Marscare

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on the finding of an onsite-unannounced home health agency Medicare recertification survey conducted on March 16, 2026 through March 19, 2026, Marscare was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness. Findings include: Surveyor was informed by Chief Operating Officer on March 17, 2026 at approximately 2:15 pm that the binder that contained the Emergency Preparedness Program information could not be located. No documentation provided to the surveyor to show evidence that the agency established and maintained a comprehensive emergency preparedness program describing the facility’s comprehensive approach to meeting the health, safety, and security needs of staff and patient populations during an emergency or disaster situation. An interview conducted with the Chief Operating Officer on March 19, 2026 starting at 1:45 PM confirmed the above findings. This condition is not met, but did not result in immediate jeopardy, as evidenced by the following standards: 484.102 (a)(1)(2) - Risk assessment 484.102 (a)(4) - Process for cooperation and collaboration 484.102 (b)(2) Secures and maintains availability of records 484.102 (c) Standard: Communication plan 484.102 (c)(2) Contact info for emergency officials 484.102 (d) Standard: Training and testing 484.102 (d)(2) EP Testing Program”

“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 a review of agency policy, a review of the clinical record, and an interview with the Chief Operating Officer, the agency failed to follow Plan of Care (G572); failed to follow the plan of care in relation to frequency and duration of visits to be made (G574); and failed to follow physician orders (580). Findings include: This condition is not met as evidenced under the following standards which did not result in immediate jeopardy: 484.60 (a)(1) Standard: Plan of Care 484.60 (a)(2)(i-xvi) Plan of Care Must Include the Following 484.60 (b)(1) As Only Ordered by the Physician”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on a review of personnel files, agency organizational chart, documentation, policy and an interview with the chief operating officer, the agency failed to organize manage and administer its resources to attain and maintain the highest practicable functional capacity in providing optimal care and failed to set forth in writing its organizational structure: the governing body failed to assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations (G942); failed to appoint a qualified administrator (G946); failed to ensure that a clinical manager is available during all operational hours (G950); failed to ensure the employment of qualified personnel (G952); failed to ensure the designation of a qualified person to assume the responsibilities in the absence of the administrator (G954); failed to ensure a qualified clinical manager to assume responsibility and oversight of patient care services and personnel (G958). Findings include: This condition is not met as evidenced under the following standards which did not result in immediate jeopardy. This condition was not met based on non-compliance with the above standards: 484.105(a) Governing Body 484.105(b)(1)(i) Administrator Appointed by the Governing Body 484.105(b)(1)(iii) ensure Clinical Manager is Available 484.105(b)(1)(iv) Ensure the HHA Employs Qualified Personnel 484.105(b)(2) Ensures Pre Qualified Person 484.105(c ) Clinical Manager”

“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 review of clinical records and an interview with the Chief Operation Officer, it was determined that the Home Health Agency (HHA) failed to encode and transmit OASIS information within 30 days of assessment for one (1) of three (3) adult Clinical (CR) reviewed. CR#7. Findings include: CR#7– Start of Care: 1/8/2020. Period Reviewed: 2/5/2026-4/5/2026. On March 18, 2026 at approximately 1:30 pm, a review of the clinical record revealed that the agency did not have submissions for Oasis for the patient, who is currently twenty (20) years of age. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of agency policy, a review of the clinical record, and an interview with the Chief Operating Officer, the agency failed to ensure frequency of visits or a treatment or service as required by the plan of care/physician order was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10). Findings include: A review of agency policy/procedure Clinical-PA-009 reviewed on March 20, 2026 at approximately 10:45 am titled: “Missed Visit Management and Reporting, revealed the following: Purpose: To establish standardized procedures for identification, reporting, documentation, and resolution of missed visits in accordance with DHS requirements, including 55 Pa. Code Chapter 601, and payer standards. Policy Statement: All scheduled and authorized services must be delivered as planned. Missed visits must be reported, documented, and addressed immediately to ensure continuity of care and compliance. Procedure: Caregiver must notify Scheduling immediately if unable to report to shift Notify On-Call Personnel at 215-805-2783 after hours, weekends, or if Scheduling is unavailable, Scheduling must attempt to secure replacement coverage and document efforts, Client/guardian must be notified of missed visit and status. Agency must report missed shift to payor in compliance with OPS 8 reporting guidelines, On-call personnel must document and escalate as needed. Documentation Requirements: Must include: Date/Time, Reason, Staff Involved, Coverage Attempts, On-Call Notification, Client Notification, Supervisor Review, Follow-Up Actions. A review of agency policy/procedures Clinical- PA-010, titled: Physician Orders Management and Compliance revealed the following: 1. Purpose: To establish standardized procedures for obtaining, verifying, implementing, and maintaining physician orders to ensure all services are delivered in accordance with medical necessity, regulatory requirements, and MARSCare standards. 5. Policy Statement MARSCare requires that all services be provided strictly in accordance with valid physician orders. No care may be initiated, continued, or modified without appropriate physician authorization. All physician orders must be: Obtained prior to or at the start of care, Accurate and complete. Signed within required regulatory timeframes and Maintained in the patient record . 6.3 Plan of Care (POC) Implementation: RN is responsible for developing and implementing the Plan of Care, All services must align with physician orders and authorization, Caregivers must follow the POC exactly as written. 6.4 Ongoing Orders and Updates, Any changes in patient condition must be reported to the RN Supervisor, Updated physician orders must be obtained for: Change in frequency, Change in services, Medication changes, Significant clinical changes, No changes to care may occur without updated orders. A review of Clinical Records was conducted on March 18, 2026 at approximately 10:15 am revealed the following: CR#1– Start of Care:11/8/2019. Period Reviewed: 2/4/2026-4/4/2026. Review of medical records revealed that not all hours provided as ordered by physician. Ninety (90) hours ordered per week for Skilled Nursing. The following hours were provided: SN to assist with ADL’s/IADL’s as assigned such as: Toileting, changing and making bed linens, and close supervision for safety. Provide Oral Care every shift, access and monitor effectiveness of medication regimen, provide instruction/ reinforcement related to safety measures to prevent injury secondary to impaired neurological status and/or seizure disorder. Week of 2/8/2026-2/14/2026 – 49 hours provided. Week of 2/15/2026-2/21/2026- 49 hours provided. Week of 2/22/2026-2/28/2026 – 55.5 hours provided. Week of 3/1/2026-3/7/2026 – 49 hours provided. Week of 3/8/2026-3/14/2026 – 62 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#2– Start of Care: 1/11/2021. Period Reviewed: 2/14/2026 – 4/14/2026. Review of clinical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing (SN) and Seventy-four (74) hours per week for Home Health Aide (HHA) Services. SN to assist with the following: Notify MD for Signs/ Symptoms of Cardiac Distress or Decompensation, administer medications as ordered, monitor and assess respiratory status, maintain close supervision to prevent injury and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). HHA to assist with the following when a SN is not available: assist with ADL’s/ IADL’s, developmental stimulation, bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, assist with ambulation, incontinence care and light housekeeping. The following hours were provided: Week of 2/15/2026 -2/21/2026 – 32 hours provided by SN; 0 hours by HHA Week of 2/22/2026 -2/28/2026 – 17 hours provided by SN; 0 hours by HHA Week of 3/1/2026 -3/7/2026 – 56 hours provided by SN; 0 hours by HHA Week of 3/8/2026 -3/14/2026 – 48 hours provided by SN; 0 hours by HHA Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#3– Start of Care: 1/1/2014. Period Reviewed: 2/18/2026-4/18/2026. Review of clinical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing. SN to assist with the following: Assist with ADL’s/IADL’s as assigned such as bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, ambulation, incontinent care, toileting, and close supervision for safety, administration of gastrostomy feeding and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/22/2026-2/28/2026 – 91 hours provided. Week of 3/1/2026 -3/7/2026 – 91 hours provided. Week of 3/8/2026 -3/14/2026 – 91 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#7– Start of Care: 1/8/2020. Period Reviewed: 2/5/2026-4/5/2026. Review of clinical records revealed that not all hours were provided as ordered by physician. Ninety-six (96) hours ordered per week for Skilled Nursing care. SN to assist with the following: Administration of Gastrostomy Tube feeding, observe and assess for gastrostomy site, elevate head of bed after feeding, maintain strict aspiration precautions and monitor for emesis at all times. Monitor urinary output, medication administration, notify physician for signs and symptoms or respiratory distress and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/8/2026-2/14/2026 – 56 hours provided. Week of 2/15/2026-2/21/2026- 56 hours provided. Week of 2/22/2026-2/28/2026– 56 hours provided. Week of 3/1/2026-3/7/2026 – 56 hours provided. Week of 3/8/2026-3/14/2026 – 56 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#9– Start of Care: 11/5/2024. Period Reviewed: 12/30/2025-2/27/2026. Review of clinical records revealed that not all hours were provided as ordered by physician. Two (2) hours per day seven (7) days per week for Skilled Nursing care. SN to assist with the following: Cleanse surgical wound of buttocks with normal saline, pat dry and pack with wet-to-dry sterile dressing. Assess/perform ostomy care each visit, insert catheter every 30 – 35 days and observe for complications, and assess right nephrostomy tube daily. Assess vital signs and dyspnea each visit. Review of Medical Record indicated missed visits for the following dates: 1/22/2026, 1/26/2026, 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026 and 1/31/2026. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#10– Start of Care: 12/13/2025. Period Reviewed: 2/11/2025-4/8/2025. Review of clinical records revealed that not all hours were provided as ordered by physician. Two (2) times per week for sixty (60) days ordered for Skilled Nursing care. SN to assist with the following: Assessment of all body systems, monitor for presence of skin lesions on lower extremities, drug regimen review, assessment of pain each visit, assess surgical wound. Review of Medical Record indicated missed visits for the following dates: 2/18/2025, 2/21/2025, 4/1/2025 and 4/4/2025. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer 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 a review of clinical records (CR), home health agency (HHA) policies, a clinical home visit observation, and an interview with the Chief Operating Officer, the agency failed to follow its policy pertaining to infection control for one (1) of one (1) clinical home visits: MR#1 Findings include: On March 19, 2026 at approximately 10:35, review of the agency policy B-180 titled: “Grooming & Dress Code” revealed the following: “Policy:….All employees are expected to follow these guidelines for appropriate dress while representing the Agency.” Dress Code/ Attire:…Appropriate shoes. On March 19, 2026 at approximately 10:40am, review of the agency policy titled: “Infection Control Policy” revealed the following: “Hand Hygiene Policy and Compliance Program” Policy: Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms. Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers and to implement a hand hygiene compliance program. Procedure: 1. Indications for staff performing hand hygiene are: Before and after direct patient care, Before and after each procedure…2. All employees are responsible for implementing hand hygiene procedures in an ongoing attempt to prevent and/or contain infectious process and communicable disease. 3. Bacteriostatic foam/gel/liquid is the preferable hand hygiene method. When using bacteriostatic foam/gel/liquid, the procedure is as follows: Place adequate amount of foam or liquid on hands…Using friction, clean between fingers, around and under nails, palms and back of hands until hands are completely dry.” An on-site clinical visit was conducted on March 18, 2026, at approximately 4:15 pm at the home of MR#1 revealed the following: LPN was observed with socks and no shoes on during duration of home visit. During the assessment process, the LPN did not perform hand hygiene prior to patient care and after patient care. LPN did not wipe down assessment equipment of thermometer and pulse oximeter before and after use, as equipment was stored on a shelving unit in the living room of the patients home. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the Chief Operating Officer, the agency failed to demonstrate the presence of the following: Infection control education provided to staff at periodic intervals consistent with accepted standards of practice. Such education must be provided at orientation, annually, and as needed to meet the staff’s learning needs to provide adequate care; identify infection signs and symptoms; identify routes of infection transmission; appropriately disinfect/sanitize/transport equipment and devices used for patient care; and use proper medical waste disposal techniques. Such education must include instructions on how to implement current infection prevention/treatment practices in the home setting. Seven (7) of Seven (7) PF’s did not meet the requirement: PF#1, 2, 3, 4, 5, 6 and 7. On March 19, 2026 at approximately 1:30 PM , review of the agency policy B-150 titled: “Employee Orientation” revealed the following: “Policy: Each employee of the agency who provides direct care, supervision of direct care, or management of services, will participate in an orientation program specific to his/her educational background, experience, position in the agency, and the role and responsibilities as an employee of the agency. Purpose: To provide employees with a comprehensive overview of Agency policies and procedures and to maintain consistent high quality client care. Special Instructions: ….J. Infection prevention and control, OSHA bloodborne pathogen policies, TB and Hepatitis prevention and control, Hepatitis B Declination, as applicable. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the following employees files did not contain infection control education upon hire and annually: PF#1– Date of Hire: 2/3/2017. File did not contain infection control education upon hire. File did not contain documentation that infection control education was provided annually since date of hire. PF#2 – Date of Hire: 7/15/2024. File did not contain infection control education upon hire. File did not contain documentation that infection control education was provided annually since date of hire. PF#3 - Date of Hire: 7/1/2024. File did not contain infection control education upon hire. File did not contain documentation that infection control education was provided annually since date of hire. PF#4 - Date of Hire: 5/9/2023. File did not contain infection control education upon hire. File did not contain documentation that infection control education was provided annually since date of hire. PF#5 - Date of Hire: 1/23/2024. File did not contain infection control education upon hire. File did not contain documentation that infection control education was provided annually since date of hire. PF#6 - Date of Hire: 12/22/2025. File did not contain infection control education upon hire. PF#7 - Date of Hire: 8/6/2025. File did not contain infection control education upon hire. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on review of agency policy/procedure, documentation, clinical records, personnel files and based on interview with the Chief Operating Officer, the agency failed to ensure documentation of competency evaluations was maintained in the personnel file for two (2) of seven (7) personnel files reviewed. PF#4 and 5. Findings include: On March 20, 2026 at approximately 10:30 am, a review of agency policy B-115 titled “Competency Assessment” revealed the following: Competency of all staff will be assessed during the interview process, orientation program and ongoing throughout employment. (Direct Care Staff will be assessed for competencies annually). Assessments of competency will be a component of the annual performance review.… 2. The skills assessment checklist and the orientation checklist will be used by the supervisor/preceptor to document the completion of satisfactory demonstration of skills. 3. Competency assessments will be completed at least annually and more often as determined by performance and supervisory reports. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the following employees’ files did not contain competency evaluations upon hire and annually: PF#4 - Date of Hire: 5/9/2023. HHA. File did not contain a competency evaluation skills assessment checklist upon hire. File did not contain documentation that competency evaluations were conducted annually since date of hire. PF#5 - Date of Hire: 1/23/2024. HHA. File did not contain documentation that competency evaluations were conducted annually since date of hire. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on a review of agency policy, personnel records (PF), and an interview the agency Chief Operating Officer, the agency failed to provide Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for two (2) of two (2) HHAs reviewed. Findings include: A review of agency policy titled Position: Home Health Aide- C-140. Position Summary: Provides personal care services under the direction of the Registered Nurse or Therapist. The Home Health Aide is assigned to specific clients by the Registered Nurse or other appropriate professional and performs services for clients as necessary to maintain their personal comfort. Essential Functions/Areas of Accountability…11. Attends in-service programs to meet compliance requirements. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the following employees’ files did not contain documentation of twelve (12) hours of in-service every twelve (12) months as required. PF#4 - Date of Hire: 5/9/2023. File did not contain documentation that the Home Health Aide has completed twelve (12) hours of in-service per year since date of hire. PF#5 - Date of Hire: 1/23/2024. File did not contain documentation that the Home Health Aide has completed twelve (12) hours of in-service per year since date of hire. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on a review of personnel files (PF), agency documentation, agency organizational chart and an interview with the Chief Operating Officer, the governing body failed to assume full legal authority and responsibility for the operation of the agency by failing to appoint a qualified administrator (PF#9), a qualified alternate administrator (PF#8), and a qualified clinical nurse manager/supervising nurse and did not have an alternate clinical nurse manager/supervising nurse position (PF#2). Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#9 listed as chief operating officer, PF8 as director of waiver services, PF#2 Manager adult services and RN supervisor, Director of Nursing vacant. There was no alternate clinical nurse manager/supervising nurse position on the organizational chart. A review of the administrator job description was conducted on March 20, 2026 at 11:00 am states: “ ADMINISTRATOR – C10 REPORTS TO: Governing body/Board of Directors POSITION SUMMARY Plans, develops, and directs the programs, services, activities, and employees of the Agency. QUALIFICATIONS• Baccalaureate degree in nursing, health service administration, business administration or equivalent experience, or related field. Masters degree preferred.• Five (5) years experience in positions of increasing responsibility in business, preferably in health care.• Minimum of two (2) years experience in supervisory or administrative positions.• Excellent verbal and written communication skills and strong interpersonal skills.• Knowledge of the regulatory requirements at the state, federal, and local level.• Knowledge of business management ESSENTIAL FUNCTIONS1. Identifies and implements the organizational structure.2. Plans, organizes, and directs the Agency’s ongoing functions. A review of the Supervising Nurse position conducted on March 20, 2026 at 11:00 am states: “POSITION: CLINICAL SUPERVISOR PHN certification preferred. • Current license as a Registered Nurse in the state(s) of practice. 1. Manages and directs a team of Nurse Case Managers ensuring safe, effective, and appropriate home care services. 2. Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients. Assists in the orientation of new personnel. support and assure quality care delivery to home care clients. 3. Receives referrals, determines services required, and Agency’s ability to meet needs. Assigns appropriate clinicians to cases. 4. Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues. Provides direction to teams to assure that client needs are met, and services are provided according to the plan. Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals. 5. Attends case conferences and other clinical meetings to facilitate coordination of care. 6. Collaborates with the Agency Director in establishing operating budget needs and priorities for the department… 26. Conducts timely performance evaluations in accordance with Agency policy. 27. Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs. Assesses safety of environment and takes the initiative to help prevent accidents and promote safety. 34. Recognizes and responds appropriately to potentially unsafe situations. A review of PFs was conducted on March 20, 2026 at 10:00 am. PF#2– Date of Hire: 7/15/2024. Clinical Manager/Director of Nursing. The file contained a current Pennsylvania Registered Nurse license (expiration date 4/30/2027) and a Trinity, Florida address. PF#2 does not reside in the state of Pennsylvania and is not available locally during operational hours to oversee patient care and personnel. PF#8 a review of resume did not contain evidence that the PF was a registered nurse, physician, had training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health or related health care programs. The resume revealed a background in business with no healthcare experience. PF#9 a review of resume revealed PF did not have training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health or related health care programs or hold an undergraduate degree. The resume revealed a certificate in massage therapy. An interview with the chief operating officer on April 1, 2026 at 10:15 am revealed that chief operating officer is the agency administrator (PF#9), the director of waiver services is the alternate administrator (PF#8). The chief operating officer confirmed that the clinical manager/supervising nurse (PF#2) resides in Florida and stated that the clinical manager/supervising nurse is available remotely.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on a review of agency documentation, personnel files (PF), and an interview with the chief operating officer (administrator), the administrator failed to ensure the clinical manager provide oversight of patient care and personnel and ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs. PF#2. Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#2 Manager adult services and RN supervisor, Director of Nursing vacant. There was no alternate clinical nurse manager/supervising nurse position on the organizational chart. A review of the Supervising Nurse position conducted on March 20, 2026 at 11:00 am states: “POSITION: CLINICAL SUPERVISOR PHN certification preferred. • Current license as a Registered Nurse in the state(s) of practice. 1. Manages and directs a team of Nurse Case Managers ensuring safe, effective, and appropriate home care services. 2. Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients. Assists in the orientation of new personnel. support and assure quality care delivery to home care clients. 3. Receives referrals, determines services required, and Agency’s ability to meet needs. Assigns appropriate clinicians to cases. 4. Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues. Provides direction to teams to assure that client needs are met, and services are provided according to the plan. Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals. 5. Attends case conferences and other clinical meetings to facilitate coordination of care. 6. Collaborates with the Agency Director in establishing operating budget needs and priorities for the department… 26. Conducts timely performance evaluations in accordance with Agency policy. 27. Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs. Assesses safety of environment and takes the initiative to help prevent accidents and promote safety. 34. Recognizes and responds appropriately to potentially unsafe situations. A review of PFs was conducted on March 20, 2026 at 10:00 am. PF#2– Date of Hire: 7/15/2024. Clinical Manager/Director of Nursing. The file contained a current Pennsylvania Registered Nurse license (expiration date 4/30/2027) and a Trinity, Florida address. PF#2 does not reside in the state of Pennsylvania and is not available locally during operational hours to oversee patient care and personnel. An interview with the chief operating officer on April 1, 2026 at 10:15 alternate confirmed that the clinical manager/supervising nurse (PF#2) resides in Florida and stated that the clinical manager/supervising nurse is available to perform duties remotely.”

“Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This Standard is not met as evidenced by: Based on a review of agency documentation, personnel files (PF) and an interview with the chief operating officer, the agency failed to employ an administrator that meets the following qualifications: 2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program for one (1) of one (1) PF. PF#9. Findings include: A review of the administrator job description was conducted on March 20, 2026 at 11:00 am states: “ ADMINISTRATOR – C10 REPORTS TO: Governing body/Board of Directors POSITION SUMMARY Plans, develops, and directs the programs, services, activities, and employees of the Agency. QUALIFICATIONS• Baccalaureate degree in nursing, health service administration, business administration or equivalent experience, or related field. Masters degree preferred.• Five (5) years experience in positions of increasing responsibility in business, preferably in health care.• Minimum of two (2) years experience in supervisory or administrative positions.• Excellent verbal and written communication skills and strong interpersonal skills.• Knowledge of the regulatory requirements at the state, federal, and local level.• Knowledge of business management ESSENTIAL FUNCTIONS1. Identifies and implements the organizational structure.2. Plans, organizes, and directs the Agency’s ongoing functions… A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#9 listed as chief operating officer. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am. PF#9 a review of resume revealed PF did not have training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health or related health care programs or is a physician or registered nurse and does not hold an undergraduate degree. The resume revealed a certificate in massage therapy. An interview with the chief operating officer on April 1, 2026 at 10:15 am revealed that chief operating officer is the agency administrator (PF#9).”

“Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This Standard is not met as evidenced by: Based on a review of agency documentation, personnel files (PF), and an interview with the chief operating officer (administrator), the administrator failed to ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs. PF#2. Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#2 Manager adult services and RN supervisor, Director of Nursing vacant. There was no alternate clinical nurse manager/supervising nurse position on the organizational chart. A review of the Supervising Nurse position conducted on March 20, 2026 at 11:00 am states: “POSITION: CLINICAL SUPERVISOR PHN certification preferred. • Current license as a Registered Nurse in the state(s) of practice. 1. Manages and directs a team of Nurse Case Managers ensuring safe, effective, and appropriate home care services. 2. Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients. Assists in the orientation of new personnel. support and assure quality care delivery to home care clients. 3. Receives referrals, determines services required, and Agency’s ability to meet needs. Assigns appropriate clinicians to cases. 4. Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues. Provides direction to teams to assure that client needs are met, and services are provided according to the plan. Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals. 5. Attends case conferences and other clinical meetings to facilitate coordination of care. 6. Collaborates with the Agency Director in establishing operating budget needs and priorities for the department… 26. Conducts timely performance evaluations in accordance with Agency policy. 27. Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs. Assesses safety of environment and takes the initiative to help prevent accidents and promote safety. 34. Recognizes and responds appropriately to potentially unsafe situations. A review of PFs was conducted on March 20, 2026 at 10:00 am. PF#2– Date of Hire: 7/15/2024. Clinical Manager/Director of Nursing. The file contained a current Pennsylvania Registered Nurse license (expiration date 4/30/2027) and a Trinity, Florida address. PF#2 does not reside in the state of Pennsylvania and is not available locally during operational hours to oversee patient care and personnel. An interview with the chief operating officer on April 1, 2026 at 10:15 alternate confirmed that the clinical manager/supervising nurse (PF#2) resides in Florida and stated that the clinical manager/supervising nurse is available to perform duties remotely.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based upon review of agency policy/procedure and clinical records and based on interview with the Chief Operating Officer, the agency failed indicate the reason for discharge on the Outcome and Assessment Information Set (OASIS) for one (1) out of ten (10) Clinical Record (CR) reviewed. CR#9. Findings include: On March 19, 2026 at approximately 10:30 AM, review of the agency policy OPS-Clinical- PA-011 titled “OASIS Assessment Process and Management” revealed the following: Purpose: To establish standardized procedures for the completion, submission, and management of OASIS assessments in compliance with CMS requirements and Pennsylvania regulations. Policy Statement: All OASIS assessments must be completed accurately, timely, and incorporated into the comprehensive assessment. Documentation must reflect true patient status. OASIS Time Points:….Discharge Procedure: Ensure documentation supports all responses Documentation Standards: Must be accurate, objective, supported, and consistent with visit notes. CR#9– Start of Care: 11/5/2024. Period Reviewed: 12/30/2025-2/27/2026. On March 18, 2026 at approximately 2:40 PM, review of the clinical record revealed the start of care date was 11/5/2024 certification period: 12/30/2025 through 2/27/2026. Review of OASIS discharge summary documentation dated 2/1/2026 revealed that the discharging RN did not document the reason the patient was discharged from services. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“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 a review of agency policy, a review of the clinical record, and an interview with the Chief Operating Officer, the agency failed to ensure frequency of visits or a treatment or service as required by the plan of care/physician order was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10). Findings include: A review of agency policy/procedure Clinical-PA-009 reviewed on March 20, 2026 at approximately 10:45 am titled: “Missed Visit Management and Reporting, revealed the following: Purpose: To establish standardized procedures for identification, reporting, documentation, and resolution of missed visits in accordance with DHS requirements, including 55 Pa. Code Chapter 601, and payer standards. Policy Statement: All scheduled and authorized services must be delivered as planned. Missed visits must be reported, documented, and addressed immediately to ensure continuity of care and compliance. Procedure: Caregiver must notify Scheduling immediately if unable to report to shift Notify On-Call Personnel at 215-805-2783 after hours, weekends, or if Scheduling is unavailable, Scheduling must attempt to secure replacement coverage and document efforts, Client/guardian must be notified of missed visit and status. Agency must report missed shift to payor in compliance with OPS 8 reporting guidelines, On-call personnel must document and escalate as needed. Documentation Requirements: Must include: Date/Time, Reason, Staff Involved, Coverage Attempts, On-Call Notification, Client Notification, Supervisor Review, Follow-Up Actions. A review of agency policy/procedures Clinical- PA-010, titled: Physician Orders Management and Compliance revealed the following: 1. Purpose: To establish standardized procedures for obtaining, verifying, implementing, and maintaining physician orders to ensure all services are delivered in accordance with medical necessity, regulatory requirements, and MARSCare standards. 5. Policy Statement MARSCare requires that all services be provided strictly in accordance with valid physician orders. No care may be initiated, continued, or modified without appropriate physician authorization. All physician orders must be: Obtained prior to or at the start of care, Accurate and complete. Signed within required regulatory timeframes and Maintained in the patient record . 6.3 Plan of Care (POC) Implementation: RN is responsible for developing and implementing the Plan of Care, All services must align with physician orders and authorization, Caregivers must follow the POC exactly as written. 6.4 Ongoing Orders and Updates, Any changes in patient condition must be reported to the RN Supervisor, Updated physician orders must be obtained for: Change in frequency, Change in services, Medication changes, Significant clinical changes, No changes to care may occur without updated orders. A review of Clinical Records was conducted on March 18, 2026 at approximately 10:15 am revealed the following: CR#1– Start of Care:11/8/2019. Period Reviewed: 2/4/2026-4/4/2026. Review of medical records revealed that not all hours provided as ordered by physician. Ninety (90) hours ordered per week for Skilled Nursing. The following hours were provided: SN to assist with ADL’s/IADL’s as assigned such as: Toileting, changing and making bed linens, and close supervision for safety. Provide Oral Care every shift, access and monitor effectiveness of medication regimen, provide instruction/ reinforcement related to safety measures to prevent injury secondary to impaired neurological status and/or seizure disorder. Week of 2/8/2026-2/14/2026 – 49 hours provided. Week of 2/15/2026-2/21/2026- 49 hours provided. Week of 2/22/2026-2/28/2026 – 55.5 hours provided. Week of 3/1/2026-3/7/2026 – 49 hours provided. Week of 3/8/2026-3/14/2026 – 62 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#2– Start of Care: 1/11/2021. Period Reviewed: 2/14/2026 – 4/14/2026. Review of clinical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing (SN) and Seventy-four (74) hours per week for Home Health Aide (HHA) Services. SN to assist with the following: Notify MD for Signs/ Symptoms of Cardiac Distress or Decompensation, administer medications as ordered, monitor and assess respiratory status, maintain close supervision to prevent injury and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). HHA to assist with the following when a SN is not available: assist with ADL’s/ IADL’s, developmental stimulation, bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, assist with ambulation, incontinence care and light housekeeping. The following hours were provided: Week of 2/15/2026 -2/21/2026 – 32 hours provided by SN; 0 hours by HHA Week of 2/22/2026 -2/28/2026 – 17 hours provided by SN; 0 hours by HHA Week of 3/1/2026 -3/7/2026 – 56 hours provided by SN; 0 hours by HHA Week of 3/8/2026 -3/14/2026 – 48 hours provided by SN; 0 hours by HHA Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#3– Start of Care: 1/1/2014. Period Reviewed: 2/18/2026-4/18/2026. Review of clinical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing. SN to assist with the following: Assist with ADL’s/IADL’s as assigned such as bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, ambulation, incontinent care, toileting, and close supervision for safety, administration of gastrostomy feeding and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/22/2026-2/28/2026 – 91 hours provided. Week of 3/1/2026 -3/7/2026 – 91 hours provided. Week of 3/8/2026 -3/14/2026 – 91 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#7– Start of Care: 1/8/2020. Period Reviewed: 2/5/2026-4/5/2026. Review of clinical records revealed that not all hours were provided as ordered by physician. Ninety-six (96) hours ordered per week for Skilled Nursing care. SN to assist with the following: Administration of Gastrostomy Tube feeding, observe and assess for gastrostomy site, elevate head of bed after feeding, maintain strict aspiration precautions and monitor for emesis at all times. Monitor urinary output, medication administration, notify physician for signs and symptoms or respiratory distress and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/8/2026-2/14/2026 – 56 hours provided. Week of 2/15/2026-2/21/2026- 56 hours provided. Week of 2/22/2026-2/28/2026– 56 hours provided. Week of 3/1/2026-3/7/2026 – 56 hours provided. Week of 3/8/2026-3/14/2026 – 56 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#9– Start of Care: 11/5/2024. Period Reviewed: 12/30/2025-2/27/2026. Review of clinical records revealed that not all hours were provided as ordered by physician. Two (2) hours per day seven (7) days per week for Skilled Nursing care. SN to assist with the following: Cleanse surgical wound of buttocks with normal saline, pat dry and pack with wet-to-dry sterile dressing. Assess/perform ostomy care each visit, insert catheter every 30 – 35 days and observe for complications, and assess right nephrostomy tube daily. Assess vital signs and dyspnea each visit. Review of Medical Record indicated missed visits for the following dates: 1/22/2026, 1/26/2026, 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026 and 1/31/2026. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#10– Start of Care: 12/13/2025. Period Reviewed: 2/11/2025-4/8/2025. Review of clinical records revealed that not all hours were provided as ordered by physician. Two (2) times per week for sixty (60) days ordered for Skilled Nursing care. SN to assist with the following: Assessment of all body systems, monitor for presence of skin lesions on lower extremities, drug regimen review, assessment of pain each visit, assess surgical wound. Review of Medical Record indicated missed visits for the following dates: 2/18/2025, 2/21/2025, 4/1/2025 and 4/4/2025. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. SN to assist with the following: An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on a review of agency policy, a review of the clinical record, and an interview with the Chief Operating Officer, the agency failed to ensure frequency of visits or a treatment or service as required by the plan of care was conducted as ordered and per agency policy. for # (6) of ten (10) Clinical Records (CR) reviewed (CR#1, 2, 3, 7, 9 and 10). Findings include: A review of agency policy/procedure Clinical-PA-009 reviewed on March 20, 2026 at approximately 10:45 am titled: “Missed Visit Management and Reporting”, revealed the following: Purpose: To establish standardized procedures for identification, reporting, documentation, and resolution of missed visits in accordance with DHS requirements, including 55 Pa. Code Chapter 601, and payer standards. Policy Statement: All scheduled and authorized services must be delivered as planned. Missed visits must be reported, documented, and addressed immediately to ensure continuity of care and compliance. Procedure: Caregiver must notify Scheduling immediately if unable to report to shift Notify On-Call Personnel at 215-805-2783 after hours, weekends, or if Scheduling is unavailable, Scheduling must attempt to secure replacement coverage and document efforts, Client/guardian must be notified of missed visit and status. Agency must report missed shift to payor in compliance with OPS 8 reporting guidelines, On-call personnel must document and escalate as needed. Documentation Requirements: Must include: Date/Time, Reason, Staff Involved, Coverage Attempts, On-Call Notification, Client Notification, Supervisor Review, Follow-Up Actions. A review of agency policy/procedures Clinical- PA-010, titled: Physician Orders Management and Compliance revealed the following: 1. Purpose: To establish standardized procedures for obtaining, verifying, implementing, and maintaining physician orders to ensure all services are delivered in accordance with medical necessity, regulatory requirements, and MARSCare standards. 5. Policy Statement MARSCare requires that all services be provided strictly in accordance with valid physician orders. No care may be initiated, continued, or modified without appropriate physician authorization. All physician orders must be: Obtained prior to or at the start of care, Accurate and complete. Signed within required regulatory timeframes and Maintained in the patient record . 6.3 Plan of Care (POC) Implementation: RN is responsible for developing and implementing the Plan of Care, All services must align with physician orders and authorization, Caregivers must follow the POC exactly as written. 6.4 Ongoing Orders and Updates, Any changes in patient condition must be reported to the RN Supervisor, Updated physician orders must be obtained for: Change in frequency, Change in services, Medication changes, Significant clinical changes, No changes to care may occur without updated orders. A review of Medical Records was conducted on March 18, 2026 at approximately 10:15 am revealed the following: CR#1– Start of Care:11/8/2019. Period Reviewed: 2/4/2026-4/4/2026. Review of medical records revealed that not all hours provided as ordered by physician. Ninety (90) hours ordered per week for Skilled Nursing. The following hours were provided: SN to assist with ADL’s/IADL’s as assigned such as: Toileting, changing and making bed linens, and close supervision for safety. Provide Oral Care every shift, access and monitor effectiveness of medication regimen, provide instruction/ reinforcement related to safety measures to prevent injury secondary to impaired neurological status and/or seizure disorder. Week of 2/8/2026-2/14/2026 – 49 hours provided. Week of 2/15/2026-2/21/2026- 49 hours provided. Week of 2/22/2026-2/28/2026 – 55.5 hours provided. Week of 3/1/2026-3/7/2026 – 49 hours provided. Week of 3/8/2026-3/14/2026 – 62 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#2– Start of Care: 1/11/2021. Period Reviewed: 2/14/2026 – 4/14/2026. Review of medical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing (SN) and Seventy-four (74) hours per week for Home Health Aide (HHA) Services. SN to assist with the following: Notify MD for Signs/ Symptoms of Cardiac Distress or Decompensation, administer medications as ordered, monitor and assess respiratory status, maintain close supervision to prevent injury and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). HHA to assist with the following when a SN is not available: assist with ADL’s/ IADL’s, developmental stimulation, bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, assist with ambulation, incontinence care and light housekeeping. The following hours were provided: Week of 2/15/2026 -2/21/2026 – 32 hours provided by SN; 0 hours by HHA Week of 2/22/2026 -2/28/2026 – 17 hours provided by SN; 0 hours by HHA Week of 3/1/2026 -3/7/2026 – 56 hours provided by SN; 0 hours by HHA Week of 3/8/2026 -3/14/2026 – 48 hours provided by SN; 0 hours by HHA Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#3– Start of Care: 1/1/2014. Period Reviewed: 2/18/2026-4/18/2026. Review of medical records revealed that not all hours provided as ordered by physician. One hundred twenty-four (124) hours ordered per week for Skilled Nursing. SN to assist with the following: Assist with ADL’s/IADL’s as assigned such as bathing, dressing, oral and hand hygiene, light housekeeping, meal preparation, feeding, medication reminder, ambulation, incontinent care, toileting, and close supervision for safety, administration of gastrostomy feeding and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/22/2026-2/28/2026 – 91 hours provided. Week of 3/1/2026 -3/7/2026 – 91 hours provided. Week of 3/8/2026 -3/14/2026 – 91 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#7– Start of Care: 1/8/2020. Period Reviewed: 2/5/2026-4/5/2026. Review of medical records revealed that not all hours were provided as ordered by physician. Ninety-six (96) hours ordered per week for Skilled Nursing care. SN to assist with the following: Administration of Gastrostomy Tube feeding, observe and assess for gastrostomy site, elevate head of bed after feeding, maintain strict aspiration precautions and monitor for emesis at all times. Monitor urinary output, medication administration, notify physician for signs and symptoms or respiratory distress and assess vital signs (temperature, pulse, respiration, blood pressure, pulse oximeter and pain status). The following hours were provided: Week of 2/8/2026-2/14/2026 – 56 hours provided. Week of 2/15/2026-2/21/2026- 56 hours provided. Week of 2/22/2026-2/28/2026– 56 hours provided. Week of 3/1/2026-3/7/2026 – 56 hours provided. Week of 3/8/2026-3/14/2026 – 56 hours provided. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. CR#9– Start of Care: 11/5/2024. Period Reviewed: 12/30/2025-2/27/2026. Review of medical records revealed that not all hours were provided as ordered by physician. Two (2) hours per day seven (7) days per week for Skilled Nursing care. SN to assist with the following: Cleanse surgical wound of buttocks with normal saline, pat dry and pack with wet-to-dry sterile dressing. Assess/perform ostomy care each visit, insert catheter every 30 – 35 days and observe for complications, and assess right nephrostomy tube daily. Assess vital signs and dyspnea each visit. Review of Medical Record indicated missed visits for the following dates: 1/22/2026, 1/26/2026, 1/27/2026, 1/28/2026, 1/29/2026, 1/30/2026 and 1/31/2026. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. SN to assist with the following: CR#10– Start of Care: 12/13/2025. Period Reviewed: 2/11/2025-4/8/2025. Review of medical records revealed that not all hours were provided as ordered by physician. Two (2) times per week for sixty (60) days ordered for Skilled Nursing care. SN to assist with the following: Assessment of all body systems, monitor for presence of skin lesions on lower extremities, drug regimen review, assessment of pain each visit, assess surgical wound. Review of Medical Record indicated missed visits for the following dates: 2/18/2025, 2/21/2025, 4/1/2025 and 4/4/2025. Per agency policy, the missed visits were not reported to the physician nor did the CR’s contain evidence that agency tried to secure coverage nor were updated physician orders obtained (See Clinical PA-010) for change of frequency per agency policy. SN to assist with the following: An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on a review of agency policy, personnel files (PF), and an interview with the Chief Operating Officer, the agency failed to follow its policy to ensure that the home health aides had evidence of completing a minimum of 75 hours of classroom instruction prior to or during the first 3 months of employment for one (1) of two (2) home health aides reviewed, (PF #5). Findings Include: On March 19, 2026 at approximately 1:40 PM , review of the agency job description, Position: Home Health Aide- C-140. Qualifications: Successful completion of a formal certification training program and/or a written skill test and competency evaluation. policy B-150 titled: “Employee Orientation” revealed the following: Each employee of the Agency who provides direct care, supervision of direct care, or management of services, will participate in an orientation program specific to his/her educational background, experience, position in the agency, and the roles and responsibilities as an employee of the Agency. Purpose: To provide employees with a comprehensive overview of Agency policies and procedures and to maintain consistent high quality client care. Special Instructions:…3. Home Health Aides will complete competency testing prior to providing client care. (Home Health Aide competency program or test per Medicare guidelines) 4. All employees will be assessed for competency prior to providing care. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the PF did not contain evidence of the following: PF#4, Date of Hire: 5/09/2023 revealed that the agency failed to provide documentation that PF#4 completed 75 hours of training/supervision through a competency program. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on a review of agency policy, personnel files (PF), and an interview with the Chief Operating Officer (PF#9), the governing body failed to appoint a qualified administrator for one (1) of (1) PFs. PF# 9. Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#9 listed as chief operating officer. A review of the administrator job description was conducted on March 20, 2026 at 11:00 am states: “ ADMINISTRATOR – C10 REPORTS TO: Governing body/Board of Directors POSITION SUMMARY Plans, develops, and directs the programs, services, activities, and employees of the Agency. QUALIFICATIONS• Baccalaureate degree in nursing, health service administration, business administration or equivalent experience, or related field. Masters degree preferred.• Five (5) years experience in positions of increasing responsibility in business, preferably in health care.• Minimum of two (2) years experience in supervisory or administrative positions.• Excellent verbal and written communication skills and strong interpersonal skills.• Knowledge of the regulatory requirements at the state, federal, and local level.• Knowledge of business management ESSENTIAL FUNCTIONS1. Identifies and implements the organizational structure.2. Plans, organizes, and directs the Agency’s ongoing functions. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am. PF#9 a review of resume revealed PF did not have training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health or related health care programs or is a physician or registered nurse and does not hold an undergraduate degree. The resume revealed a certificate in massage therapy. An interview with the chief operating officer on April 1, 2026 at 10:15 am revealed that chief operating officer is the agency administrator (PF#9).”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on a review of agency documentation, personnel files (PF), and an interview with the chief operating officer (administrator), the administrator failed to ensure the availability of the clinical manager during operational hours for one (1) of one (1) PFs. PF#2. Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#2 Manager adult services and RN supervisor, Director of Nursing vacant. There was no alternate clinical nurse manager/supervising nurse position on the organizational chart. A review of the Supervising Nurse position conducted on March 20, 2026 at 11:00 am states: “POSITION: CLINICAL SUPERVISOR PHN certification preferred. • Current license as a Registered Nurse in the state(s) of practice. 1. Manages and directs a team of Nurse Case Managers ensuring safe, effective, and appropriate home care services. 2. Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients. Assists in the orientation of new personnel. support and assure quality care delivery to home care clients. 3. Receives referrals, determines services required, and Agency’s ability to meet needs. Assigns appropriate clinicians to cases. 4. Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues. Provides direction to teams to assure that client needs are met, and services are provided according to the plan. Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals. 5. Attends case conferences and other clinical meetings to facilitate coordination of care. 6. Collaborates with the Agency Director in establishing operating budget needs and priorities for the department… 26. Conducts timely performance evaluations in accordance with Agency policy. 27. Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs. Assesses safety of environment and takes the initiative to help prevent accidents and promote safety. 34. Recognizes and responds appropriately to potentially unsafe situations. A review of PFs was conducted on March 20, 2026 at 10:00 am. PF#2– Date of Hire: 7/15/2024. Clinical Manager/Director of Nursing. The file contained a current Pennsylvania Registered Nurse license (expiration date 4/30/2027) and a Trinity, Florida address. PF#2 does not reside in the state of Pennsylvania and is not available locally during operational hours to oversee patient care and personnel. An interview with the chief operating officer on April 1, 2026 at 10:15 alternate confirmed that the clinical manager/supervising nurse (PF#2) resides in Florida and stated that the clinical manager/supervising nurse is available to perform duties remotely.”

“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 a review of agency policy, personnel files (PF), and an interview with the Chief Operating Officer (PF#9), the administrator failed to organize and direct agency functions, employ qualified personnel and ensure adequate staff education evaluations, failed to appoint a qualified person to act in absence of the administrator (PF#8) and failed to appoint a qualified clinical manager/director of nursing (PF#2). The administrator failed to ensure annual employee performance evaluations and failed to follow its “Employment Policy” for new hires for six (6) of seven (7) PF reviewed (PF #1, 2, 3, 4, 5 and 7). Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed PF#9 listed as chief operating officer, PF#8 as director of waiver services, PF#2 Manager adult services and RN supervisor, Director of Nursing vacant. There was no alternate clinical nurse manager/supervising nurse position on the organizational chart. A review of the Supervising Nurse position conducted on March 20, 2026 at 11:00 am states: “POSITION: CLINICAL SUPERVISOR PHN certification preferred. • Current license as a Registered Nurse in the state(s) of practice. 1. Manages and directs a team of Nurse Case Managers ensuring safe, effective, and appropriate home care services. 2. Is available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients. Assists in the orientation of new personnel. support and assure quality care delivery to home care clients. 3. Receives referrals, determines services required, and Agency’s ability to meet needs. Assigns appropriate clinicians to cases. 4. Meets with Case Managers/clinical staff on a regular basis to provide guidance and information related to specific issues. Provides direction to teams to assure that client needs are met, and services are provided according to the plan. Assists clinical staff in establishing priorities, setting goals, and evaluating progress toward goals. 5. Attends case conferences and other clinical meetings to facilitate coordination of care. 6. Collaborates with the Agency Director in establishing operating budget needs and priorities for the department… 26. Conducts timely performance evaluations in accordance with Agency policy. 27. Provides on-site supervision per Agency policy and as needed to determine staff competency and respond to educational and developmental needs. Assesses safety of environment and takes the initiative to help prevent accidents and promote safety. 34. Recognizes and responds appropriately to potentially unsafe situations. Review of agency policy B-235 titled: “Personnel Records on March 20, 2026 at approximately 10:00 am revealed the following: Policy: Personnel files will be established and maintained for all personnel. All information will be considered confidential and made available to authorized personnel only. All client-identifying data will be removed from employee personnel records. Personnel records may not be removed from the Agency unless ordered by subpoena. Purpose: The purpose of this policy is to identify the content of personnel files and a system for maintaining accurate, complete, and current information. Special Instructions: 1. Personnel Record – the employee personnel record will include, but not be limited to:… Reference checks, Criminal history and background checks as required by law… b. Employment Information: Competency testing for home health aides and specific competencies per job title, License and certifications, CPR certification, Skills checklist, Orientation checklist – completed and signed… c. Ongoing Employment: Performance appraisals and documentation of established performance plans…In-services, Updated license/certifications, Competency reviews (written and observed as indicated)… Hepatitis B declination or immunization record, TB screening (2-step Mantoux), chest x-ray or evidence of treatment as indicated… e. Employment: On going immunization and TB testing… Criminal background (as required), check results. In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19) Review of agency policy B-130 – “Criminal Background Check” on March 20, 2026, at approximately 10:15 am stated: “Policy: The selected candidate in the hiring process must satisfactorily clear a criminal background check prior to starting work. Guidelines – This policy applies to all selected candidates, including active employees, who have received a conditional offer for a job vacancy. Former employees are required to have a criminal background check conducted if they have been away from the Agency for nine months or longer or per agency policy/state requirements. Review of agency policy B-165 – “Employment Policy” on March 20, 2026 at approximately 10:20 am Policy: The Agency seeks to hire individuals who meet the highest standards of character and subscribe to the purpose and goals of the Agency. All employment practices are to be consistent with applicable laws and other such acts and regulations that control the employment relationship. GUIDELINES: Supervisors carefully select qualified employees through written application, personal interview and reference checks. After all available information is thoroughly evaluated, a supervisor may offer the applicant a job with the Agency contingent upon a clear criminal history check. If all facets of the new hire process are successfully carried out, the person is then selected to become a member of the Agency staff. Reference Check - References must be checked for any final candidate in order to verify employment history. At least two references should be obtained—no more than one of them from a family member. • Criminal Background Check - A criminal background check must be done for any candidate who has received a job offer. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the following employees files did not contain the following: PF#1– Date of Hire: 2/3/2017. LPN. The following information was not on file during review of the personnel file: PA Criminal Background conducted late – dated for 3/3/2017. Child Abuse Clearance – last one dated for 4/19/2016, Current Nursing license, Current CPR certification, Documentation of New Hire Orientation, Documentation of Initial Competency Examination, Documentation of Annual Competency Examination, Emergency Preparedness Training, Infection Control Education, No performance evaluations, TB symptom screening and risk assessment upon hire and no annual TB education. PF#2– Date of Hire: 7/15/2024. . Clinical Manager/Director of Nursing. The file contained a current Pennsylvania Registered Nurse license (expiration date 4/30/2027) and a Trinity, Florida address. PF#2 does not reside in the state of Pennsylvania. The following information was not on file during review of the personnel file: No employment references, No PA criminal background – dated for 9/15/2017 but no results obtained. No current FBI check conducted – as RN resides in Florida and has not provided proof of Pennsylvania residency for 2 years. No Documentation of the following: New Hire Orientation, Initial Competency Examination, Annual Competency Examination, Emergency Preparedness Training, Infection Control Education, Performance evaluations, Proof of TB testing upon hire, TB symptom screening and risk assessment upon hire and no annual TB education. Based upon PF#2 job description, the RN does not qualify to be named as the Supervising RN as PF#2 resides in the State of Florida. PF#3– Date of Hire: 7/1/2024. RN The following information was not on file during review of the personnel file: No employment references, Documentation of New Hire Orientation, Documentation of Initial Competency Examination, Documentation of Annual Competency Examination, Emergency Preparedness Training, Infection Control Education, No performance evaluations, No proof of TB testing upon hire, TB symptom screening and risk assessment upon hire and no annual TB education. PF#4– Date of Hire: 5/9/2023. Home Health Aide. The following information was not on file during review of the personnel file: No PA criminal background, No child abuse clearance. No proof that HHA completed that Home Health Aide 75 hour training program that they were signed up for, No CPR on file, Documentation of New Hire Orientation, Documentation of Initial Competency Examination, Documentation of Annual Competency Examination, No HHA Annual In-Service, Emergency Preparedness Training, Infection Control Education, No performance evaluations. No proof of TB testing upon hire, TB symptom screening and risk assessment upon hire and no annual TB education. PF#5– Date of Hire: 1/23/2024. Home Health Aide. The following information was not on file during review of the personnel file: No signed Job Description, No employment references, No CPR on file, Documentation of Annual Competency Examination, No HHA Annual In-Service, Emergency Preparedness Training, Infection Control Education, No performance evaluations, No proof of TB testing upon hire, TB symptom screening and risk assessment upon hire, and no annual TB education. PF#7 – Date of Hire: 8/6/2025. LPN. The following information was not on file during review of the personnel file: No signed Job Description, No employment references, CPR on file - expiration date of 10/5/2025, Documentation of New Hire Orientation, Documentation of Initial Competency Examination, Emergency Preparedness Training, Infection Control Education, No performance evaluations, No proof of TB testing upon hire, TB symptom screening and risk assessment upon hire. No documentation regarding Hepatitis B Acceptance or Declination on file. An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on a review of personnel files (PF), agency documentation, agency organizational chart and an interview with the Chief Operating Officer, the administrator and governing body failed to authorize qualified pre-designated person to assume the responsibilities of the administrator when the administrator is not available. (PF#8). Findings include: A review of the organizational chart on March 20, 2026 at 11:30 am revealed that PF#8 as director of waiver services. A review of PFs was conducted on March 20, 2026 at 10:00 am. PF#8 a review of resume did not contain evidence that the PF was a registered nurse, physician, had training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health or related health care programs. The resume revealed a background in business with no healthcare experience. An interview with the chief operating officer on April 1, 2026 at 10:15 am revealed that chief operating officer the director of waiver services is the alternate administrator (PF#8).”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical record and interview with the Chief Operating Officer, the agency failed to ensure clinical record contents were maintained in accordance with agency policy/procedure for three (3) of ten (10) Clinical records (CR) reviewed. (CR# 3, 6 and 9) Findings include: On March 20, 2026 at approximately 11:00 AM, review of agency policy Clinical- PA-010, titled “Physician Orders Management and Compliance” revealed the following: “Purpose – To establish standardized procedures for obtaining, verifying, implementing, and maintaining physician orders to ensure all services are delivered in accordance with medical necessity, regulatory requirements, and MARScare standards.”…5. Policy Statement: MARScare requires that all services be provided strictly in accordance with valid physician orders. MARScare requires that all services be provided strictly in accordance with valid physician orders. No care may be initiated, continued, or modified without appropriate physician authorization. All physician orders must be: Obtained prior to or at the start of care, Accurate and complete, Signed within required regulatory timeframes, Maintained in the patient record….6.4 – Ongoing Orders and Updates – Any changes in patient condition must be reported to the RN Supervisor, Updated physician orders must be obtained for: Change in frequency, Change in services, Medication changes, Significant clinical changes, No changes to care may occur without updated orders. 6.5 – Documentation Requirements – All physician orders must be: Uploaded and maintained in KanTime, Linked to the appropriate Plan of Care, Accessible for audits and surveys, Visits notes must: Reflect services provided per physician orders. 7. Timeliness Requirements – Orders must be obtained prior to or at SOC, Verbal orders must be signed within regulatory timeframe…12. Record Retention – All physician orders will be retained in accordance with CMS, Pennsylvania regulations, and MARScare policy. A review of personnel files (PF) was conducted on March 19, 2026 at approximately 11:00 am revealed that the following employees files did not contain the following: CR#3– Start of Care: 1/1/2014. Period Reviewed: 2/18/2026-4/18/2026. File did not contain evidence that the patient/responsible party signed consent/rights upon admission CR#6– Start of Care: 1/23/2018. Period Reviewed: 2/10/2026-4/10/2026. File did not contain evidence that the patient/responsible party signed consent/rights upon admission CR#9– Start of Care: 11/5/2024. Period Reviewed: 12/30/2025-2/27/2026. File did not contain evidence that the patient/responsible party signed consent/rights upon admission An interview conducted on March 19, 2026 at approximately 2:15 pm with the Chief Operating Officer confirmed the above findings.”