Providence Home Care

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness Coordinator designation in the emergency preparedness program was updated for all patients and employees. Findings: A review of emergency preparedness records showed no change in the Emergency Preparedness Coordinator after a personnel change. On 07/29/26 at 2:45 p.m., Staff A stated the emergency preparedness program was not updated.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the communication plan was updated with current employee contact information for all patients and staff. Findings: A review of the emergency preparedness records showed no updated contact information for current employees in the communication plan. On 07/29/26 at 2:44 p.m., Staff A stated the emergency preparedness communication plan was not updated.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure annual training and testing for emergency preparedness in calendar years 2024 and 2025 was conducted for all patients and employees. Findings: A review of emergency preparedness records showed no annual employee emergency preparedness training and testing. On 07/29/26 at 2:40 p.m., Staff A stated there were no annual training employee records.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted in calendar years 2024 and 2025 for all patients and employees. Findings: A review of emergency preparedness records showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted in calendar years 2024 and 2025. On 07/29/26 at 2:42 p.m., Staff A stated there were no exercises or events in 2024 and 2025.”

“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 and interview, the agency failed to ensure that neither advance beneficiary notice nor HHCOC notice was provided to two (Patients #15 and #16) of 17 patients. Findings: Patient #15 A review of the clinical record showed no advance notice of discharge or home health change of care notice was provided prior to discharge from the agency on 03/20/26 for insurance payer source denial of payment for services. On 07/29/26 at 3:52 p.m., Staff A stated there was no ABN or HHCOC notice prior to the discharge. Patient #16 A review of the clinical record showed no advance notice of discharge was provided prior to discharge from the agency on 05/13/26 for non-compliance. On 07/29/26 at 3:55 p.m., Staff A stated there was no ABN prior to the discharge.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to: Show documentation of the problems encountered by the HHA related to behaviors that impeded the HHA from providing care and services for one (Patient #15) of 17 patients.Educate the patient on potential health outcomes from discontinued HHA care and services for one (Patient #15) of 17 patients.Inform the physician of the patient’s imminent discharge from the HHA for cause for one (Patient #15) of 17 patients. Findings: Patient #15 A review of a plan of care for 04/13/26 to 06/11/26 showed a SN visit frequency of one time a week for nine weeks for SN to assess and teach respiratory disease management, wound site assessment and medication management; a PT visit frequency of one time a week for one week then two times a week for three weeks for strengthening and OT visit frequency of one time a week for one week then two times a week for three weeks, then one time a week for one week for energy conservation. A review a communication note dated 05/13/26 stated the patient was experiencing low blood pressure but admitted to additional dose of blood pressure medication. The ordering physician was notified and stated the patient was being fired from medical provider care for non-compliance. The clinical record showed no identified problems encountered by the HHA related to behaviors or conditions that impeded the HHA from providing care and services, no communication or education attempts to the patient for potential health outcomes resulting from discontinued HHA care and services, no physician notification of the patient’s behaviors and living conditions that impeded the HHA from providing care and services and no notification to the physician of the patient’s imminent discharge from the HHA for cause prior to the discharge date of 05/13/26. On 07/29/26 at 4:10 p.m., Staff A stated the patient was not given advance notice of discharge for cause prior to the discharge date on 05/13/26.”

“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 and interview, the agency failed to ensure individualized patient POCs included: Identification of wound sites and related goals for six (Patient #4, 6, 7, 13, 15 and #16) of 17 patients.A primary and secondary diagnoses for one (Patient #5) of 17 patients.Goals related to the primary diagnosis for one (Patient #6) of 17 patients.Type and size of urinary catheter and related goals for one (Patient #8) of 17 patients.Identification of central intravenous infusion catheter site and related goals for one (Patient #9) of 17 patients. Patient #5 A review of the POC dated 07/19/26 to 09/16/26 showed no primary or secondary diagnoses and showed no disease management interventions, no physician notification and no change in orders. On 07/29/26 at 3:10 p.m., Staff A stated the POC for patient #5 did not include diagnoses from the start of care. Patient #6 A review of the POC dated 06/22/26 to 08/20/26 showed a primary diagnosis of hypertension and showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no goals related to the wound or the primary diagnosis, no physician notification and no change in orders. On 07/29/26 from 3:15 p.m., Staff A stated the POCs for patient #6 did not identify the site of the wound and had no goals for the wound or the primary diagnosis. Patient #8 A review of the POC dated 07/07/26 to 09/04/26 showed orders for SN to conduct urinary catheter changes every month. The POC did not identify the type and size of urinary catheter and related goals, showed no physician notification and no change in orders. On 07/29/26 from 3:22 p.m., Staff A stated the POCs for patient #8 did not identify the type and size of urinary catheter and had related goals. Patient #9 A review of the POC dated 05/16/26 to 07/14/26 showed orders for SN to central intravenous infusion catheter site management and related goals. The POC did not identify the location of the intravenous infusion catheter and related goals, showed no physician notification and no change in orders. On 07/29/26 from 3:23 p.m., Staff A stated the POCs for patient #9 did not identify the location of the PICC line and had no related goals. Patient #4 A review of the POC dated 05/27/26 to 07/25/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no related goals, no physician notification and no change in orders. Patient #7 A review of the POC dated 07/07/26 to 09/04/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no related goals, no physician notification and no change in orders. Patient #13 A review of the POC dated 01/12/26 to 03/12/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no related goals, no physician notification and no change in orders. Patient #15 A review of the POC dated 02/10/26 to 03/20/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no related goals, no physician notification and no change in orders. Patient #16 A review of the POC dated 04/13/26 to 06/11/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated. The POC did not identify the location of the wound site, showed no related goals, no physician notification and no change in orders. On 07/29/26 from 3:00 p.m. to 3:55 p.m., Staff A stated the POCs for patients #4, 6, 7, 13, 15 and #16 did not identify the site of the wounds and had no wound goals.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC’s: SN to measure wound sites every visit as ordered for one (Patient #4) of 17 patients.SN to conduct visit frequencies as ordered by the physicians for three (Patients #4, 7 and #13) of 17 patients.PT to conduct visit frequencies as ordered by the physicians for one (Patient #6) of 17 patients.SN to monitor blood sugar log every visit as ordered for one (Patient #9) of 17 patients.SN to monitor patient weight log every visit as ordered for three (Patients #1, 10 and #15) of 17 patients. Findings: Patient #1 A review of the POC dated 07/07/26 to 09/04/26 showed orders to monitor the patient’s weight every visit. A review of the clinical record showed: SN visits dated 07/17/26 showed no monitoring of the patient’s weight was conducted. The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 2:55 p.m., Staff A stated the patient’s weight was not monitored. Patient #4 A review of the POC dated 05/27/26 to 07/25/26 showed orders for SN to conduct assessment and measure the wound site every visit as indicated with a SN visit frequency of once a week for nine weeks. A review of the clinical record showed: SN visits dated 06/25/26 and 07/24/26 showed no wound site measurements conducted. During the weeks of: 05/27/26 to 05/30/26 no SN visit conducted (one visit ordered, no visit conducted).05/31/26 to 06/06/26 no SN visit conducted (one visit ordered, no visit conducted).06/07/26 to 06/13/26 no SN visit conducted (one visit ordered, no visit conducted).06/14/26 to 06/20/26 no SN visit conducted (one visit ordered, no visit conducted). The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:00 p.m., Staff A stated the wound site was not measured. Patient #6 A review of the POC dated 06/22/26 to 08/20/26 showed orders for a PT visit frequency of one time a week for one week then two times a week for three weeks. A review of the clinical record during the weeks of: 07/12/26 to 07/18/26 no PT visit (two visits ordered, no visit conducted).07/19/26 to 07/25/26 no PT visit (two visits ordered, no visit conducted). The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:15 p.m., Staff A stated the PT visits were not conducted. Patient #7 A review of the POC dated 07/07/26 to 09/04/26 showed orders for SN visit frequency of two times a week for one week then three times a week for eight weeks. The clinical record during the week of 07/19/26 to 07/25/26 SN visits were scheduled and ‘not started’ on 07/20/26, 07/22/26 and on 07/24/26 (three visits ordered, no visits conducted) and showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:20 p.m., Staff A stated the SN visits were not conducted. Patient #9 A review of the POC dated 05/16/26 to 07/14/26 showed orders for SN to monitor the patient’s blood sugar log every visit. A review of the clinical record showed: SN visits dated 05/18/26, 06/02/26, 06/08/26, 06/16/26, 06/22/26, 06/29/26 and 07/06/26 showed no blood sugar log monitoring was conducted. The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:23 p.m., Staff A stated the blood sugar was not monitored. Patient #10 A review of the POC dated 05/20/26 to 07/18/26 showed orders to monitor the patient’s weight every visit. A review of the clinical record showed: SN visits dated 05/21/26, 05/22/26, 05/28/26, 06/08/26, 06/12/26, 06/18/26 and 06/25/26 showed no monitoring of the patient’s weight was conducted. The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:30 p.m., Staff A stated the patient’s weight was not monitored. Patient #13 A review of the POC dated 01/12/26 to 03/12/26 showed orders for SN orders to monitor the patient’s weight every visit. A review of the clinical record showed: SN visits dated 01/27/26, 02/05/26 and 02/10/26 showed no monitoring of the patient’s weight was conducted. The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:50 p.m., Staff A stated the patient’s weight was not monitored. Patient #15 A review of the POC dated 02/10/26 to 03/20/26 showed orders to monitor the patient’s weight every visit. A review of the clinical record showed: SN visits dated 03/12/26 and 03/17/26 showed no monitoring of the patient’s weight was conducted. The clinical record showed no patient refusal, no physician notification and no change in orders. On 07/29/26 at 3:23 p.m., Staff A stated the patient’s weight was not monitored.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes were completed for two (Patients #6 and #7) of 17 patients. Findings: Patient #6 A plan of care dated 06/22/26 to 08/20/26 documented a principal diagnosis of hypertension. A review of the clinical record showed a SN visit note dated 07/15/26 was saved, blank and unsigned by the nurse. Patient #7 A plan of care dated 07/07/26 to 09/04/26 documented a principal diagnosis of Diabetes Mellitus Type II. A review of the clinical record showed SN visit notes dated 07/08/26 and 07/17/26 were saved, blank and unsigned by the nurse. On 07/29/26 at 3:15 p.m., Staff A stated the visit notes for patients #6 and 7 were not completed.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure completed: Transfer summaries were provided to the receiving service provider for four (Patients #9, 10, 12 and #17) of 17 patients. Discharge summaries were provided to the physician (medical provider) for three (Patients #15, 16 and #17) of 17 patients. Findings: Patient #9 A review of the clinical record showed transfer from the agency on 05/22/26 to in-patient hospital services and showed no transfer summary was provided. Patient #10 A review of the clinical record showed transfers from the agency on 05/31/26, 06/29/26 and 07/06/26 to in-patient hospital services and showed no transfer summary was provided. Patient #12 A review of the clinical record showed transfer from the agency on 06/15/26 to in-patient hospital services and showed no transfer summary was provided. Patient #15 A review of the clinical record showed discharge from the agency on 03/20/26 and showed no discharge summary was provided to the physician (medical provider). Patient #16 A review of the clinical record showed discharge from the agency on 05/13/26 and showed no discharge summary was provided to the physician (medical provider). Patient #17 A review of the clinical record showed transferred to in-patient hospital services on 07/02/26 and later discharged from the agency effective 07/02/26 and showed no transfer or discharge summary was provided to the in-patient provider or the physician (medical provider). On 07/29/26 from 3:23 p.m. to 4:00 p.m., Staff A stated the transfer and discharge summaries for patients # #9, 10, 12, 15, 16 and #17 were sent by fax but there was no confirmation documentation that the summaries were sent and received to the providers.”