Visiting Nurse Association of Indiana County

“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 review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the agency staff failed to follow the plan of care according to physicians orders for medication administration, wound care and pain assessment for one (1) of four (4) patients MR’s reviewed (MR4). Based on review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the agency staff failed to follow the plan of care according to physicians orders for medication administration, wound care and pain assessment for one (1) of four (4) patients MR’s reviewed (MR4). Findings included: Review of the agency policy was reviewed on 12/10/2025 at approximately 3:55 PM which revealed, “SUBJECT: OASIS…C. Initial Assessment, 1. An initial assessment visit will be conducted to determine the immediate care and support needs of the patient using the OASIS start of care form, and may also determine eligibility for the home health benefit, including homebound status. 2. A qualified rehabilitation skilled professional will conduct the initial assessment for therapy only cases. 3. A qualified clinician will communicate to obtain orders for the Plan of Care. D. General Guidelines 1.Each patient will receive a patient-specific comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement or desired outcomes. 2. The comprehensive assessment must also incorporate the use of the current version of the Outcome Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items as specified by CMS. 3. The comprehensive assessment will identify the patient’s medical, nursing, rehabilitative, social and discharge planning needs as well as the patient’s current health, psychosocial, functional and cognitive status…” Review of the agency services was reviewed on 12/10/2025 at approximately 3:55 PM which revealed, “SUBJECT: Nursing Services…A. Provider Care The most frequent professional service provided by the agency is skilled nursing and is provided by Registered Nurses (RN) and Licensed Practical Nurses (LPN). It is given in accordance with the attending physician’s or allowed practitioner’s order. The RN, assigned as the “primary nurse”, is considered the case manager/coordinator when multiple disciplines are visiting. The RN is responsible for all aspects of the nursing process including: comprehensive evaluation/re-evaluation of the patient, provision of skilled care, all aspects of patient teaching, observation of clinical signs and symptoms, supervision of the LPN and home health aide. Nursing care includes general medical-surgical functions as well as specialty services in wound care, infusion therapy and psychiatric/mental health and palliative care…” Focused review of the agency policy on 11/12/2025 at approximately 1:20 PM revealed, “POSITION DESCRIPTION-REGISTERED NURSE…POSITION SUMMARY…The Registered Nurse provides care consistent with all relevant professional standards and state and federal regulations DUTIES AND RESPONSIBILITIES Clinical Skills A. Provide skilled nursing care that includes activities such as teaching, treatments, (including IV therapy, venipuncture, complex wound care) and health promotion practices…C. Assesses signs and symptoms in conjunction with reporting reactions to treatments including drugs, and changes in patient’s physical, mental, or emotional condition to the physician…Communication A. Calls the physician for a verbal order to continue visits at start of care, resumption of care, and re-certifications B. Interacts with field staff, patients, families, physicians, other health disciplines, agencies. Insurance companies, hospitals, labs, employers, government agencies and representatives as necessary, Professional Standards A. Protects patient privacy and confidentiality by being discreet and professional in sharing information on a need-to-know basis B. Adheres to all polices set forth in Nurse Practice Act and maintains a professional standard of conduct, projecting a positive image of the agency C. Complies with infection control and safety policies and procedures…E. Adheres to all policies and practices of the agency to maintain established Standards of Care…” Review of the agency admission packet on 11/12/2025 at approximately 9:45 AM revealed, booklet “Patient Information for Home Health Care…How you can help us relieve you pain (page 35)…You will be asked to rate your pain on a 0-10 scale using the pain scale on the inside of the back cover of this book. 0= No Pian, 10= The worst possible pain *Tell us which pain medications you are taking and if they are helping you *If your pain scale is 4 or more, we will look at how long the pain lasts, how mush it hurts and other aspects of the pain, such as how it affects what you are able to do everyday * Tell us if something we try does not work-we will call your doctor for an order to try something else *Do not wait until the pain gets so bad before telling us *Pain can be controlled safely…” A review of the MR4 on 11/12/2025 at approximately 3:00 PM start of care date of 8/19/2025 with an admitting diagnosis type 2 diabetes mellitus with other specified complications. The following documentation was found within MR: Confirmed via email from EMP3 on 12/10/2025 at approximately 11:14 medication in question for MR4 on 8/22/2025 was Levofloxacin to start 8/21/2025. “Client Medication Report…LEVOFLOXACIN 750 MG/150 ML IN 5% DEXTROSE INTRAVENOUS PIGGYBACK…Instructions: 750 MG/15ML D5W over 90MIN VIA GRAVITY AT 100ML/HR…” Per EMP5 “Visit Note Report…Visit Date: 08/23/2025…Interventions Provided…INFUSED LOVOFLOXACIN 750MG/150ML D5W OVER APPROXIMATELY 60 MINUTES AT 100/HR VIA GRAVITY…” Per EMP6 “Visit Note Report…Visit Date: 08/30/2025…Narrative…SINGLE LUMEN PICC TO RIGHT RAC RAN IV ANTIBIOTIC LEVOFLOXACIN OVER AN HR VIA GRAVITY DRIP. PATIENT TOLERATED WELL LUNGS CLEAR, HEART NSR…” Per home health certification and plan of care for certification period 8/19/2025 to 10/17/2025. “Orders of Discipline and Treatments…CLINICAN TO PERFORM/TEACH WOUND CARE TO LOCATION OF WOUND RIGHT GREAT TOE AREA DIABETIC ULCER. CLEANSE WITH SOAP AND WATER APPLY MEPILEX DRESSING USING CLEAN/ASEPTIC TECHNIQUE…” “Visit Note Report…Visit Date: 08/23/2025…WOUND CARE PROVIDED, CLEANSED WITH NSS OR WOUND CLEANSER. APPLY XERFORM TO WOUND BED. COVER WITH DRY DRESWSING AND CONFORMING WRAP GAUSE SECURE WITH TAPE…” “Visit Note Report…Visit Date: 08/27/2025…WOUND CARE PROVIDED, CLEANSED WITH NSS OR WOUND CLEANSER. APPLY XERFORM TO WOUND BED. COVER WITH DRY DRESWSING AND CONFORMING WRAP GAUSE SECURE WITH TAPE…” Per home health certification and plan of care for certification period 8/19/2025 to 10/17/2025. “Orders of Discipline and Treatments…SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED, SKILLED NURSE WILL INSTRUCT AND REINFORCE MEDICATIOPN TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES…SKILLED NURSE TO PROVIDED SKILLED ASSESSMENT/TEACHING/REINFORCEMENT TO PROPERLY MANAGE PAIN…” “Visit Note Report…Visit Date: 09/14/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/15/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/16/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/18/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/20/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/21/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/14/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 10/02/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 7…” “Visit Note Report…Visit Date: 10/04/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/05/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/06/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/10/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/16/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/19/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 10…” The surveyor could not confirm pain medications were available from 9/14/2025 to 10/19/2025. An interview was conducted on 12/10/2025 at approximately 10:48 AM with the executive director to confirm the above information.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the skilled professional failed to provide ongoing medication administration, wound assessments and pain assessment for one (1) of four (4) patients MR’s reviewed (MR4). Based on review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the skilled professional failed to provide ongoing medication administration, wound assessments and pain assessment for one (1) of four (4) patients MR’s reviewed (MR4). Findings Included: Review of the agency services was reviewed on 12/10/2025 at approximately 3:55 PM which revealed, “SUBJECT: Nursing Services…A. Provider Care The most frequent professional service provided by the agency is skilled nursing and is provided by Registered Nurses (RN) and Licensed Practical Nurses (LPN). It is given in accordance with the attending physician’s or allowed practitioner’s order. The RN, assigned as the “primary nurse”, is considered the case manager/coordinator when multiple disciplines are visiting. The RN is responsible for all aspects of the nursing process including: comprehensive evaluation/re-evaluation of the patient, provision of skilled care, all aspects of patient teaching, observation of clinical signs and symptoms, supervision of the LPN and home health aide. Nursing care includes general medical-surgical functions as well as specialty services in wound care, infusion therapy and psychiatric/mental health and palliative care…” Review of the agency policy was reviewed on 12/10/2025 at approximately 3:55 PM which revealed, “SUBJECT: OASIS…C. Initial Assessment, 1. An initial assessment visit will be conducted to determine the immediate care and support needs of the patient using the OASIS start of care form, and may also determine eligibility for the home health benefit, including homebound status. 2. A qualified rehabilitation skilled professional will conduct the initial assessment for therapy only cases. 3. A qualified clinician will communicate to obtain orders for the Plan of Care. D. General Guidelines 1.Each patient will receive a patient-specific comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement or desired outcomes. 2. The comprehensive assessment must also incorporate the use of the current version of the Outcome Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items as specified by CMS. 3. The comprehensive assessment will identify the patient’s medical, nursing, rehabilitative, social and discharge planning needs as well as the patient’s current health, psychosocial, functional and cognitive status…” Focused review of the agency policy on 11/12/2025 at approximately 1:20 PM revealed, “POSITION DESCRIPTION-REGISTERED NURSE…POSITION SUMMARY…The Registered Nurse provides care consistent with all relevant professional standards and state and federal regulations DUTIES AND RESPONSIBILITIES Clinical Skills A. Provide skilled nursing care that includes activities such as teaching, treatments, (including IV therapy, venipuncture, complex wound care) and health promotion practices…C. Assesses signs and symptoms in conjunction with reporting reactions to treatments including drugs, and changes in patient’s physical, mental, or emotional condition to the physician…Communication A. Calls the physician for a verbal order to continue visits at start of care, resumption of care, and re-certifications B. Interacts with field staff, patients, families, physicians, other health disciplines, agencies. Insurance companies, hospitals, labs, employers, government agencies and representatives as necessary, Professional Standards A. Protects patient privacy and confidentiality by being discreet and professional in sharing information on a need-to-know basis B. Adheres to all polices set forth in Nurse Practice Act and maintains a professional standard of conduct, projecting a positive image of the agency C. Complies with infection control and safety policies and procedures…E. Adheres to all policies and practices of the agency to maintain established Standards of Care…” Review of the agency admission packet on 11/12/2025 at approximately 9:45 AM revealed, booklet “Patient Information for Home Health Care…How you can help us relieve you pain (page 35)…You will be asked to rate your pain on a 0-10 scale using the pain scale on the inside of the back cover of this book. 0= No Pian, 10= The worst possible pain *Tell us which pain medications you are taking and if they are helping you *If your pain scale is 4 or more, we will look at how long the pain lasts, how mush it hurts and other aspects of the pain, such as how it affects what you are able to do everyday * Tell us if something we try does not work-we will call your doctor for an order to try something else *Do not wait until the pain gets so bad before telling us *Pain can be controlled safely…” A review of the MR4 on 11/12/2025 at approximately 3:00 PM start of care date of 8/19/2025 with an admitting diagnosis type 2 diabetes mellitus with other specified complications. The following documentation was found within MR: Confirmed via email from EMP3 on 12/10/2025 at approximately 11:14 medication in question for MR4 on 8/22/2025 was Levofloxacin to start 8/21/2025. “Client Medication Report…LEVOFLOXACIN 750 MG/150 ML IN 5% DEXTROSE INTRAVENOUS PIGGYBACK…Instructions: 750 MG/15ML D5W over 90MIN VIA GRAVITY AT 100ML/HR…” Per EMP5 “Visit Note Report…Visit Date: 08/23/2025…Interventions Provided…INFUSED LOVOFLOXACIN 750MG/150ML D5W OVER APPROXIMATELY 60 MINUTES AT 100/HR VIA GRAVITY…” Per EMP6 “Visit Note Report…Visit Date: 08/30/2025…Narrative…SINGLE LUMEN PICC TO RIGHT RAC RAN IV ANTIBIOTIC LEVOFLOXACIN OVER AN HR VIA GRAVITY DRIP. PATIENT TOLERATED WELL LUNGS CLEAR, HEART NSR…” Per home health certification and plan of care for certification period 8/19/2025 to 10/17/2025. “Orders of Discipline and Treatments…CLINICAN TO PERFORM/TEACH WOUND CARE TO LOCATION OF WOUND RIGHT GREAT TOE AREA DIABETIC ULCER. CLEANSE WITH SOAP AND WATER APPLY MEPILEX DRESSING USING CLEAN/ASEPTIC TECHNIQUE…” “Visit Note Report…Visit Date: 08/23/2025…WOUND CARE PROVIDED, CLEANSED WITH NSS OR WOUND CLEANSER. APPLY XERFORM TO WOUND BED. COVER WITH DRY DRESWSING AND CONFORMING WRAP GAUSE SECURE WITH TAPE…” “Visit Note Report…Visit Date: 08/27/2025…WOUND CARE PROVIDED, CLEANSED WITH NSS OR WOUND CLEANSER. APPLY XERFORM TO WOUND BED. COVER WITH DRY DRESWSING AND CONFORMING WRAP GAUSE SECURE WITH TAPE…” Per home health certification and plan of care for certification period 8/19/2025 to 10/17/2025. “Orders of Discipline and Treatments…SKILLED NURSE TO REVIEW MEDICATION PROFILE AND RECONCILE MEDICATIONS AS NEEDED, SKILLED NURSE WILL INSTRUCT AND REINFORCE MEDICATIOPN TEACHING RELATED TO USE OF MEDICATIONS TO TREAT DISEASE PROCESSES…SKILLED NURSE TO PROVIDED SKILLED ASSESSMENT/TEACHING/REINFORCEMENT TO PROPERLY MANAGE PAIN…” “Visit Note Report…Visit Date: 09/14/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/15/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/16/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/18/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 09/20/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/21/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 09/14/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 8…” “Visit Note Report…Visit Date: 10/02/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 7…” “Visit Note Report…Visit Date: 10/04/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/05/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/06/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/10/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/16/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 6…” “Visit Note Report…Visit Date: 10/19/2025…Assessment…INDICATE CLIENT’S CURRENT PAIN SCALE RATING: 10…” The surveyor could not confirm pain medications were available from 9/14/2025 to 10/19/2025. An interview was conducted on 12/10/2025 at approximately 10:48 AM with the executive director to confirm the above information.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to administer drug therapy according to physician orders for one (1) of four (4) MR reviewed (MR4). Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to administer drug therapy according to physician orders for one (1) of four (4) MR reviewed (MR4). Findings included: Focused review of the agency policy on 11/25/2025 at approximately 1:00 PM revealed, “SUBJECT: Infusion Therapy I. Policy (Agency) will assist patients in attaining an optimal state of health by providing comprehensive care including the safe administration of infusion therapy services. Registered Nurses (RN) who have the education, experience and demonstrated competency with infusion therapy incompliance with established agency policy and procedures will be eligible to provide infusion therapy care to patients...II. Procedure A. The Intake Coordinator/Liaisons, Clinical supervisor, or designee, receives the home health referral for Infusion Therapy, verifies physician orders, anticipates potential adverse reaction, establishes patient contact and investigates insurance coverage. B. The Agency accepts referrals requiring intravenous fluids and medications, administered either peripherally or centrally. Acceptance for IV therapy depends on safety, feasibility and the clinical evaluation…” A review of the MR4 on 11/12/2025 at approximately 3:00 PM start of care date of 8/19/2025 with an admitting diagnosis type 2 diabetes mellitus with other specified complications. The following documentation was found within MR: Confirmed via email from EMP3 on 12/10/2025 at approximately 11:14 medication in question for MR4 on 8/22/2025 was Levofloxacin to start 8/21/2025. “Client Medication Report…LEVOFLOXACIN 750 MG/150 ML IN 5% DEXTROSE INTRAVENOUS PIGGYBACK…Instructions: 750 MG/15ML D5W over 90MIN VIA GRAVITY AT 100ML/HR…” Per EMP5 “Visit Note Report…Visit Date: 08/23/2025…Interventions Provided…INFUSED LOVOFLOXACIN 750MG/150ML D5W OVER APPROXIMATELY 60 MINUTES AT 100/HR VIA GRAVITY…” Per EMP6 “Visit Note Report…Visit Date: 08/30/2025…Narrative…SINGLE LUMEN PICC TO RIGHT RAC RAN IV ANTIBIOTIC LEVOFLOXACIN OVER AN HR VIA GRAVITY DRIP. PATIENT TOLERATED WELL LUNGS CLEAR, HEART NSR…” An interview was conducted on 12/10/2025 at approximately 10:48 AM with the executive director to confirm the above information.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to ensure the physician was notified of changes in the patient’s condition for one (1) of four (4) MR reviewed. (MR4). Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to ensure the physician was notified of changes in the patient’s condition for one (1) of four (4) MR reviewed. (MR4). Findings included: Focused review of the agency policy on 11/12/2025 at approximately 2:18 PM revealed, “SUBJECT: Medical Management by Allowed Practitioners…II. Procedure A. The cooperative effort of the allowed practitioner and the Agency require a comprehensive exchange of information between the physician and the Agency in relation to the treatment goals, clinical interventions, personnel availability, emergency procedures, the timely exchange of clinical questions and concerns and other relevant matters. The physician must certify or attest that the patient meets home health criteria matters. The physician must certify or attest that the patient meets home health criteria to receive services…SUBJECT: Medical Management by Allowed Practitioner, When orders are not returned in a timely manner, agency staff will use appropriate measures to follow-up and secure these orders. As quality patient care and reimbursement are dependent on orders being signed, it is expected that the allowed practitioner will cooperate by quickly returning these communications. E. Part of the allowed practitioner’s role in home health is to diagnose the patient’s illness and determine, but consultation with Agency staff, a plan of care to bring about the recovery of, or best possible outcome for, the patient under existing clinical conditions. F. The allowed practitioner is requested to provide the Agency with a phone number at which he/she can be reached, and will be responsible to designate coverage when he or she is unavailable. G. When specialty physicians are required, it is the primary clinicians role to collaborate with the attending physician and verify that orders may be issued by these specialists. The clinician must also notify the Agency that a specialty referral was made while assisting in obtaining signed orders from these specialist, if necessary…L. The allowed practitioner should regularly have contact with his/her patient as often as is clinically necessary. Any changes in goals, treatment modalities, services offered by the Agency or frequency of visits that are a result of allowed practitioner/patient discussion should be communicated in a timely manner to the Agency. M. Failure of the allowed practitioner to follow the physician’s rights and responsibilities could result in patient discharge of our services and/or refusal of the allowed practitioner’s future referrals…” Focused review of the agency policy on 11/12/2025 at approximately 1:20 PM revealed, “SUBJECT: Physician Rights and Responsibilities I. Policy To maintain quality and continuity of care requires a collaborative relationship between the physician and home health. The following standards outline the rights and responsibilities of the physician. Every physician who utilizes our services is given a copy of the Physician’s Rights and Responsibilities, along with a cover letter explaining its purpose. II. Procedure…PHYSICIAN RESPONSIBILITIES > Management of the patient’s medical problems with a frequency of contact predicated by the patient’s condition > Establish a plan of care, including changes to the plan of care in a timely manner by providing information necessary to achieve long and short-term goals communicated in understandable clinical language. > Appropriate and timely monitoring of care received by the patient with corresponding evidence-based orders to the caregiver. >Provision for continuity of care during the physician’s absence; availability to answer questions from changes in patient’s condition or the addition or orders by specialists and referrals to other community resources. >Provide assistance in family decisions concerning patient’s desires about hospitalization, both elective and emergency; resuscitation, and application or continuation of various medical modalities. >Be available to provide guidance and suggestions regarding patient care. > Complete and sign patient orders in a timely manner, per agency policy. > Comply with referral, admission and discharge policies…” A review of the MR4 on 11/12/2025 at approximately 3:00 PM start of care date of 8/19/2025 with an admitting diagnosis type 2 diabetes mellitus with other specified complications. The following documentation was found within MR: The following information was provided on 11/12/2025 at approximately 1:20 PM: “Client Occurrence Report Client (MR4)…Occurrence Date: 10/29/2025 12:00 AM…Code T87.43, Description INFECTION OF AMPUTATION STUMP, RIGHT LOWER EXTREMITY, Onset/Exac. EXACERBATION, O/E Date 11/4/2025(EMP3)…Description of Occurrence: PHONE CALL PLACED BY EXECUTIVE DIRECTOR THIS DATE TO (physician) OFFICE TO ADDRESS CONCERNS VOICED BY STAFF OF NOT BEING ABLE TO REACH THE OFFICE/MD FOR TIMELY RESPONSES TO CHANGES OF PATIENT CONDITIONS. THE OFFICE DID NOT ANSWER THIS DATE. A VOICE MAIL WAS LEFT FOR THE OFFICE TO CALL ME BACK. I SPECIFICALLY VERBALIZED CONCERNS OF LACK OF CALL BACK/FOLLOW THROUGH ON STAFF COMMUNICATION ATTEMPTS FOR (MR4) PRIOR TO HIS HOSPITALIZATION. CLINICAL MANAGER AND I PREVIOUSLY MET WITH (physician) OFFICE ON JUNE 23RD, 2025 TO ADDRESS THE SAME CONCERNS. ON SEPTEMBER 19TH, OFFICE LEADERSHIP ONCE AGAIN CONTACTED (physician) OFFICE TO ADDRESS MULTIPLE PATIENT CONCERNS AND LACK OF ORDER FOLLOW THROUGH. SPECIFICAL (MR4) AT THAT TIME…” Complaint Report…Date 10/23/2025…Client: (MR4) Complainant: CAREGIVER/FAMILY…MUILTIPLE COMMUNICATION ATTEMPTS HAVE BEEN MADE WITH (physician) TO ADDRESS CONCERNS THAT THE ORGANIZATION DID NOT RECEIVE A RESPONSE FROM RESULTING IN HOME HEALTH AGENCY RECOMMENDING HOSPITAL PLACEMENT TO ADDRESS POTENTIAL INFECTION…” An interview was conducted on 12/10/2025 at approximately 10:48 AM with the executive director to confirm the above information.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on review of agency policy, job descriptions, Medical records (MR), and staff (EMP) interview, it was determined that the agency failed to ensure wounds were measured weekly for one (1) of four (4) MR’s reviewed. (MR2 ). Findings included: Review of agency training guidance on 9/17/2025 at approximately 3:25 PM revealed, “Wound Cre: Assessment and Measurement…*gather your supplies, perform hand hygiene, and don clean gloves. *Place supplies, such as a plastic shaft applicator, gauze, and penlight, on a clean drape or field. *Ensure adequate lighting is present…Step 4: Inspect the Wound *Visually inspect the wound, and use a penlight or flashlight to see all aspects of the wound. Step 5: Measure the Wound *Use a plastic shaft applicator to measure the wound, measuring length as the longest area from head to toe, width as the longest area horizontally, and depth as the deepest area in relation to the wound margin. *Note that best practice is to use centimeters. Step 6: Measure Tunnels *Place the applicator in the tunnel. The measurement will be from the base to where it begins. *To measure undermining, you want to use the deepest areas of undermining and document it using clock terminology, such as 3 centimeters of undermining is noted at 3 o’clock. *Document your measurements at least once a week. Step 7: *Assess wound tissue and determine the percentage of granular, necrotic, and nongranulating tissue. *Document what percentage of each kind of tissue you see. *Assess the periwound tissue. *You may use an applicator or gloved finger to feel the tissue in the wound or to feel if bone is present or close to the wound bed…” Review of agency policy on 10/1/2025 at approximately 1:00 PM revealed, “POSITION DESCRIPTION-REGISTERED NURSE…POSITION SUMMARY… The Registered Nurse is a licensed health care professional with advanced medical knowledge who administers skilled nursing care to patients requiring intermittent visits. She/he provides complex care to the patient and coordinates necessary support services. These nursing services are provided to patients in accordance with a physician’s plan of care. Registered Nurses who serve as primary nurses utilize a case manager approach in assessing, implementing, coordinating, and evaluating client care. Additionally, the Registered Nurse manages other members of the nursing team. The Registered Nurse provides care consistent with all relevant professional standards and state and federal regulations. A. Provides skilled nursing care that includes activities such as teaching, treatments, (including IV therapy, venipuncture, complex wound care) and health promotion practices…S. Meets with Clinical Supervisor or Case Manager weekly for an evaluation of patients under his/her care…” Review of agency policy on 10/1/2025 at approximately 1:00 PM revealed, “POSITION DESCRIPTION-LICENSED PRACTICAL NURSE…POSITION SUMMARY The Licensed Practical Nurse (LPN) works under the guidance of the Registered Nurse (RN) as a member of a team to give direct nursing care to patients requiring intermittent visits. The LPN collaborates patient care with the case managing RN, physician, and patient and follows a patient specific treatment plan. The LPN provides care consistent with all relevant professional standards and state and federal regulations…DUTIES AND RESPONSIBILITIES Clinical Skills A. Provides skilled nursing care that includes activities such as teaching and treatments (including IV therapy- if IV certified, venipuncture and complex wound care) and health promotion practices…F. Documents all communications with the physician and the interdisciplinary team on the patient’s electronic health record…” Review of MR2 was conducted on 9/17/2025 at approximately 2:52 PM revealed, “Home Health Certification and Plan of Care” with a start of care date of 5/9/2025 and a certification period starting 5/9/2025 and ending 7/7/2025. The primary diagnosis was encounter for surgical aftercare following surgery on the genitourinary system. Wound assessments were review from the date’s visits were conducted: 5/9/2025 Measurements documented 5/12/2025 No measurements 5/14/2025 No measurements 5/16/2025 No measurements 5/18/2025 No measurements 5/20/2025 No measurements 5/22/2025 No measurements 5/24/2025 No measurements 5/26/2025 Measurements documented 5/28/2025 Measurements documented 5/30/2025 Refused measurements An exit interview was conducted with the quality manager on 9/17/2025 at approximately 3:45 PM which confirmed the above findings.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Findings Included: Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, “SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient’s physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care…E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient’s discharge from service. Agency Standards for Care require a Discharge Summary to be written for HomeHealth patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters.” Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was provided to confirm the patient was discharge from the agency. No documentation was provided to confirm the patient or patient representative was provided agency documents “Discharge Planning Guide, Discharge Instructions (or) Therapy Discharge Instructions,” upon termination of services. An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.”

“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 a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Findings Included: Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, “SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient’s physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care…E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient’s discharge from service. Agency Standards for Care require a Discharge Summary to be written for Home Health patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters.” Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was available to confirm the patient or patient representative was provided with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient upon discharge. An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on a review of the facility Emergency Disaster Preparedness Plan and staff (EMP) interview, it was determined the facility failed to develop and maintain a procedure for the use of volunteers in an emergency or emergency staffing strategies. Findings Included: Review of the facility Emergency Disaster Preparedness Plan was conducted 11/16/2023 at approximately 10:05 AM. Facility plan did not contain documented evidence of a procedure for the use of volunteers. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.”

“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 review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for four (4) of seven (7) observations where staff was providing direct care to patients (OBV1, OBV3, OBV5 and OBV7). Findings Included: Review of the agency policy and procedures was conducted on 12/01/2023 at approximately 1:00 PM which revealed, Document provided by agency for nursing/supply bag technique “Skills: Supply Bag Technique (Home Health Care) PROCEDURE Preparing the Bag…2. Create a dedicated area of the bag for clean, reusable items (e.g., blood pressure cuff). 3. Create a dedicated area of the bag for clean, sterile, nonreusable items, such as dressings and supplies. 3. When reentering the home, place the bag on a clean, dry surface with a water-resistant barrier placed between the bag and the surface…” Obversions (OBV1) on 11/17/2023 at approximately 9:25 AM patient care was conducted for (MR1) revealed, EMP5 provided direct patient care. EMP5 placed two chuck/barrier on a couch with the nursing/supply bag on top of one of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier onto the front of the couch. Obversions (OBV3) on 11/17/2023 at approximately 9:42 AM patient care was conducted for (MR3) revealed, EMP7 provided direct patient care. EMP7 placed a chuck/barrier on a chair with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the side of the chair. Obversions (OBV5) on 11/17/2023 at approximately 10:47 AM patient care was conducted for (MR5) revealed, EMP9 provided direct patient care. EMP9 placed a chuck/barrier on a chair with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the side of the chair. Obversions (OBV7) on 11/17/2023 at approximately 12:47 PM patient care was conducted for (MR7) revealed, EMP11 provided direct patient care. EMP11 placed two chuck/barrier on a couch with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier onto the side of the couch. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on a review of agency policy, medical record (MR), observation (OBV) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, and identify and address potential adverse effects, drug reactions, significant side effects and drug interactions for two three (3) of seventeen (17) MR’s reviewed (MR3, MR6 and MR10). Based on a review of agency policy, medical record (MR), observation (OBV) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, and identify and address potential adverse effects, drug reactions, significant side effects and drug interactions for two three (3) of seventeen (17) MR’s reviewed (MR3, MR6 and MR10). Findings Included: Review of the agency policy and procedures was conducted on 12/01/2023 at approximately 1:00 PM which revealed, “SUBJECT: Medication Administration…*Procedure…G. Administration safeguards are utilized such as reviewing allergy history, assuring correct labeling, checking expiration date and medication stability, and evaluating patient prior to administration…K. The clinical record of the patient includes: A complete medication profile to include but not be limited to allergies to both food and drugs; medication history; patient’s knowledge of the purposed and significant side effects of the prescribed drug; appropriate dosage; contraindications; effectiveness of the drug; awareness of potential adverse effects; route of administration; use of over the counter drugs; and cognitive status…” Review of MR3 (OBV3) medication list were compared on 11/17/2023 at approximately 2:20 PM revealed, “Home Health Certification and Plan of Care” with a start of care date of 9/8/2023 and a current certification period starting 11/7/2023 and ending 1/5/2024. The primary diagnosis was pressure ulcer of right ankle, unstageable. The Home Health Certification and Plan of Care and Client Medication Report listed, “Allergies: PENICILLIN” was compared to the facilities “MAR.” which listed “...ALLERGIES PENCILLINS, SULFA (SULFONAMIDE ANTIBIOTICS).” The allergies documented on the forms did not match. Review of MR5 (OBV5) medication list were compared on 11/17/2023 at approximately 2:20 PM. The agency’s document “Home Health Certification and Plan of Care” had a start of care date of 11/3/2023 and a current certification period starting 11/3/2023 and ending 1/1/2024. The primary diagnosis was other iron deficiency anemias. The Home Health Certification and Plan of Care and Client Medication Report was compared to the facilities “MAR.” The following two (2) medications were not listed on the on the agency documents. “ACETAMINOPHEN (MAPAP) 500MG...Date Written: 1-Nov-2023…” “NITROGLYCERN SUB 0.4MG...Date Written: 3-Nov-2023…” The following medication was not listed on the on the agency’s client medication report. “METOPROLOL TARTRATE 100 MG TABLET…Start Date/End Date 11/03/2023…” Review of MR10 was conducted on 11/16/2023 at approximately 1:40 PM which revealed: The agency’s document “Home Health Certification and Plan of Care” had a start of care date of 6/12/2021 and a current certification period starting 9/30/2023 and ending 11/28/2023. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The Home Health Certification and Plan of Care and Client Medication Report (date 11/14/2023) was compared to a physician’s report (fax date 6/11/2021). The Client Medication Report listed Client Allergies as follows: “APIXABAN, ASPIRIN, CARBAMAZEPINE, GABAPENTIN, HYDROCONONE BITARTRATE, HYDROXYCHLOROQUINE, LAMOTRIGINE, MORPHINE, NITROUS OXIDE, PENICILLINS, WARFARIN, ZITHROMAX.” The physician’s report listed allergies as follows: Allergies, Allergen, Morphine…Apixaban…Asprin…Carbamazepine…Gabapentin…Hydroxychloroquine…Hysingla Er [Hydrocodone Bitartrate]…Lamotrigine…Nitric Oxide…Nitro Transdermal …Penicillins…Warfarin…” The medication allergy “Nitro Transdermal” was not listed on the agency client medication report. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.”