L A Home Healthcare, Inc.

“Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This Condition is not met as evidenced by: Based on record review, observations, and staff interviews, the agency was not primarily engaged in providing the services of a home health agency. This affects all patients. The census was zero. The agency had no patients and are not primarily engaged.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on policy review, record review, and staff interview, the agency failed to ensure the physician had been notified of missed visits. In addition, the agency failed to ensure the plan of care contained all the required elements. Additionally, the agency failed to ensure the services provided were ordered by the physician. See G572, G574 and G580. Findings”

“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 medical record review, review of the error summary report, staff interview, and review of agency policy, the agency failed to ensure Outcome and Assessment Information Set (OASIS) assessments were completed and submitted to the Centers for Medicare and Medicaid Services (CMS). This affected seven (Patient #1, #2, #3, #4, #5, #6 and #7) of seven patients reviewed for OASIS submission, with the potential to affect all 27 patients on the caseload prior to recent discharge. The agency census was zero. 1. Review of the Error Summary by Agency report dated 01/01/25 through 12/31/25 revealed an error code of 87.63 percent of the records, 163 were submitted late: The submission date was more than 30 days after the date the assessment was completed. Interview on 07/09/26 at 4:15 P.M. with the Owner/Administrator Staff II verified the assessments were completed and not submitted in 30 days as regulated. He included he was the only one who submitted OASIS. He did not have a second staff member who had the password to transmit OASIS assessments. He was out of the country in 2025 for extended periods and had not submitted the OASIS assessments timely. He further verified he had not kept transmission logs to see which OASIS had been submitted and/or denied. 2. Review of Patient #1’s medical record revealed a start of care date of 09/18/25 . Diagnoses included diabetes mellitus, hypertension, low back pain, osteoarthritis, hyperlipidemia, and anemia. Review of the Centers for Medicare and Medicaid Services (CMS)-485 form with a certification period of 03/17/26 through 05/15/26 included the patient was to receive 40 hours of home health aide and skilled nursing twice a week. Review of the comprehensive OASIS assessment revealed Patient #1’s recertification visit was on 05/11/26. The recertification was completed and export ready, The OASIS was not transmitted within 30 days of completion. 3. Review of Patient #2’s medical record revealed a start of care date of 07/18/25. Diagnoses included chronic respiratory failure with hypoxia. Review of the CMS-485 form revealed the last certification period was 03/15/260 through 5/13/26. There was a discharge OASIS assessment dated 05/11/26. There was no evidence of the discharge OASIS being transmitted. 4. Review of Patient #3’s medical record revealed a start of care date of 03/23/22. Diagnoses included type II diabetes, bipolar, gastroesophageal reflux disease and hypercholesterolemia. Review of the CMS-485 form revealed the last certification period was 05/01/26 through 06/29/26. There was a recertification OASIS assessment dated 04/28/26. There was no evidence of the recertification OASIS being transmitted. 5. Review of Patient #4’s medical record revealed a start of care date of 01/17/19. Diagnoses included mild intermittent asthma, uncomplicated gastroparesis, benign prostate hypertrophy and gastroesophageal reflux disease. Review of the CMS-485 form revealed the last certification period was 05/04/26 through 06/08/26. There was a recertification OASIS assessment dated 04/07/26. There was no evidence of the recertification OASIS being transmitted. 6. Review of Patient #5’s medical record revealed a start of care date of 02/25/26. Diagnoses included hypertension, major depressive disorder and type II diabetes. Review of the CMS-485 form revealed the last certification period was 04/26/26 through 06/24/26. There was a recertification OASIS assessment dated 04/22/26. There was no evidence of the recertification OASIS being transmitted. 7. Review of Patient #6’s medical record revealed a start of care date of 01/14/25. Diagnoses included type II diabetes, hypertension, and osteoarthritis of knee. Review of the CMS-485 form revealed the last certification period was 05/09/26 through 07/07/26. There was a recertification OASIS assessment dated 05/05/26. There was no evidence of the recertification OASIS being transmitted. 8. Review of Patient #7’s medical record revealed a start of care date of 10/03/18. Diagnoses included polyosteoarthritis and gastroesophageal reflux disease. Review of the CMS-485 form revealed the last certification period was 04/23/26 through 06/21/26. There was a recertification OASIS assessment dated 04/19/26. There was no evidence of the recertification OASIS being transmitted. Interviewon 07/09/26 and 07/13/26 from 2:11 P.M. to 5:09 P.M., with the Owner/Administrator Staff II verified the assessments for Patient #1, #2, #3, #4, #5, #6 and #7 were completed and not submitted in 30 days as regulated. Review of the agency policy titled, “Reporting of OASIS Information”, revised 2009, revealed the agency would report electronically all OASIS data collected according to current federal and/or state requirements. Agency must encode and have the capability of transmitting OASIS data for each patient within 30 days of completing any required OASIS data set collection.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on policy review and staff interview, the agency failed to provide patient discharge planning when the agency suddenly stopped service to 27 patients following a suspension with the Medicaid provider. This affected all 27 patients who were receiving care. The census was zero. Findings Included: During a telephone interview on 07/08/26 at 11:08 A.M., the Owner/Administrator Staff II said they had no patients. He said he received a call from a case manager on 05/26/26 that they were suspending payment and they discharged all patients. Interview on 07/09/26 at 10:25 A.M., the former Director of Nursing Staff E said on 06/03/26 Staff E and Staff JJ called all the patients and let them know they could not provide services any longer effective 06/03/26 and to find another agency. Staff E included some of the patients already knew from their case manager that they were going to need to find another provider. However, she verified the call had not included any assistance by sharing data on quality measures and resource use measures relevant and applicable to the patient’s goals of care and treatment. She verified the call was not followed up with a written 30 day notice that provided contact information, quality measures, data and resources for other agencies or providers as applicable to meet the patient goals of care and treatment. Staff E stated she thought the case manager finds another agency for the patients and had not offered assistance in finding an alternate agency. Review of the agency’s undated policy titled “Patient Discharge Policy,” revealed the agency will ensure the discharge is appropriate, documented, and communicated in accordance with the CMS Home Health Conditions of Participation.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on staff interview, record review, and policy review, the agency failed to ensure all patients received a current medication list upon discharge. This affected 26 of 27 patients discharged following a suspension with the Medicaid provider. The agency identified Patient #4 was discharged 06/02/26. The census was zero. Findings Included: During a telephone interview on 07/08/26 at 11:08 A.M. the Owner/Administrator Staff II said they had no patients. He said he received a call from a case manager on 05/26/26 that they were suspending payment. All patients were discharged from the agency. Interview on 07/09/26 at 10:25 A.M. the former Director of Nursing Staff E said on 06/03/26 Staff E and Staff JJ called all the patients and let them know they could not provide services any longer effective 06/03/26 and to find another agency. Staff E stayed with the agency until she finished the discharge summaries on all 26 patients they discharged. Staff E stated finished all the discharge Outcome and Assessment Information Set (OASIS) and the summaries. She stated they were non visit discharges and a medication list was not provided. She verified they had not sent a list of reconciled medications to the discharged patients as they did not know they needed to. Review of the record for Patient #1, #2, #3, #5, #6 and #7 revealed there was a checkmark noted on the discharge summary that no medication list was provided. A follow-up interview on 07/09/26 at 4:15 P.M. the former Director of Nursing Staff E verified the discharge for Patient #1 was a non visit discharge, The summary was marked a medication list was not provided. She verified they had not sent a list of reconciled medications to Patient #1. She further verified none of the discharged residents received a medication list. Review of the agency’s undated policy titled “Patient Discharge Policy,” revealed the agency will ensure the discharge is appropriate, documented, and communicated in accordance with the CMS Home Health Conditions of Participation.”

“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 record review, staff interview and policy review, the agency failed to ensure the physician had been notified of a missed visit. This affected one (Patient #1) out of seven records reviewed. The census was zero. Findings Included: Review of Patient #1’s medical record revealed a start of care date of 09/18/25. Diagnoses included diabetes mellitus, hypertension, low back pain, osteoarthritis, hyperlipidemia and anemia. Review of the Centers for Medicare and Medicaid Services (CMS)-485 form with a certification period of 05/16/26 through 07/15/26 included the patient was to receive 40 hours of home health aide services a week and skilled nursing services twice a week. The skilled nursing service was to educate Patient #1 on diabetic foot care, precautions and assess the skin for lesions on the lower extremities. Review of the electronic medical record revealed Patient #1 was receiving skilled nursing services on Monday and Friday’s. The last skilled nurse visit was Monday 06/01/26. There was no evidence of a skilled nurse visit 06/05/26. There was no evidence of the physician being notified of the missed visit. Patient #1 was discharged on 06/06/26. Interview 07/09/26 at 4:15 P.M. with Staff E verified there was not a skilled nurse visit on 06/05/26. Staff E revealed she told the nurse not to make the visit since the patient was notified 06/03/26 that they could not provide services any longer effective 06/03/26 and to find another agency. Staff E verified Patient #1 did not receive a 30 day notice and remained their patient until discharged on 06/06/26. The agency had not provided the nursing services as ordered until discharged on 06/06/26 and the physician was not notified of the missed visit. Review of the agency policy titled “Plan of Care – CMS#485 and Physician’s Orders,” revised 2011, revealed if the agency provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on staff interview and policy review, the agency failed to ensure patients received a written notice of the agency terminating services. This affected 26 of 27 patients who received home health services. The agency identified Patient #4 was discharged on 06/02/26 prior to terminating services. The census was zero. Findings Included: During an initial telephone interview on 07/08/26 at 11:08 A.M. the Owner/Administrator Staff II said they had no patients. He said he received a telephone call from a case manager on 05/26/26 that Medicaid was suspending payment. All patients were discharged. Interview on 07/09/26 at 10:09 A.M. with Owner/Administrator Staff II reiterated on 05/26/26 they received a call from a case manager that payment was suspended. Staff II stated on 05/26/26 they had 27 patients on the list. Medicaid suspended their provider agreement and they were no longer servicing patients. Interview on 07/09/26 at 10:25 A.M. the former Director of Nursing Staff E said on 06/03/26 Staff E and Staff JJ called all the patients and let them know they could not provide services any longer effective 06/03/26 and to find another agency. Staff E said some of the patients already knew from their case manager that they were going to need to find another provider. She verified the call made to patients had not included assistance with finding another provider. She further verified the call was not followed up with a written 30 day notice to their patients. Review of the agency’s undated policy titled “Patient Discharge Policy,” revealed the agency will provide discharge instructions to the patient or caregiver when applicable.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review, interview, review of an email correspondence and review of an Ohio Department of Medicaid letter, the facility failed to maintain a Medicaid payor source. This affected all 27 patients on the agency’s caseload at the time of notification. The current census was zero. Findings Included: Interview on 07/09/26 at 10:09 A.M., with Owner/Administrator Staff II revealed on 05/26/26 the agency received a call from a case manager that payment was suspended. The owner called Medicaid and said Medicaid knew nothing. Staff II stated on 05/26/26 they had 27 patients at the time. On Wednesday 05/26/26 Medicaid suspended their provider agreement and they were no longer servicing patients. He said the case manager called on 06/02/26 and said it was an error. That evening around 5:00.P.M. the case manager called back and said that they have had their payment suspended and could not provide services. Further interview on 07/09/26 at 10:20 A.M., Owner/Administrator Staff II revealed all bills were rejected and we found out they were denied when nothing came to the bank. The last patient was discharged on 06/06/26. Owner/Administrator Staff II verified the Medicaid payor source had been suspended. On 07/09/26 at 10:25 A.M., the former Director of Nursing Staff E arrived and said on 06/03/26 Staff E and Staff JJ called all the patients and let them know services were being stopped effective 06/03/26. Review of an email correspondence and attached letter received on 07/14/26 at 6:42 P.M. from Owner/Administrator Staff II revealed he received certified letter on 06/03/26 from the Ohio Department of Medicaid (ODM) documenting they were required to suspend an Ohio Medicaid Provider Agreement when there was a credible allegation of fraud against the Medicaid provider. Review of the attached letter titled Notice of Suspension of Ohio Medicaid provider payments revealed The Ohio Department of Medicaid (ODM) is issuing this notice to inform you that effective immediately the Ohio Department of Medicaid is suspending all Medicaid payments for services rendered regardless of the date the services were rendered pursuit pursuant to Ohio administrative code, OAC5160 –1– 17.51 and 42 CFR 455.23. The Ohio Department of Medicaid is required to suspend payments when there is credible allegation of fraud against the Medicaid provider. ODM has determined that credible allegation of fraud exist based on evidence of billing for services not provided and not utilizing electronic visit verification (EVV) as required. An investigation is pending under the Medicaid program. In furtherance of this investigation Ohio Department of Medicaid will be conducting a review of your claims. You must fully and completely cooperate with this review, including responses to any request for information or records within specific time frames. A credible allegation of fraud is defined in 42 CFR 455.2 as allegation which has been verified by the state from a source including, but not limited to the following: fraud hotline tips verified by further evidence, claims data mining and patterns identified through provider audit, civil false claim cases and law-enforcement investigations. Allegations are considered to be credible when they have indicia of reliability and the state Medicaid agency has reviewed all allegations, facts and evidence carefully and expeditiously on a case by case basis. This payment suspension is temporary, but may be lifted in whole or part. This payment suspension applies to all claims submitted by you, including claims submitted, but not paid before the date of this notice and also applies to payments of Medicaid funds from managed-care entities and other entities delegated by ODM to administer portions of the Medicaid program.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on staff interview and policy review, the agency failed to ensure patients were provided contact information for other agencies or providers who may be able to provide care when notified of discharge. This affected 26 out of 27 patients reviewed. The agency identified Patient #4 was discharged on 06/02/26. The census was zero. Findings Included: During a telephone interview on 07/08/26 at 11:08 A.M. the Owner/Administrator Staff II said they had no patients. He said he received a call from a case manager on 05/26/26 that they were suspending payment. All patients were discharged from the agency. Interview on 07/09/26 at 10:25 A.M. the former Director of Nursing Staff E said on 06/03/26 Staff E and Staff JJ called all the patients and let them know they could not provide services any longer effective 06/03/26 and to find another agency. Staff E included some of the patients already knew from their case manager that they were going to need to find another provider. She verified the calls made to patients had not included contact information on what other agencies may provide services. She further verified the calls were not followed up with a written 30 day notice that provided contact information for other agencies or providers who may be able to provide care when notified of discharge. Review of the agency’s undated policy titled “Patient Discharge Policy,” revealed the agency will coordinate the patients discharge and communicate with the ordering physician and other appropriate providers to support continuity of care. The policy did not include providing contact information for other agencies or providers who may be able to provide care when notified of discharge.”

“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 record review, staff interview, and policy review, the agency failed to ensure the plan of care contained all the required elements. This affected five (Patient #3, #4, #5, #6 and #7) out of seven records reviewed. The census was zero. Findings Included: 1.Review of Patient #3’s medical record revealed a start of care date of 03/23/22. Diagnoses included type II diabetes, bipolar, gastroesophageal reflux disease and hypercholesterolemia. Review of the Centers for Medicare and Medicaid Services (CMS)-485 form revealed the last certification period was 05/01/26 through 06/29/26. Patient #3’s CMS-485 did not include required assessment in the areas of mental and cognitive status, types of services, supplies and equipment required, rehabilitation potential, functional limitations, activities permitted, safety measures to protect against injury, and homebound narrative. The Home Health Aid (HHA) care plan did not include diet, HHA frequency or allergies. Interview on 07/13/26 at 2:11 P.M. with the Owner/Administrator Staff II verified the CMS-485 did not include assessment in the areas of mental and cognitive status, types of services, supplies and equipment required, rehabilitation potential, functional limitations, activities permitted, safety measures to protect against injury, and homebound narrative as regulated. The HHA care plan did not include diet, HHA frequency or allergies as regulated. 2. Review of Patient #4’s medical record revealed a start of care date of 01/17/19. Diagnoses included mild intermittent asthma, uncomplicated gastroparesis, benign prostate hypertrophy and gastroesophageal reflux disease. Review of the CMS-485 form revealed the last certification period was 05/04/10/26 through 06/08/26. Patient #4’s CMS-485 did not include required assessment in the area of nutrition. The HHA care plan did not include diet or allergies. Interview 07/13/26 at 2:57 P.M. with the Owner/Administrator Staff II verified the CMS-485 did not include the required assessment in the area of nutrition. The HHA care plan did not include diet or allergies. 3. Review of Patient #5’s medical record revealed a start of care date of 02/25/26. Diagnoses included hypertension, major depressive disorder and type II diabetes. Review of the CMS-485 form revealed the last certification period was 05/01/26 through 06/29/26. Patient #5’s CMS-485 did not include the required assessment in the areas of supplies and equipment required, caregiver status, goals, medical necessity and homebound narrative. The HHA care plan did not include diet or allergies. Interview 07/13/26 at 4:07 P.M. with the Owner/Administrator Staff II verified Patient #5’s CMS-485 did not include required assessment in the areas of supplies and equipment required, caregiver status, goals, medical necessity and homebound narrative as required. The HHA care plan did not include diet or allergies. 4. Review of Patient #6’s medical record revealed a start of care date of 01/14/25. Diagnoses included type II diabetes, hypertension, and osteoarthritis of knee. Review of the CMS-485 revealed the last certification period was 05/09/26 through 07/07/26. Patient #6’s CMS-485 did not include required assessment in the areas of mental and cognitive status, types of services, supplies and equipment required, rehabilitation potential, discharge plan, functional limitations, safety measures to protect against injury, caregiver status, and homebound narrative. The HHA care plan did not include diet or allergies. Interview 07/13/26 at 4:40 P.M. with the Owner/Administrator Staff II verified Patient #6’s CMS-485 did not include required assessment in the areas of mental and cognitive status, types of services, supplies, and equipment required, rehabilitation potential, discharge plan, functional limitations, safety measures to protect against injury, caregiver status, and homebound narrative as required. The HHA care plan did not include diet or allergies. 5. Review of Patient #7’s medical record revealed a start of care date of 10/03/18. Diagnoses included polyosteoarthritis and gastroesophageal reflux disease. Review of the CMS-485 form revealed the last certification period was 04/23/26 through 06/21/26. Patient #$7’s CMS-485 did not include required assessment in the areas of supplies and equipment required, rehabilitation potential, discharge plan, nutritional requirements, caregiver status, medical necessity and homebound narrative. The HHA care plan did not include diet, HHA frequency or allergies. Interview 07/13/26 at 5:09 P.M. with the Owner/Administrator Staff II verified Patient #7’s CMS-485 did not include required assessment in the areas of supplies and equipment required, rehabilitation potential, discharge plan, nutritional requirements, caregiver status, medical necessity and homebound narrative as regulated. The HHA care plan did not include diet, HHA frequency or allergies. Review of the agency policy titled “Plan of Care - CMS #485 and Physician’s Orders,” revised 2011 revealed the plan of care includes mental status, types of services and equipment required, frequency of visits and duration, rehabilitation potential , functional limitations, homebound status, activities permitted, nutritional requirements, specific procedures deemed essential for the health and safety of the patient, instructions for timely discharge or referral, goals, food and drug allergies and discharge plans.”

“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 record review, staff interview, and policy review, the agency failed to ensure the services provided were ordered by the physician. This affected one (Patient #1) out of seven patients reviewed. The census was zero. Findings Included: Review of Patient #1’s medical record revealed a start of care date of 09/18/25. Diagnoses included diabetes mellitus, hypertension, low back pain, osteoarthritis, hyperlipidemia, and anemia. Review of the Centers for Medicare and Medicaid Services (CMS)-485 form with a certification period of 03/17/26 through 05/15/26 included Patient #1 was to receive 40 hours of home health aide services a week. The CMS-485 form was signed by the physician on 05/01/26. Review of the handwritten time sheets signed by the Home Health Aide (HHA) and Patient #1 revealed the HHA provided 41 hours of service weekly not 40 hours as ordered. Interview on 07/09/26 at 4:28 P.M. with Staff E verified the HHA was providing 41 hours of service weekly instead of 40 hours as ordered. Review of the agency policy titled “Plan of Care – CMS#485 and Physician’s Orders,” revised 2011, revealed care and services provided will be provided according to physician orders.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on personnel record review, review of the Bureau of Criminal Investigation (BCI) log, policy review, and staff interview, the agency failed to ensure the receipt and logging of background check results upon hire. This affected three employees (Staff DD, Staff OO, and Staff BB) out of five personnel records reviewed and one (Staff EE) of the eight employees listed on the BCI log, and 10 employees (Staff E, Staff F, Staff G, Staff I, Staff J, Staff Z, Staff AA, Staff BB, Staff II and Staff JJ), who were not on the revised BCI log, of the 36 employees the agency employed at the time they discharged their patients. This had the potential to affect all 28 patients who recieved services prior to discharge. The agency census was zero. Findings Included: Review of the roster of agency employees provided included 36 employees prior to the staff quitting because they were no longer servicing patients. Review of Home Health Aid (HHA) Staff DD’s personnel file revealed a hire date of 11/24/21. Review of the BCI log revealed HHA Staff DD was not listed on the log. Review of HHA Staff OO’s personnel file revealed a hire date of 02/10/20. Review of the BCI log revealed HHA Staff O was not on the BCI log. Review of Registered Nursing (RN) Staff BB’s personnel file revealed a hire date of 01/25/23. Review of the BCI log revealed RN Staff BB was not on the BCI log. Review of the BCI log revealed eight names were on the log and the last employee, Staff EE, on the log was dated 07/03/19. The log had no information of a hire date, a date the BCI was requested or received for Staff EE. During an interview on 7/09/26 at 2:43 P.M. with the Owner/Administrator Staff II verified the BCI log was not kept up to date. The Owner/Administrator Staff II tried to find a BCI log on his computer and pulled up a log with the last entry being an employee hired on 07/09/19. Review of an updated BCI log provided by the Owner/Administrator Staff on 07/13/26 which contained 29 names. Staff E, Staff F, Staff G, Staff I, Staff J, Staff Z, Staff AA, Staff BB, Staff II and Staff JJ, who were on the list of the 36 employees the agency employed at the time they discharged their patients, were not on the BCI log. Review of the agency’s undated policy titled “Personnel Background Check Policy Records” did not include the agency would maintain a BCI log.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an accurate medical record. This affected one (Patient #2) of seven records reviewed. The census was zero. Findings Included: Review of Patient #2’s medical record revealed a start of care date of 07/18/25. Diagnoses included chronic respiratory failure with hypoxia. Review of the Centers for Medicare and Medicaid Services (CMS)-485 form revealed the last certification period was 03/15/26 through 05/13/26. The CMS-485 included Patient #2 was to receive 14 Home Health Aide (HHA) hours per week. Review of the HHA care plan included the patient was to receive 14 Home Health Aide (HHA) hours per week. Review of the HHA time sheets revealed the patient received seven HHA hours a week. Review of Care Source (Medicaid Provider) letters revealed on 01/30/26 and 03/19/26 CareSource denied the request for 14 HHA hours weekly. Interview 07/13/26 at 2:34 P.M. with the Owner/Administrator Staff II revealed the agency requested 14 hours of HHA weekly but it was denied each time. Staff II verified the CMS-485 and HHA care plan said the patient was to receive 14 hours of HHA weekly however, she was never ordered 14 hours and the HHA care plan and the CMS-485 should have said seven HHA hours a week and not 14 hours.”