Extended Home Care

“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 all clinicians coordinate care to meet the patient’s needs and involve the patient. This was evident for one (1) of three (3) clinical records reviewed. (Patients #1). Failure to ensure that all clinicians involve the patient in the coordination and delivery of care has the potential for negative patient outcome. The findings are: The “Care Coordination” Policy (Revised July 2025) documents: “Each patient will be assigned a Case Manager upon admission by the Clinical Director or Clinical Supervisor.” “Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group;” and “Care coordination will include but not limited to:” “Coordination of care delivery to meet the patient’s need, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities.” The “Patient Notification of Changes in Care” Policy (Revised July 2025) documents: “Policy - The patient will be notified within 24 hours of any significant changes in the agreed upon schedule or plan of care.” Procedure: Visit Schedule, “When a significant variation of tentative time for visit (i.e. greater than one (1) hour) is anticipated, the clinical personnel will notify the patient of the change and verify acceptance.” 1. Patient #1 has a Start of Care date of 06/17/2025, Discharge Date of 07/03/2025, with diagnoses Anoxic Brain Damage, Hypertensive Heart Disease with Heart Failure, Muscle Wasting and Atrophy, documented in the Home Health Certification and Plan of Care for the Certification Period 06/17/2025 to 08/15/2025. The Home Health Certification and Plan of Care for the Certification Period 06/17/2025 to 08/15/2025 documents the following orders: Physical Therapy 1 Week 1 (to evaluate), then 2 Week 4 (twice a week for four weeks).” The PT (Physical Therapy) Evaluation visit note dated 06/18/2025 documents: Planned visit (frequency and duration) 1W1 (one visit a week for one week (evaluation),2W4 (two visits a week for four weeks); “Planned visit “Next visit date 06/23/2025;” and plan of care “discussed and agreed to by Pt (Patient)/Family.” The Case Communication- Authorization Approval note dated 06/23/2025 documents the agency received insurance authorization to provide 9 Physical Therapy visits 06/18/2025-07/31/2025. The Case Communication – Request of Change in Rehab Services note dated 06/24/2025 documents: “Continue 8 PT (Physical therapy) visits 2 Week x 4 Eff. (Effective) 6/25/25 – 7/19/25.” The Family Communication note dated 06/24/2025 documents: “TCT (Telephone call to) CG (Caregiver). Message was left regarding scheduled svc (service). Call back number was provided.” The PT (Physical Therapy) Routine visit note dated 06/25/2025 documents the next visit was on 06/25/2025, not on 06/23/2025. The clinical record lacks documented evidence of the agency informing the patient/family of the change in the scheduled visit for 06/23/2025, in accordance with the agency’s Patient Notification of Changes In Care Policy. The Home Health Certification and Plan of Care for the Certification Period 06/17/2025 to 08/15/2025 documents the following orders: Occupational Therapy 1 Week 1 (to evaluate).” The Case Communication – OT (Occupational Therapy) Placement note dated 06/19/2025 documents a request for Occupational Therapy placement/assignment: “OT (Occupational Therapy)1 Eval visit 6/19/25 – 6/27/25.” The Occupational Therapy Initial Examination note dated 06/27/2025 documents a plan for two visits a week for four weeks. The Case Communication – HMO Authorization Request OT (Occupational Therapy) note dated 07/01/2025 documents the agency requested insurance authorization on 6/30/2025 for nine (9) OT visits: “1 Week 1, 2 Week 4;” 06/2725-7/31/25. The Case Communication – ST (Speech Therapy) Placement note dated 06/19/2025 documents a request for Speech Therapy placement/assignment: “ST(Speech Therapy) 1 Eval visit 6/19/25 – 6/27/25.” The Case Communication – Speech Therapy Assignment note dated 06/26/2025 documents: “Due to lack of ST (Speech Therapy) staff in patient service area, no ST (Speech Therapy) has been assigned. MD (Medical Doctor) (name) office aware. Patient/caregiver informed via phone call voicemail.” The Family Communication note dated 07/02/2025 documents: telephone call to caregiver, “discussed svc (service). Informed that OT (Occupational Therapy) auth (authorization) currently pending, ST (Speech Therapy) was not assigned yet due to lack of ST (Speech Therapy) staff for pt’s (patient’s) area. EHC (Extended Home Care) will continue to look for ST (Speech Therapy).” The Case Communication – HMO Authorization D/C (Discharge) note dated 07/03/2025 documents: “Please inform insurance that pt’s (patient’s) caregiver cancelled all svc (service) from EHC (Extended Home Care) and requested D/C (discharge) today 7/03/25.” The clinical record lacks documented evidence of the agency communicating timely with the patient/family to discuss the delay in Occupational Therapy and Speech Therapy services and if the delays are acceptable with the patient/family. On 08/27/2025 at 04:45 PM, the Administrator/Director of Patient Services, the Director of Rehab, the Clinical Manager, the Field Supervisor and the Director of Quality were interviewed. The Director of Rehab stated the physical therapist “scheduled the visit prior to receiving insurance authorization.” The Director of Rehab stated the request for Occupational Therapy and Speech Therapy staffing was “sent to 10 vendors” on 06/20/2025 and the agency was able to staff Occupational Therapy and continued to look for Speech Therapy staff. There was no explanation provided for the lack of timely communication regarding the change in the physical therapist visit schedule and the delay in providing Occupational Therapy and Speech Therapy services.”

“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 a review of the Home Health Agency(HHA) Error Summary Report for the period 02/07/2025 through 05/07/2025 and staff interviewed, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This is evident for three thousand seven hundred and ninety-two (3792) clinical records documented in the HHA Error Summary by Agency Report. Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: 1. The HHA Error Summary by Agency Report for the period 02/07/2025 through 05/07/2025 documents: “Error # -3330 Record Submitted Late: The submission date is more than 30 days after M0090 (Start of Care) on this new record… # of Assessments with error three thousand seven hundred and ninety-two (3792). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 5/12/2025 at 02:30 PM, the Administrator/Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for two (2) of eighteen (18) clinical records reviewed (Patient: #12, #17). Failure to ensure that all patients receive services as documented in their individualized plan of care, has the potential for negative patient outcomes. The Findings Are: #3. Patient #14 has a Start of Care Date of 01/09/2024 with diagnoses of Unspecified Intellectual Disabilities, Other Abnormalities of Gait and Mobility, Developmental of Speech and Language Unspecified, and Down Syndrome Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 05/03/2025 to 07/01/2025. The Home Health Certification and Plan of Care with a Certification Period from 03/04/2025 to 05/02/2025 documents, “PT will notify the MD for any findings outside the established parameters: BP 140/90, HR 50-120 BPM, T 96-101 F, R 15-28 P/M,” (Physical Therapist will notify the Medical Doctor for any findings outside the established parameters: Blood Pressure less than 85/55, greater than 140/90, Heart Rate 50-120 Beats Per Minute, Temperature 96-101 Fahrenheit, Respirations 15-28 Per Minute). The Physical Therapy visit notes dated 03/05/2025, 03/10/2025, 03/14/2025, 03/17/2025, 03/19/2025, 03/24/2025, 03/26/2025, 03/31/2025, 04/02/2025, 04/07/2025, 04/09/2025, 04/14/2025, 04/16/2025, 04/21/2025, 04/23/2025, 04/28/2025, 05/05/2025, and 05/07/2025, document “NT” (Not Tested)” for “Vitals Pre TX BP (Vital Signs Pre-Treatment Blood Pressure), Vitals Pre TX Pulse, Vitals Pre TX Resp (Respirations), Vitals Post TX BP, Vitals Post TX Pulse, Vitals Post TX Resp.” There is no documented evidence of the Physical Therapist assessing the patient’s blood pressure, heart rate, temperature, and respirations as ordered. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. The Home Health Certification and Plan of Care with a Certification Period from 03/04/2025 to 05/02/2025 documents, “OT will notify the MD for any findings outside the established parameters: BP > 140/90, HR 50-120 BPM, T 96-101 F, R 15-28 P/M,” (Occupational Therapist will notify the Medical Doctor for any findings outside the established parameters: Blood Pressure less than 85/55, greater than 140/90, Heart Rate 50-120 Beats Per Minute, Temperature 96-101 Fahrenheit, Respirations 15-28 Per Minute). The Occupational Therapy visit notes dated 03/05/2025, 03/11/2025, 03/14/2025, 03/17/2025, 03/21/2025, 03/23/2025, and 03/28/2025 lack documented evidence of the Occupational Therapist assessing the patient’s blood pressure, heart rate, temperature, and respirations as ordered. On 05/16/2025 at 3:31 PM, the Director of Patient Services and Field Supervisor were interviewed. The Director of Patient Services stated, “We have a plan moving forward,” and “Kids usually don’t want to be touched,” and “We cannot call the pediatrician every visit.” 1. Patient #12 has a Start of Care date of 04/25/2025 with diagnoses of Primary Generalized Osteoarthritis, Parkinson’s Disease without Dyskinesia, Pressure Ulcer Unspecified Site, Other Constipation a, Essential Primary Hypertension documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents Nutritional Requirements: Low Sodium, High Fiber. The SN (Skilled Nursing) Routine Visit on the following dates: 04/30/2025, 05/02/2025, 05/05/2025, 05/07/2025 and 05/09/2025 documents “Diet: Low Salt, High Protein; Diet Compliance: Compliant.” The clinical record lacks documented evidence of the diet/nutritional requirements being followed as written in the plan of care. There is no evidence the authorized practitioner was consulted to approve any diet/nutritional modifications to the original plan. On 05/15/2025 at 11:30 AM, the findings were reviewed with the Director of Patient Services/Administrator and no explanation was provided. 2. Patient#17 has a Start of Care date of 03/18/2025 with diagnoses of Unspecified Intellectual Disability, Polyneuropathy Unspecified, Constipation, Other Dysphagia, Need for Assistance with Personal Care documented in the Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025. The Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025 documents Nutritional Requirements: Regular, Soft Solids, NFR (No Fluid Restriction. The SN (Skilled Nursing) Routine Visit on the following dates documents: 04/09/2025,04/23/2025,05/08/2025 documents “Diet: Low Salt; Diet Compliance: Compliant.” The clinical record lacks documented evidence of the diet/nutritional requirements being followed as written in the plan of care. There is no evidence the authorized practitioner was consulted to approve diet/nutritional modifications to the original plan. On 05/15/2025 at 11:30 AM, the findings were reviewed with the Director of Patient Services/ Administrator and no explanation was provided.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to ensure that all healthcare personnel follow standard infection control precautions. This was evident for one (1) of seven (7) home visits (Patient: #12). Failure to monitor that all healthcare personnel follow standard infection control precautions, has the potential for negative patient outcomes. The Findings Are: 1. Patient #12 has a Start of Care date of 04/25/2025 with diagnoses of Primary Generalized Osteoarthritis, Parkinson’s Disease without Dyskinesia, Pressure Ulcer Unspecified Site, Other Constipation a, Essential Primary Hypertension documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents SN (Skilled Nurse) to perform wound care to Wound#1 Pressure Injury Stage 3 Left Buttock; Wound Order: Cleanse wound with NSS (Normal saline Solution, Pat dry, Apply Santyl on yellow/tan slough wound bed, Cover with DSD (Dry Sterile Dressing) and Foam dressing three tines a week; Caregiver to perform wound care between SN ( Skilled Nurse ) visits. The Infection Control Policy and Procedure # 7.7A, Wound Measuring and Staging Revised November 2024, documents the following under Wound Management for Procedure No.7: “Remove gloves, perform hand hygiene and reapply gloves” and Procedure No. 8: “Perform wound care as per MD order and dispose of waste as appropriate.” On 05/12/2025 at 4:15 PM a home visit was conducted, the SN (Skilled Nurse) was observed performing wound care without removing gloves, not performing hand hygiene and not reapplying new gloves after the removal of the soiled dressing. The same pair of gloves was observed being used throughout the wound care procedure. There is no documented evidence of the SN following accepted standards of practice to prevent the transmission and cross contamination of infection and following the agency’s policy and procedure. On 05/15/2025 at 11:30 AM, the Administrator/Director of Patient Services was interviewed, and no explanation was provided.”

“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 clinical record reviewed, and staff interview, the agency failed to ensure that the comprehensive assessment accurately reflected the patient’s status, and/or the safety teaching needs of the patient. This was evident for two (2) of eighteen (18) records reviewed. (Patient #4 and #13 Failure to ensure the patient’s plan of care is complete and accurate has the potential for negative patient outcome. The findings are: 1. Patient #4 has a Start of Care Date of 11/07/2024 with diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Other Part of left Foot with Other Specified Severity, and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene documented on the Home Health Certification and Plan of Care with a Certification Period from 05/06/2025 to 07/04/2025. The SN (Skilled Nurse) Admission (Comprehensive Assessment) visit dated 11/07/2024 documents, “Eyes, 1-Glasses, 6-Other (specify) LT (Left) eye blindness due to DM (Diabetes Mellitus),” and “Ears 1-Hearing Aide, 3- Other (specify) RT (Right) ear deaf.” The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow-Up Visit dated 03/05/2025 documents, “Eyes - WNL (Within Normal Limits)” and “Ears - WNL.” The PT Recertification Comprehensive Assessment dated 03/05/2025 does not include documented evidence of the patient having left eye blindness and being deaf in the right ear. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. The SN (Skilled Nurse) Admission visit note dated 11/07/2024 documents, “PT (Patient) has DM (Diabetes Mellitus) Ulcer Wound: Wound #1: Top of Left Foot.” The SN visit note dated 12/09/2024 documents, “PT has DM Ulcer Wound: Wound #1: Top of Left Foot Healed.” The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow-Up Visit dated 03/05/2025 documents, “Clinical Note Subjective: (Name of Patient) reports chronic pain in his knees and difficulty walking due to the amputation of his big toes and foot ulcer,” and “Assessment: (name of patient) presents with substantial challenges in mobility and balance due to his complex medical history, including bilateral knee osteoarthritis, amputation of big toes, diabetes, and a chronic foot ulcer.” The comprehensive assessment does not accurately reflect that the patient does not have a foot ulcer. On 05/16/2025 at 3:31 PM, the Administrator/ Director of Patient Services and the Field Supervisor were interviewed. The Administrator / Director of Patient Services stated the patient “doesn’t have a foot ulcer.” The Field Supervisor stated the Physical Therapist was writing “his notes based on the diagnosis.” #2. Patient #13 has a Start of Care Date of 10/12/2023 with Diagnoses of Cerebral Palsy Unspecified, Unspecified Intellectual Disabilities, and Developmental Disorder of Scholastic Skills Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025. The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow up visit dated 01/28/2025 documents, “Safety Measures, 6 – Teach home oxygen therapy safety precautions.” The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow up visit dated 04/01/2025 documents, “Safety Measures, 6 – Teach home oxygen therapy safety precautions.” There is no documented evidence of the patient being on oxygen therapy. The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow up visits dated 01/28/2025 and 04/01/2025 do not accurately reflect the safety teaching needs of the patient. On 05/15/2025 at 12:00 PM, the Administrator /Director of Patient Services and the Field Supervisor were interviewed and did not provide an explanation.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on clinical record review, and staff interview, the agency failed to ensure that a discharge comprehensive assessment including the Outcome and Assessment Information Set (OASIS) was completed within two days of the patient’s discharge date. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient #10). Failure to ensure that a discharge comprehensive assessment including the OASIS is completed within two days of the patient’s discharge date has the potential for negative patient outcomes. The Findings Are: 1. Patient #10 has a Start of Care Date of 01/13/2025 and a discharge date of 03/13/2025, with diagnoses of Hypertensive Heart Disease without Heart Failure, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus without Complications documented on the Home Health Certification and Plan of Care with a Certification Period from 01/13/2025 to 03/13/2025. The “Discharge/Transfer Summary” documents “Discharge Date: 03/13/2025.” The Physical Therapy visit note dated 03/11/2025 documents, “Progress Towards Goals – DC (Discharge) on next visit.” The next visit was on 03/13/2025. The “PT D/C (Physical Therapy Discharge) with OASIS (Outcome and Assessment Information Set)” visit dated 03/13/2025 documents the OASIS Assessment was created on “04/13/2025” and completed on “04/20/2025.” There is no documented evidence of the discharge OASIS being completed within 2 days after the knowledge of patient’s discharge from the agency on 03/13/2025. On 05/15/2025 at 12:00 PM, the Administrator /Director of Patient Services and the Field Supervisor were interviewed and did not provide an explanation.”

“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 records review and staff interview the agency failed to ensure each patient’s individualized plan of care was complete and included all the required information. This was evident for five (5) of eighteen (18) clinical records reviewed (Patient #1, #4, #11, #12, #13). Failure to ensure each patient’s plan of care is complete and accurate has the potential for negative patient outcome. The findings are: #5. Patient #3 has a Start of Care date of 10/31/2024 with diagnoses of Pressure Ulcer of Sacral Region Stage 2, Unspecified Injury of Right Shoulder and Upper Arm, Chronic Obstructive Pulmonary Disease Unspecified, Hypertensive Heart Disease with Heart Failure, Diabetes Mellitus without Complications, Dependence on Supplemental Oxygen documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The Home Health Certification and Plan of Care for the Certification Period(s) 10/31//2024 to 12/29/2024; 12/30/2024 to 02/27/2025; 02/28/2025 to 04/28/2025; and 04/29/2025 to 06/27/2025 documents marked boxes for the following Functional Limitations: Bowel and Bladder (Incontinence); Endurance; and Ambulation.” The SN (Skilled Nursing) Admission Visit dated 10/31/2024 OASIS (Outcome and Assessment Information Set) Assessment Items for SOC (Start of Care) documents the following: “Conditions Affecting Respiratory Status: Dyspnea.; (M1400) When is the patient dyspneic or noticeably short of breath? 3-With minimal exertion (for example, while eating, talking or performing other ADLs (Activities of Daily Living) or with agitation.” The SN (Skilled Nursing) Recert (Recertification) / Follow-Up OASIS (Outcome and Assessment Information Set) Assessment Items on the following visit dates 02/24/2025 and 04/26/2025 documents “Conditions Affecting Respiratory Status: Dyspnea.” The clinical record lacks documented evidence of “Dyspnea with Minimal Exertion” being marked as the patient’s functional limitation in the individualized plan of care. On 05/15/2025 at 11:30 AM, the findings were reviewed with the Director of Patient Services/ Administrator and no explanation was provided. #6. Patient #12 has a Start of Care date of 04/25/2025 with diagnoses of Primary Generalized Osteoarthritis, Parkinson’s Disease without Dyskinesia without Mention of Fluctuations, Muscle Weakness, Pressure Ulcer Unspecified Site, Other Constipation, Essential Primary Hypertension, Other Chronis Pain documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents the following Functional Limitations marked boxes: “Bowel and Bladder (Incontinence), Endurance, and Ambulation.” The SN (Skilled Nursing) Admission Visit dated 04/25/2025 OASIS (Outcome and Assessment Information Set) Assessment Items for SOC (Start of Care) documents the following: “Ear Notes HOH (Hard of Hearing); 2- Moderate difficulty-speaker has to increase volume and speak distinctively.” The SN (Skilled Nursing) Routine Visit on the following dates: 04/28/2025, 04/30/2025, 05/02/2025, 05/05/2025, 05/07/2025 and 05/09/2025 documents “Ear Notes- HOH (Hard of Hearing).” On 05/12/2025 at 4:00 PM during the home visit, the surveyor observed the SN (Skilled Nurse) and the patient’s private aide speaking in a louder voice and closer to the patient’s ear. The clinical record lacks documented evidence of “Hearing” being marked as the patient’s functional limitation in the individualized plan of care. On 05/15/2025 at 11:30 AM, the findings were reviewed with the Director of Patient Services/ Administrator and no explanation was provided. #1. Patient #1 has a Start of Care Date of 04/03/2025 with diagnoses of Muscle Wasting and Atrophy Not Elsewhere Classified Multiple Sites, Age-Related Osteoporosis with Current Pathological Fracture Other Site, Subsequent Encounter Fracture with Routine Healing, and Alzheimer’s Disease, Unspecified documented on the Home Health and Certification and Plan of Care with a Certification Period from 04/03/2025 to 06/01/2025. The SN (Skilled Nurse) Admission (Comprehensive Assessment) visit dated 04/03/2025 documents the following question, “(B00200) Hearing – Ability to hear (with hearing aid or hearing appliances if normally used),” and response, “1-Hearing Aid, 2- Moderate difficulty – speaker has to increase volume and speak directly.” The Home Health and Certification and Plan of Care with a Certification Period from 04/03/2025 to 06/01/2025 lacks documented evidence - the patient has a functional limitation with hearing, as documented in the SN Admission (Comprehensive Assessment) visit dated 04/03/2025. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. #2. Patient #4 has a Start of Care Date of 11/07/2024 with diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Other Part of left Foot with Other Specified Severity, and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene documented on the Home Health Certification and Plan of Care with a Certification Period from 05/06/2025 to 07/04/2025. The SN (Skilled Nurse) Admission (Comprehensive Assessment) visit dated 11/07/2024 documents, “Eyes, 1-Glasses, 6-Other (specify) LT (Left) eye blindness due to DM (Diabetes Mellitus),” and “Ears 1-Hearing Aide, 3- Other (specify) RT (Right) ear deaf.” The Home Health Certification and Plan of Care with a Certification Period from 11/07/2024 to 01/05/2025 lacks documented evidence - the patient has functional limitations with hearing and vision as documented in the SN Admission (Comprehensive Assessment) visit dated 11/07/2025. There is no documented evidence of a Home Health Certification and Plan of Care that includes the patient has functional limitations with hearing and vision as documented in the SN Admission (Comprehensive Assessment) visit dated 11/07/2025. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. #3. Patient #11 has a Start of Care date of 05/11/2023 with diagnoses of Developmental Disorder of Speech and Language unspecified, Personal History of Pneumonia, and Mild Intermittent Asthma Uncomplicated documented on the Home Health Certification and Plan of Care with a Certification Period from 04/30/2025 to 06/28/2025. The OT (Occupational Therapy) Comprehensive Pediatric Assessment dated 02/26/2025 and 04/28/2025 documents the patient’s “diet” is “puree.” The Home Health Certification and Plan of Care with a Certification Period from 03/01/2025 to 04/29/2025 and 04/30/2025 to 06/28/2025 documents, “Nutritional Requirements: Soft, No Fluid Restrictions.” The Home Health Certification and Plan of Care with a Certification Period from 03/01/2025 to 04/29/2025 and 04/30/2025 to 06/28/2025 lacks documented evidence of a puree diet, as documented in the OT Comprehensive Pediatric Assessment dated 02/26/2025 and 4/28/2025. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. #4. Patient #13 has a Start of Care Date of 10/12/2023 with Diagnoses of Cerebral Palsy Unspecified, Unspecified Intellectual Disabilities, and Developmental Disorder of Scholastic Skills Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025. The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow up visit dated 01/28/2025 documents, “Nutritional Requirements/Special Diet, 1-Regular, 3- High Fiber, 10- Other (specify) NFR (No Fluid Restrictions), 3- Pureed,” and “Diet/Nutritional Status, 1- Chewing/Swallowing difficulties.” The Home Health Certification and Plan of Care with a Certification Period from 02/03/2025 to 04/03/2025 documents, “Nutritional Requirements: Regular Diet, High Fiber Diet, No Fluid Restriction,” and “Safety Measures: Standard, Safety/Fall Precautions/ Seizure Precautions, COVID Precautions.” The Home Health Certification and Plan of Care with a Certification Period from 02/03/2025 to 04/03/2025 lacks documented evidence of including a pureed diet and aspiration precautions as documented on the Comprehensive Assessment dated 01/28/2025. The PT (Physical Therapy) Recertification (Comprehensive Assessment)/Follow up visit dated 04/01/2025 documents, “Nutritional Requirements/Special Diet, 1-Regular, 10- Other (specify) NFR (No Fluid Restrictions), 3- Pureed,” and “Diet/Nutritional Status, 1- Chewing/Swallowing difficulties.” The Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025 documents, “Nutritional Requirements: Regular Diet, High Fiber Diet, No Fluid Restrictions,” and “Safety Measures: Standard, Safety/Fall Precautions/ Seizure Precautions, COVID Precautions.” The Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025 lacks documented evidence of including a pureed diet and aspiration precautions. The Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025 documents the following medications, “ferrous sulfate 325 mg (milligrams) (65 mg iron) tablet 10/12/2023 take 1 tablet (325 mg) by oral route every day,” and “Vitamin D3 125 mcg (micrograms) (5,000 unit) tablet 10/12/2023 take 1 Tab (tablet) by oral route every week.” On 05/13/2025 at 10:20 AM, a home visit was conducted and the patient’s parent was interviewed. The parent stated - the patient has not been taking the ferrous sulfate and Vitamin D3 for approximately over a year. The parent presented a box of Clobazam (2.5 milligrams/milliliter) and stated - the patient has been taking 20 mg of the Clobazam every night for over a year. The Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025 lacks documented evidence of including the Clobazam. The Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025 lacks documented evidence of the medications the patient is currently taking. On 05/15/2025 at 12:00 PM, the Director of Patient Services and Field Supervisor were interviewed and did not provide an explanation. On 05/16/2025 at 3:31 PM, the Director of Patient Services and Field Supervisor were interviewed. The Director of Patient Services stated, “We will send a nurse to visit to reconcile the medications.””

“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 records review and staff interview the agency failed to ensure each patient’s physician was promptly alerted to changes in condition that suggest the outcomes are not being achieved and required the plan of care to be altered. This was evident for four (4) of eighteen (18) clinical records reviewed (Patient #11, #13, #14 #18). Failure to ensure the patient’s physician is promptly notified of changes, that require the plan of care to be altered has the potential for negative patient outcome. The findings are: 1. Patient #11 has a Start of Care date of 05/11/2023 with diagnoses of Developmental Disorder of Speech and Language unspecified, Personal History of Pneumonia, and Mild Intermittent Asthma Uncomplicated documented on the Home Health Certification and Plan of Care with a Certification Period from 04/30/2025 to 06/28/2025. The Home Health Certification and Plan of Care with a Certification Period from 03/01/2025 to 04/29/2025 documents, “Occupational Therapy will notify MD (Medical Doctor) of any findings outside the established parameters B/P (Blood Pressure) above 140/90 or below 85/55 MM/HG (Millimeters of Mercury), HR (Heart Rate) about 120 or below 50 BPM (Beats Per Minute), Temp (Temperature) less than 96 or greater than 101 F (Fahrenheit), Resp (Respiratory) Rate below 15 or above 28 BP/M (Beats Per Minute). The OT visit notes from 03/12/2025 to 03/13/2025, 03/17/2025, 03/19/2025, 03/24/2025, 03/26/2025, 04/07/2025, 04/09/2025, 04/14/2025, 04/16/2025, 04/21/2023, 04/23/2025 document, “Clinical Note: Vital signs were not tested due to patient would not allow but the patient appeared in NAD (No Acute Distress).” There is no documented evidence of the Occupational Therapist informing the physician that the patient’s vital signs were not able to be tested as ordered. On 05/15/2025 at 12:00 PM, the Administrator/Director of Patient Services and the Field Supervisor were interviewed and did not provide an explanation. 2. Patient #13 has a Start of Care Date of 10/12/2023 with Diagnoses of Cerebral Palsy Unspecified, Unspecified Intellectual Disabilities, and Developmental Disorder of Scholastic Skills Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 04/04/2025 to 06/02/2025. The Home Health Certification and Plans of Care (medical orders) with a Certification Period from 02/03/2025 to 04/03/2025 and 04/04/2025 to 06/02/2025 documents, “PT (Physical Therapy) will notify the MD (Medical Doctor) for any findings outside the established parameters: B/P , 140/90 MMHG, (Blood Pressure less than 80/60 Millimeters of Mercury and greater than 140/90), HR 60-90 BPM (Heart Rate 60-90 Beats Per Minute), Temp 96-101 (Temperature 96-101 Fahrenheit), R 16-24 P/M (Respirations 16-24 Per Minute).” The Physical Therapy visit notes dated 02/04/2025, 2/18/2025, 02/25/2025, 03/04/2025, 03/11/2025, 03/27/2025, 04/10/2025, 04/15/2025, 04/22/2025, 04/29/2025, and 05/06/2025 documents, “Vitals Pre TX BP (Vital Signs Pre Treatment Blood Pressure) - “Pt (patient) refused,” and “N/A” (Not Applicable) for “Vitals Pre TX Pulse, Vitals Pre TX Resp (Respirations), Vitals Post TX BP, Vitals Post TX Pulse, Vitals Post TX Resp.” There is no documented evidence of the Physical Therapist informing the physician that the patient’s vital signs could not be taken because the patient was refusing. On 05/15/2025 at 12:00 PM, the Administrator/Director of Patient Services and the Field Supervisor were interviewed and did not provide an explanation. 3. Patient #14 has a Start of Care Date of 01/09/2024 with diagnoses of Unspecified Intellectual Disabilities, Other Abnormalities of Gait and Mobility, Developmental of Speech and Language Unspecified, and Down Syndrome Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 05/03/2025 to 07/01/2025. The Home Health Certification and Plan of Care with a Certification Period from 03/04/2025 to 05/02/2025 documents, “PT will notify the MD for any findings outside the established parameters: BP 140/90, HR 50-120 BPM, T 96-101 F, R 15-28 P/M,” (Physical Therapist will notify the Medical Doctor for any findings outside the established parameters: Blood Pressure less than 85/55, greater than 140/90, Heart Rate 50-120 Beats Per Minute, Temperature 96-101 Fahrenheit, Respirations 15-28 Per Minute). The Physical Therapy visit notes dated 03/05/2025, 03/10/2025, 03/14/2025, 03/17/2025, 03/19/2025, 03/24/2025, 03/26/2025, 03/31/2025, 04/02/2025, 04/07/2025, 04/09/2025, 04/14/2025, 04/16/2025, 04/21/2025, 04/23/2025, 04/28/2025, 05/05/2025, and 05/07/2025, document “NT” (Not Tested)” for “Vitals Pre TX BP (Vital Signs Pre-Treatment Blood Pressure), Vitals Pre TX Pulse, Vitals Pre TX Resp (Respirations), Vitals Post TX BP, Vitals Post TX Pulse, Vitals Post TX Resp.” There is no documented evidence of the Physical Therapist assessing the patient’s blood pressure, heart rate, temperature, and respirations as ordered or notifying the Medical Doctor of the vitals not being done. On 05/15/2025 at 12:00 PM, the Administrator/Director of Patient Services and the Field Supervisor were interviewed and did not provide an explanation. The Home Health Certification and Plan of Care with a Certification Period from 03/04/2025 to 05/02/2025 documents, “OT will notify the MD for any findings outside the established parameters: BP > 140/90, HR 50-120 BPM, T 96-101 F, R 15-28 P/M,” (Occupational Therapist will notify the Medical Doctor for any findings outside the established parameters: Blood Pressure less than 85/55, greater than 140/90, Heart Rate 50-120 Beats Per Minute, Temperature 96-101 Fahrenheit, Respirations 15-28 Per Minute). The Occupational Therapy visit notes dated 03/05/2025, 03/11/2025, 03/14/2025, 03/17/2025, 03/21/2025, 03/23/2025, and 03/28/2025 lack documented evidence of the Occupational Therapist assessing the patient’s blood pressure, heart rate, temperature, and respirations as ordered or notifying the Medical Doctor it was not done. On 05/16/2025 at 3:31 PM, the Administrator /Director of Patient Services and the Field Supervisor were interviewed. The Administrator/ Director of Patient Services stated, “We have a plan moving forward,” and “Kids usually don’t want to be touched,” and “We cannot call the pediatrician every visit.” 4. Patient #18 has a Start of Care date of 02/01/2025 with diagnoses of Autistic Disorder, Unspecified Intellectual Disabilities, and Developmental Disorder of Speech and Language Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 04/02/2025 to 05/31/2025. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 02/01/2025 to 04/01/2025 documents, “Physical Therapy to assess all systems and vital signs, report findings/abnormalities to MD (Medical Doctor). PT (Physical Therapist) to report V/S (Vital Signs) outside parameters of BP 130/80, HR 50-110, T 96-101.4 F, R 12-20 P/M (Blood Pressure less than 80/50 or greater than 130/80, Heart Rate 50-110, Temperature 96-101.4 Fahrenheit, Respirations 12-20 Per Minute).” The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 04/02/2025 to 05/31/2025 documents, “Physical Therapy to assess all systems and vital signs, report findings/abnormalities to MD (Medical Doctor). PT (Physical Therapist) to report V/S (Vital Signs) outside parameters of BP 140/90, HR 50-120, T 96-101 F, R 15-28 P/M.” The PT visits dated 02/06/2025 and 03/29/2025 document “unable to assess vitals due to hyperactive patient.” The PT visit notes dated 02/14/2025, 02/22/2025, 03/01/2025, 03/08/2025, 03/15/2025, 03/22/2025, 04/05/2025, 04/18/2025 to 04/19/2025, 04/25/2025 to 04/27/2025, 05/03/2025, and 05/09/2025 to 05/10/2025 document, “Unable to formally access vital signs due to hyperactive patient but the patient appeared in NAD (No Acute Distress).” There is no documented evidence of the physician being notified that the Physical Therapist was unable to assess the patient’s vital signs due to the patient being hyperactive. On 05/16/2025 at 11:40 PM, the Field Supervisor was interviewed and stated, “We need to start having a general order if it is able to be done.””

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to ensure all patients received integrated services provided by various disciplines. This was evident for four (4) of eighteen (18) clinical records reviewed (Patient: #3 #12, #16 #17). Failure to ensure all patients receive integrated services provided by various disciplines has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 10/31/2024 with diagnoses of Pressure Ulcer of Sacral Region Stage 2, Unspecified Injury of Right Shoulder and Upper Arm, Chronic Obstructive Pulmonary Disease Unspecified, Hypertensive Heart Disease with Heart Failure, Diabetes Mellitus without Complications, Dependence on Supplemental Oxygen documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The Home Health Certification and Plan of Care for the following Certification Period(s): 10/31//2024 to 12/29/2024; 12/30/2024 to 02/27/2025; 02/28/2025 to 04/28/2025; and 04/29/2025 to 06/27/2025 documents: Diagnosis 1. Pressure Ulcer of Sacral Region, Stage 2. The SN (Skilled Nursing) Admission Visit dated 10/31/2024 OASIS (Outcome and Assessment Information Set) Assessment Items for SOC (Start of Care) documents the following: “Wound Location (1): Sacrum; Ulcer Stage Wound (1): Stage 2.” The SN (Skilled Nursing) Recert (Recertification) / Follow-Up OASIS (Outcome and Assessment Information Set) Assessment Items on the following visit dates 02/24/2025 and 04/26/2025 documents the following: Wound Location (1): Sacrum; Type Wound (1): Pressure ulcer; Ulcer Stage Wound (1): Stage 2. The Wound Pros-Wound Care Experts Progress Notes on the following dates 01/13/2025, 03/05/2025, 03/19/2025, 03/26/2025,0 4/02/2025 04/09/2025, 04/16/2025, 04/23/2025, and 04/30/2025 document the following Wound Details: Location- Center Midline Sacrum; Classification- Pressure Ulceration; Stage- Stage III; Diagnosis- L.89.153 Pressure Ulcer of Sacral Region, Stage 3. The clinical record lacks documented evidence of the coordination of care provided by all disciplines, Skilled Nursing documents the patient’s pressure ulcer Stage 2, whereas The Wound Pros-Wound Care Experts documents pressure ulcer Stage 3. On 05/15/2025 at 11:30 AM, the Administrator /Director of Patient Services was interviewed, and no explanation was provided. 2. Patient #12 has a Start of Care date of 04/25/2025 with diagnoses of Primary Generalized Osteoarthritis, Parkinson’s Disease without Dyskinesia, Pressure Ulcer Unspecified Site, Other Constipation a, Essential Primary Hypertension documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents the following DME (Durable Medical Equipment) and Supplies: Has Walker (standard), Has Wheelchair, Has Hoyer lift, Has Bedside commode, Has Grab bars (toilet/ shower/tub), Has Incontinent Supplies, and Wound Supplies. The SN (Skilled Nursing) Admission Visit dated 04/25/2025, OASIS (Outcome and Assessment Information Set) Assessment Items for SOC (Start of Care) documents: “GG0170 Mobility- Has Walker (standard), Has Wheelchair, Has Hoyer lift, Has Bedside commode, Has Grab bars (toilet/ shower/tub)”. The PT (Physical Therapy) Evaluation Visit dated 04/28/2025 documents Stairs Negotiation Comments: Chairlift in use” The PT (Physical Therapy) Routine Visit on the following dates: 05/02/2025, 05/05/2025, and 05/09/2025 documents “Stairs Negotiation Comments: Chair Lift in Use.” On 05/12/2025 at 4:00 PM, a home visit was conducted, and no Hoyer lift was observed in the home. The patient’s family member was interviewed during the home visit and stated “My mom does not have Hoyer lift. Hopefully she won’t be at that stage where she will need to be using it. She can stand with assistance and walk with two assistance and with her walker, about 3 to 4 steps.” The clinical record lacks documented evidence of the coordination of care to assure the identification of patient needs. Skilled Nursing documents patient has Hoyer lift at home and Physical Therapy documents chair-lift in use in the stairs negotiation comments. On 05/15/2025 at 11:30 AM, the Administrator / Director of Patient Services was interviewed, and no explanation was provided. 3. Patient#16 has a Start of Care date of 05/03/2025 with diagnoses of Cerebral Infarction Due to Thrombosis of Left Middle Cerebral Artery, Acute Kidney Failure, Essential Primary Hypertension, Type 2 Diabetes Mellitus documented in the Home Health Certification and Plan of Care for the Certification Period 05/03/2025 to 07/01/2025. The Home Health Certification and Plan of Care for the Certification Period 05/03/2025 to 07/201/2025 documents the following DME (Durable Medical Equipment) and Supplies: RW (Rolling Walker), Commode, Incontinent Supplies. The SN (Skilled Nursing) Admission Visit dated 05/03/2025 OASIS (Outcome and Assessment Information Set) Assessment Items for SOC (Start of Care) documents: “GG0170 Mobility- Has Wheelchair, Has Bedside commode, Has Grab bars (toilet/ shower/tub)”. The PT (Physical Therapy) Evaluation Visit dated 05/06/2025 documents: Clinical Notes: DME (Durable Medical Equipment) at Home- RW (Rolling Walker), Commode”. On 05/13/2025 at 11:05 AM,a home visit was conducted the patient was observed sitting in their wheelchair. The patient’s family member was present and was interviewed. The family member stated “She has been using the wheelchair. She also has a walker.” The clinical record lacks documented evidence of the coordination of care provided by all disciplines, Skilled Nursing documents patient has wheelchair and commode, and Physical Therapy documents rolling walker and commode. On 05/15/2025 at 11:30 AM, the Administrator /Director of Patient Services was interviewed, and no explanation was provided. 4. Patient#17 has a Start of Care date of 03/18/2025 with diagnoses of Unspecified Intellectual Disability, Polyneuropathy Unspecified, Constipation, Other Dysphagia, Need for Assistance with Personal Care documented in the Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025. The Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025 documents DME (Durable Medical Equipment) and Supplies: Grab bars (toilet/shower/tub), Urinal, Incontinence Supplies.” The SN (Skilled Nursing) Routine Visit notes on the following dates documents: 04/09/2025 “Musculoskeletal: Weakness; Ambulates with assistance” 04/23/2025 “Musculoskeletal: Weakness; Ambulates with assistance-Cane” 05/08/2025 “Musculoskeletal: Weakness; Ambulates with assistance-Walker” On 05/13/2025 at 9:00 AM , a home visit was conducted and there is no walker and grab bars in the toilet/shower/tub observed in the patient’s home. The patient was interviewed regarding the use of cane the patient and stated “Yes, I’m using it when walking outside the streets.” The clinical record lacks documented evidence of the coordination of care being provided by all disciplines to assure the identification of patient needs with the use of cane and factors that could affect patient safety including grab bars in the toilet/shower/tub as ordered in the plan of care. On 05/16/2025 at 10:00 AM, the Administrator / Director of Patient Services was interviewed and stated, “the walker was an error, the patient uses cane.””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to ensure that all patients were provided with a copy of written instructions outlining the visit schedule/frequency of home health agency personnel visits. This was evident for four (4) of seven (7) home visits (Patient: #12, #15, #16 #17). Failure to ensure that all patients are provided with written instructions outlining the visit schedule/frequency of has the potential for negative patient outcomes. The Findings Are: 1. Patient #12 has a Start of Care date of 04/25/2025 with diagnoses of Primary Generalized Osteoarthritis, Parkinson’s Disease without Dyskinesia, Pressure Ulcer Unspecified Site, Other Constipation, Essential Primary Hypertension documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents the following orders for Discipline: SN (Skilled Nurse) 1 Week 1 (once a week for one week), 3 Week 8 (three times a week for eight weeks, and 1 Week 1 (once a week for one week); and PT (Physical Therapy) 2 Week 4 (two times a week for four weeks). On 05/12/2025 at 4:00 PM a home visit was conducted the surveyor reviewed the patient’s admission packet, is no written visit schedule for Skilled Nursing and Physical Therapy was observed in the packet. There is no documented evidence of the written visit schedule of Skilled Nursing and Physical Therapy being provided to the patient and caregiver. On 05/15/2025 at 11:30 AM, the Administrator / Director of Patient Services was interviewed and stated, “One of our staff oversees the mailing of visit calendars to the patients’ home address.” 2. Patient #15 has a Start of Care date of 05/05/2025 with diagnoses of Other Chronic Pain, Unilateral Primary Osteoarthritis Right Hip, Recurrent dislocation Right Hip, Essential Primary Hypertension, Constipation, History of Falling documented in the Home Health Certification and Plan of Care for the Certification Period 05/05/2025 to 07/03/2025. The Home Health Certification and Plan of Care for the Certification Period 05/05/2025 to 07/03/2025 documents the following orders for Discipline: SN (Skilled Nurse) 2 Week 1 (two times a week for one week), 1 Week 2 (once a week for two weeks); PT (Physical Therapy) 2 Week 6 (two times a week for six weeks); and HHA ( Home Health Aide) 3 Week 1 ( three times a week for one week), 5 Week 1 ( five times a week for one week), 3 Week 2 ( three times a week for two weeks). On 05/13/2025 at 10:00 AM a home visit was conducted the surveyor reviewed the patient’s admission packet, and there was no written visit schedule observed for the Skilled Nursing, Physical Therapy and Home Health Aide included in the packet. The patient was interviewed and stated “I have a very nice PT (Physical Therapy) twice a week. They call me if they are coming for the day. I will definitely call them if they don’t call coz (because)I know everyone.” There is no documented evidence of the written visit schedule for Skilled Nursing, Physical Therapy and Home Health Aide being provided to the patient and caregiver. On 05/15/2025 at 11:30 AM, the Administrator /Director of Patient Services was interviewed and stated, “The patient is newly admitted last week. One of our staff oversees the mailing of visit calendars to the patients’ home address.” 3. Patient #16 has a Start of Care date of 05/03/2025 with diagnoses of Cerebral Infarction Due to Thrombosis of Left Middle Cerebral Artery, Acute Kidney Failure, Essential Primary Hypertension, Type 2 Diabetes Mellitus documented in the Home Health Certification and Plan of Care for the Certification Period 05/03/2025 to 07/01/2025. The Home Health Certification and Plan of Care for the Certification Period 05/05/2025 to 07/01/2025 documents the following orders for Discipline: SN (Skilled Nurse) 1 Week 2 (once a week for two weeks), 2 Week 1 (two times a week for one week); PT (Physical Therapy) 2 Week 5 (two times a week for five weeks, 1 Week 1 (once a week for one week). On 05/13/2025 at 11:05 AM a home visit was conducted, the surveyor reviewed the patient’s admission packet, and there was no written visit schedule observed for the Skilled Nursing and Physical Therapy included in the packet. The patient’s family member was present during the home visit and was interviewed. They stated, “We have our own notebook to write when the nurse comes to write the vital signs and to monitor the blood sugar.” The Registered Nurse was present during the home visit. They were interviewed and stated, “I call maybe around twenty to thirty minutes before I come to visit.” There is no documented evidence of the written visit schedule for the Skilled Nursing and Physical Therapy being provided to the patient and caregiver. On 05/15/2025 at 11:30 AM, the Administrator /Director of Patient Services was interviewed and stated, “One of our staff oversees the mailing of visit calendars to the patients’ home address.” 4. Patient#17 has a Start of Care date of 03/18/2025 with diagnoses of Unspecified Intellectual Disability, Polyneuropathy Unspecified, Constipation, Need for Assistance with Personal Care documented in the Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025. The Home Health Certification and Plan of Care for the Certification Period 03/18/2025 to 05/16/2025 documents the following orders for Discipline: SN (Skilled Nurse) 1 Week 1 for SOC (once a week for one week for Start of Care), 1 Every Other Week 8 (once every other week for eight weeks), 1 Week 1 (once a week for one week); and HHA ( Home Health Aide) 2 Week 1(two times a week for one week), 5 Week 8 ( five times a week for eight weeks). On 05/13/2025 at 9:00 AM a home visit was conducted, the surveyor reviewed the patient’s admission packet, and there was no written visit schedule observed for Skilled Nursing and Home Health Aide included in the packet. There is no documented evidence of the written visit schedule for the Skilled Nursing and Home Health Aide being provided to the patient and caregiver. On 05/15/2025 at 11:30 AM, the Administrator /Director of Patient Services was interviewed and stated, “One of our staff oversees the mailing of visit calendars to the patients’ home address.” and no further 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 observation, clinical record review, and staff interviews, the agency failed to ensure each patient’s individualized plan of care is complete, accurate and includes all the required information. This was evident for one (1) of three (3) patient care records reviewed (Patient #2). Failure to ensure the development of a complete, accurate, and individualized plan of care for all patients, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 08/08/2023 with the following diagnosis “Venous Insufficiency (Chronic) (Peripheral), Non-Pressure Chronic Ulcer of Left Calf, Non-Chronic Ulcer of Right Calf, Primary Generalized (Osteo) Arthritis “ documented on the Home Health Certification and Plan of Care for the Certification Period 08/08/2023 to 10/06/2023. The Home Health Certification and Plan of Care for the Certification Period 08/08/2023 to 10/06/2023 documents:”08/08/2023-10/06/2023 SN (Skilled Nurse) 3 week 3(three times a week for three weeks) SN (Skilled Nurse) to provide and instruct: Wound care to Stasis Ulcer Left Lower Extremity as follows: Cleanse wound with soap and water, pat dry apply Triad with moist Vash moist soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape.” The SN (Skilled Nurse) Admission Visit Dated 08/08/2023 documents:” Patient has wound as follows: Wound#1: Stasis Ulcer to Posterior Calf of Left Lower Extremity Size: 6.0Lx4.0Wx0.2D cm ... Wound#2: Stasis Ulcer to Posterior Calf of Right Lower Extremity Size:2.0Lx1.7Wx0.2 cm ... DX (RX-Prescription) for wound#1, #2: Cleanse wound with soap and water, pat dry apply Triad with moist Vashe soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape. Frequency: Daily” The SN (Skilled Nurse) Visit Note dated 08/08/2023, 08/10/2023 and 08/12/2023 documents: “SN performed wound care for wound 1# and #2 Cleanse wound with soap and water, pat dry apply Triad with moist Vashe soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape.” The Supplemental Order Begin Date: 08/14/2023 and Discontinue Date: 09/01/2023 documents: “SN (Skilled Nurse) to provide and instruct: Wound care to Stasis Ulcer Left and Right Lower Extremity as follows: Cleanse with NS (Normal Saline Solution) apply Silvadene to open areas, apply Adaptic Unna Boot and wrap with Coban twice a week.” The Home Health Certification and Plan of Care for the Certification Period 08/08/2023 to 10/06/2023 lacks documented evidence of the wound treatment for wound #2(Stasis Ulcer of Right Lower Extremity), and frequency for wound #1(Stasis Ulcer of Left Lower Extremity) from 08/08/2024 to 08/14/2024. On 05/13/2024 at 4:20 pm, the Administrator and the Field Supervisor were interviewed and did not provide an explanation for the findings.”

“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 ensure that treatments are administered only as ordered by the physician for each patient. This was evident for one (1) of three (3) patient care records reviewed (Patient #2). Failure to ensure that treatments are administered only as ordered by the physician has the potential for negative patient outcomes. The Findings are: 1. Patient #2 has a Start of Care date of 08/08/2023 with the following diagnosis “Venous Insufficiency (Chronic) (Peripheral), Non-Pressure Chronic Ulcer of Left Calf, Non-Chronic Ulcer of Right Calf, Primary Generalized (Osteo) Arthritis “ documented on the Home Health Certification and Plan of Care for the Certification Period 08/08/2023 to 10/06/2023. The Home Health Certification and Plan of Care for the Certification Period 08/08/2023 to 10/06/2023 documents:”08/08/2023 - 10/06/2023 SN (Skilled Nurse) to provide and instruct: Wound care to Stasis Ulcer Left Lower Extremity as follows: Cleanse wound with soap and water, pat dry apply Triad with moist Vash moist soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape.” The SN (Skilled Nurse) Admission Visit Dated 08/08/2023 documents:” Patient has wound as follows: Wound#1: Stasis Ulcer to Posterior Calf of Left Lower Extremity Size: 6.0Lx4.0Wx0.2D cm ... Wound#2: Stasis Ulcer to Posterior Calf of Right Lower Extremity Size:2.0Lx1.7Wx0.2 cm ... DX (RX-Prescription) for wound#1, #2: Cleanse wound with soap and water, pat dry apply Triad with moist Vashe soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape. Frequency: Daily” The SN (Skilled Nurse) Visit Note dated 08/08/2023, 08/10/2023 and 08/12/2023 documents: “SN performed wound care for wound 1# and #2 Cleanse wound with soap and water, pat dry apply Triad with moist Vashe soaked gauze dressing, covered with DSD (Dry Sterile Dressing), wrapped with Kerlix, and secure with tape.” The Supplemental Order Begin Date: 08/14/2023 and Discontinue Date: 09/01/2023 documents: “SN (Skilled Nurse) to provide and instruct: Wound care to Stasis Ulcer Left and Right Lower Extremity as follows: Cleanse with NS (Normal Saline Solution) apply Silvadene to open areas, apply Adaptic Unna Boot and wrap with Coban twice a week.” There is no documented evidence of a wound treatment order for the SN to administer treatment to wound #2 on 08/08/2023, 08/10/2023 and 08/12/2023. On 05/13/2024 at 4:20 pm, the Administrator and the Field Supervisor were interviewed and did not provide an explanation for the findings.”