Gurwin Certified Home Health Agency

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on policy review and staff interview, the Governing Authority failed to develop a comprehensive Emergency Preparedness Program. This was evident in review of the “Emergency Disaster Plan”. Failure to establish a comprehensive Emergency Disaster Plan, has the potential for negative patient outcomes. 1)The “Emergency Disaster Plan” dated 12/2024 lacks documented evidence of an alternate means for communication with the agency’s staff and local emergency management agencies. Interviews were conducted with the Director of Home Care and Director of Patient Services on 06/26/2025 at 12:00 PM, no additional information was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to obtain consent for planned services prior to initiation of care. This was evident in seven (7) of thirteen (13) records reviewed (Patients#1, #2, #4, #6, #7, #10, #11). Failure to ensure that patients consent to planned services and care, has the potential for negative patient outcomes. 1) Patient #4 has a start of care date of 06/04/2025 with diagnoses of “Hypertensive Chronic Kidney Disease, Unspecified Hydronephrosis, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Anemia in Chronic Kidney Disease as documented in the Plan of Care” for certification period 06/04/2025 thru 08/02/2025. The “Plan of Care” for certification period 06/04/2025 thru 08/02/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 7 (seven) weeks. Physical Therapy 2 (two) encounters every week for 4 (four) weeks, Occupational Therapy 2 (two) encounters for 4 (four) weeks, and Home Health Aide 1 - 2 (one to two) encounters every week for 5 (five) weeks”. The “Patient Consent” for services dated 06/04/2025 lack documented evidence of the Skilled Nurse, Physical Therapy, Occupational Therapy, and Home Health Aide services, visit frequency and duration of visits/encounters. The Agency did not obtain patient consent for all services/disciplines that will furnish the care and the frequency of visits/encounters. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/24/25 at 03:20 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 2) Patient #6 has a start of care date of 05/27/2025 with diagnoses of “Other specified Disorder of Brain, Metabolic Encephalopathy, Hypothyroidism, and Major Depressive Disorder as documented the Plan of Care” for certification period 05/27/2025 thru 07/25/2025. The “Plan of Care” for certification period 05/27/2025 thru 07/25/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 7 (seven) weeks. Physical Therapy 2 (two) encounters every week for 6 (six) weeks, and Occupational Therapy 1 (one) encounter every week for 1 (one) week, 2 (two) encounters for 4 (four) weeks”. The “Patient Consent” for services dated 05/27/2025 lack documented evidence of the Skilled Nurse, Physical Therapy, Occupational Therapy services, visit frequency and duration of visits/encounters. The Agency did not obtain patient consent for all services/disciplines that will furnish the care and the frequency of visits/encounters. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:44 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 3) Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the Plan of Care” for certification period 06/05/2025 thru 08/03/2025. The “Plan of Care” for certification period 06/05/2025 thru 08/03/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 8 (eight) weeks. Physical Therapy 2 (two) encounters every week for 4 (four) weeks, and Occupational Therapy 2 (two) encounters for 4 (four) weeks”. The “Patient Consent” for services dated 06/05/2025 lack documented evidence of the Skilled Nurse, Physical Therapy, ad Occupational Therapy services, visit frequency and duration of visits/encounters. The Agency did not obtain patient consent for all services/disciplines that will furnish the care and the frequency of visits/encounter. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 4) Patient #11 has a start of care date of 04/16/2025 with diagnoses of “Encounter for surgical aftercare following surgery of the circulatory system, Atherosclerotic Heart Disease, Hypertensive Heart Disease with Heart Failure, and Unspecified Diastolic Heart Failure as documented in the Plan of Care” for certification period 04/16/2025 thru 06/14/2025. The “Plan of Care” for certification period 04/16/2025 thru 06/14/2025 documents an order for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 8 (eight) weeks”. The “Patient Consent” for services dated 04/16/2025 lack documented evidence of the Skilled Nurse services, visit frequency and duration of visits/encounters. The Agency did not obtain patient consent for all services/disciplines that will furnish the care and the frequency of visits. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:54PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 5).Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “ Skilled Nursing- one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” The” Patient Consent” dated 5/24/2025 lacks documented evidence of the frequency of discipline services. 6).Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” certification period 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “ Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The” Patient Consent” dated 6/12/2025 lacks documented evidence of the frequency of discipline services. 7).Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025 then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The” Patient Consent” dated 4/10/2025 lacks documented evidence of the frequency of discipline services. The Agency failed to inform the patient of the frequency of discipline visits prior to the initiation of care. On 6/26/2025 at 4:30pm findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare Operations and the Administrator. Findings acknowledged and no further explanation was given.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on clinical record review and staff interview, the Governing Authority failed to inform patients of payments in writing, and the extent such charges may be expected prior to the initiation of care. This was evident in the review of three (3) of thirteen (13) records. (Patients #1,#2, and #10). Failure to inform patients of the extent to which payment will be expected has the potential for negative patients outcome. Findings are: 1) Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (Certified Home Health Agency) Skilled Nursing- one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” The” Patient Consent” dated 5/24/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. 2) Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The “Patient Consent” dated 6/12/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. 3) Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025, then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The “Patient Consent” dated 4/10/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. The Agency failed to inform the patient of which payment the Agency services may be expected and the charges for service that may not be covered by the Medicare, Medicaid or any other federally funded or federal aid program known to the Agency. 1) Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (Certified Home Health Agency) Skilled Nursing- one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” The” Patient Consent” dated 5/24/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. 2) Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The “Patient Consent” dated 6/12/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. 3) Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025, then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The “Patient Consent” dated 4/10/2025 lacks documented evidence that the patient was informed of their financial liability prior to the initiation of care. The Agency failed to inform the patient of which payment the Agency services may be expected and the charges for service that may not be covered by the Medicare, Medicaid or any other federally funded or federal aid program known to the Agency. On 6/26/2025 at 4:30PM findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare Operations and the Administrator. Findings acknowledged and no further explanation was given.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to inform patients of Federal and State-funded entities serving areas where patients reside. This was evident in the review of two (2) of thirteen (13) records. (Patients #8,#9). Failure to ensure patients have access to federally-funded and State-funded services has the potential for negative patient outcomes. Findings are: 1) Patient #8 has a start of care date of 04/21/2025 with diagnoses of “Left lower leg Cellulitis, End Stage Renal Disease and Lymphedema” as documented on the “Plan of Care” certification period, 04/21/2025 to 06/19/2025. Patient was discharged on 05/16/2025. The “Plan of Care” for certification period 04/21/2025 to 06/19/2025 documents order for discipline and treatment: “Skilled Nursing two (2) encounters every week for one (1) week. One encounter every week for eight weeks and four encounters as needed for nine weeks.” The “Consent Acknowledgment and Release” form signed by patient on 04/21/2025 failed to fully inform patients of their rights to access Federal and State-funded resources. The findings and interview were conducted with the Director of Patient Services, the Administrator and the Director of Home Care on 06/25/2025 at 02:10PM. No explanation was provided. 2) Patient #9 has a start of care date of 11/23/2024 with diagnoses of “Chronic Obstructive Pulmonary Disease, Chronic Kidney disease stage-3, Diabetes Mellitus and Hyperglycemia” as documented on the “Plan of Care” for certification period 01/22/2025 to 03/22/2025. The “Plan of Care” for certification period 01/22/2025 to 03/22/2025 document order for discipline “Skilled Nursing one (1) encounter every week for three (3) weeks. Physical Therapy one encounter every week for three (3) weeks. Occupational Therapy one encounter every week for (4) four weeks.” The “Consent Acknowledgment and Release” form signed by patient on 11/23/2024 failed to fully inform patients of their rights to access Federal and State-funded resources. The findings and interview were conducted with the Director of Patient Services, the Administrator and the Director of Home Care on 06/25/2025 at 02: 20PM.No explanation was provided.”

“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 clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient. This was evident in four (4) of thirteen (13) records. (Patients #1, #2, #10 and #12). Failure to develop a comprehensive POC has the potential for negative patient outcomes. The findings are: 1) Patient #3 has a start of care date of 03/24/2025 with diagnoses of “Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Acute/Chronic Kidney Disease, Acute Respiratory Failure with Hypoxia, Atrial Fibrillation and Sepsis” as documented on the “Plan of Care” for certification period 05/23/2025 to 07/21/2025. The “Plan of Care” for certification periods 03/24/2025 to 05/22/2025 and 05/23/2025 to 07/21/2025 documents orders for “Skilled Nurse (SN) 1 encounter for every week for 8 weeks and w encounters every week for 7 weeks, Physical Therapy 1 encounter every week for 3 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounter every week for 4 weeks.”. The “Skilled Nurse” visits notes dated 04/24/2025 documented “edema to bilateral lower legs persist, has doctor appointment in two days for follow-up. Instructions on Lasix, increased S/S of dizziness due to low blood pressure, instructed on daily weight, if more than two-pound weight gain must seek MD evaluation”. The “Skilled Nurse” visits notes dated 05/01/2025 documented “patient Systolic blood pressure 148 during visit, spoke with Nurse Practitioner from the Cardiology office who noted patient is on Midodrine, she added parameters and order patient not to take medication if Systolic blood pressure is greater than 110”. The visit note lacked documented evidence of coordination of care with Case Manager. The Plan of Care lacked documented evidence Skilled Nurse responsibility on teaching patient/caregiver on weight parameters, signs to report to nurse and doctor and blood pressure parameters for medication administration. An interview was conducted on 06/25/2025 at 4pm with the Director of Patient Service and acknowledge findings. 2) Patient #12 has a start of care date of 04/02/2025 with diagnoses of Pressure ulcer of sacral region, stage 4, Pressure-induced deep tissue damage of let hip, Pressure ulcer of right lower back unstageable, Traumatic Subdural Hemorrhage, Sepsis, Urinary Tract Infection Paraplegia, Multiple Sclerosis and Benign Prostatic Hyperplasia” as documented on the “Plan of Care” for certification period 06/01/2025 - 07/30/2025. The “ Plan of Care” for certification period 06/01/2025 - 07/30/2025 documents an order for “Skilled Nurse (SN) 2 encounters every week for 10 weeks and 4 encounters as needed for 10 weeks for change in condition, skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. Wound care for deep tissue injury to right hip and left hip deep tissue injury to be done daily and as needed if integrity is compromised, cleanse with normal saline, apply Santyl to wound bed and cover with adhesive dressing, and unstageable pressure ulcer to sacrum to be done daily and as needed (PRN), cleanse with Darkin solution, irrigate tunneling with normal saline, apply Santyl and Hydrofera blue, fill with protective dressing , peri-wound with skin prep and cover with clean padded Tegaderm. Urologist managing foley maintenance and foley changes”. The “Plan of Care” dated 04/02/2025 to 05/31/2025 documents diagnosis of “Pressure ulcer of sacral region unstageable” orders for “Skilled Nurse (SN): 1 encounter every week for one week from 04/02/25 to 04/06/25 2 encounters every week for 1 week 04/07/25 to 04/13/25 1 encounter every week for 1 week, I encounter every week for 9 weeks 4/14/25 to 5/31/25 and 4 encounters as needed for 11 weeks. Skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. May apply normal saline if dressing supplies unavailable. Physical therapy :1 encounter every week for 1 week 4/2/25 2 encounters every week for 3 weeks 4/7/25 to 4/27/25. Occupational therapy: 1encounter every week for 1week 4/7/25 to 4/13/25, 2 encounters every week for 4 weeks 4/14/25 to 5/11/25. The “Skilled nurse Oasis” visit notes dated 04/02/25 documents “patient recently hospitalized for urinary tract infection (UTI) and subdural hemorrhage, referred for home care services for disease management, skilled nursing, physical and occupational therapy. Urinary catheter in place, refuse inspection, states “doctor takes care of foley maintenance”. Patient has unstageable pressure ulcer to sacrum 5 cm/3cm/0.3cm, as per doctor’s orders wound is treated with Santyl daily”. The “Plan of Care” dated 04/02/2025 to 05/31/2025 lacked documented evidence of wound care orders for Santyl and Urology for foley management. An interview was conducted on 06/27/25 at 1pm with the Director of Patient Services and acknowledge findings. Survey findings reviewed with the Administrator and Director of Patient Services on 06/27/2025 at 04:35 PM, no additional explanation was provided. 3).Patient #1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (certified home health agency) Skilled Nursing- one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” The record lacks documented evidence of the patient’s risk for emergency department visits, hospital readmission and necessary interventions to address these risk factors. 4).Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents the patient medication as “Eliquis oral tablet 5 milligrams, two (2) times per day and a diagnosis of Long-Term Current Use of Anticoagulants.” The record lacks documented evidence of the patient’s bleeding precautions, the patient’s risk for emergency department visits, hospital readmission and necessary interventions to address these risk factors. 5).Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025 then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The record lacks documented evidence of the patient’s risk for emergency department visits, hospital readmission and necessary interventions to address these risk factors. The Agency failed to ensure the patient’s individualized plan of care includes patient specific safety measures to protect them against injury and a description of the patient’s risk for emergency department visits, hospital re-admission, and all necessary interventions to address underlying risk factors. On 6/26/2025 at 4:30pm findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare and the Administrator. Findings acknowledged and no further explanation was given.”

“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 clinical record review and staff interview, the Agency failed to provide treatment and services in accordance with Physician Orders. This was evident in one (1) of thirteen (13) records reviewed. (Patient #12). Failure to provide treatment and services in accordance with the Plan of Care, has the potential for negative patient outcome. Findings are: Patient #12 has a start of care date of 04/02/2025 with diagnoses of Pressure ulcer of sacral region stage 4, Pressure-induced deep tissue damage of let hip, Pressure ulcer of right lower back unstageable, Traumatic Subdural Hemorrhage, Sepsis, Urinary Tract Infection Paraplegia, Multiple Sclerosis and Benign Prostatic Hyperplasia” as documented on the “Plan of Care” for certification period 06/01/2025 - 07/30/2025. The “Plan of Care” dated 04/02/2025 to 05/31/2025 documents diagnosis of “Pressure ulcer of sacral region unstageable” orders for “Skilled Nurse (SN): 1 encounter every week for one week from 04/02/25 to 04/06/25 2 encounters every week for 1 week 04/07/25 to 04/13/25 1 encounter every week for 1 week, I encounter every week for 9 weeks 04/14/25 to 05/31/25 and 4 encounters as needed for 11 weeks. Skilled nurse to change dressing on each visit to assess wound, notify MD (medical doctor) if pain is not controlled by medication, patient and/caregiver to demonstrate competency. May apply normal saline if dressing supplies unavailable. Physical therapy :1 encounter every week for 1 week 4/2/25 2 encounters every week for 3 weeks 04/7/25 to 04/27/25. Occupational therapy: 1 encounter every week for 1 week 04/07/25 to 04/13/25, 2 encounters every week for 4 weeks 04/14/25 to0 5/11/25. The “Skilled nurse” visit notes dated 04/07/2025, 04/10/2025 and 04/14/2025 lacked documented evidence pain assessment and wound care. The Agency did not provide pain assessment and wound care treatment services as ordered by the Physician. An interview was conducted on 06/27/25 at 1pm with the Director of Patient Services and acknowledged the nurse was not providing treatment as ordered. The Director of Patient Services (DPS) stated “the nurse was terminated when we found out that the patient had developed two more pressure ulcers, and the sacral ulcer had gotten worse and now tunneling.” Survey findings were reviewed with the Administrator and Director of Patient Services on 06/27/2025 at 04:35 PM, no additional explanation was provided.”

“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 clinical record review and staff interview, the Agency failed to promptly alert the Physician of changes in patient’s status. This was evident in one (1) of thirteen (13) records reviewed (Patient #7). Failure to promptly alert the Physician of changes in patient status, has the potential for negative patient outcomes. 1) Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the Plan of Care” for certification period 06/05/2025 through 08/03/2025. The “Plan of Care” for certification period 06/05/2025 thru 08/03/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 8 (eight) weeks. Physical Therapy 2 (two) encounters every week for 4 (four) weeks, and Occupational Therapy 2 (two) encounters for 4 (four) weeks”. The clinical visit note dated 06/10/2025, the Occupational Therapist documents that the patient “complaints of pain in right leg, especially last night when she rated pain 10/10 (ten out of ten) she is taking Tylenol for pain”. The clinical visit note dated 06/12/2025, the Occupational Therapist documents the patient “complaints of pain in right knee, rated pain 8/10 (eight out of ten) she is taking Tylenol for pain”. There is no documented evidence of Physician’s notification of the patient’s high pain level. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care.”

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on home visit observation, clinical record review and staff interview, the Governing Authority failed to inform physician of a change patient’s health status requiring revision to plan of care. This was evident in one (1) of thirteen (13) records reviewed. (Patient #1). Failure to update plan of care due to a change in patient’s health status has the potential for negative patient outcome. 1).Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” certification period 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “ Skilled Nursing- one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” A home visit was conducted on 6/25/2025 at 10:00am with the Agency Registered Nurse (RN). Medication reconciliation found that the patient has been receiving Lasix oral tablet, 40 milligrams daily with a start date of 6/13/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 and the “Patient Medication List” that was printed for this survey on 6/24/2025 documents the patient medication as Lasix oral tablet, 20 milligrams daily with a start date of 5/24/2025. The record lacks documented evidence of a progress note or interim order addressing the change in the Lasix dosage. The Agency failed to ensure that any revision to the plan of care was communicated to all disciplines issuing orders for this patient. On 6/26/2025 at 4:30pm findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare Operations and the Administrator. Findings acknowledged and the DPS states she was unaware of the medication change and will update the patient record. No further explanation was given.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure coordination of patient care among all clinicians. This was evident in seven (7) of thirteen (13) records reviewed.(Patients #1,#2,#3,#5,#7,#10,and #12). Failure to ensure coordination of care has the potential for negative patient outcomes. 4).Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the “Plan of Care” for certification period 06/05/2025 thru 08/03/2025. The “Plan of Care” for certification period 06/05/2025 thru 08/03/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 8 (eight) weeks. Physical Therapy 2 (two) encounters every week for 4 (four) weeks, and Occupational Therapy 2 (two) encounters for 4 (four) weeks”. The clinical visit note dated 06/06/2025, the Occupational Therapist documents that the patient “rated pain 5/10 (five out of ten) at rest and 8/10 (eight out of ten) with movement. Screamed out while transferring from wheelchair to chair”. The clinical visit note dated 06/07/2025, the Occupational Therapist documents that the patient “complaints of pain in right knee rates pain 4/10 (four out of ten) she is taking Tylenol for the pain”. The clinical visit note dated 06/10/2025, the Occupational Therapist documents that the patient “complaints of pain in right leg, especially last night when she rated pain 10/10 (ten out of ten) she is taking Tylenol for pain”. The clinical visit note dated 06/12/2025, the Occupational Therapist documents that the patient “complaints of pain in right knee, rated pain 8/10 (eight out of ten) she is taking Tylenol for pain”. There is no documented evidence of coordination of care among the Occupational Therapist and the Skilled Nurse related to the patient’s pain management. The Agency did not ensure coordination of care among all services and disciplines. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 1) Patient #3 has a start of care date of 03/24/2025 with diagnoses of “Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Acute/Chronic Kidney Disease, Acute Respiratory Failure with Hypoxia, Atrial Fibrillation and Sepsis” as documented on the “Plan of Care” for certification period 05/23/2025 to 07/21/2025. The “Plan of Care” for certification periods 03/24/2025 to 05/22/2025 and 05/23/2025 to 07/21/2025 documents orders for “Skilled Nurse (SN) 1 encounter for every week for 8 weeks and with encounters every week for 7 weeks, Physical therapy 1 encounter every week for 3 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounter every week for 4 weeks”. The “Skilled Nurse” visits notes doted 04/24/2025 documents “edema to biliteral lower legs persist, doctor’s appointment in two days for follow-up instructions on Lasix increased and signs and symptoms of dizziness due to low blood pressure, instructed on weigh daily, if more than two-pound weight gain must seek MD evaluation”. The visit note lacked documented evidence of coordination and communication of care with Case Manager. The “Skilled Nurse” visits notes doted 05/01/2025 documents “patient systolic blood pressure 148 during visit, spoke with Nurse Practitioner from the Cardiology office who noted patient is on Midodrine, she added parameters and order patient not to take medication is Systolic blood pressure is greater than 110”. The visit note lacked documented evidence of coordination and communication of care with Case Manager. The “Skilled Nurse” visit notes dated 03/27/2025, 04/24/2025, 04/14/2025, 04/09/2025, 05/01/2025, 05/07/2025, 05/17/2025, 05/20/2025 06/02//2025, 06/12/2025, 06/16/2025, 06/18/2025 and 06/20/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” notes dated 03/26/2025, 03/28/2025, 04/02/2025, 04/10/2025, 04/17/2025, 04/30/2025, 05/06/2025, 05/19/2025 05/21/2025, 05/28/2025, 06/04/2025 and 06/16/2025 lacked documented evidence of coordination of care with Skilled Nurse and Case Manager. The “Occupational Therapy” visit notes dated 03/31/2025, 04/02/2025, 04/08/2025, 04/10/2025, 04/15/2025, 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/19/2025, 06/05/2025, lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapy. There is no documented evidence of communication or coordination of care between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. 2) Patient #5 has a start of care date of 06/13/2025 with diagnoses of “Malignant Neoplasm of brain, right Bronchus and Nervous system, drug-induced Polyneuropathy and Atherosclerotic Heart Disease” as documented on the “Plan of Care” for certification period 06/13/2025 to 08/11/2025. The “Plan of Care” for certification period 06/13/2025 to 08/11/2025 documents orders for “Skilled Nurse (SN) 1 encounter for 1 week, 2 encounters every week for 1 weeks, 1 encounter every week for 7 weeks and 4 encounters as needed for 9 weeks for change in oasis”, Physical therapy 2 encounters every week for 4 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounter every week for 4 weeks. Aide 1- 2 encounters every week for 5 weeks”. The “Skilled Nurse” visits notes dated 06/18/2025 and 06/20/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” visit note dated 06/18/2025 lacked documented evidence of coordination of care with Skilled Nurse. The “Occupational Therapy” visit note dated 06/20/2025 lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapist. There is no documented evidence of communication and coordination of care between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. 3) Patient #12 has a start of care date of 04/02/2025 with diagnoses of “Pressure ulcer of sacral region stage 4, Pressure-induced deep tissue damage of let hip, Pressure ulcer of right lower back unstageable, Traumatic Subdural Hemorrhage, Sepsis, Urinary Tract Infection Paraplegia, Multiple Sclerosis and Benign Prostatic Hyperplasia” as documented on the “Plan of Care” for certification period 06/01/2025 - 07/30/2025. The “ Plan of Care” for certification period 06/01/2025 - 07/30/2025 documents an order for “Skilled Nurse (SN) 2 encounters every week for 10 weeks and 4 encounters as needed for 10 weeks for change in condition, skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. Wound care for deep tissue injury to right hip and left hip deep tissue injury to be done daily and as needed if integrity is compromised, cleanse with normal saline, apply Santyl to wound bed and cover with adhesive dressing, and unstageable pressure ulcer to sacrum to be done daily and as needed (PRN), cleanse with Darkin solution, irrigate tunneling with normal saline, apply Santyl and Hydrofera blue fill with protective, peri-wound with skin prep and cover with clean padded Tegaderm. Urologist managing foley maintenance and foley changes”. The “Skilled Nurse” visit notes dated 04/07/2025, 04/10/3025 and 04/14/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” visit notes dated 04/04/2025, 4/07/2025, 04/10/2025, 04/17/2025 and 04/24/2025 lacked documented evidence of coordination of care with Skilled Nurse. The “Occupational Therapy” visit notes dated 04/15/2025, 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/06/2025, 05/08/2025, 05/13/2025, 05/15/2025, 05/20/2025, 0527/2025, 05/29/202506/05/2025 and 06/12/2025 lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapist. There is no documented evidence of communication between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. An interview was conducted on 06/27/25 at 1pm with the Director of Patient Services and acknowledge findings. Survey findings were reviewed with the Administrator and Director of Patient Services on 06/27/2025 at 04:35 PM, no additional explanation was provided 5) Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (certified home health agency) Skilled Nursing (SN) - one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy (PT) two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy (OT) one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” A home visit was conducted on 6/25/2025 at 10:00am at the patient’s assisted living facility, with the Agency Registered Nurse (RN). Medication reconciliation found that the patient has been receiving Lasix oral tablet, 40 milligrams daily with a start date of 6/13/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 and the “Patient Medication List” that was printed for this survey on 6/24/2025 documents the patient medication as Lasix oral tablet, 20 milligrams daily with a start date of 5/24/2025. The record lacks documented evidence of a progress note or interim order addressing the change in the Lasix dosage and each discipline coordinating care delivery and activities among all care givers. · SN: missing coordination of care for the following visit dates: 5/28/2025, 5/30/2025, 6/2/2025, 6/10/2025, 6/20/2025 · PT: missing coordination of care for the following visit dates: 6/2/2025, 6/6/2025, 6/9/2025, 6/11/2025, 6/16/2025, 6/18/2025 · OT: missing coordination of care for the following visit dates: 6/2/2025, 6/6/2025, 6/9/2025, 6/11/2025, 6/17/2025, 6/20/2025 6) Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The record lacks documented evidence of each discipline coordinating care delivery and activities among all care givers: · Skilled Nursing: missing coordination of care for the following visit dates: 6/18/2025. · Physical Therapy: missing coordination of care for the following visit dates: 6/23/2025. · Speech Language Pathology : missing coordination of care for the following visit dates: 6/20/2025. 7) Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025 then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The record lacks documented evidence of each discipline coordinating care delivery and activities among all care givers. · Skilled Nursing: missing coordination of care for the following visit dates: 4/25/2025, 5/1/2025, 5/9/2025, 5/15/2025, 5/21/2025, 5/27/2025, 6/18/2025 · Physical Therapist: missing coordination of care for the following visit dates: 4/12/2025, 4/14/2025, 4/17/2025, 4/23/2025, 4/29/2025, 5/1/2025, 5/9/2025, 5/15/2025, 5/17/2025 · Occupational Therapist: missing coordination of care for the following visit dates: 4/16/2025 On 6/26/2025 at 4:30pm findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare Operations and the Administrator. Findings acknowledged and no further explanation was given. 1) Patient # 1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (certified home health agency) Skilled Nursing (SN) - one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy (PT) two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy (OT) one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” A home visit was conducted on 6/25/2025 at 10:00am at the patient’s assisted living facility, with the Agency Registered Nurse (RN). Medication reconciliation found that the patient has been receiving Lasix oral tablet, 40 milligrams daily with a start date of 6/13/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 and the “Patient Medication List” that was printed for this survey on 6/24/2025 documents the patient medication as Lasix oral tablet, 20 milligrams daily with a start date of 5/24/2025. The record lacks documented evidence of a progress note or interim order addressing the change in the Lasix dosage and each discipline coordinating care delivery and activities among all care givers. SN: missing coordination of care for the following visit dates: 5/28/2025, 5/30/2025, 6/2/2025, 6/10/2025, 6/20/2025 PT: missing coordination of care for the following visit dates: 6/2/2025, 6/6/2025, 6/9/2025, 6/11/2025, 6/16/2025, 6/18/2025 OT: missing coordination of care for the following visit dates: 6/2/2025, 6/6/2025, 6/9/2025, 6/11/2025, 6/17/2025, 6/20/2025 2) Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The record lacks documented evidence of each discipline coordinating care delivery and activities among all care givers: Skilled Nursing: missing coordination of care for the following visit dates: 6/18/2025. Physical Therapy: missing coordination of care for the following visit dates: 6/23/2025. Speech Language Pathology: missing coordination of care for the following visit dates: 6/20/2025. 3) Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025 then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The record lacks documented evidence of each discipline coordinating care delivery and activities among all care givers. Skilled Nursing: missing coordination of care for the following visit dates: 4/25/2025, 5/1/2025, 5/9/2025, 5/15/2025, 5/21/2025, 5/27/2025, 6/18/2025 Physical Therapist: missing coordination of care for the following visit dates: 4/12/2025, 4/14/2025, 4/17/2025, 4/23/2025, 4/29/2025, 5/1/2025, 5/9/2025, 5/15/2025, 5/17/2025 Occupational Therapist: missing coordination of care for the following visit dates: 4/16/2025 Interview conducted and findings were reviewed with the Director of Patient Services and the Director of Home Care On 6/26/2025 at 4:00PM. Findings acknowledged. 4) Patient #3 has a start of care date of 03/24/2025 with diagnoses of “Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Acute/Chronic Kidney Disease, Acute Respiratory Failure with Hypoxia, Atrial Fibrillation and Sepsis” as documented on the “Plan of Care” for certification period 05/23/2025 to 07/21/2025. The “Plan of Care” for certification periods 03/24/2025 to 05/22/2025 and 05/23/2025 to 07/21/2025 documents orders for “Skilled Nurse (SN) 1 encounter for every week for 8 weeks and with encounters every week for 7 weeks, Physical therapy 1 encounter every week for 3 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounter every week for 4 weeks”. The “Skilled Nurse” visits notes doted 04/24/2025 documents “edema to biliteral lower legs persist, doctor’s appointment in two days for follow-up instructions on Lasix increased and signs and symptoms of dizziness due to low blood pressure, instructed on weigh daily, if more than two-pound weight gain must seek MD evaluation”. The visit note lacked documented evidence of coordination and communication of care with Case Manager. The “Skilled Nurse” visits notes doted 05/01/2025 documents “patient systolic blood pressure 148 during visit, spoke with Nurse Practitioner from the Cardiology office who noted patient is on Midodrine, she added parameters and order patient not to take medication is Systolic blood pressure is greater than 110”. The visit note lacked documented evidence of coordination and communication of care with Case Manager. The “Skilled Nurse” visit notes dated 03/27/2025, 04/24/2025, 04/14/2025, 04/09/2025, 05/01/2025, 05/07/2025, 05/17/2025, 05/20/2025 06/02//2025, 06/12/2025, 06/16/2025, 06/18/2025 and 06/20/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” notes dated 03/26/2025, 03/28/2025, 04/02/2025, 04/10/2025, 04/17/2025, 04/30/2025, 05/06/2025, 05/19/2025 05/21/2025, 05/28/2025, 06/04/2025 and 06/16/2025 lacked documented evidence of coordination of care with Skilled Nurse and Case Manager. The “Occupational Therapy” visit notes dated 03/31/2025, 04/02/2025, 04/08/2025, 04/10/2025, 04/15/2025, 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/19/2025, 06/05/2025, lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapy. There is no documented evidence of communication or coordination of care between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. 5) Patient #5 has a start of care date of 06/13/2025 with diagnoses of “Malignant Neoplasm of brain, right Bronchus and Nervous system, drug-induced Polyneuropathy and Atherosclerotic Heart Disease” as documented on the “Plan of Care” for certification period 06/13/2025 to 08/11/2025. The “Plan of Care” for certification period 06/13/2025 to 08/11/2025 documents orders for “Skilled Nurse (SN) 1 encounter for 1 week, 2 encounters every week for 1 weeks, 1 encounter every week for 7 weeks and 4 encounters as needed for 9 weeks for change in oasis”, Physical therapy 2 encounters every week for 4 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounter every week for 4 weeks. Aide 1- 2 encounters every week for 5 weeks”. The “Skilled Nurse” visits notes dated 06/18/2025 and 06/20/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” visit note dated 06/18/2025 lacked documented evidence of coordination of care with Skilled Nurse. The “Occupational Therapy” visit note dated 06/20/2025 lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapist. There is no documented evidence of communication and coordination of care between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. 6) Patient #12 has a start of care date of 04/02/2025 with diagnoses of “Pressure ulcer of sacral region stage 4, Pressure-induced deep tissue damage of let hip, Pressure ulcer of right lower back unstageable, Traumatic Subdural Hemorrhage, Sepsis, Urinary Tract Infection Paraplegia, Multiple Sclerosis and Benign Prostatic Hyperplasia” as documented on the “Plan of Care” for certification period 06/01/2025 - 07/30/2025. The “ Plan of Care” for certification period 06/01/2025 - 07/30/2025 documents an order for “Skilled Nurse (SN) 2 encounters every week for 10 weeks and 4 encounters as needed for 10 weeks for change in condition, skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. Wound care for deep tissue injury to right hip and left hip deep tissue injury to be done daily and as needed if integrity is compromised, cleanse with normal saline, apply Santyl to wound bed and cover with adhesive dressing, and unstageable pressure ulcer to sacrum to be done daily and as needed (PRN), cleanse with Darkin solution, irrigate tunneling with normal saline, apply Santyl and Hydrofera blue fill with protective, peri-wound with skin prep and cover with clean padded Tegaderm. Urologist managing foley maintenance and foley changes”. The “Skilled Nurse” visit notes dated 04/07/2025, 04/10/3025 and 04/14/2025 lacked documented evidence of coordination of care with Case Manager. The “Physical Therapy” visit notes dated 04/04/2025, 4/07/2025, 04/10/2025, 04/17/2025 and 04/24/2025 lacked documented evidence of coordination of care with Skilled Nurse. The “Occupational Therapy” visit notes dated 04/15/2025, 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/06/2025, 05/08/2025, 05/13/2025, 05/15/2025, 05/20/2025, 0527/2025, 05/29/202506/05/2025 and 06/12/2025 lacked documented evidence of coordination of care with Skilled Nurse and Physical Therapist. There is no documented evidence of communication between the Occupational Therapy, Physical Therapy, and the Skilled nurse regarding patient care. There is no documented evidence of ongoing interdisciplinary communication between the Occupational Therapy, Physical Therapy and Skilled Nurse (SN) to meet the patient’s needs. An interview was conducted on 06/27/25 at 1pm with the Director of Patient Services and acknowledge findings. Survey findings were reviewed with the Administrator and Director of Patient Services on 06/27/2025 at 04:35 PM, no additional explanation was provided 7). Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the “Plan of Care” for certification period 06/05/2025 thru 08/03/2025. The “Plan of Care” for certification period 06/05/2025 thru 08/03/2025 documents orders for “Skilled Nurse 1 (one) encounter every week for 1 (one) week, 4 (four) encounters as needed for 9 (nine) weeks, 2 (two) encounters every week for 1 (one) week, 1 encounter every week for 8 (eight) weeks. Physical Therapy 2 (two) encounters every week for 4 (four) weeks, and Occupational Therapy 2 (two) encounters for 4 (four) weeks”. The clinical visit note dated 06/06/2025, the Occupational Therapist documents that the patient “rated pain 5/10 (five out of ten) at rest and 8/10 (eight out of ten) with movement. Screamed out while transferring from wheelchair to chair”. The clinical visit note dated 06/07/2025, the Occupational Therapist documents that the patient “complaints of pain in right knee rates pain 4/10 (four out of ten) she is taking Tylenol for the pain”. The clinical visit note dated 06/10/2025, the Occupational Therapist documents that the patient “complaints of pain in right leg, especially last night when she rated pain 10/10 (ten out of ten) she is taking Tylenol for pain”. The clinical visit note dated 06/12/2025, the Occupational Therapist documents that the patient “complaints of pain in right knee, rated pain 8/10 (eight out of ten) she is taking Tylenol for pain”. There is no documented evidence of coordination of care among the Occupational Therapist and the Skilled Nurse related to the patient’s pain management. The Agency did not ensure coordination of care among all services and disciplines. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review and staff interview, the Governing Authority failed to ensure skilled professionals involved in patient care perform complete assessment and engage in interdisciplinary discussions regarding patients’ health status, recommendations and changes to the plan of care. These was evident in four (4) of thirteen (13) patient records reviewed. (Patients #1,#2, #4, #10). Failure to establish an ongoing interdisciplinary assessment of patient has the potential for negative patient outcome. 1) Patient #1 has a start of care date of 5/24/2025 with diagnoses of “Lymphedema, Moderate Protein-calorie Malnutrition, Essential Primary Hypertension, Pulmonary Hypertension, Hyperthyroidism, Dementia, Hearing Loss, Gastro-esophageal Reflux, Osteoarthritis, Osteoporosis, and Urinary Incontinence” as documented on the “Plan of Care” dated 05/24/2025 to 07/22/2025. The “Plan of Care” dated 05/24/2025 to 07/22/2025 documents “CHHA (certified home health agency) Skilled Nursing (SN) - one (1) encounter every week for one week: 5/24/2025 to 5/25/2025, four (4) encounters as needed for nine (9) weeks for changes in health status: 5/24/2025 – 7/20/2025, two (2) encounters every week for one (1) week: 6/5/26/2025 to 6/1/2025, and then one (1) encounter every week for six (6) weeks: 6/2/2025 to 7/22/2025. CHHA Physical Therapy two (2) encounters every week for three (3) weeks: 6/2/2025 to 6/22/2025, and CHHA Occupational Therapy one (1) encounter every week for one (1) week: 5/26/2025 to 6/1/2025, then two (2) encounters every week for four (4) weeks: 6/2/2025 to 6/29/2025.” The record lacks documented evidence of communication among the interdisciplinary team regarding the patients’ health status. 2) Patient # 2 has a start of care date of 6/12/2025 with diagnoses of “Aphasia following Cerebral Infarction, Dysphagia, Dysarthria, Disorientation, Type II Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Atherosclerotic Heart Disease, Neuromuscular Dysfunction of the Bladder, Hyperlipidemia, Thrombocytopenia, Presence of Prosthetic Heart Valve, and Long Term Use of Anticoagulants, Insulin, and Hypoglycemic Drugs” as documented on the “Plan of Care” dated 06/12/2025 to 08/10/2025. The “Plan of Care” dated 06/12/2025 to 08/10/2025 documents “CHHA Skilled Nursing one (1) encounter every week for one (1) week: 6/12/2025 to 6/15/2025, four (4) encounters as needed for eight (8) weeks for changes in patient’s health status: 6/12/2025 to 8/3/2025, one (1) encounters every week for one (1) week: 6/16/2025 to 6/22/2025, and one (1) encounter every week for eight (8) weeks: 6/23/2025 to 8/10/2025. Physical Therapy one (1) encounter every week for one (1) week: 6/16/2025 to 6/22/2025, then two (2) encounters every week for three (3) weeks: 6/23/2025 to 7/13/2025. CHHA Speech Language Pathology two (2) encounters every week for three (3) weeks: 6/16/2025 to 7/6/2025.” The record lacks documented evidence of communication among the interdisciplinary team regarding the patients’ health status. 3) Patient # 10 has a start of care date of 4/10/2025 with diagnoses of “Non-Traumatic Intracerebral Hemorrhage, Unspecified Abnormalities of Gait and Mobility, Weakness, Memory Deficit, Compression of Brain, Atrial Fibrillation, Hyperlipidemia, Gastro-esophageal Reflux, Irritable Bowel Syndrome, Depression, Anxiety Disorder, Nonrheumatic Mitral Valve Insufficiency, and Nonrheumatic Mitral Valve Annulus Calcification” as documented on the “Plan of Care” dated 6/9/2025 to 8/7/2025. The “Plan of Care” dated 6/9/2025 to 8/7/2025 documents “CHHA Skilled Nursing one (1) encounter every week for nine (9) weeks: 6/9/2025 to 8/7/2025, and four (4) encounters as needed for nine (9) weeks for change in condition/ Oasis, Physical Therapy two (2) encounters every week for six (6) weeks 4/9/2025 to 5/18/2025, and Occupational Therapy one (1) encounter every week for one (1) week 4/14/2025 to 4/20/2025 then two (2) encounters every week for four (4) weeks 4/21/2025 to 5/18/2025.” The record lacks documented evidence of communication among the interdisciplinary team regarding the patients’ health status. The Agency failed to ensure there is discussion among the team regarding the patient’s health status and recommendations for the plan of care. On 6/26/2025 at 4:30pm findings were reviewed with the Director of Patient Services (DPS), The Director of Homecare Operations and the Administrator. Findings acknowledged and no further explanation was given. Findings are: 4)Patient #9 has a start of care date of 11/23/2024 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Kidney disease stage3, Diabetes Mellitus and Hyperglycemia as documented on the “Plan of Care” for certification period 01/22/2025 to 03/22/2025. The “Plan of Care” for certification period 01/22/2025 to 03/22/2025 document order for discipline “Skilled Nursing one encounter every week for three weeks. Physical Therapy one encounter every week for three weeks. Occupational Therapy one encounter every week for four weeks.” The Physical Therapist noted dated 04/23.2025,04/25/2025,04/28/2025,05/05/2025, 05/12/2025 and 05/16/2025 lacked documented evidence of assessment of patient’s blood pressure and pulse and communication with other clinicians. The “Physical Therapy Services -E007” policy and procedure dated 08/2013 assessment/evaluation (page 3) documented “blood pressure and pulse will be taken routinely before and after treatment, The Physical Therapist communicates via phone or in person with appropriate supervising nurse after the initial visit and at least monthly There is no documented evidence of communication between the Physical Therapist and the supervising nurse. The findings were reviewed with the Director of Patient Services and the Administrator at the exit conference on 06/27/2025 at 2: 30.PM. No explanation was provided.”

“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, the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes that reflect the current patient’s status. This was evident for three (3) of thirteen (13) clinical records reviewed. (Patients #4, #6, and #7) Failure to ensure clinicians prepare and document complete and accurate clinical notes has the potential for negative patient outcomes. . The findings are: 1) Patient #4 has a start of care date of 06/04/2025 with diagnoses of “Hypertensive Chronic Kidney Disease, Unspecified Hydronephrosis, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Anemia in Chronic Kidney Disease as documented in the “Plan of Care” for certification period 06/04/2025 through 08/02/2025. The “Plan of Care” for certification period 06/04/2025 through 08/02/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 4 (four) weeks”. Notify Medical Doctor if Blood Pressure is greater than 160/90 or less than 90/60. The clinical visit notes dated 06/09/25, 06/11/25, 06/18/25 lacks documented evidence that the Physical Therapy assessed the patient’s blood pressure before and after therapeutic exercises. The Physical Therapy Services policy and procedure dated 11/96, revised 8/2020 stated “evaluations will vary depending on diagnosis, but should include blood pressure and pulse taken routinely before and after treatment.” The Agency did not ensure Physical Therapist follows policy and procedure. Interview conducted with the Director of Patient Services, Director of Home Care on 06/24/25 at 03:20 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Director of Home Care at the exit conference. 2) Patient #6 has a start of care date of 05/27/2025 with diagnoses of “Other specified Disorder of Brain, Metabolic Encephalopathy, Hypothyroidism, and Major Depressive Disorder as documented the “Plan of Care” for certification period 05/27/2025 through 07/25/2025. The “Plan of Care” for certification period 05/27/2025 through 07/27/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 6 (six) weeks, and Occupational Therapy 1 (one) encounter every week for 1 (one) week, 2 (two) encounters for 4 (four) weeks”. Notify Medical Doctor if Blood Pressure is greater than 160/90 or less than 90/60. The clinical visit notes dated 05/29/25, 06/02/25, 06/09/25 lack documented evidence that the Physical Therapy assessed the patient’s blood pressure before and after therapeutic exercises. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:44 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care at the exit conference. 3). Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the “Plan of Care” for certification period 06/05/2025 through 08/03/2025. The “Plan of Care” for certification period 06/05/2025 through 08/03/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 4 (four) weeks.” The clinical visit notes dated 06/09/25, 06/11/25 and 06/16/25 lack documented evidence that the Physical Therapist assessed the patient’s blood pressure level before and after therapeutic exercises. The Physical Therapist failed to follow agency’s policy and procedure on patient assessment. Interview conducted with the Director of Patient Services, Director of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to ensure that clinical notes include all services and treatments. This was evident in five (5) of thirteen (13) records reviewed (Patients #3, #4, #6, #7 and #12). Failure to ensure clinical notes include all services and treatments, has the potential for negative patient outcomes 1) Patient #4 has a start of care date of 06/04/2025 with diagnoses of “Hypertensive Chronic Kidney Disease, Unspecified Hydronephrosis, Benign Prostatic Hyperplasia with lower urinary tract symptoms, and Anemia in Chronic Kidney Disease as documented in the Plan of Care” for certification period 06/04/2025 thru 08/02/2025. The “Plan of Care” for certification period 06/04/2025 thru 08/02/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 4 (four) weeks”. Notify Medical Doctor if Blood Pressure is greater than 160/90 or less than 90/60. The clinical visit notes dated 06/09/25, 06/11/25, 06/18/25 lack documented evidence that the Physical Therapy assessed the patient’s blood pressure before and after therapeutic exercises. The clinical visit notes dated 06/11/25, 06/16/25, 06/18/25 lack documented evidence that the Physical Therapist assessed the patient’s pain level before and after therapeutic exercises. The Agency did not ensure clinical notes includes all services and treatments. Interview conducted with the Director of Patient Services, Director of Home Care on 06/24/25 at 03:20 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Director of Home Care. 2) Patient #6 has a start of care date of 05/27/2025 with diagnoses of “Other specified Disorder of Brain, Metabolic Encephalopathy, Hypothyroidism, and Major Depressive Disorder as documented the Plan of Care” for certification period 05/27/2025 thru 07/25/2025. The “Plan of Care” for certification period 05/27/2025 thru 07/27/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 6 (six) weeks, and Occupational Therapy 1 (one) encounter every week for 1 (one) week, 2 (two) encounters for 4 (four) weeks”. Notify Medical Doctor if Blood Pressure is greater than 160/90 or less than 90/60. The clinical visit notes dated 05/29/25, 06/02/25, 06/09/25 lack documented evidence that the Physical Therapy assessed the patient’s blood pressure before and after therapeutic exercises. The clinical visit notes dated 06/02/25, 06/09/25 lack documented evidence that the Physical Therapist assessed the patient’s pain level before and after therapeutic exercises. Interview conducted with the Director of Patient Services, Director and Chief of Home Care on 06/25/25 at 04:44 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. 3) Patient #7 has a start of care date of 06/05/2025 with diagnoses of “Unilateral Primary Osteoarthritis, Right Knee, Other Chronic Pain, Old Myocardial Infarction, and Nutritional Anemia as documented the Plan of Care” for certification period 06/05/2025 thru 08/03/2025. The “Plan of Care” for certification period 06/05/2025 thru 08/03/2025 documents orders for “Physical Therapy 2 (two) encounters every week for 4 (four) weeks.” The clinical visit notes dated 06/09/25, 06/11/25 and 06/16/25 lack documented evidence that the Physical Therapist assessed the patient’s pain level before and after therapeutic exercises. Interview conducted with the Director of Patient Services, Director of Home Care on 06/25/25 at 04:48 PM, no explanation was provided. The survey findings were reviewed on 06/27/2025 at 02:30 PM with the Director of Patient Services and Chief of Home Care. Patient #3 has a start of care date of 03/24/2025 with diagnoses of “Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Acute/Chronic Kidney Disease, Acute Respiratory Failure with Hypoxia, Atrial Fibrillation and Sepsis” as documented on the “Plan of Care” for certification period 05/23/2025 to 07/21/2025. The “Plan of Care” for certification periods 03/24/2025 to 05/22/2025 and 05/23/2025 to 07/21/2025 documents orders for “Skilled Nurse (SN) 1 encounter for every week for 8 weeks and 2 encounters every week for 7 weeks, Physical therapy 1 encounter every week for 3 weeks, Occupational therapy 1 encounter every week for 1 week, 2 encounters every week for 4 weeks”. The “Physical Therapy” notes dated 03/26/2025,03/28/2025, 04/02/2025, 04/10/2025, 04/17/2025, 04/30/2025, 05/06/2025, 05/21/2025, 06/04/2025, lacked documented evidence of assessment of patient vital signs and pain before and after therapy. The “Occupational Therapy” visit notes dated 04/02/2025 and 05/19/2025 lacked documented evidence of vital signs assessment before and after therapy. The “Occupational Therapy” visit notes dated 03/31/2025, 04/08/2025, 04/10/2025, 04/15/2025, 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/19/2025, 06/05/2025, lacked documented evidence of pain assessment. The clinical documentation lacks consistency and does not clearly indicate the patient status. The Governing Authority failed to ensure accurate documentation and a comprehensive patient assessment to include pain and vital signs evaluation. An interview conducted on 06/25/2025 at 4pm with the Director of Patient Service and acknowledge findings. Patient #12 has a start of care date of 04/02/2025 with diagnoses of “Pressure ulcer of sacral region stage 4, Pressure-induced deep tissue damage of let hip, Pressure ulcer of right lower back unstageable, Traumatic Subdural Hemorrhage, Sepsis, Urinary Tract Infection Paraplegia, Multiple Sclerosis and Benign Prostatic Hyperplasia” as documented on the “Plan of Care” for certification period 06/01/2025 - 07/30/2025. The “ Plan of Care” for certification period 06/01/2025 - 07/30/2025 documents an order for “Skilled Nurse (SN) 2 encounters every week for 10 weeks and 4 encounters as needed for 10 weeks for change in condition, skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. Wound care for deep tissue injury to right hip and left hip deep tissue injury to be done daily and as needed if integrity is compromised, cleanse with normal saline, apply Santyl to wound bed and cover with adhesive dressing, and unstageable pressure ulcer to sacrum to be done daily and as needed (PRN), cleanse with Darkin solution, irrigate tunneling with normal saline, apply Santyl and Hydrofera blue fill with protective, peri-wound with skin prep and cover with clean padded Tegaderm. Urologist managing foley maintenance and foley changes”. The “Plan of Care” dated 04/02/2025 to 05/31/2025 documents diagnosis of “Pressure ulcer of sacral region unstageable” orders for “Skilled Nurse (SN): 1 encounter every week for one week from 04/02/25 to 04/06/25 2 encounters every week for 1 week 04/07/25 to 04/13/25 1 encounter every week for 1 week, I encounter every week for 9 weeks 4/14/25 to 5/31/25 and 4 encounters as needed for 11 weeks. Skilled nurse to change dressing on each visit to assess wound once patient and/caregiver demonstrate competency. May apply normal saline if dressing supplies unavailable. Physical therapy :1 encounter every week for 1 week 4/2/25 2 encounters every week for 3 weeks 4/7/25 to 4/27/25. Occupational therapy: 1encounter every week for 1week 4/7/25 to 4/13/25, 2 encounters every week for 4 weeks 4/14/25 to 5/11/25”. The “Skilled Nurse” visit notes dated 04/07/2025,04/10/3025 and 04/14/2025 lacked documented evidence of pain assessment and wound care provided. The “Physical Therapy” visit notes dated 4/07/2025, 04/10/2025, 04/17/2025 and 04/24/2025 lacked documented evidence of pain assessment. The “Occupational Therapy” visit notes dated 04/15/2025 lacked documented evidence of patient pain and vitals assessment. The “Occupational Therapy” visit notes dated 04/17/2025, 04/22/2025, 04/24/2025, 04/29/2025, 05/01/2025, 05/06/2025, 05/08/2025, 05/13/2025, 05/15/2025, 05/20/2025, 0527/2025, 05/29/202506/05/2025 and 06/12/2025 lacked documented evidence of pain assessment. The clinical documentation lacks consistency and does not clearly indicate the patient status. The Governing Authority failed to ensure accurate documentation and a comprehensive patient assessment to include wounds, pain and vital signs evaluation. An interview conducted on 06/2725 at 1pm with the Director of Patient Services and acknowledge findings. Survey findings reviewed with the Administrator and Director of Patient Services on 06/27/2025 at 04:35 PM, no additional explanation was provided.”