Care to reflect the patient’s status as evidenced by: Patient #16 – This 71-year-old patient with the diagnoses of venous insufficiency, lymphedema, and chronic ulcer of the left lower leg with fat layer exposed was admitted to the home care agency on 06/05/2022. Review of the Registered Nurse Visit Note Dated 12/08/2023 revealed “(patient) states she is unable to use vashe. Need order for wound spray will clarify with wound medical doctor.” Review of the clinical record lacks an order for wound spray. During interview on 03/07/2025 at 10:05 AM, the Registered Nurse, Clinical Manager stated there was not an order for the wound spray. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, Chronic Obstructive Pulmonary Disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. Review of Add-On Discipline order dated 12/16/2024 at 3:48PM revealed an order for the following: Physical Therapy effective 12/15/2024 two (2) times per week for four (4) weeks and then one (1) time per week for one (1) week. Review of the clinical record revealed missed Physical Therapy visits on the following dates: 12/20/2024, 12/24/2024, 12/27/2024, and 01/01/2025. Review of the clinical record lacks orders for a change in frequency of Physical Therapy due to missed visits. During interview on 03/10/2025 at 09:53 AM, the Director of Branch Operations stated that no orders were obtained for change in frequency of visits. HV Patient #10- This 57-year-old with the diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the agency on 04/17/2017. A. During an observational home visit on 03/07/2025 at 10:35 AM, the surveyor observed the home health aide empty the patient’s urinary catheter and secure to patient’s leg with leg band. Review of the clinical record lacks an order for the home health aide to assist the patient with catheter care. During interview on 03/10/2025 at 10:35 AM, the Registered Nurse stated that there should be an order for the home health aide to assist patient with catheter care. B. Review of the Licensed Practical Nurse Subsequent Visit Note dated 02/23/2025 revealed the Licensed Practical Nurse documented “per patient, wdr [doctor] plans to send cephalexin and methylprednisone to pharmacy, medication list will need to be updated at next visit…this narrative emailed to cm [case manager] nurse.” Review of the Licensed Practical Nurse Subsequent Visit Note dated 02/25/2025 revealed the Licensed Practical Nurse documented the “patient has started abt [antibiotic] and prednisone for potential cellulitis brought on by use of bactrim to left flank area…this notation sent to case manager via email.” The clinical record lacks orders for the medications. During interview on 03/10/2025 at 10:49 PM, the Registered Nurse stated the medications were not added to the medication list and should have been.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on review of clinical records, and interviews with agency staff, nine (9) of seventeen (17) patients (Patient #s: 2, 5, 8, 10, 11, 13, 14, 15, and 17), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician’s order has the potential to result in poor quality of care. Patient #17- This 71- year- old patient with the diagnoses of unspecified fracture of the right femur, subs for closed fracture with routine healing, unspecified alzheimer’s disease, and dementia in other disease classified elsewhere, unspecified severity without behaviors/ psychosis/ mood disturbance/ anxiety was admitted to the home care agency on 05/26/2024. Review of the Home Health Certification and Plan of Care for 05/26/2024 to 07/24/2024 revealed the order “Licensed Professional to report vital signs falling outside of the established parameters. Temp lower than 96.8 greater than 100.4, pulse less than 60 greater than 100, respirations less than 12 greater than 24, systolic blood pressure less than 95 greater than 140, diastolic blood pressure greater than 89, oxygen saturation less than 92 percent.” A. Review of the Physical Therapy Subsequent Visit Note dated 05/28/2024 lacks documented evidence the Physical Therapist assessed the patient’s respiration rate. During interview on 03/07/2025 at 03:42 PM, the Director of Clinical Operations stated that agency expectation is that the clinician should have taken the patient’s respiratory rate. B. Review of the Occupational Therapy Add-on Evaluation Visit Note dated 06/03/2024 lacks documented evidence the Occupational Therapist assessed that respiration rate. During interview on 03/07/2025 at 03:37 PM, the Physical Therapist stated that they typically do not obtain a respiratory rate unless the patient is short of breath. Additionally, the Manager of Rehabilitation stated that usually a pulse oximetry can assist in monitoring a patient’s respiratory status. C. Review of the Physical Therapy Subsequent Visit Notes revealed the Physical Therapist’s documentation lacks the following: - On 06/04/2024, 06/06/2024, and 06/13/2024, the documentation lacks assessment of the patient’s temperature and respiratory rate. - On 06/07/2024, the documentation lacks assessment of the patient’s temperature, pulse, blood pressure and pulse oximetry. - On 06/11/2024, the documentation lacks assessment of the patient’s temperature, pulse and blood pressure. During interview on 03/07/2025 at 03:18 PM, the Physical Therapist stated that the patient would often pull off the blood pressure cuff before the Physical Therapist was finished obtaining blood pressures or would get agitated when trying to obtain vital signs. The Physical Therapist also stated that they did not always document this, but they should have. Patient #2- This 72- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of right artificial knee joint, and essential primary hypertension was admitted to the home care agency on 02/19/2025. Review of the Home Health Certification and Plan of Care for 02/19/2025 to 04/19/2025 revealed the order “Licensed Professional to report vital signs falling outside of the established parameters. Temperature lower than 96.8 greater than 100.4, pulse less than 60 greater than 100, respirations less than 12 greater than 24, systolic blood pressure less than 95 greater than 140, diastolic blood pressure greater than 89, oxygen saturation less than 92 percent.” Review of the Physical Therapy Subsequent Visit Notes dated 02/21/2025, 02/24/2025, 02/27/2025, and 03/04/2025 lack documented evidence the Physical Therapist assessed temperature and respiration rate at each visit. During interview on 30/07/2025 at 02:08 PM, the Physical Therapist stated that they are unbale to remember why the patient’s temperature or respiratory rate were not obtained at those visits. Patient #11- This 73- year- old patient with the diagnoses of encounter for surgical aftercare following surgery on digestive system, diverticuli of the intestines, part unspecified, with perforation and abscess without bleed, and retention of urine, unspecified was admitted to the home care agency on 02/08/2025. Review of the Registered Nurse Resumption of Care Visit Note Report dated 03/01/2025 revealed the Registered Nurse documented that the patient requested a Home Health Aide for assistance with Activities of Daily Living. Review of the Physician Orders for Resumption of Care dated 03/01/2025 revealed the following order: Home Health Aide effective 03/02/2025, one (1) per week for one (1) week, and two (2) times per week for four (4) weeks. Review of the clinical record lacks documented evidence of a Home Health Aide placement. During interview on 03/10/2025 at 11:34 AM, the Registered Nurse stated that the agency is trying to get an aide placed, but one has not been placed as of this time. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, Chronic Obstructive Pulmonary Disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. A. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 01/18/2025 revealed the following order: Licensed Professional to report vital signs falling outside of the following established parameters. Temperature lower than 96.8 greater than 100.4, pulse less than 60 greater than 100, respirations less than 12 greater than 24, systolic blood pressure less than 95 greater than 140, diastolic blood pressure greater than 89, oxygen saturation less than 92 percent. Review of the Occupational Therapy Reassessment Visit Note dated 12/31/2024 lacks documented evidence the Occupational Therapist assessed oxygen saturation. During interview on 03/10/2025 at 09:56AM, the Director of Branch Operations confirmed there was no oxygen saturation level documented and that it should have been obtained and documented at visit by Occupational therapist. Review of the Physical Therapy Recertification and Add-On Evaluation Visit Note dated 01/14/2025 lacks documented evidence the Physical Therapist assessed oxygen saturation. During interview on 03/10/2025 at 09:50AM, the Physical Therapist confirmed there was no oxygen saturation level documented and that it should have been obtained and documented at visit. B. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the following: oxygen gas for inhalation – 2.5 (two and a half) liters oxygen continuous for chronic obstructive pulmonary disease. Review of the Occupational Therapy Add-On Discipline Description Visit Note dated 12/05/2024 revealed: Therapy Assessment/Plan – Patient as on two liters of continuous oxygen via nasal cannula. Vital Signs - oxygen saturation level 99 (ninety-nine) percent on oxygen 2 (two) liters. During interview on 03/10/2025 at 09:52AM the Director of Branch Operations stated that she cannot answer to what the occupational therapist saw on concentrator during visit but does confirm that documentation states in both the vital signs and the narrative inaccurately state that the patient is on 2L of oxygen, so she assumes that is the amount of oxygen the patient was using during visit. Review of the Occupational Therapy Subsequent Visit Note dated 12/11/2024 revealed: vital signs – oxygen saturation 96 percent on 2 liters. During interview on 03/10/2025 at 9:55AM the Director of Branch Operations stated she assumes the amount of oxygen documented is the amount of oxygen the patient was using during visit. Review of the Occupational Therapy Subsequent Visit Note dated 12/19/2024 revealed: vital signs – oxygen saturation 98 percent on 2 liters. During interview on 3/10/2025 at 9:55AM the Director of Branch Operations stated she assumes the amount of oxygen documented is the amount of oxygen the patient was using during visit. Review of the Occupational Therapy Subsequent Visit Note dated 12/23/2024 revealed: vital signs – oxygen saturation 96 percent on 2 liters. During interview on 3/10/2025 at 9:55AM the Director of Branch Operations stated she assumes the amount of oxygen documented is the amount of oxygen the patient was using during visit. C. Registered Nurse Subsequent Visit Note dated 11/26/2024 revealed the following: patient’s flu shot administered in her right deltoid, tolerated well. Review of the clinical record lacks documented evidence that an order was obtained for the influenza vaccination. During an interview on 03/10/2025 at 09:39AM the Registered Nurse stated that the patient requested the vaccination at the start of care visit and the agency has a standing order for administration of the influenza vaccine. The Registered Nurse confirmed that no supplemental order is obtained or activated for a patient when a standing order is utilized. Patient #15- This 91- year -old patient with the diagnoses of pressure ulcer of right heel stage 3, peripheral vascular disease, venous insufficiency, and paroxysmal atrial fibrillation was admitted to the home care agency on 05/20/2023. Review of the Home Health Certification and Plan of Care for 01/15/2024 to 03/14/2024 revealed the order “Skilled Nurse to report weight gain of greater than 3 (three) pounds in one day or greater than 5 (five) pounds in one week for heart failure.” Review of the Registered Nurse Subsequent Visit Note dated 01/19/2024, 01/22/2024 and 01/26/2024 lack documented evidence the Registered Nurse assessed the patient’s weight daily. During interview on 03/07/2025 at 12:36 PM, the Registered Nurse stated the weights were done by the caregiver daily, and that she reviewed the weights, but those weights were not documented. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by: Patient #14 – This 41-year-old patient with the diagnoses of infection following a procedure, bacteremia, and staphylococcus as the cause of disease was admitted to the home care agency on 06/25/2024. Review of the Home Health Certification and Plan of Care for 06/25/2024 to 08/23/2024 revealed the order “Licensed Professional to report vital signs falling outside of the established parameters. Temp lower than 96.8 greater than 100.4, pulse less than 60 greater than 100, respirations less than 12 greater than 24, systolic blood pressure less than 95 greater than 140, diastolic blood pressure greater than 89, oxygen saturation less than 92 percent.” Review of the Physical Therapy Add-On Evaluation Note dated 07/03/2024 lacks documented evidence the Physical Therapist assessed temperature and respiration rate. During interview on 03/07/2025 at 12:14 PM, the Registered Nurse, IV (intravenous) and Pediatric Team Manager stated those vital signs were not documented. HV Patient #8- This 19-year-old with the diagnoses of acute leukemia of unspecified cell type not achieve remission, encounter for antineoplastic chemotherapy, and other acute pancreatitis without necrosis or infection was admitted to the home care agency on 12/23/2024. A. During an observational home visit on 03/05/2025 at 09:25 AM, this surveyor observed the Registered Nurse draw up 6 (six) milliliters blood and discard. Review of the Registered Nurse Visit Note dated 02/26/2025 revealed the Registered Nurse documented: “obtained lab specimen via vascular access…drew up and discarded 6 milliliters blood.” Review of the Home Health Certification and Plan of Care for 02/21/2024 to 04/21/2025 revealed an order for skilled nurse to draw up and discard 10 (ten) milliliters blood. During interview on 03/06/2025 at 02:35 PM, the Registered Nurse stated the order should be written for between 5 (five) to 7 (seven) milliliters of waste and does not. Additionally, what was drawn and discarded should not be different from the medical orders. B. Review of the Home Health Certification and Plan of Care for 02/21/2024 to 04/21/2025 revealed an order for skilled nurse to draw up and discard 10 milliliters blood. Review of the Registered Nurse Infusion Subsequent Visit dated 02/24/2025 revealed the Registered Nurse documented 5 (five) -7 (seven) milliliters of blood was drawn up and discarded. During interview on 03/06/2025 at 02:58 PM, the Registered Nurse stated they were unaware that the order was to draw up and discard 10 milliliters of blood. C. Review of the Registered Nurse Infusion Subsequent Visit Note dated 02/26/2025 revealed the Registered Nurse documented only medication currently taking is amlodipine and bactrim while on chemotherapy hold. Review of the Home Health Certification and Plan of Care for 02/21/2024 to 04/21/2025 revealed the following orders: - Cyproheptadine 4 milligram tablet one (1) tablet three (3) times daily; - Famotidine 20 milligram tablet one (1) tablet two (2) times daily; - Granisetron HCL 1 milligram tablet one (1) tablet two (2) times daily; and - Milk thistle 150 milligram capsule 180 milligram capsules four (4) times daily During interview on 03/06/2025 at 02:32 PM, the Registered Nurse stated the patient takes the daily medications only while receiving chemotherapy. Additionally, there was not a discussion with the doctor to switch medications from daily to as needed while patient is receiving chemotherapy. There should have been orders indicating what the patient is currently taking. Patient #13- This 78-year-old with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the home care agency on 09/10/2024. A. Review of the Home Health Certification and Plan of Care for 09/10/2024 to 11/08/2024 revealed the order for “Licensed Professional to report vital signs falling outside of the established parameters…respirations less than 12 (twelve) greater than 24 (twenty-four).” Review of the Physical Therapy Add-On Evaluation Note dated 09/19/2024 lacks documented evidence the Physical Therapist assessed the respiration rate. During interview on 03/06/2025 at 03:56 PM, the Manager of Rehabilitation stated the respiratory rate should have been assessed and was not documented. B. Review of the Registered Nurse Subsequent Visit Note dated 09/19/2024 revealed the Registered Nurse documented “patient to have staples removed from incision Monday 09/23/2024. Plan for discharge 09/24/2024.” Review of the Registered Nurse Discharge From Agency Visit note dated 09/24/2024 revealed the Registered Nurse documented the following: - Yes, the patient has at least one (observable) surgical wound. - #1- Left abdominal left lower quadrant, surgical incision (inactivated 09/24/2024) …change in wound status, inactivate wound-discharged, wound assessed, yes. The clinical record lacks documented evidence that the patient’s wound was assessed at discharge. During interview on 03/06/2024 at 03:37 PM, the Registered Nurse stated they were unable to confirm if patient was seen by the physician and when the patient’s staples were removed, Additionally, the Registered Nurse states recalling that the staples were not present and just a pin hole remaining for the surgical wound but did not document the assessment. Patient #10- This 57-year-old with diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the home care agency on 04/17/2017. Review of the Home Health Certification and Plan of Care for 01/05/2025 to 03/05/2025 revealed an order for Licensed professional to report vital signs falling outside of the following established parameters…”O2 [oxygen] saturation less than 92.” Review of the clinical record lacks documented evidence that the oxygen level was obtained during the Licensed Practical Nurse Subsequent Visits on 01/06/2025, 01/08/2025, 01/10/2025, 01/14/2025, 01/16/2025, 01/22/2025, 01/24/2025, 01/28/2025, 02/05/2025, 02/11/2025, 02/13/2025, 02/19/2025, 02/21/2025, 02/25/2025, 02/27/2025, and 03/01/2025. During interview on 03/10/2025 at 10:45 AM, the Registered Nurse stated that it would be expected that the licensed practical nurse should be documenting the patient’s oxygen level in order to notify provider if it is below 92 percent.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff for three (3) of seventeen (17) patients (Patient #s: 11, 13, and 16), the agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the Plan of Care may need to be altered. Failure to promptly notify the physician to changes in the patient’s condition or needs that may suggest that outcomes are not being achieved and/or the Plan of Care should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #11- This 73- year- old patient with the diagnoses that include encounter for surgical aftercare following surgery on digestive system, diverticuli of the intestines, part unspecified, with perforation and abscess without bleed, and retention of urine, unspecified was admitted to the home care agency on 02/08/2025. Review of the Registered Nurse Resumption of Care Visit Note dated 03/01/2025 revealed the Registered Nurse documented the following: “Nutritional: Nutritional Approaches: Check all the Nutritional Approaches that apply on admission: Mechanically altered diet- requires change in texture of food or liquids (e.g., pureed food, thickened liquids); Therapeutic diet (e.g., low salt, diabetic, low cholesterol).” Review of the clinical record from 03/01/2025 to 03/10/2025 (last day of survey) lacks documented evidence the Registered Nurse contacted the physician regarding the need for a mechanically altered diet. Additionally, the clinical record lacks an order for the special diet. During interview on 03/07/2025 at 01:32 PM, the Registered Nurse stated the patient developed issues with swallowing and the physician was not made aware. Patient #13- This 78-year-old with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the agency on 09/10/2024. Review of the Home Health Certification and Plan of Care for 09/10/2024 to 11/08/2024 revealed the order for Skilled Nurse two (2) week two (2), one (1) week one (1). Review of the Client Coordination Narrative Note dated 09/17/2024 revealed the Registered Nurse documented the following: “10:00 AM phone call to patient to schedule time for visit today. Patient had concerns regarding nursing visits. This writer offered to have nurse manager call her regarding her concerns. Did not want visit today, visit may be rescheduled pending results of conversation between patient and manager.” Review of the Client Coordination Narrative Note dated 09/17/2024 revealed the Registered Nurse documented the following: “5:00 PM phone call to patient after speaking with manager, to set up visit for Wednesday 9/18. Patient states she cannot have visit on Wednesday as she has a MD visit on 09/18/2024. Visit rescheduled for 09/19/2024. Manager notified.” Review of the clinical record revealed a Skilled Nursing Visit was completed on 09/19/2024. Review of the clinical record lacks documented evidence a Skilled Nursing visit occurred or documentation that the physician was notified of the missed skilled nursing visit for the week of 09/15/2024. During interview on 03/06/2025 at 04:03 PM, the Manager of Clinical Services stated there is no documentation of a call to the physician about the missed visit. The agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the Plan of Care may need to be altered as evidenced by: Patient #16 – This 71-year-old patient with the diagnoses of venous insufficiency, lymphedema, and chronic ulcer of the left lower leg with fat layer exposed was admitted to the home care agency on 06/05/2022. A. Review of the Licensed Practical Nurse Visit Note dated 12/01/2023 revealed “Patient depressed and is no longer going to continue with dialysis.” Review of the clinical record lacks documented evidenced the Licensed Practical Nurse spoke with the physician regarding the patient’s desire to stop dialysis and feeling depressed. During interview on 03/07/2025 at 10:22 AM, the Registered Nurse, Clinical Manager stated there is no documentation of a call to the physician. B. Review of the Registered Nurse Visit Note dated 12/06/2023 revealed “patient has been having visual hallucinations this morning.” Review of the clinical record lacks documented evidence the Registered Nurse spoke with the physician regarding the patient’s hallucinations. During interview on 03/07/2025 at 09:50 AM, the Director of Operations stated the clinician did document leaving a message for the physician but did not document a call back to discuss the patient’s change in condition. C. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed the order “Licensed Professional to report vital signs falling outside of the established parameters. Temp lower than 96.8 greater than 100.4, pulse less than 60 greater than 100, respirations less than 12 greater than 24, systolic blood pressure less than 95 greater than 140, diastolic blood pressure greater than 89, oxygen saturation less than 92 percent.” Review of the Registered Nurse Visit Note dated 12/06/2023 revealed the patient’s blood pressure is 180/90. Review of the clinical record lacks documented evidence the Registered Nurse spoke with the physician regarding the patient’s high blood pressure. During interview on 03/07/2025 at 09:50 AM, the Director of Operations stated the clinician did document leaving a message for the physician but did not document a call back to discuss the patients change in condition.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on review of clinical records and staff interview for two (2) of seventeen (17) patients (Patient #’s: 13 and 14) the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the Plan of Care. Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. Patient #13- This 78-year-old patient with the diagnoses of malignant neoplasm of left kidney, except renal pelvis, essential (primary) hypertension, and paroxysmal atrial fibrillation was admitted to the home care agency on 09/10/2024. Review of the Home and Health Certificate and Plan of Care for 09/10/2024 to 11/08/2024 revealed an order for “Skilled Nurse to perform/teach wound care to incision/staples site located left abdomen. Patient may shower letting water run over incision, dry thoroughly and leave open to air (OTA) using clean/aseptic technique.” Review of the clinical record from 09/10/2024 to 03/10/2025 (last day of survey) lacks documented evidence that education was provided, and wound care was redemonstrated by the patient/caregiver. During interview on 03/06/2025 at 03:29 PM, the Registered Nurse stated that it is expected the patient/caregiver redemonstrates wound care competence and it was not done. The agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the Plan of Care as evidenced by: Patient #14 – This 41-year-old patient with the diagnoses of infection following a procedure, bacteremia, and staphylococcus as the cause of disease was admitted to the home care agency on 06/25/2024. Review of the Home Health Certification and Plan of Care for 06/25/2024 to 08/23/2024 revealed “Skilled Nurse to perform/teach wound care to incision/suture site located lower abdomen cleanse with normal saline. Pack open area with iodoform packing strips, cover with gauze and abdominal pad. Change dressing daily using clean/aseptic technique.” Review of the Registered Nurse Infusion Outcome Assessment and Information Set Admission Note dated 06/25/2024 revealed “Patient’s sister who is Registered Nurse will complete wound care on non-nursing days.” Review of the clinical record from 06/25/2024 to 03/10/2025 (last day of survey) lacks documented evidence the sister received appropriate education and performed a re-demonstration of wound care. During interview on 03/07/2025 at 12:04 PM, the Director of Operations stated there is no documentation that the sister was taught how to perform wound care.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for eight (8) of seventeen (17) patients (Patient #s: 2, 4, 5, 8, 10, 11, 15 and 16), the agency failed to prepare and document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #4 – This 62- year -old patient with the diagnoses of type 2 diabetes mellitus with foot ulcer, non- pressure chronic ulcer other part left foot, cutaneous abscess of right foot, and acquired absence of right great toe was admitted to the home care agency on 10/19/2024. Review of the Registered Nurse Outcome Assessment and Information Set Admission Note dated 10/19/52024 revealed the following assessment: Diabetes: -Is the client taking Insulin - no -Is the client taking an antidiabetic agent -yes Review of the Home Health Certification and Plan of Care for 10/19/2024 to 12/17/2024 revealed the order for Humulin R regular insulin 100 unit/ml (milliliters) injection 35 units 3 times a day with meals. During interview on 03/07/2025 at 11: 24 AM, the Registered Nurse stated she checked no in error. The Registered Nurse added she is aware the patient is taking insulin. Patient #15- This 91- year -old patient with diagnoses of pressure ulcer of right heel stage 3, peripheral vascular disease, venous insufficiency, and paroxysmal atrial fibrillation was admitted to the home care agency on 05/20/2023. Review of the Licensed Practical Nurse Visit Note dated 01/31/2024 revealed the following assessment: Pain: - Are you having pain – yes - Indicate the location of pain (ask the patient to point to the area- If more than one area, ask which is more bothersome). Type (acute, chronic, recent onset) and quality of pain (aching, burning, cramping) -Right shoulder Review of the Licensed Practical Nurse narrative note dated 01/31/2024, revealed the Licensed Practical Nurse documented the patient denies pain today. During interview on 03/07/2025 at 12:50 PM, the Licensed Practical Nurse stated the documentation was in error. Patient #8- This 19-year-old patient with the diagnoses of acute leukemia of unspecified cell type not achieve remission, encounter for antineoplastic chemotherapy, and other acute pancreatitis without necrosis or infection was admitted to the home care agency on 12/23/2024. A. Review of the Client Care Coordination Lab Drop Off Note dated 02/24/2025 revealed the Registered Nurse documented the following: - Date lab dropped off: 2/25/2025 - Specimen type: CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) - Color and number of each tube delivered: Mint and Lavender. Review of the clinical record lacks documentation of the number of specimen tubes that were dropped off at the lab, and the actual date the tubes were dropped off. It is unclear why the documentation states that the laboratory specimens were dropped off on a future date. During interview on 03/06/2025 at 02:54 PM, the Registered Nurse stated there is a discrepancy in the date, it was completed on 02/25/2025. Additionally, one mint and one lavender specimen tube was dropped off. B. Review of the Registered Nurse Visit Note dated 02/24/2025 revealed the Registered Nurse documented the following: - Indicate port dressing type (mark all that apply): Other (specify); - Describe other port dressing: not applicable; and - Indicate port dressing condition (Mark all that apply): Other (specify). During interview on 03/06/2025 at 02:57 PM, the Registered Nurse stated the documentation was an error; there was no dressing over the port. C. Review of the Review of the Home Health Certification and Plan of Care for 02/21/2025 to 04/21/2025 revealed an order for licensed professional to report vital signs falling outside the following established parameters…”O2 (oxygen) less than 92.” During interview on 03/06/2025 at 02:11 PM, the Registered Nurse stated that there was no order to monitor patient’s oxygen levels. Additionally, the oxygen parameters to notify the physician was pre-populated in error. Patient #10- This 57-year-old with diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the agency on 04/17/2017. A. Review of the Aide Visit Notes dated 01/05/2025, 01/07/2025, 01/09/2025, 01/10/2025, 01/11/2025, 01/13/2025, 01/14/2025, 01/16/2025, 01/17/2025, 01/18/2025, 01/19/2025, 01/20/2025, 01/22/2025, 01/23/2025, 01/24/2025, 01/27/2025, 01/28/2025, 01/30/2025, 01/31/2025, 02/01/2025, 02/02/2025, 02/03/2025, 02/04/2025, 02/06/2025, 02/07/2025, 02/10/2025, 02/11/2025, 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, 02/17/2025, 02/18/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/24/2025, 02/252025, 02/27/2025, 02/28/2025, 03/01/2025, 03/02/2025, and 03/03/2025 revealed the Home Health Aide documented the following: - Service: Any Change in Patient Condition must be phoned into the office and documented in a coor [coordination note]; - Completed: Y [yes]. During interview on 03/10/2025 at 10:42 AM, the Registered Nurse stated that answering “yes” would indicate that the aide completed the task. Additionally, the aide may have misread the question and documented the answer in error. Furthermore, there are no care coordination notes from the Home Health Aide indicating any change in the patient’s condition. B. Review of the Aide Care Plan dated 01/05/2025 revealed an order for Specialized Procedures - Home Health Aides only - provide the following specialized procedures: Perform therapy program on non-bowel days. Review of the Aide Visit Note dated 01/08/2025, 01/11/2025, 01/22/2025, 01/28/2025, and 02/19/2025 revealed the Licensed Practical Nurse documented the following: - Service: Perform Therapy Program - Completed: Y [yes] Review of the Licensed Practical Nurse Subsequent Visit Note dated 01/08/2025, 01/11/2025, 01/22/2025, 01/28/2025, and 02/19/2025 revealed the Licensed Practical Nurse documented bowel regimen completed. During interview on 03/10/2025 at 10:44 AM, the Director Branch Operations stated that the Licensed Practical Nurse documented in error that the therapy program was completed during the aide visit. Patient #11- This 73- year- old patient with the diagnoses that include encounter for surgical aftercare following surgery on digestive system, diverticuli of the intestines, part unspecified, with perforation and abscess without bleed, and retention of urine, unspecified was admitted to the home care agency on 02/08/2025. A. Review of the Registered Nurse Outcome Assessment and Information Set Visit Report dated 02/08/2025 revealed the Registered Nurse documented the following: “Care Management: Special Treatments, Procedures, and Programs: Check all of the following treatments, procedures and programs that apply on admission: C1. Oxygen Therapy; Indicate type of administration of oxygen therapy on admission: C4. High- concentration.” Review of the clinical record lacks documented evidence that the patient utilizes oxygen therapy. During interview on 03/07/2025 at 01:22 PM, the Registered Nurse stated that they meant to reference the patient’s continuous positive airway pressure (CPAP), but documented oxygen in error. B. Review of the Registered Nurse Outcome Assessment and Information Set Visit Report dated 02/08/2025 revealed the Registered Nurse documented the following: “Medications: Management of injectable medications: Patient’s current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/ intervals. Excludes Intravenous Medications: Not Applicable- No injectable medications prescribed.” Review of the Home Health Certification and Plan of Care for 02/08/2025 to 04/08/2025 revealed an order for the following medication: “Repatha sureclick 140 milligrams/ per milliliter subcutaneous pen injector; subcutaneously; 1 milliliter; every other week; for hyperlipidemia; administered by patient every two (2) weeks.” During interview on 03/07/2025 at 01:23 PM, the Registered Nurse stated that “Not applicable” was an error, and that the patient is taking an injectable medication. C. Review of the Registered Nurse Resumption of Care Visit Report dated 03/01/2025 revealed the Registered Nurse documented the following: “Wound Care Provided: Portion of surgical incision open on abdomen. Measurements and photo obtained. Minimal drainage, cleanse with wound cleanser, cover with DCD (dry, clean dressing), daily and as needed if soiled.” Review of the Physician Orders for Resumption of Care dated 03/01/2025 revealed the following wound care orders: “Skilled Nurse to perform/ teach wound care the dehisced midline abdominal surgical incision: Cleanse with wound cleanser, cover with DSD (dry, sterile dressing), daily and as needed for soiled or dislodged dressing.” During interview on 03/07/2025 at 01:36 PM, the Registered Nurse stated that “DSD” on the physician order is a typo, the agency does not provide sterile dressings in the patient’s homes. Patient #2- This 72- year- old patient with diagnoses that include aftercare following joint replacement surgery, presence of right artificial knee joint, and essential primary hypertension was admitted to the home care agency on 02/19/2025. Review of the Physical Therapist Outcome Assessment and Information Set Visit Report dated 02/19/2025 revealed the Physical Therapist documented the following: “Environmental: Patient Living Situation: Which of the following best describes the patient’s residential circumstance and availability of assistance: Patient lives alone; Neurologic: Indicate Patient’s mental status: Alert, oriented to person, oriented to place, oriented to time, able to follow multi-step commands, able to follow simple commands; Medications: Management on oral medications: Patient’s current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/ intervals. Excludes injectable and intravenous medications: 3- Unable to take medication unless administered by another person.” Review of the clinical records lacks documented evidence regarding why the patient is unable to administer their own medications, or who would administer medications to the patient. During interview on 03/07/2025 at 02:22 PM, the Branch Manager stated that they are unsure why the clinician documented that the patient could not administer the medications, and the clinician’s documentation is inconsistent with the overall picture of the patient’s condition and functional status. Patient #5 – This 78-year-old patient with the diagnoses of difficulty ambulating, chronic obstructive pulmonary disease (COPD) with oxygen dependency, and non-insulin dependent type 2 diabetes was admitted to home care agency on 11/20/2024. Review of the Home Health Certification and Plan of Care for 11/20/2024 to 1/18/2025 revealed the following: Oxygen gas for inhalation – 2.5 (two and a half) liters oxygen continuous for chronic obstructive pulmonary disease. A. Review of the Registered Nurse Visit Note dated 11/25/2024 revealed the following assessment: oxygen saturation level 96 percent on Oxygen 2 (two) liters. During interview on 03/10/2025 at 09:36 AM, the Registered Nurse stated documenting 2 (two) liters inside the assessment was an error, but did document the patient was 96 percent on 2.5 (two and a half) liters of oxygen within the narrative of visit note. B. Review of the Physical Therapy Add-On Evaluation Visit Note dated 12/16/2024 revealed the following assessment: oxygen saturation level 100 (one hundred) percent on room air. During interview on 03/10/2025 at 09:45 AM, the Physical Therapist stated he checks the oxygen concentrator and tubing each visit, and documenting room air was an error. C. Review of the Physical Therapy Visit Note dated 01/03/2025 revealed the following assessment: oxygen saturation level 99 percent on oxygen 2 (two) liters. During interview on 03/10/2025 at 09:48 AM, the Physical Therapist stated he checks the oxygen concentrator and tubing each visit, and documenting room air was an error. D. Review of the Physical Therapy Visit Note dated 01/07/2025 revealed the following assessment: oxygen saturation level 99 percent on oxygen 2 (two) liters. During interview on 03/10/2025 at 09:50 AM, the Physical Therapist stated he checks the oxygen concentrator and tubing each visit, and documenting room air was an error. E. Review of the Physical Therapy Visit Note dated 01/09/2025 revealed the following assessment: oxygen saturation level 99 percent on oxygen 2 (two)liters. During interview on 03/10/2025 at 09:50 AM, the Physical Therapist stated he checks the oxygen concentrator and tubing each visit, and documenting room air was an error. The agency failed to prepare and document complete and accurate clinical notes as evidenced by: Patient #16 – This 71-year-old patient with the diagnoses of venous insufficiency, lymphedema, and chronic ulcer of the left lower leg with fat layer exposed was admitted to the home care agency on 06/05/2022. A. Review of the Licensed Practical Nurse Visit Notes dated 11/29/2023 and 12/01/2023 revealed the following assessment: IV (intravenous) access: - Does patient have an IV access – yes - Indicate vascular access type – central line Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/24/2024 lacks an order for a central line. During interview on 03/07/2025 at 09:47 AM, the Registered Nurse, Clinical Manager stated the patient has a fistula that is only accessed at dialysis. There is information on the plan of care regarding the patient’s dialysis. B. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed “Skilled Nurse to perform/teach wound care to left upper leg…cleanse with vashe, apply santyl, then hydrofera blue, then foam. Change three times a week. Left buttocks… apply triad, apply foam, change three times a week using clean/aseptic technique.” Review of the Review of the Licensed Practical Nurse Visit Notes dated 11/29/2023 and 12/01/2023, and the Registered Nurse Visit Note dated 12/04/2023 revealed the Skilled Nurses copied and pasted the patient’s entire Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024, including information not pertinent to the wounds. The Skilled Nurses failed to document only what wound care was provided. During interview on 03/07/2025 at 10:00 AM, the IV (intravenous) and Pediatric Team Manager and Director of Operations stated the expectation is for the Skilled Nurses to only document exactly what wound care was provided. C. Review of the Registered Nurse Visit Note Dated 12/08/2023 revealed “(patient) states she is unable to use vashe. Need order for wound spray will clarify with wound medical doctor.” Review of the Registered Nurse Visit Note dated 12/11/2023 revealed the following wound care: Skilled Nurse to perform/teach wound care to left upper leg measures 12 centimeters x 7 centimeters x 0.2 centimeters left thigh wound orders: cleanse with vashe, apply santyl, then hydrofera blue, then foam. Change three (3) times a week. Using clean aseptic technique. Wound cleaned with vashe. Santyl applied to woundbed. Hydrafera blue applied over santyl. Fiam dressing applied and secured with clear tape.” During interview on 03/07/2025 at 10:05 AM, the Registered Nurse, Clinical Manager stated they did not use vashe but used wound spray. The documentation was copied and pasted and therefore does not reflect the wound care that was done. D. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed “Skilled Nurse to report weight gain of greater than three (3) lbs (pounds) in one (1) day or greater than five (5) lbs (pounds) in one (1) week.” Review of the Licensed Practical Nurse Visit Note dated 11/29/2023 revealed the patient weighed 209.5 lbs (pounds). Review of the Licensed Practical Nurse Visit Note dated 12/01/2023 revealed the patient weighed 293 lbs (pounds). During interview on 03/07/2025 at 10:23 AM the Director of Operations stated the weight of 209.5 lbs (pounds) was a typo.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of clinical records and interview with agency staff, for one (1) of four (4) patients receiving Home Health Aide (HHA) services (Patient #10), the agency failed to ensure the HHA is supervised at least every fourteen (14) days. Failure to provide adequate supervision of paraprofessional staff places patients at risk for negative outcomes and unmet patient needs. Patient #10- This 57-year-old patient with the diagnoses of neurogenic bowel, not elsewhere classified, quadriplegia, C5-C7 incomplete, and autonomic dysreflexia was admitted to the home care agency on 04/17/2017. Review of the Home Health Certification and Plan of Care for 01/05/2025 to 03/05/2025 revealed the order: “HHA seven (7) times per week for eight (8) weeks, four (4) times a week for one (1) week.” Review of the Registered Nurse Recertification Without Skill Visit Note dated 01/03/2025 revealed the Registered Nurse documented the following: Was a home health aide supervisory performed: Yes Indicate reason for supervisory visit: Direct supervision Review of the clinical record from 01/03/2025 to 03/05/2025 lacks documented evidence that the aide was supervised the week of 01/12/2025, 01/26/2025, 02/09/2025, and 02/23/2025. The clinical record lacks documented evidence of aide supervision every fourteen (14) days. During interview on 03/10/2025 at 10:17 AM, the Registered Nurse stated aide supervisions were not completed for those weeks. During interview on 03/10/2025 at 10:19 AM, the Director Branch Operations stated the aide supervisions are missing from the clinical record.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and staff interview, for two (2) of seventeen (17) patients (Patient #’s 8 and 16), the agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services. Failure to follow agency policies and procedures and ensure compliance with accepted professional standards has the potential to result in unmet patient needs and inadequate care. HV Patient #8- This 19-year-old patient with the diagnoses of acute leukemia of unspecified cell type not achieve remission, encounter for antineoplastic chemotherapy, and other acute pancreatitis without necrosis or infection was admitted to the home care agency on 12/23/2024. Review of the agency policy entitled “Laboratory Specimen Collection, Storage, Transportation and Requisitions” effective date 10/19/2021 revealed “Procedure: B. Double identify the patient (i.e., ask patient to state first and last name and date of birth…G. Collect specimen per the appropriate specimen collection procedure.” During an observational home visit on 03/05/2025 at 09:30 AM, this surveyor observed the Registered Nurse draw labs without double identifying the patient before the lab specimen was collected. During interview on 03/06/2025 at 02:51 PM, the Registered Nurse stated the patient’s identification should have been verified before the labs were collected. The agency failed to follow agency policies and procedures, current clinical practice guidelines and accepted professional standards when providing services as evidenced by: Review of the undated “Skin and Wound Care – Assessment: Wound” procedure revealed the following: “Wounds and patients change, therefore wounds need to be reassessed regularly and treated according to the changing needs of the patient and the wound: a. In home care, a professional reassessment of most wounds is indicated at least once a week. b. Reassessment and documentation of the wound should include: 1) Wound measurements.” Patient #16 – This 71-year-old patient with the diagnoses of venous insufficiency, lymphedema, and chronic ulcer of the left lower leg with fat layer exposed was admitted to the home care agency on 06/05/2022. A. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed “Skilled Nurse to perform/teach wound care to left upper leg…cleanse with vashe, apply santyl, then hydrofera blue, then foam. Change three times a week. Left buttocks… apply triad, apply foam, change three times a week using clean/aseptic technique.” Review of the clinical record from 11/26/2023 to 12/02/2023 and 12/03/2023 to 12/09/2023 lacks documented evidence of wound measurements for each week. During interview on 03/07/2025 at 10:21 AM, the Registered Nurse and Registered Nurse, IV (intravenous) and Pediatric Team Manager stated the wound was not measured during that time period, but it is expected they are done weekly. Review of the Home Health Certification and Plan of Care for 11/27/2023 to 01/25/2024 revealed “Skilled Nurse to assess and monitor patient’s pain level and effectiveness of pain control therapy. Skilled Nurse to report increase in pain level to physician for prompt intervention and instruct patient on pharmacologic and non-pharmacologic measures to mitigate pain such as distraction, imagery, deep breathing, relaxation, calming self-statements, and meditation.” B. Review of the undated “Pain Management – Assessment: Screening and Assessment” revealed the following: “Comprehensive pain assessment 1. Inquire and observe if the pain is affecting the patient’s ability to perform activities of daily living, including sleeping and activities that are meaningful to the patient. 1. Ask about physical characteristics of the pain: a. Location b. Intensity c. Quality d. Pattern e. Aggravating factors f. Alleviating factors g. Associated symptoms 2. Ask about the patient’s pain management plan: a. Pain medication b. Pain medication side effects c. Other treatments d. History of abuse 7. If patient has pain, take action to relieve the pain through a joint care planning meeting with the patient and the care team. Do not document the patient has pain and do nothing about it.” Review of the Registered Nurse Visit Note dated 12/04/2023 revealed the following pain assessment: - Are you having pain? Yes - Indicate the location of pain… type… and quality: bilateral lower extremity and back pain - Indicate the formalized pain scale selected to assess the patient’s pain: numeric rating scale - How would you rate your paint right now on scale of 0 (zero the least) to 10 (ten the worst)? 7 Review of the clinical record lacks documented evidence the Registered Nurse completed a full pain assessment per agency policy and lacks documented evidence the physician was notified. During interview on 03/07/2025 at 10:24 AM, the Director of Operations stated the assessment is incomplete and the clinician did not alert the physician of the patient’s pain level. C. Review of the Registered Nurse Visit Note dated 12/06/2023 revealed the following pain assessment: - Are you having pain? Yes - Indicate the location of pain… type… and quality: hips, joints - Indicate the formalized pain scale selected to assess the patient’s pain: numeric rating scale - How would you rate your paint right now on scale of 0 (zero the least) to 10 (ten the worst)? 9 Review of the clinical record lacks documented evidence the Registered Nurse completed a full pain assessment per agency policy and lacks documented evidence the physician was notified. During interview on 03/07/2025 at 10:26 AM, the Registered Nurse stated a message was left for the physician but there is no documentation of follow-up. D. Review of the Registered Nurse Visit Note dated 12/08/2023 revealed the following pain assessment: - Are you having pain? Yes - Indicate the location of pain… type… and quality: bilateral hip pain - Indicate the formalized pain scale selected to assess the patient’s pain: numeric rating scale - How would you rate your paint right now on scale of 0 (zero the least) to 10 (ten the worst)? 9 Review of the clinical record lacks documented evidence the Registered Nurse completed a full pain assessment per agency policy and lacks documented evidence the physician was notified. During interview on 03/07/2025 at 09:58 AM, the Director of Clinical Operations stated there is documented evidence of a call to the physician however it does not specify issues with pain. There is no documented evidence of follow-up with the patient’s pain. E. Review of the Registered Nurse Visit Note dated 12/11/2023 revealed the following pain assessment: - Are you having pain? Yes - Indicate the location of pain… type… and quality: spinal arthritis - Indicate the formalized pain scale selected to assess the patient’s pain: numeric rating scale - How would you rate your paint right now on scale of 0 (zero the least) to 10 (ten the worst)? 8 Review of the clinical record lacks documented evidence the Registered Nurse completed a full pain assessment per agency policy and lacks documented evidence the physician was notified. During interview on 03/07/2025 at 10:00 AM, the Director of Operations stated there is documented evidence of a call to the physician however it does not specify issues with pain. There is no documented evidence of follow-up with the patient’s pain.”