Revolutionary Home Health Inc.

“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: Findings: This condition is not met as evidenced under the following standards/elements but did not result in Immediate Jeopardy: §484.60(a)(2) The individualized plan of care must include the following (G574-Element): The agency failed to ensure the clinical record included orders for therapy interventions active patients for whom therapy frequency orders were included on the “Home Health Certification and Plan of Care”. §484.60(b)(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies (G584-Element): The agency failed to ensure licensed clinical personnel obtained physician orders for missed home health aide (HHA) visits for patients for whom orders for home health aide (HHA) services were included on the plan of care. §484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. (G592-Element): The agency failed to ensure the updated plan of care included orders for services which were recommended by the assessing clinician during the comprehensive assessment for patients who were recertified for care. §484.60(d)(1) Coordination of Care. The HHA must: Assure communication with all physicians or allowed practitioners involved in the plan of care (G602-Element): The agency failed to ensure interim order changes provided by a registered pharmacist/infusion company were communicated to the primary care physician. §484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities (G608-Element): The agency failed to ensure agency staff coordinated patient care with the supervising clinician and patient for patients for whom missed visit or discipline frequency change orders had been obtained.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure electronic physician order approval authentication had been completed in accordance with agency policy/procedures for two (2) of four (4) patients for whom orders for missed visits had been obtained. (Patients #1 and #2) Findings include: On February 13, 2026 at approximately 8:30 AM, review of the agency policy titled “Verbal Orders And Electronic Signature Integrity Policy” revealed the following: Policy...Verbal orders are accepted, documented, authenticated, and monitored in accordance with Medicare Conditions of Participation, Pennsylvania state regulation, and agency standards of clinical integrity... On February 12, 2026 at approximately 9:09 AM, review of the agency policy titled “Missed Visit Documentation and Physician Notification Policy” revealed the following: Missed visit documentation is completed by the assigned clinician when a scheduled visit does not occur. Patient #1 (Formerly Patient #2): Between February 10, 2026 at approximately 11:36 AM and February 13, 2026 at approximately 7:27 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that the following services are to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/06 through 03/06/2026: -PT: One (1) time a week for eight weeks effective 01/11/2026 -Skilled Nursing (SN): Two (2) times a week for eight (8) weeks effective 01/11/2026 -Home Health Aide (HHA): Two (2) times a week for eight (8) weeks effective 01/11/2026 Review of “Physician’s Order” documentation revealed orders for the following missed visits (MV) were obtained and that the physician orders were electronically signed by the below referenced disciplines: PHYSICAL THERAPY: Missed Visit Date 01/23/2026-Order electronically signed by a physical therapy assistant (PTA-Employee #16) but approved by a PT (Employee #11). SKILLED NURSING: Missed Visit Date 01/15/2026-Order electronically signed by an LPN (Employee #10) but approved by a PT (Employee #11). HOME HEALTH AIDE: Missed Visit Date 01/13/, 01/15, 01/20, 01/22 and 01/27/2026- Order electronically signed by HHA (Employee #12) but approved by a PT (Employee #11) On February 12, 2026 at approximately 11:03 AM, review of the agency document titled “Documented Response Regarding Electronic Signature Field Display” dated 02/12/2026 revealed the following: During state survey agency review, it was observed that the name and professional discipline designation of the PT appears printed above the electronic signature line on a missed verbal order. The audit trail confirms that the PTA completed the electronic authentication of the documentation under secure, individual login credentials. An immediate internal audit review was conducted. System audit log analysis verified the following...The PT did not authenticate or access signature function for the identified order...Although the PT’s name appeared above the signature line as part of the template display configuration, the legally binding electronic signature was applied by the PTA through secure credentialed authentication. Review of the aforementioned agency document dated 02/12/2026 failed to reveal the PT (Employee #11) had electronically approved the above referenced orders for the missed PT, SN and HHA visits. Patient #2: Between February 10, 2026 at approximately 1:50 PM and February 13, 2026 at approximately 8:16 AM, review of the clinical record revealed the SOC date was 11/18/2025 and that the following services are to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026: SN One (1) time a week for eight (8) weeks effective 01/18/2026. Review of “Physician’s Order” documentation revealed an order for the following MV was obtained and that the physician order was electronically signed by the below referenced disciplines: SKILLED NURSING: Missed Visit Date 01/29/2026-Order electronically signed by an LPN (Employee #15) but approved by a PT (Employee #11). Review of the aforementioned agency document dated 02/12/2026 failed to reveal the PT (Employee #11) had electronically approved the above referenced orders for the missed PT, SN and HHA visits. During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received. The Administrator and Alternate Administrator did not present any questions related to the above referenced findings for the above identified patients.”

“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 the review of agency policies/procedures, documentation and clinical records, and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure the clinical record included orders for therapy interventions for one (1) of four (4) active patients for whom therapy frequency orders were included on the “Home Health Certification and Plan of Care”. (Patient #1) Findings include: On February 12, 2026 at approximately 8:10 AM, review of the agency policy titled “Plan of Care” policy revealed the following: Purpose: To ensure all Plans of Care (POC) are comprehensive, accurate and compliant with Conditions of Participation (CoP’s). On February 12, 2026 at approximately 8;14 AM, review of the agency policy titled “Medicare Record Documentation Policy” revealed the following: Documentation Guidelines...Plan of Care... -The plan of care (POC) will outline interventions and services to be provided by the agency staff. Patient #1: Between February 10, 2026 at approximately 11:36 AM and February 13, 2026 at approximately 7:27 AM, review of the clinical record revealed the SOC date was 09/08/2025, that occupational therapy (OT) services are to be provided two (2) times a week for eight (8) weeks and that OT goals related to the following care needs are ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026: -Range of motion -Decline in Transfers and Functional Mobility -Decline in Independence with Activities of Daily Living -Decline in Positioning Review of the OT recertification comprehensive assessment dated 01/05/2026 revealed an OT (Employee #1) documented that the plan for the next OT visit included mobilization, sitting and standing balance, reduce caregiver burden, right upper extremity (arm) passive range of motion (PROM-Moving a joint without the assistance of the patient) and edema (swelling caused by fluid collection in tissues) management. Review of OT and certified occupational therapy assistant (COTA) “Service Note” documentation dated 01/14, 01/20, 01/27, 01/28, 02/03 and 02/10/2026 revealed OT/COTA interventions included exercises of the left upper extremity and PROM of the right upper extremity. There was no documentation which provided evidence the OT interventions for exercises of the LUE nor PROM of the RUE had been included on the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026. On February 13, 2026 at approximately 7:77 AM, review of agency email documentation dated 02/12/2026 at 5:11 PM revealed the Alternate Administrator confirmed the following: “The agency remains committed to ensuring ordered services are delivered and clearly reflected in the clinical record.” During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received. The Administrator and Alternate Administrator did not present any questions related to the above referenced surveyor/clinical record review findings for the patient #1.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policy,/procedure, documentation and clinical records and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure licensed clinical personnel obtained physician orders for missed home health aide (HHA) visits for one (1) of two (2) patients for whom orders for home health aide (HHA) services were included on the plan of care. (Patient #1) Findings include: On February 13, 2026 at approximately 8:30 AM, review of the agency policy titled “Verbal Orders And Electronic Signature Integrity Policy” revealed the following: Policy...Verbal orders are accepted, documented, authenticated, and monitored in accordance with Medicare Conditions of Participation, Pennsylvania state regulation, and agency standards of clinical integrity... Procedure-Verbal Orders...Verbal and telephone orders may only be accepted by licensed clinical personnel acting within their scope of practice... Between February 10, 2026 at approximately 12:00 PM and February 12, 2026 at approximately 11:12 AM, review of the personnel list revealed the following the following: Employee #12: The date of hire of the HHA was 06/05/2025. There was no documentation which provided evidence the HHA was a licensed clinician. Patient #1 (Formerly Patient #2): Between February 10, 2026 at approximately 11:36 AM and February 13, 2026 at approximately 7:27 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/06 through 03/06/2026: -Home Health Aide (HHA): Two (2) times a week for eight (8) weeks effective 01/11/2026 Review of “Physician’s Order” documentation revealed orders for the following missed visits (MV) were obtained and that the physician orders were electronically signed by the below referenced disciplines: HOME HEALTH AIDE: Missed Visit Date 01/13/, 01/15, 01/20, 01/22 and 01/27/2026- Order electronically signed by HHA (Employee #12). There was no documentation in the clinical record which provided evidence licensed clinical personnel had obtained physician orders for the above referenced missed HHA visits as the HHA’s name (Employee #12) and title were entered on the signature line titled “Electronically Signed By” on the above referenced physician orders. During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received that a HHA had had obtained physician orders for missed HHA visits for patient #1. The Administrator and Alternate Administrator did not present any questions related to the above referenced findings for patient #1.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on the review of agency policies/procedures, documentation and clinical records, and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure the updated plan of care included orders for services which were recommended by the assessing clinician during the comprehensive assessment for one (1) of two (2) patients who were recertified for care. (Patient #2) Findings include: On February 12, 2026 at approximately 8:10 AM, review of the agency policy titled “Plan of Care” policy revealed the following: Purpose: To ensure all Plans of Care (POC) are comprehensive, accurate and compliant with Conditions of Participation (CoP’s). On February 12, 2026 at approximately 9:05 AM, review of the agency policy titled “Comprehensive and Ongoing Assessment Policy” revealed the following under “Procedure”: Reassessments....A comprehensive reassessment will be conducted at least every 60 days...The assessment will update: -Continued need for skilled services.... Patient #2: Between February 10, 2026 at approximately 1:50 PM and February 13, 2026 at approximately 8:16 AM, review of the clinical record revealed the SOC date was 11/18/2025 and that the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026 included orders for skilled nursing (SN), physical therapy (PT) and social work (SW) services. Review of the comprehensive SN recertification assessment dated 01/16/2026 revealed a registered nurse (RN-Employee #9) documented that occupational therapy (OT) and home health aide (HHA) services remain indicated and that recertification for care was recommended. There was no documentation which provided evidence the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026 had included physician orders for OT and HHA services. On February 13, 2026 at approximately 7:47 AM, review of agency email documentation dated 02/12/2026 at 5:11 PM revealed the Alternate Administrator confirmed the following: “In the instances identified where OT or HH aide services were documented as indicated but not reflected on the Home Health Certification and Plan of Care, the agency has reviewed the associated records. Orders for services were obtained and documented within the clinical record. The agency acknowledges that clearer alignment between interdisciplinary documentation and the formal Plan of Care document would strengthen clarity within the record. A focused internal review of Plan of Care reconciliation processes has been initiated.” During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received. The Administrator and Alternate Administrator did not present any questions related to the above referenced surveyor/clinical record review findings for patient #2.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy and clinical records, documentation and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure agency staff coordinated patient care with the supervising clinician and patient for four (4) of four (4) patients for whom missed visit or discipline frequency change orders had been obtained . (Patient #1, #2, #4 and #5) Findings include: On February 12, 2026 at approximately 8:14 AM, review of the agency policy titled “Medical Record Documentation Policy” revealed the following: Staff Responsibilities…Staff will ensure that records reflect communication with…interdisciplinary team as appropriate. Patient #1 (Formerly Patient #2): Between February 10, 2026 at approximately 11:36 AM and February 13, 2026 at approximately 7:27 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that the following services are to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/06 through 03/06/2026: -Skilled Nursing (SN): Two (2) times a week for eight (8) weeks effective 01/11/2026 -Home Health Aide (HHA): Two (2) times a week for eight (8) weeks effective 01/11/2026 -Occupational Therapy (OT): Two (2) times a week for eight (8) weeks effective 01/11/2026 Review of “Physician’s Order” documentation revealed orders for the following missed visits (MV) were obtained and that the physician orders were electronically signed by the below referenced disciplines: SKILLED NURSING: Missed Visit Date 01/15/2026-Order electronically signed by an LPN (Employee #10). There was no documentation in the clinical record which provided evidence that employee #10 had coordinated patient care with the a RN after the MV order for SN services was obtained or approved by the LPN. HOME HEALTH AIDE: -Missed Visit Date 01/13/, 01/15, 01/20 and 01/27/2026- Order electronically signed by HHA (Employee #12). -Missed Visit Date 01/22/2026- Order electronically signed by HHA (Employee #12) and a second verbal order for the same missed visit date was electronically signed and approved by LPN/Assistant Administrator (Employee #6) -Missed Visit Date 02/05/2026-Order electronically signed and approved by an LPN (Employee #13). -There was no documentation in the clinical record which provided evidence employees #6, #12 nor #13 had coordinated patient care with a RN after the MV orders for HHA services had been obtained or approved by a HHA or LPN. OCCUPATIONAL THERAPY: Missed Visit Date 01/22/2026- Order electronically signed and approved by an RN (Employee #14). There was no documentation in the clinical record which provided evidence employee #14 had coordinated patient care with an OT after the MV order for OT services was obtained or approved by an RN. Patient #2: Between February 10, 2026 at approximately 1:50 PM and February 13, 2026 at approximately 8:16 AM, review of the clinical record revealed the SOC date was 11/18/2025 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/17 through 03/17/2026: SN One (1) time a week for eight (8) weeks effective 01/18/2026. Review of “Physician’s Order” documentation revealed an order for the following MV was obtained and that the physician order was electronically signed by the below referenced disciplines: SKILLED NURSING: Missed Visit Date 01/29/2026-Order electronically signed by an LPN (Employee #15). There was no documentation in the clinical record which provided evidence that employees #15 had coordinated patient care with a RN after the MV order for SN services had been obtained or approved by the LPN. Patient #4: Between February 10, 2026 at approximately 2:56 PM and February 13, 2026 at approximately 8:34 AM, review of the clinical record revealed the SOC date was 01/27/2026 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the initial certification period of 01/27 through 03/27/2026: PT One (1) time a week for one (1) week effective 01/27/2026. Review of “Physician’s Order” documentation revealed the order for the following PT frequency revision was obtained and that the physician order was electronically signed and approved by the below referenced disciplines: PHYSICAL THERAPY: PT Delay in Initial Evaluation Order Date 01/28/2026-Effective 02/02/2026 One (1) time a week for one (1) week. Order electronically signed and approved by LPN (Employee #13). There was no documentation in the clinical record which provided evidence that employee #13 had coordinated patient care with a PT after order for delay the initial PT evaluation visit had been obtained or approved by the LPN. There was no documentation in the clinical record which provided evidence the patient was notified of or in agreement of the revised PT visit frequency (delay in the initial PT evaluation visit). Patient #5: Between February 11, 2026 at approximately 1:14 PM and February 13, 2026 at approximately 8:43 AM, review of the clinical record revealed the SOC date was 01/08/2026 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the initial period of 01/08 through 03/08/2026: PT One (1) a day for one (1) day. Review of “Physician’s Order” documentation revealed the order for the following MV was obtained and that the physician order was electronically signed and approved by the below referenced disciplines: PHYSICAL THERAPY: Missed Visit Order Date 02/06/2026- Order electronically signed and approved by LPN (Employee #13). There was no documentation in the clinical record which provided evidence that employee #13 had coordinated patient care with a PT after the MV order was obtained or approved by the LPN. On February 13, 2026 at approximately 7:47 AM, review of agency email documentation dated 02/12/2026 at 5:11 PM revealed the Alternate Administrator confirmed the following: ” The agency has reinforced expectations with clinical staff to promote consistent alignment between verbal communications, missed visit documentation, and Plan of Care reconciliation to enhance clarity within the record.” During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received. The Administrator and Alternate Administrator did not present any questions related to the above referenced findings for the above identified patients.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of agency policy,/procedure, documentation, clinical records and personnel files and based on interview with the Administrator (Employee #5) and the Alternate Administrator (Employee #6), the agency failed to ensure documentation was maintained in the clinical record which provided evidence an onsite supervisory visit had been conducted every 14 days by a registered nurse (RN) or other skilled professional familiar with the patient for two (2) of two (2) patients for whom orders for home health aide (HHA) services were included on the plan of care and for whom HHA services were provided. (Patients #1 & #2) Findings include: On February 12, 2026 at approximately 8:07AM, review of the agency policy titled “Home Health Aide Supervisory Visit Policy” revealed the following: Supervisory Requirements.. A supervisory visit shall occur in the patient’s home at least very fourteen (14) days... Documentation...Supervisory visits are documented and include date, observations, evaluation finding... Between February 10, 2026 at approximately 12:00 PM and February 12, 2026 at approximately 11:12 AM review of personnel file documentation revealed the following: -Employee #4: The date of hire of the Care Coordinator was 10/20/2025. -Employee #7: The date entered on the signed Patient Care Coordinator job description was 09/22//2025. During interview conducted on February 13, 2026 at approximately 10:07 AM, the Alternate Administrator (Employee #6) confirmed the date of hire for employee #7 was 09/22/2025. There was no documentation in the personnel file which provided evidence Employees #4 nor #7 were licensed as an RN or other skilled professional. Patient #1 (Formerly Patient #2): Between February 10, 2026 at approximately 11:36 AM and February 13, 2026 at approximately 7:27 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the recertification period of 01/06 through 03/06/2026: -Home Health Aide (HHA): Two (2) times a week for eight (8) weeks effective 01/11/2026 Review of “Physician’s Order” documentation revealed orders for the following missed visits (MV) were obtained and that the physician orders were electronically signed by the below referenced disciplines: HOME HEALTH AIDE: Missed Visit Dates 01/13/, 01/15, 01/20, 01/22 and 01/27/2026- Orders were electronically signed by HHA (Employee #12). Review of “Service Note” documentation revealed that during the aforementioned recertification period, a single HHA visit was completed by employee #12 on 02/06/2026. “Service Note” documentation revealed that all assigned tasks, which included bathing each visit and dressing, were documented by employee #12 as being “Not Applicable This Visit” on 02/06/2026. There was no documentation on the “Services Note” dated 02/06/2026 which provided evidence the HHA had performed six (6) of six (6) assigned tasks. Review of recertification assessment “Service Note” documentation revealed the OT (Employee #1) completed an onsite supervisory visit of the HHA on 01/05/2026. Review of Supervisory Visit-HHA (Pay Only) documentation dated 02/10/2026 revealed that a Care Coordinator (Employee #4) documented that the HHA supervisory visit was completed but that there was no documented time-in nor time-out nor was documentation present which provided evidence that a RN or other skilled professional familiar with the patient had conducted an onsite supervisory visit. There was no documentation in the clinical record which provided evidence an onsite supervisory visit of the HHA had been performed every 14 days by a RN or other skilled professional familiar with the patient after the 01/05/2026 supervisory visit. Patient #5: Between February 11, 2026 at approximately 1:14 PM and February 13, 2026 at approximately 8:43 AM, review of the clinical record revealed the SOC date was 01/08/2026 and that the following service is to be provided as ordered on the “Home Health Certification and Plan of Care” for the initial certification period of 01/08 through 03/08/2026: -Home Health Aide (HHA): Two (2) times a week for eight (8) weeks effective 01/11/2026 Review of “Physician’s Order” documentation revealed orders for the following missed visits (MV) were obtained: -HOME HEALTH AIDE: Missed Visit Dates 01/27, 01/28, 02/03 and 02/06/2026. Review of “Service Note” documentation revealed a HHA (Employee #17) provided HHA services on 01/16, 01/20 and 01/22/2026. Review of “Service Note” documentation revealed the OT (Employee #18) completed an onsite supervisory visit of the HHA on 02/06/2026. There was no documentation in the clinical record which provided evidence an onsite supervisory visit of the HHA had been performed by a RN or other skilled professional familiar with the patient within 14 days (01/30/2026) after initiation of HHA services on 01/16/2026. On February 13, 2026 at approximately 7:51 AM, review of agency email documentation dated 02/12/2026 at approximately 4:41 PM, failed to reveal that the agency had provided evidence that onsite supervisory visits had been performed every 14 days by a RN or other skilled professional familiar with patients #1 and #5. During Teams conference conducted on February 13, 2025 at approximately 10:07 AM, the Administrator and Alternate Administrator confirmed the above referenced surveyor findings had been received regarding HHA supervisory visits. The Administrator and Alternate Administrator did not present any questions related to the above referenced findings for patients #1 and #5.”

“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 agency policy and clinical records and based on interview with the Administrator (Employee #7) and the Chief Executive Officer/Alternate Administrator (CEO/Alt Admin-Employee #8), the agency failed to ensure home health services were provided in accordance with ordered visit frequencies for three (3) of three (3) patients. (Patients #1, #2 and #3) Findings include: On December 18, 2025 at approximately 10:30 AM, review of the agency policy titled “Policy: Visit Frequency Orders and Beneficiary Notices” revealed the following: Policy: Visit frequency orders are established based on physician orders, comprehensive assessment findings, and professional clinical judgment... Visit Frequency Orders (VFOs): 1. Visit frequency orders reflect anticipated care needs... 2. Actual visit delivery may vary from ordered frequencies due to: · Changes in patient condition or response to care · Patient or caregiver availability or preference · Clinical judgment and interdisciplinary coordination · Physician direction 3. Variance from ordered visit frequency does not constitute noncompliance when supported by documentation and ongoing assessment. 4. Visit frequency orders are reviewed and updated as clinically indicated or when required by the patient’s payer. Patient #1 (Discharge-Formerly Patient #5): Between December 16, 2025 at approximately 9:55 AM and December 17, 2025 at approximately 9:48 AM, review of the clinical record revealed the start of care (SOC) date was 06/16/2025, that skilled nursing (SN) services were to be provided two (2) times a month for one (1) month between 11/09 and 11/30/2025, one (1) time a month for one (1) month between 12/01/2025 and 12/09/2025 and that 10 as needed (prn) visits were ordered for the time period of 10/26 through 12/12/2025 and that SN was to provide wound care to and assess the left lower extremity (leg) wound as documented on the “CUP-Clinical Update” form dated 12/01/2025. Review of “Outcome and Assessment Information Set” assessment documentation for the recertification period of 10/14/2025 through 12/12/2025 revealed the patient’s payor source was traditional Medicare. Review of “Service Note” documentation dated 12/01 and 12/05/2025 revealed two (2) SN visits were provided during the treatment week of 11/30 through 12/06/2025. There was no documentation on the services notes which provided evidence that either of the aforementioned SN visits were prn visits. There was no documentation in the clinical record prior to 12/16/2025 which provided evidence SN services had been provided as per the ordered frequency included on the above referenced “CUP-Clinical Update” during the treatment week of 11/30 through 12/06/2025. Patient #2: Between December 16, 2025 at approximately 1:52 PM and December 17, 2025 at approximately 11:31 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that physical therapy (PT) services were to be provided one (1) time a week for one (1) week effective 11/07/2025 as evidenced by orders included on the “Home Health Certification and Plan of Care” for the recertification period of 11/07/2025 through 01/05/2026. Review of the start of care “Outcome and Assessment Information Set” assessment dated 09/08/2025 revealed the patient’s payor sources are traditional Medicare and Medicare HMO/managed care/Advantage plan. Review of the “Physician Order” dated 11/07/2025 revealed a missed PT visit occurred on 11/07/2025 because the patient failed to answer the phone for a visit but that the PT would attempt a visit the following week (11/09 through 11/15/2025). There was no documentation in the clinical record prior to 12/16/2025 which provided evidence that a PT had attempted nor completed a visit during the treatment week of 11/09 through 11/15/2025 nor was documentation present which provided evidence the patient had refused PT services during the treatment week of 11/09 through 11/15/2025. There was no documentation in the clinical record which provided evidence PT services had been provided per the visit frequency ordered on the above referenced MV physician order. Patient #3: Between December 16, 2025 at approximately 3:12 PM and December 17, 2025 at approximately 1:58 PM, review of the clinical record revealed the SOC date was 11/18/2025 and that services to be provided included the following as evidenced by orders included on the “Home Health Certification and Plan of Care” for the initial certification period of 11/18/2025 through 01/16/2026: SN: One (1) time a week for one (1) week effective 11/18/2025, then one (1) time a week for eight (8) weeks effective 11/23/2205 with 10 prn visits; and Occupational Therapy (OT): One (1) time a week for one (1) week effective 11/18/2025. Review of the start of care “Outcome and Assessment Information Set” assessment dated 11/18/2025 revealed the patient’s payor source is Medicare HMO/managed care/Advantage plan. Review of MV “Physician Order” documentation revealed a missed SN visit occurred on 11/28/2025 but a reason for the missed visit was not documented on the physician order. There was no documentation in the clinical record prior to 12/16/2025 which provided evidence the patient had refused a SN visit during the treatment week of 11/23 to 11/29/2025. Review of the “Physician Order” dated 11/20/2025 revealed that effective 11/30/2025, PT services were to be provided one (1) time a week for one (1) for an evaluation visit. There is no documentation in the clinical record prior to 12/16/2025 which provided evidence a PT evaluation had been performed on or after 11/30/2025 nor was documentation present which provided evidence the patient had refused PT services on or after 11/30/2025. There is no documentation in the clinical record prior to 12/16/2025 which provided evidence that an OT eval had been performed on or after 11/18/2025 nor was documentation present which provided evidence the patient had refused OT services on or after 11/18/2025. There was no documentation in the clinical record which provided evidence SN, PT nor OT services had been provided per the visit frequency ordered on the above referenced “Home Health Certification and Plan of Care” or on the “Physician Order” forms. During Teams conference conducted on December 18, 2025 at approximately 10:03 AM, the Administrator and CEO/Alt Admin failed to provide documented evidence that home health services (SN, PT and OT) had been provided in accordance with the ordered visit frequency for the above identified patients.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on review of agency policy, clinical records and Centers for Medicare/Medicaid Services (CMS) instructions and based on interview with the Administrator (Employee #7) and the Chief Executive Officer/Alternate Administrator (CEO/Alt Admin-Employee #8), the agency failed to ensure written notification was provided to one (1) of two (2) patients for whom a verbal order was obtained to reduce or terminate services. (Patient #2) Findings include: On December 18, 2025 at approximately 10:52 AM, review of the agency policy titled “Policy: Patient Rights and Responsibilities” revealed the following under “Patient Rights Policy”: Patients have the right to...Be advised of changes in the plan of care before they are made. On December 18, 2025 at approximately 11:00 AM, review of the “Form Instructions for the Home Health Change of Care Notice (HHCCN) CMS-10280 OMB Approval Number: 0938-1196” revealed the following: Overview ...Medicare currently requires home health agencies (HHAs) to issue HHCCNs to Medicare beneficiaries receiving the home health care benefits for notification of plan of care changes. Consistent with the Medicare Condition of Participation and the 2nd Circuit Court’s decision in Lutwin v. Thompson regarding notification procedures, home health agencies must provide the HHCCN whenever they reduce or terminate a beneficiary’s home health services due to physician/provider orders or limitations of the HHA in providing the specific service. Notification is required for covered and non-covered services listed in the plan of care (POC). Patient #2: Between December 16, 2025 at approximately 1:52 PM and December 17, 2025 at approximately 11:31 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that services to be provided included the following as evidenced by orders included on the “Home Health Certification and Plan of Care” for the recertification period of 11/07/2025 through 01/05/2026: -Home Health Aide (HHA): One (1) time a week for one (1) week effective 11/07/2025 followed by three (3) times a week for eight (8) weeks effective 11/09/2025. Review of the start of care “Outcome and Assessment Information Set” assessment dated 09/08/2025 revealed the patient’s payor sources are traditional Medicare and Medicare HMO/managed care/Advantage plan. Review of the “Physician Order” dated 11/24/2025 revealed that effective 11/24/2025, the HHA visit frequency was reduced to one (1) time a week for six (6) weeks. There was no documentation in the clinical record which provided evidence written notification for the reduction in the HHA visit frequency had been provided to the patient via issuance of the HHCCN on or prior to 11/24/2025. During Teams conference conducted on December 18, 2025 at approximately 10:03 AM, the Administrator and CEO/Alt Admin failed to provide documented evidence that a HHCCN for the reduction in the HHA visit frequency had been provided to patient #2 on or prior to 11/24/2025.”

“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 review of agency policy, clinical records and documentation and based on interview with the Assistant to the Administrator (Employee #6), the Administrator (Employee #7) and the Chief Executive Officer/Alternate Administrator (CEO/Alt Admin-Employee #8), the agency failed to ensure documentation was maintained in the clinical record which provided evidence the contact information for other agencies or providers, who may be able to provide care, had been provided to one (1) of one (1) patient who was discharged for cause due to non-compliance with the plan of care. (Patient #1) Findings include: On December 18, 2025 at approximately 10:52 AM, review of the agency policy titled “Policy: Patient Rights and Responsibilities” revealed the following under “Policy Statement”: The Agency will protect and promote the exercise of these rights and ensure compliance with all federal and state requirements. Patient #1 (Discharge-Formerly Patient #5): Between December 16, 2025 at approximately 9:55 AM and December 17, 2025 at approximately 9:48 AM, review of the clinical record revealed the start of care (SOC) date was 06/16/2025, that skilled nursing (SN) services were to be provided two (2) times a month for one (1) month between 11/09 and 11/30/2025, one (1) time a month for one (1) month between 12/01/2025 and 12/09/2025 and that 10 as needed (prn) visits were ordered for the time period of 10/26 through 12/12/2025 and that SN was to provide wound care to and assess the left lower extremity (leg) wound as documented on the “CUP-Clinical Update” form dated 12/01/2025. Review of “Outcome and Assessment Information Set” assessment documentation for the recertification period of 10/14/2025 through 12/12/2025 revealed the patient’s payor source was traditional Medicare. Review of the SN service notes dated 12/01 and 12/05/2025 revealed the following was documented under “Narrative/Teaching/Plan/ABN”: Patient refused to sign ABN notice (Advanced Beneficiary Notice-Notice of Medicare Non-Coverage) for discharge on 12/8/25. Supervisor is aware. Review of “Discharge Summary Form” documentation revealed a verbal order for agency discharge on 12/08/2025 was obtained on 12/08/2025. On December 17, 2025 at approximately 9:45 AM, review of the agency documentation revealed a letter dated 11/25/2025 was forwarded to the patient via certified mail on 11/26/2025 and included the following under “Discharge From Home Health Services”: Because we cannot deliver the necessary care due to non-compliance, your services with Revolutionary Home Health will be discontinued on December 8, 2025. On December 16, 2025 at approximately 11:37 AM, review of agency meeting minutes dated 12/02/2025 revealed the following under “5. Discharge for Cause Oversight”: One case closed in November with full documentation. Administrator reiterated the requirement that the clinical team demonstrate clear attempts to eliminate barriers prior to recommending discharge. During an interview conducted on December 16, 2025 at approximately 12:17 PM, the Assistant to the Administrator (Employee #6) reported the patient referenced in the aforementioned meeting minutes is patient #1. There is no documentation in the clinical record which provided evidence that the agency had provided the patient with the contact information for other agencies or providers, who may be able to provide care, between the date the certified letter was forwarded to the patient (11/26/2025) and the discharge date (12/08/2025). During Teams conference conducted on December 18, 2025 at approximately 10:03 AM, the Administrator reported the contact information for other agencies/providers was provided to patient #1 during a recent telephone call but the Administrator and CEO/Alt Admin failed to provide documented evidence that the clinical record included documentation prior to 12/16/2025 which confirmed that the contact information for other agencies or providers had been provided to patient #1 between 11/26/2025 and 12/08/2025.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policy, clinical records and Pennsylvania Department of Health (PA DOH) state licensure regulations and based on interview with the Administrator (Employee #7) and the Chief Executive Officer/Alternate Administrator (CEO/Alt Admin-Employee #8), the agency failed to ensure verbal orders were signed/authenticated in accordance with regulatory requirements (immediately) and agency policy (during or immediately after) for three (3) of three (3) patients for whom orders for missed visits were obtained by agency staff. (Patients #1, #2 and #3) Findings include: On December 18, 2025 at approximately 1:30 PM, review of the agency policy titled “Policy: Verbal Orders” revealed the following: Policy Statement...The Agency accepts verbal orders from physicians and other authorized providers in accordance with federal and state regulations. Verbal orders are an essential and valid means of ensuring timely patient care. The Agency allows clinical and quality assurance staff to assist in the transcription and processing of verbal orders under the oversight of a licensed nurse or therapist... 2. Documentation Requirements... All verbal orders must include... Date and time order was received or clarified... Name and credentials of the staff member documenting/scribing - Documentation may occur during or immediately after scribing to ensure accuracy. On December 18, 2025 at approximately 1:25 PM, review of the PA DOH state licensure regulations for home health agencies (28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601) revealed the following: 601.31(d) Conformance With Physician’s Orders ...The licensed nurse or other individual, who is authorized by appropriate statutes and the State Boards in the Bureau of Professional and Occupational Affairs, shall immediately record and sign oral orders ... Patient #1 (Discharge-Formerly Patient #5): Between December 16, 2025 at approximately 9:55 AM and December 17, 2025 at approximately 9:48 AM, review of the clinical record revealed the start of care (SOC) date was 06/16/2025, that skilled nursing (SN) services were to be provided two (2) times a month for one (1) month between 11/09 and 11/30/2025, one (1) time a month for one (1) month between 12/01/2025 and 12/09/2025 and that 10 as needed (prn) visits were ordered for the time period of 10/26 through 12/12/2025 and that SN was to provide wound care to and assess the left lower extremity (leg) wound as documented on the “CUP-Clinical Update” form dated 12/01/2025. Review of “Discharge Summary Form” documentation revealed the patient was discharged from home health servicses effective 12/08/2025. Review of “Physician Order” documentation revealed orders for missed SN services were obtained and signed by a licensed agency nursing staff on the following dates: -Verbal MV order date 10/27/2025: Electronically signed by a registered nurse (RN) on 11/25/2025 which was 29 days after the verbal order was obtained. -Verbal MV order date 11/01/2025: Electronically signed by an RN on 11/25/2025 which was 24 days after the verbal order was obtained. -Verbal MV order date 11/04/2025: Electronically signed by an RN on 12/09/2025 which was 35 days after the verbal order was obtained. -Verbal MV order date 11/10/2025: Electronically signed by an RN on 12/10/2025 which was 30 days after the verbal order was obtained. -Verbal MV order date 11/28/2025: Electronically signed by an RN on 12/10/2025 which was 12 days after the verbal order was obtained. -Verbal order discharge date 12/08/2025: Electronically signed by a licensed practical nurse (LPN) on 12/16/2025 which was 8 days after the verbal order was obtained and 8 days after the patient discharge date. There was no documentation in the clinical record which provided evidence the above referenced verbal MV physician orders had been signed/authenticated by the licensed nurse in accordance with regulatory requirements and agency policy. Patient #2: Between December 16, 2025 at approximately 1:52 PM and December 17, 2025 at approximately 11:31 AM, review of the clinical record revealed the SOC date was 09/08/2025 and that services to be provided included the following as evidenced by orders included on the “Home Health Certification and Plan of Care” for the recertification period of 11/07/2025 through 01/05/2026: -SN: One (1) time a week for eight (8) weeks effective 11/07/2025 -Physical therapy (PT): One (1) time a week for one (1) week effective 11/07/2025. -Occupational therapy (OT): One (1) time a week for one (1) week effective 11/07/2025 -Home Health Aide (HHA): One (1) time a week for one (1) week effective 11/07/2025 followed by three (3) times a week for eight (8) weeks effective 11/09/2025. Review of “Physician Order” documentation revealed orders for missed visits were obtained and signed by a licensed agency staff on the following dates: -Four (4) verbal orders dated 11/07/2025 for SN, PT, OT and HHA MV: Electronically signed and by an RN or LPN on 12/16/2025 for missed SN and HHA visits and for the missed PT and OT visits, the verbal orders were electronically signed by an LPN on 12/16/2025. The verbal orders obtained on 11/07/2025 were signed 39 days after the date the verbal orders was received. -Verbal order date 11/18/2025 for OT MV: Electronically signed by an LPN on 12/16/2025 which was 28 days after the verbal order was obtained. -Verbal order date 11/28/2025 for SN MV: Electronically signed by the RN on 12/15/2025 which was 17 days after the verbal order was obtained. -Verbal order date 12/05/2025 for PT MV: Electronically signed by an LPN on 12/16/2025 which was 11 days after the verbal order was obtained. There was no documentation in the clinical record which provided evidence the above referenced verbal MV physician orders had been signed/authenticated by licensed agency staff in accordance with regulatory requirements and agency policy. Patient #3: Between December 16, 2025 at approximately 3:12 PM and December 17, 2025 at approximately 1:58 PM, review of the clinical record revealed the SOC date was 11/18/2025 and that services to be provided included the following as evidenced by orders included on the “Home Health Certification and Plan of Care” for the initial certification period of 11/18/2025 through 01/16/2026: SN: One (1) time a week for one (1) week effective 11/18/2025, then one (1) time a week for eight (8) weeks effective 11/23/2205 with 10 prn visits; and Occupational Therapy (OT): One (1) time a week for one (1) week effective 11/18/2025. Review of the “Physician Order” dated 11/20/2025 revealed that effective 11/30/2025, PT services were to be provided one (1) time a week for one (1) for an evaluation visit. Review of “Physician Order” documentation revealed orders for missed visits were obtained and signed by a licensed agency nursing staff on the following dates: -Verbal order date 11/22/2025 for OT MV: Electronically signed by an LPN on 12/16/2025 which was 24 days after the verbal order was obtained. -Verbal order date 11/28/2025 for SN MV: Electronically signed by an RN on 12/16/2025 which was 18 days after the verbal order was obtained. -Verbal order date 12/03/2025 for SN MV: Electronically signed by an LPN on 12/16/2025 which was 13 days after the verbal order was obtained. -Verbal order date 12/04/2025 for PT MV: Electronically signed by an LPN on 12/16/2025 which was 12 days after the verbal order was obtained. There was no documentation in the clinical record which provided evidence the above referenced verbal MV physician orders had been signed/authenticated by licensed agency staff in accordance with regulatory requirements and agency policy. During Teams conference conducted on December 18, 2025 at approximately 10:03 AM, the Administrator and CEO/Alt Admin failed to provide documented evidence that licensed agency staff signed/authenticated verbal orders in accordance with regulatory requirements and agency policy/procedure.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and professional standards regarding clinical (medical) record corrections and based on interview with the Administrator/Regional Administrator (Employee #9-Formerly Employee #5) and the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the agency failed to ensure the clinical record corrections were completed in accordance with agency policy/procedure or professional standards for three (3) of four (4) patients for whom a corrected “Service Note” was provided by the agency.. (Patient #1, #2 and #5) Findings: On November 7, 2025 at approximately 8:55 AM, review the agency policy titled “Correction to the Clinical Record” revealed the following: Purpose…This policy ensures that all documentation corrections preserve the original medical record, accurately reflect care provided and meet regulatory and payer requirements. Policy Statement…All entries in the patient’s clinical record must be accurate, complete and timely. When documentation error or omissions are identified, they must be correct in a manner that clearly indicates the revised information without obscuring r deleting the original entry… 2. Making Corrections…The clinician must finalize and sign the correct entry in the EMR once the changes are complete. On November 5, 2025 at approximately 10:12 AM, review of the American Health Information Management Association web-based article titled “Amendments in the Electronic Health Record TOOLKIT “ revealed the following on page 6 under “Late Entry”: An addition to the health record when a pertinent entry was missed or was not written in a timely manner.1 The late entry should be timely, bear the current date, time, and reason for the additional information being added to the health record and be electronically signed. On November 5, 2025 at approximately 3:03 PM, review of the agency policy titled “Central Line Dressing, Flushing and PICC Line Assessment Policy” revealed the following: PICC Line Assessment Standards...A complete PICC line assessment is required at every home visit where the line is uses, assessed, or the dressing is changed and before each medication administration or blood draw. The assessment must include: Visual inspection of the insertion site and surrounding skin (erythema (redness), edema, drainage, tenderness, warmth, induration (thickening of the skin))... Documentation...PICC Line Assessment results: Site condition, dressing integrity... Patient #1 (Formerly Patient #1): On November 3, 2025 at approximately 11:23 AM and November 7, 2025 between the approximate times of 7:30 AM and 9:40 AM, review of the clinical record revealed the SOC date was 10/23/2025, the primary diagnosis is blood stream infection due to central venous catheter and that SN interventions include weekly peripherally inserted central catheter (PICC-intravenous (IV) line dressing changes and that SN goals included for the IV access to remain free of signs/symptoms of infection as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10//23/2025 through 12/21/2025. Review of the original, uncorrected start of care (SOC) assessment “Service Note” dated 10/23/2025 revealed the PICC line dressing was changed and that the following was documented by the registered nurse (RN-Employee #7) under the section titled Admission/ROC Summary: Arm circumference is 9 inch and exposed catheter length Is 0.1inch. The SOC “Service Note” was electronically signed by the RN on 10/23/2025 at 8:08 PM. On November 3, 2025 at approximately 12:00 PM, review of a second SOC assessment dated 10/23/2025 revealed a section titled Central Line Care had been added to the SOC “Service Note” and that the following assessment findings had been added under the section titled Admission/ROC Summary: Insertion site and surrounding skin inspected; no redness, swelling, drainage, warmth, or signs of infection noted. Palpation through intact dressing revealed no tenderness, cord-like vein, or subcutaneous emphysema. Dressing (transparent) clean, dry, intact, edges sealed, and properly dated/initialed. Securement device intact and appropriately positioned. The second SOC “Service Note” was electronically signed by the RN on 10/23/2025 at 8:08 PM. There was no documentation in the clinical record which provided evidence that the section titled Central Line Care and additional documentation entered under Admission/ROC Summary on the second, corrected assessment had been included on the original, uncorrected SOC assessment nor was documentation present which provided evidence the RN had entered the date the aforementioned additions or corrections had been made to the original SOC “Service Note”. On November 3, 2025 at approximately 1:55 PM, review of email documentation forwarded by the CM/Alt Admin/CEO on 11/03/2025 revealed the following related to the clinical record review findings for patient #1: While the corrected assessment does not display a “late entry” notation, it does accurately reflect the patient’s clinical condition and the services provided. The correction was made in compliance with agency procedure under the Policy: Corrections to the Clinical Record (effective April 1, 2024). Patient #2 (New Review): On November 3, 2025 at approximately 12:49 PM and November 7, 2025 at approximately 10:28 AM, review of the clinical record revealed the SOC date was 10/04/2025, that the primary diagnosis is pressure ulcer of the buttocks stage 4, that SN is to provide wound care to 3 wounds (left and right ischium (the curved bone forming the base of each half of the pelvis) and sacral (area at base of spine) wound) and that SN interventions include wound measurements every visit and wound assessment for healing, signs/symptoms of infection and effectiveness of wound care as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10//04/2025 through 12/02/2025. Review of the original, uncorrected “Service Note” dated 10/10/2025 revealed wound care was completed and that the following was documented by the RN (Employee #1) under the section titled Narrative/Teaching/Plan/ABN: Narrative Note: Wound is intact no signs of infection noted. Right side buttock wound measures 5.0cmx3.0cmx0.1depth and left side buttock measures 5.5cnx4.5cmx2.5cm depth. The “Service Note” was electronically signed by the RN on 10/10/2025 at 5:57 PM. On November 3, 2025 at approximately 3:12 PM, review of a second “Service Note” dated 10/10/2025 revealed sections titled Wound-Diabetic Ulcer 1, Wound -Pressure Ulcer 1, Wound-Pressure Ulcer 2, Wound-Pressure Ulcer 3 had been added to the service note and that the following was added under the section titled Narrative/Teaching/Plan/ABN: The patient presents with a large central sacral ulcer measuring 8 cm (length) x 4 cm (width) x 3 cm (depth) with approximately 6 cm of superior tunneling. The wound bed contains slough and/or eschar and is therefore classified as unstageable. The wound was cleansed thoroughly with normal saline. The wound was then packed with ¼-inch iodoform packing and covered with a Mepilex dressing. The dressing was secured and left clean, dry, and intact. Home health nursing is to change the dressing once weekly or more frequently if soiled, dislodged, or as otherwise clinically indicated. The patient tolerated the procedure well without signs of distress. The second SOC “Service Note” was electronically signed by the RN on 10/10/2025 at 5:57 PM. There was no documentation in the clinical record which provided evidence that the above referenced wound sections (diabetic ulcer 1 and pressure ulcers 1, 2, and 3) and additional documentation entered under Narrative/Teaching/Plan/ABN on the second, corrected assessment had been included on the original, uncorrected SOC assessment nor was documentation present which provided evidence the RN had entered the date the aforementioned additions or corrections had been made to the original “Service Note”. Patient #5 (New Review): On November 4, 2025 at approximately 12:33 PM and November 5, 2025 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 06/16/2025, that the primary diagnosis is chronic venous hypertension with ulcer of bilateral (both) extremities, that skilled nursing (SN) is to provide wound care to the left lower extremity (leg) wound and that SN interventions include wound measurements every visit and wound assessment for healing, signs/symptoms of infection and effectiveness of wound care as documented on the “Home Health Certification and Plan of Care” for the recertification period of 10//14/2025 through 12/12/2025. Review of the original, uncorrected “Service Note” dated 10/14/2025 revealed wound care was completed and that the following was documented by the RN (Employee #2) under the section titled Narrative/Teaching/Plan/ABN: Narrative Note: Wound care performed The “Service Note” was electronically signed by the RN on 10/14/2025 at 6:28 PM. On November 4, 2025 at approximately 3:22 PM, review of a second “Service Note” dated 10/14/2025 revealed the following was added under the section titled Narrative/Teaching/Plan/ABN: Narrative Note: Wound care performed, patient has venous stasis ulcer on her calf left midline proximal, 6.3×10.2×0.2 with moderate serosanguineous (blood tinged) brown drainage. The second SOC “Service Note” was electronically signed by the RN on 10/14/2025 at 6:28 PM. There was no documentation in the clinical record which provided evidence that the additional documentation entered under Narrative/Teaching/Plan/ABN on the second, corrected assessment had been included on the original, uncorrected SOC assessment nor was documentation present which provided evidence the RN had entered the date the aforementioned additions or corrections had been made to the original “Service Note”. During interview conducted on November 7, 2025 at approximately 12:30 PM, the Administrator/Regional Administrator and CM/Alt Admin/CEO confirmed that the agency policy titled “Correction to the Clinical Record” is current and in effect.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and based on interview with the Administrator/Regional Administrator (Employee #9-Formerly Employee #5) and the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the agency failed to ensure the name of the administrator, in order to received complaints, had been provided to two (2) of two (2) patients for whom the start of care date was after September 29, 2025. (Patients #1 and #2) Findings include: On November 5, 2025 at approximately 3:10 PM, review of the agency policy titled “Patient Bill of Rights & Financial Disclosure”, which was revised on 10/01/2025, revealed the following: Purpose...To ensure all patients and caregivers are informed of their rights... Scope...All patients must be informed of their rights...during admission... On November 5, 2025 at approximately 3:11 PM, review of the undated agency policy titled “Patient Rights and Responsibilities” revealed the following: Purpose...To ensure that all patients receiving services from the agency are informed of their rights...in accordance with Medicare Conditions of Participation and the Pennsylvania Department of Health regulations. On November 3, 2025 at approximately 2:01 PM, review of the agency organizational chart revealed the agency Administrator was employee #9. On November 5, 2025 at approximately 3:08 PM, review of the agency admission packet form titled “Patient Bill of Rights” revealed the following under number 4: Make complaints to Revolutionary Home Health regarding treatment or care that is or fails to be furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the agency. Contact information of Revolutionary Home Health’s Clinical Manager/Director Nursing to make complaints. The name and contact information of the CM/Alt Admin/CEO (Employee #8) was listed under number 4 on the “Patient Bill of Rights” form. There was no documentation which provided evidence the name and contact information of the Administrator (Employee #9) had been included on the “Patient Bill of Rights” form in order to receive complaints. Patient #1 (Formerly Patient #1): On November 3, 2025 at approximately 11:23 AM and November 7, 2025 between the approximate times of 7:30 AM and 9:40 AM, review of the clinical record revealed the SOC date was 10/23/2025 and that the primary diagnosis is blood stream infection due to central venous catheter as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10//23/2025 through 12/21/2025. There was no documentation on the “Home Health Consents and Agreements Eynon” form, which was signed by the patient on 10/23/2024, which provided evidence the name of the Administrator (*Employee #9), in order to receive complaints, had been included on the patient rights notification forms. Patient #2 (New Review): On November 3, 2025 at approximately 12:49 PM and November 7, 2025 at approximately 10:28 AM, review of the clinical record revealed the SOC date was 10/04/2025 and that the primary diagnosis is pressure ulcer of the buttocks stage 4 as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10//04/2025 through 12/02/2025. There was no documentation on the “Home Health Consents and Agreements Eynon” form, which was signed by the patient on 10/04/2024, which provided evidence the name of the Administrator (*Employee #9), in order to receive complaints, had been included on the patient rights notification forms. On November 7, 2025 at approximately 12:26 PM, review of the email forwarded by the Administrator/Regional Administrator (Employee #9) on November 7, 2025 at approximately 12:25 PM confirmed the name of the Administrator (Employee #9), in order to receive complaints, had not been included on the patient rights forms as the Administrator/Regional Administrator (Employee #9) documented that the patient rights forms were updated to include the name of the Administrator (Employee #9). During interview conducted on November 7, 2025 at approximately 12:30 PM, the Administrator/Regional Administrator and CM/Alt Admin/CEO confirmed the above referenced polices related to patient rights are current and in effect.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and based on interview with the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the agency failed to ensure one (1) of one (1) patient was notified that discharge for cause was being considered. (Patient #5) Findings include: On November 5, 2025 at approximately 3:10 PM, review of the agency policy titled “Patient Bill of Rights & Financial Disclosure”, which was revised on 10/01/2025, revealed the following: Purpose...To ensure all patients and caregivers are informed of their rights... Scope...All patients must be informed of their rights...during admission... On November 5, 2025 at approximately 3:11 PM, review of the undated agency policy titled “Patient Rights and Responsibilities” revealed the following: Purpose...To ensure that all patients receiving services from the agency are informed of their rights...in accordance with Medicare Conditions of Participation and the Pennsylvania Department of Health regulations. On November 5, 2025 at approximately 3:08 PM, review of the agency admission packet form titled “Patient Bill of Rights” revealed the following under number 16(e)(i): Advise the patient...that a discharge for cause is being considered... Patient #5 (New Review): On November 4, 2025 at approximately 12:33 PM and November 5, 2025 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 06/16/2025, that the primary diagnosis is chronic venous hypertension with ulcer of bilateral (both) extremities, that skilled nursing (SN) is to provide wound care to the left lower extremity (leg) wound and that SN services are to be provided two (2) times a week for eight (8) weeks followed by two (2) times a week for one (1) week as documented on the “Home Health Certification and Plan of Care” for the recertification period of 10//14/2025 through 12/12/2025. Review of “Notes” documentation dated 10/25/2025 revealed the CM/Alt Admin/CEO documented that the CM/Alt Admin/CEO had spoken to the physician about discharge for non-compliance with the plan of care and that “they will speak to her”. Review of “Case Communication-DC Log” documentation revealed the CM/Alt Adm/CEO (Employee #8) forwarded the following notification to the attending physician on 11/01/2025 related to the case coordination discussion with the podiatry office nurse on 10/30/2025: Home health informed the podiatry office nurse that if the patient continues to refuse wound assessments or fails to comply with the prescribed plan of care, discharge will be necessary as the patient is independently managing wound care and no longer demonstrates a skilled need. There was no documentation in the clinical record which provided evidence the agency provided notification to the patient between 10/25 and 11/04/2025 that the agency was considering discharge for cause due to non-compliance with the plan of care and refusal of wound assessments. During interview conducted on November 7, 2025 at approximately 12:30 PM, the CM/Alt Admin/CEO reported the patient #5 had not been discharged from the agency. The CM/Alt Admin/CEO failed to provide documented evidence that patient #5 was provided notification between 10/25 and 11/04/2025 that the agency was considering discharge for cause due to non-compliance with the plan of care and refusal of wound assessments.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records and based on interview with the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the agency failed to make efforts to resolve problems for one (1) of one (1) patient for whom discharge for cause was being considered. (Patient #5) Findings include: On November 5, 2025 at approximately 3:10 PM, review of the agency policy titled “Patient Bill of Rights & Financial Disclosure”, which was revised on 10/01/2025, revealed the following: Purpose...To ensure all patients and caregivers are informed of their rights... Scope...All patients must be informed of their rights...during admission... On November 5, 2025 at approximately 3:11 PM, review of the undated agency policy titled “Patient Rights and Responsibilities” revealed the following: Purpose...To ensure that all patients receiving services from the agency are informed of their rights...in accordance with Medicare Conditions of Participation and the Pennsylvania Department of Health regulations. On November 5, 2025 at approximately 3:08 PM, review of the agency admission packet form titled “Patient Bill of Rights” revealed the following under number 16(e)(ii): Make efforts to resolve the problems presented by the patient’s behavior... Patient #5 (New Review): On November 4, 2025 at approximately 12:33 PM and November 5, 2025 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 06/16/2025, that the primary diagnosis is chronic venous hypertension with ulcer of bilateral (both) extremities, that skilled nursing (SN) is to provide wound care to the left lower extremity (leg) wound and that SN services are to be provided two (2) times a week for eight (8) weeks followed by two (2) times a week for one (1) week as documented on the “Home Health Certification and Plan of Care” for the recertification period of 10//14/2025 through 12/12/2025. Review of “Notes” documentation dated 10/25/2025 revealed the CM/Alt Admin/CEO documented that the CM/Alt Admin/CEO had spoken to the physician about discharge for non-compliance with the plan of care and that “they will speak to her”. Review of “Case Communication-DC Log” documentation revealed the CM/Alt Adm/CEO (Employee #8) forwarded the following notification to the attending physician on 11/01/2025 related to the case coordination discussion with the podiatry office nurse on 10/30/2025: Home health informed the podiatry office nurse that if the patient continues to refuse wound assessments or fails to comply with the prescribed plan of care, discharge will be necessary as the patient is independently managing wound care and no longer demonstrates a skilled need. There was no documentation in the clinical record which provided evidence the agency made efforts to resolve the problems related to patient non-compliance with the plan of care and refusal of wound assessments which resulted in the agency’s consideration of discharge for cause. During interview conducted on November 7, 2025 at approximately 12:30 PM, the CM/Alt Admin/CEO reported the patient #5 had not been discharged from the agency. The CM/Alt Admin/CEO failed to provide documentation which provided evidence the agency made efforts to resolve the problems related to patient non-compliance with the plan of care and refusal of wound assessments which resulted in the agency’s consideration of discharge for cause.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records, Pennsylvania Department of Health (PA DOH) documentation and based on interview with the Administrator/Regional Administrator (Employee #9-Formerly Employee #5) and the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the agency failed to involve one (1) of two (2) patients in the care coordination process for whom an order was received to reduce the skilled nursing (SN) visit frequency. (Patient #5) Findings include: On November 3, 2025 at approximately 3:11 PM, review of the agency policy titled “Patient Rights and Responsibilities” revealed the following under “Patient Rights Policy”: Be advised of changes in the plan of care before they are made. On November 5, 2025 at approximately 3:08 PM, review of the agency admission packet form titled “Patient Bill of Rights” revealed the following under number 5: Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to...Any changes in the care to be furnished. Patient #5 (New Review): On November 3, 2025 at approximately 12:30 PM, review of agency documentation revealed the following: -Typewritten note by the Administrator/Regional Administrator (Employee #9) dated 10/20/2025 revealed a conversation with the patient included concerns regarding ongoing staffing issues. The Administrator/Regional Administrator documented that the patient reported that appointments are scheduled on conflicting days leading to missed care opportunities. On November 4, 2025 at approximately 12:33 PM and November 5, 2025 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 06/16/2025, that the primary diagnosis is chronic venous hypertension with ulcer of bilateral (both) extremities, that SN services are to be provided two (2) times a week for eight (8) weeks (effective 10/14/2025) followed by two (2) times a week for one (1) week (effective 12/07/2025) and that SN is to provide wound care as documented on the “Home Health Certification and Plan of Care” for the recertification period of 10//14/2025 through 12/12/2025, Review of physician orders revealed the registered nurse (RN-Employee #7) documented that effective 10/25/2026, the patient was in agreement with a visit frequency reduction to one (1) time a week for one (1) week followed by one (1) time a week for six (6) weeks. Review of “CUP-Clinical Update with Orders” documentation revealed the CM/Alt Admin/CEO obtained the following order on 11/01/2025: SN 1WK1 - effective 11/2/2025, 2MO1, 1MO1 - Discussed POC with PCP and podiatrist to decrease nursing visits to every other week due to non-compliance with care. There was no documentation in the clinical record which provided evidence the patient had been involved in the care coordination process related to the reduction in the SN visit frequency for which the CM/Alt Admin/CEO had received a verbal order on 11/01/2025. During interview conducted on November 7, 2025 at approximately 12:30 PM, the Administrator/Regional Administrator and CM/Alt Adm/CEO confirmed the policy titled “Patient Rights and Responsibilities”, which includes a requirement that the patient be advised of changes in the plan of care before the change is made, is currently in effect.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records, Chapter 7 of the Medicare Beneficiary Manual and Pennsylvania Department of Health (PA DOH) documentation and based on interview with the Administrator/Regional Administrator (Employee #9-Formerly Employee #5) and the Clinical Manager/Alternate Administrator/Chief Executive Officer (CM/Alt Admin/CEO-Employee #8 (Formerly Employee #12)), the CM/Alt Admin/CEO failed to ensure the adequate supplies were available to two (2) of five (5) active patients. (Patients #2 and #5) Findings include: On November 5, 2025 at approximately 3:08 PM, review of the agency admission packet form titled “Patient Bill of Rights” revealed the following under number 10: Patient Responsibility and Rights to Information on Supplies...You have the right to know what medical supplies or equipment you may need for your care and what your insurance will pay for. During your admission visit your nurse or therapist will speak to you about any supplies or equipment that may be ordered. On November 3, 2025 at approximately 3:05 PM, review of the agency policy titled “Management and Ordering of Patient Supplies” revealed the following: Purpose...To establish a process for patient supply ordering that promotes patient independence, ensures compliance with Medicare Conditions of Participation and Pennsylvania Department of Health regulations and clarifies the agency role in supply management. Scope...This policy applies to all patients admitted to the Agency and to all staff involved in patient admission and education. Policy Statement...The agency supports patients in ordering their own care by promoting independence in supply ordering. Patients are provided with the necessary information and tools to order their own supplies direct from the designated supplier. The agency is not a Durable Medical Equipment (DME) company and does not provide supplies beyond those required by Medicare for covered services. The agency does not assume responsibility for ordering, paying for, or distributing supplies outside of Medicare coverage. 3. Staff Role...Staff may assist patients with supply ordering if needed but this is not required. Any assistance provided by staff is considered supportive and does not establish an expectation that the agency will provide supplies. If a staff member provides supplies to a patient, it is done voluntarily and does not obligate the agency to continue providing supplies. 4. Agency Responsibility...The agency will only provide supplies that are required by Medicare for covered services... On November 7, 2025 at approximately 7:26 AM, review of Chapter 7 of the Medicare Beneficiary Manual revealed the following: 50.4.1.1 - The Law, Routine and Nonroutine Medical Supplies, and the Patient’s Plan of Care...A. The Law... The Medicare law governing the home health prospective payment system (PPS) is specific to the type of items and services bundled to the HHA and the time the services are bundled. Medical supplies are bundled while the patient is under a home health plan of care. If a patient is admitted for a condition which is related to a chronic condition that requires a medical supply...the HHA is required to provide the medical supply while the patient is under a home health plan of care during a 30-day period of care. Patient #2 (New Review): On November 3, 2025 at approximately 12:49 PM and November 7, 2025 at approximately 10:28 AM, review of the clinical record revealed the SOC date was 10/04/2025, that the primary diagnosis is pressure ulcer of the buttocks stage 4, that skilled nursing (SN) services are to be provided one (1) time a week for one (1) week (effective 10/14/2025), one (1) time a week for eight (8) weeks (effective 10/05/2025) and one (1) time a week for one (1) week (effective 11/30/2025) and that SN care needs and interventions include the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 10//04/2025 through 12/02/2025: Care Need...Wound Care...Interventions: -Left ischium (the curved bone forming the base of each half of the pelvis): Wound vac therapy with white foam due to bone exposure, suction to 125 millimeters of mercury (mm/Hg). Home health to change dressing once a week on Fridays. -Right ischium: Wound vac therapy with black foam, suction to 125 millimeters of mercury (mm/Hg). Home health to change dressing once a week. Review of SN “Service Note” documentation revealed a licensed practical nurse (LPN-Employee #11) provided wound care to the left and right ischium wounds on 10/24/2025. There was no documentation on the 10/24/2024 service note which provided evidence the LPN assessed the quantity of wound vac supplies to determine if adequate supplies were available to perform wound vac changes. On November 3, 2025 at approximately 12:49 PM, review PA DOH “HHA Survey Investigation Worksheet Calendar” documentation revealed the following was reported by the patient during a telephone interview conducted on October 30, 2025: The patient’s parent provides wound care to the left and right ischium wounds on days when the SN visits are not performed. The patient has been without wound vac supplies since 10/27/2025. A wet-to-dry dressing had to be applied to the left and right ischium wounds due to the lack of wound vac supplies. The patient notified the LPN on 10/24/2025 that the patient was nearly out of wound vac supplies and that the patient required more supplies. The patient reported the supply company cannot send additional wound vac supplies until the agency provides the supply company with the current wound measurements. The patient has private insurance. There was no documentation in the clinical record which provided evidence adequate wound vac supplies were available the patient to perform wound care on non-nursing days after 10/24/2025. Patient #5 (New Review): On November 3, 2025 at approximately 12:30 PM, review of agency documentation revealed the following: -“Client Complaint Log” documentation revealed that on 10/18/2025, the CM/Alt Admin/CEO documented the patient requested change in the entity which delivers supplies and that a registered nurse completed delivery of supplies to the patient and assisted with contacting the supply company to request a change in the delivery method. -Typewritten note by the Administrator/Regional Administrator (Employee #9) dated 10/20/2025 revealed a conversation with the patient included concerns regarding ongoing medical supply issues. Under “Recap”, the Administrator/Regional Administrator (Employee #9) documented that employee #9 will monitor (check on) the status of supplies and ensure that the necessary items are arranged for the patient’s care. On November 4, 2025 at approximately 12:33 PM and November 5, 2025 at approximately 7:00 AM, review of the clinical record revealed the SOC date was 06/16/2025, that the primary diagnosis is chronic venous hypertension with ulcer of bilateral (both) extremities, that SN services are to be provided two (2) times a week for eight (8) weeks (effective 10/14/2025) followed by two (2) times a week for one (1) week (effective 12/07/2025) and that SN care needs and interventions include the following as documented on the “Home Health Certification and Plan of Care” for the recertification period of 10//14/2025 through 12/12/2025: Care Need...Wound Care...Interventions: Left lower extremity (LLE-leg): Do not remove adaptic (wound dressing) or steri-strips (wound closure strips).Apply calcium alginate (wound treatment) directly over adaptic, or foam pads if calcium alginate not available wrap with plain wrap, then wrap with ace wrap every 5 to 7 days. Reinforce dressing if draining is seeping through every 1 to 2 days. Patient performs wound care. Review of the resumption of care service note dated 10/11/2025 revealed the patient’s home health payment source was traditional Medicare. Review of “Notes” documentation dated 10/24/2025 revealed supplies needed to be picked up at the agency office because the patient did not have any supplies for wound care. Review of SN “Service Note” documentation dated 10/25/2025 revealed the registered nurse (RN-Employee #7) “could not perform wound care due to not having enough supplies” as documented under the “Narrative Note”. Review of “Notes” documentation dated 10/25/2025 revealed the CM/Alt Admin/CEO (Employee #8) documented that the supplies are consistently returned to the sender because the patient forget to obtain supplies from the security office. Review of supply tracking screenshots forwarded by the Administrator/Regional Administrator on 11/05/2025 revealed the following: -August 22, 2025: The package was held by carrier because the address was incorrect or incomplete. -Undated supply order: Problem occurred with adaptic. On November 3, 2025 at approximately 12:32 PM, review PA DOH “HHA Survey Investigation Worksheet Calendar” documentation revealed the following was reported by the patient during a telephone interview conducted on October 30, 2025: The delivery service (US Postal Service) does not deliver to the patient’s home. The LLE extremity has a significant amount of drainage which requires reinforcement with diapers to collect drainage. The patient has had to purchase wound care supplies from Amazon due to the lack wound care supplies. The agency is responsible for ordering wound care supplies. There was no documentation in the clinical record which provided evidence the CM/Alt Admin/CEO verified the RN assigned to provide SN services on 10/25/2025 had adequate wound care supplies to complete wound care as per the orders included on the “Home Health Certification and Plan of Care”. During interview conducted on November 7, 2025 at approximately 12:30 PM, the Administrator/Regional Administrator and CM/Alt Adm/CEO confirmed the policy titled “Management and Ordering of Patient Supplies”, which includes a requirement the agency will only provide supplies that are required by Medicare for covered services, is currently in effect.”

“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 review of agency policy/procedures and clinical records and interviews with agency staff, the agency failed to ensure the “Home Health Certification and Plan of Care” (POC) included skilled nursing (SN) interventions and goals (G572); the agency failed to ensure POC included physician orders for medication administration and associated laboratory studies and wound and tracheostomy care (G574); the agency failed to ensure interim verbal orders related to SN interventions had been incorporated into the clinical record (G576); and the agency failed to ensure interim order changes were communicated to the primary care physician for supplemental orders were provided by an registered pharmacist/infusion company (G602). Findings: This condition is not met as evidenced under the following standards/elements and resulted in Immediate Jeopardy: §484.60(a) Standard: Plan of Care (G572-Standard): The agency failed to ensure the “Home Health Certification and Plan of Care” (POC) included skilled nursing (SN) interventions and goals were included on the initial POC. §484.60(a)(2) The individualized plan of care must include the following (G574-Element): The agency failed to ensure the POC included physician orders for medication administration and associated laboratory studies and wound and tracheostomy care were included on the initial POC. §484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care (G576-Element): The agency failed to ensure interim verbal orders related to skilled nursing (SN) interventions had been incorporated into the clinical record. §484.60(d)(1) Coordination of Care. The HHA must: Assure communication with all physicians or allowed practitioners involved in the plan of care (G602-Element): The agency failed to ensure interim order changes provided by a registered pharmacist/infusion company were communicated to the primary care physician. Immediate Jeopardy was identified on September 26, 2025 under standard §484.60(a) Standard: Plan of Care. The agency was presented with the IJ template at 11:06 AM. The first draft of the removal plan was received on September 26, 2025 at 2:26 PM and was returned for revisions at 3:34 PM. The second revision received on September 29, 2025, at 12:46 AM was rejected at 10:54 AM. The third revision received on September 29, 2025 at 11:40 AM was rejected at 12:49 PM. The fourth revision received on September 29, 2025 at 1:29 PM was rejected at 1:40 PM. The fifth revision received on September 29, 2025 at 1:55 PM was accepted at 2:15 PM. The onsite visit on September 29, 2025 verified the implementation of the removal plan and removed the immediate jeopardy.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on review of agency policy/procedures, documentation, clinical records, personnel files and professional practice standards and based on interviews with agency staff, the agency failed to ensure the following: The agency failed to ensure patient assessment conducted by skilled nursing (SN) staff had been performed in accordance with physician orders, agency policies/procedures and/or professional standards (G706), the agency failed to ensure SN services were provided in accordance with the visit frequency ordered on the “Home Health Certification and Plan of Care” (POC) (G710): and the agency failed to ensure documentation was maintained which provided evidence a registered nurse (RN) provided oversight of the skilled nursing (SN) services provided licensed practical nurses (LPN) (G726). Findings: This condition is not met as evidenced under the following standards/elements and resulted in Immediate Jeopardy: §484.75(b) Standard: Responsibilities of Skilled Professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following:] (1) Ongoing interdisciplinary assessment of the patient (G706): The agency failed to ensure patient assessment conducted by skilled nursing (SN) staff had been performed in accordance with physician orders, agency policies/procedures and/or professional standards. [§484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following:] (3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care (G710): The agency failed to ensure SN services were provided in accordance with the visit frequency ordered on the “Home Health Certification and Plan of Care” (POC). §484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k).(G726): The agency failed to ensure documentation was maintained which provided evidence a registered nurse (RN) provided oversight of the skilled nursing (SN) services provided licensed practical nurses (LPN). Immediate Jeopardy situation was identified on September 26, 2025 under standard §484.75(b) Standard: Responsibilities of Skilled Professionals (G706). The agency was presented with the IJ template at 11:06 AM. The first draft of the removal plan was received on September 26, 2025 at 2:26 PM and was returned for revisions at 3:34 PM. The second revision received on September 29, 2025, at 12:46 AM was rejected at 10:54 AM. The third revision received on September 29, 2025 at 11:40 AM was rejected at 12:49 PM. The fourth revision received on September 29, 2025 at 1:29 PM was rejected at 1:40 PM. The fifth revision received on September 29, 2025 at 1:55 PM was accepted at 2:15 PM. The onsite visit on September 29, 2025 verified the implementation of the removal plan and removed the immediate jeopardy.”

“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 review of Pennsylvania (PA) Department of Health (DOH) state licensure regulations, Pennsylvania State Board of Nursing training requirements, agency policies/procedures, documentation and personnel files and social media posts and based on interview with agency staff, the Governing Body failed to ensure the following: The Governing Body failed to ensure agency documentation included clear lines of authority related to administrative and supervisory functions on agency documents (G942), the Chief Executive Officer (CEO)/Alternate Administrator failed to ensure documentation was maintained in the personnel file which provided evidence competency or qualification (licensure) verification was completed in accordance with agency policies/procedures for registered nurses (RN) who provided skilled nursing (SN) services (G952) and the Chief Executive Officer/Alternate Administrator failed to ensure licensed practical nurses (LPN) completed a PA State Board of Nursing approved intravenous (IV) training program (G954). Findings: This condition is not met as evidenced under the following standards/elements and resulted in Immediate Jeopardy: §484.105(a) Standard: Governing body (G942): The Governing Body failed to ensure agency documentation included clear lines of authority related to administrative and supervisory functions on agency documents. [§484.105(b)(1) The administrator must: (G952): The Chief Executive Officer (CEO)/Alternate Administrator failed to ensure documentation was maintained in the personnel file which provided evidence competency or qualification (licensure) verification was completed in accordance with agency policies/procedures for registered nurses (RN) who provided skilled nursing (SN) services. §484.105(b)(2) When the administrator is not available, a qualified, pre-designated person...assumes the same responsibilities and obligations as the administrator (G954): The Chief Executive Officer/Alternate Administrator failed to ensure licensed practical nurses (LPN) completed a PA State Board of Nursing approved intravenous (IV) training program. Immediate Jeopardy was identified on September 26, 2025 under standard §484.105(a) Standard: Governing body. The agency was presented with the IJ template at 11:06 AM. The first draft of the removal plan was received on September 26, 2025 at 2:26 PM and was returned for revisions at 3:34 PM. The second revision received on September 29, 2025, at 12:46 AM was rejected at 10:54 AM. The third revision received on September 29, 2025 at 11:40 AM was rejected at 12:49 PM. The fourth revision received on September 29, 2025 at 1:29 PM was rejected at 1:40 PM. The fifth revision received on September 29, 2025 at 1:55 PM was accepted at 2:15 PM. The onsite visit on September 29, 2025 verified the implementation of the removal plan and removed the immediate jeopardy.”

“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 agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure the “Home Health Certification and Plan of Care” (POC) included skilled nursing (SN) interventions and goals for one (1) of five (5) patients for whom orders for SN services were included on the initial POC. (Patient #1) Findings include: On September 23, 2025 at approximately 5:09 PM, review of the agency policy titled “Plan of Care (POC) Policy” revealed the following: The agency will establish, implement and periodically review a patient-centered Plan of Care (POC) that meets the Medicare Conditions of Participation... Procedure...Development of the POC… -The POC will be based on patient-specific needs...and goals...The POC will include at minimum...Types of services...Medications and treatments... On September 23, 2025 at approximately 11:49 AM, review of the agency policy titled “PICC Line Maintenance & Care Policy and Procedure” revealed the following regarding care of a peripherally inserted central catheter (PICC): Policy: The agency will ensure that all PICC lines are maintained according to current evidenced based standards… Dressing Change: PICC line dressing will be changed every 7 days…. Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided for nine (9) weeks with five (5) as needed (PRN) visits as documented on the original “Home Health Certification and Plan of Care” (POC) for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse was entered on the aforementioned original POC on 07/29/2025. Review of infusion company documentation dated 07/25/2025, which was three (3) days prior to the SOC, revealed the following treatment plan details were forwarded to the agency: -Medication Administration: Primacor (generic milrinone-medication utilized to treat heart failure) administer at an infusion rate of 2.3 ml per hour, continuously, daily; -Access: Peripherally inserted central catheter (PICC-type of intravenous inserted into the arm); -Access Flushes: 5 to 10 ml of 0.9% normal saline solution (NSS) before and after therapy and heparin 10 units per ml-administer 5 ml after final saline flush and as directed; and -Laboratory: Basic metabolic profile (BMP) to be drawn one (1) week post discharge. Review of the SN SOC “Service Note” dated 07/28/2025 revealed a double lumen (2 ports) PICC was present in the right upper arm and that the RN flushed both ports with NSS and that the red port was flushed with heparin. Review of SN “Service Note” documentation revealed PICC “change” and/or “care” was completed on 08/03, 08/07, 08/14, 08/18, 08/20, 08/22, 08/27, 08/31, 09/03 and 09/05/2025 and that medication administration was completed on 08/03/2025. SN “Service Note” documentation dated 09/08/2025 revealed the patient was transferred to the emergency department due to PICC line discomfort and open wound around PICC. Review of inpatient referral documentation revealed the following: -The patient was admitted to the hospital on 09/09/2025; -Superficial thrombophlebitis (inflammation of a vein caused by a blood clot) of the right upper extremity was identified; -Blood cultures findings revealed staphylococcus aureus bacteremia (blood stream infection and that an infectious disease consult was ordered; and -The PICC line required replacement. There was no documentation in the clinical record which provided evidence the original initial POC for the initial certification period included orders for SN interventions and goals, including but not limited to, PICC line dressing changes and flushes nor medication administration and associated laboratory orders. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator (Employee #5) confirmed there was no documentation in the clinical record which provided evidence the above referenced original POC included the aforementioned orders for patient #1.”

“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 review of Pennsylvania (PA) Department of Health (DOH) state licensure regulations, agency policies/procedures, documentation and personnel files and social media posts and based on interview with the Regional/New Administrator (Employee #5), the Governing Body failed to ensure agency documentation included clear lines of authority related to administrative and supervisory functions for three (3) of three (3) agency documents. (Chart 1, Chart 2 and Patient Bill of Rights” form) Findings include: On September 29, 2025 at approximately 8:10 AM, review of the PA DOH state licensure regulations 28 PA Code, Part IV, Health Facilities, Subpart G. Chapter 601 revealed the following under “GOVERNANCE AND MANAGEMENT”: § 601.21. Organization, services and administration. (a) Writing requirements. Organization, services provided, administrative control and lines of authority for the delegation of responsibility to the patient care level shall be clearly set forth in writing and shall be readily identifiable. On September 29, 2025 at approximately 8:13 AM, review of the agency policy titled “Governing Body Policy” revealed the following under “Responsibilities of the Governing Body”: Leadership Appointments: Reviews and approves appointments or changes in key leadership positions, including the Director of Nursing (DON), Administrator... On September 29, 2025 at approximately 1:57 PM, review of the “Field Supervisor” crosswalk form revealed the following: Job Description Summary: The position is responsible for all nursing staff... Position Qualifications: Registered nurse with current licensure... On September 23, 2025 at approximately 3:44 PM, review of the agency job description titled “Local Administrator” revealed the following: Job Description Summary: The Local Administrator is responsible for the current overall direction of home health clinical services.... Position Qualifications: Master’s degree in Healthcare Administration or may be a RN with current licensure to practice professional services in the State or possess Master’s degree in Health Care Administration or other related field. On September 23, 2025 at approximately 4:15 PM, review of the first organizational chart (Chart 1) provided revealed following: -The organizational chart was updated on 02/20/2025. The administrator was a registered nurse (RN-Employee #4); and -The chart did not include a job title for clinical manager nor supervising RN. The organizational chart did include job titles for a “Director of Professional Services” and “Clinical Supervisor” but staff names were for those positions were not included on the chart. On September 23, 2025 at approximately 4:39 PM, review of an undated organizational chart (Chart 2) revealed the following: -The administrator and the alternate to the DON was an RN (Employee #4); and -The alternate administrator and DON was the Chief Executive Officer (CEO)/Family Nurse Practitioner (Employee #12). On September 24, 2025 at approximately 4:38 PM, review of the Governing Body Meeting Minutes dated 09/01/2025 revealed the following: -The administrator was a RN (Employee #4); and -The alternate administrator was the agency regional administrator/ RN (Employee #5). On September 23, 2025 at approximately 12:22 PM, review of the email received from the RN/Administrator (Employee #4) revealed Employee #4 remained administrator in an advisory capacity and that the RN continues to provide guidance and oversight regarding compliance, ensuring quality care and services and strategic planning and project management. The RN documented that the LPN (Employee #6) has assumed increased office duties and reports and reports to the CEO (Employee #12) On September 29, 2025 at approximately 7:33 AM, review of social media posts revealed the following the RN (Employee #4) documented the following regarding employment status: -Former administrator of the agency (employment dates December 2024 through 2025); and -Current Position: Clinical supervisor at a different agency effective June 25, 2025. On September 22, 20254 at approximately 12:06 PM and September 29,. 2025 at approximately 11:50 AM, review of the patient admission folder revealed an LPN (Employee #6) was identified as the Home Health Administrator/Clinical Manager to make complaints as documented on the “Patient Bill of Rights” form. Between 09/23/2025 at approximately 3:44 PM and 09/26/2025 at approximately 1:50 PM and on 09/29/2025 at approximately 10:45 AM, review of personnel file documentation revealed the following: Employee #6: The date of hire of the LPN was July 2019. The “Local Administrator” job description was signed by the LPN on 04/07/2025 and included a handwritten note which revealed the LPN was starting as assistant administrator for eight (8) months then will decide if full administrator is a good fit. Review of the post graduate diploma revealed the LPN obtained a Master’s Degree in Organizational Leadership on 07/09/2023. Review of Chart 1, Chart 2 and the “Patient Bill of Rights” forms on the above referenced dates/times revealed the Governing Body failed to ensure agency charts and forms included documentation of clear lines of authority related to administrative and supervisory functions. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/Alternate Administrator confirmed agency charts and forms failed to include documentation of clear lines of authority related to administrative and supervisory functions.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to provide written notification of the charges which may be incurred for wound care supplies for one (1) of one (1) patient for whom agency documentation revealed the patient would be responsible for payment for wound care supplies. (Patient #3) Findings include: On September 26, 2025 at approximately 12:30 PM, review of the agency policy titled “Patient Rights and Responsibilities” revealed the following: Purpose: To ensure that all patients receiving services from the agency are informed of their rights and responsibilities in accordance with the Medicare Conditions of Participation and the Pennsylvania Department of Health regulations... Patient Rights Policy...Patients have the right to.... -Be informed of...any charges for services provided by the agency that are not covered by Medicare or another payer, before care is furnished. On September 26, 2025 at approximately 12:32 PM, review of the agency policy titled “Management and Ordering of Patient Supplies” revealed the following: Scope: This policy applies to all patients admitted to the agency and to all staff involved in the patient admission and education. Policy Statement: The agency supports patients in managing their own care by promoting independence in supply ordering. Patients are provided with the necessary information and tools to order their own supplies directly from the designated supplier. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the start of care date was 07/18/2025, that the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that supplies included unsterile gloves, drains and other supplies and that skilled nursing (SN) was to provide the following wound to the abdominal surgical wound as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025: Cleanse with normal saline solution, pack with Kerlix (bulky white gauze dressing), frequency: 3 to 4 times a day. Review of SN service note documentation revealed the following: -08/01/2025: Patient required emergency room evaluation due to lack of supplies; -08/05, 08/07 and 08/08/2025: The licensed practical nurse (LPN-Employee #8) documented the patient was tolerating wound care; and -08/22 and 08/29/2025: The registered nurse (RN-Employee #11) provided wound care. Review of patient “Notes” documentation dated 07/31/2025 revealed a call was received from a case manager (CM) at a local health care system. The CM was “very upset” the patient was still without supplies. The agency patient care coordinator (PCC-Employee #13) notified the CM that due to excessive wound drainage, the patient is now out of supplies and that it is up to “them to supply additional supplies”. The PCC documented that the patient’s spouse was on the way to obtain supplies from the local health care system which included packing gauze and Kerlix. Review of the “Home Health Consents and Agreement Eynon” form, which was signed by the patient on 07/18/2025, revealed “Services/Financial Responsibility” included SN services but wound care supplies were not included as a financial responsibility of the patient. There was no documentation in the clinical record which provided evidence the agency provided the patient with written notice of the patient’s financial responsibility for wound care supplies prior to 07/31/2025. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation in the clinical record which provided evidence the agency provided the patient with written notice of the patient’s financial responsibility for wound care supplies.”

“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 review of agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure the “Home Health Certification and Plan of Care” (POC) included physician orders for medication administration and associated laboratory studies and wound and tracheostomy care for four (4) of four (4) patients for whom skilled nursing (SN) interventions were ordered on the initial POC. (Patients #2, #3, #4 and #5) Findings include: On September 23, 2025 at approximately 5:09 PM, review of the agency policy titled “Plan of Care (POC) Policy” revealed the following: The agency will establish, implement and periodically review a patient-centered Plan of Care (POC) that meets the Medicare Condition of Participation... Procedure...The POC will be based on patient-specific needs...The POC will include at minimum... -Types of services...Medications and treatments... Patient #2: Between September 22, 2025 at approximately 11:12 AM and September 24, 2025 at approximately 4:21 PM, review of the clinical record revealed the start of care (SOC) date was 09/10/2025, the primary diagnosis is type-2 diabetes mellitus (diabetes) with foot ulcer, that medications include meropenem (antibiotic) to be administered intravenously (IV) every 24 hours and that SN services are to be provided for one (1) week followed by five (5) as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/10/2025 through 11/08/2025. Review of the interim verbal order dated 09/14/2025 revealed the SN visit frequency was increased to three (3) times week for eight (8) weeks. Review of patient “Notes” documentation revealed the following: -09/10/2025: The following laboratory studies are to be obtained (due) every Monday: Completed blood count (CBC) and basic metabolic profile (BMP); and -09/16/2025: The pharmacy was unable to process the laboratory specimens because the specimens did not include the patient’s name. There was no documentation in the clinical record which provided evidence orders to obtain a CBC and BMP every Monday had been included on the initial POC. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the SOC date was 07/18/2025, the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that medications included total parental nutrition (TPN-nutritional supplement administered IV) to be administered intravenously every 12 hours and that SN services were to be provided for 10 weeks with 10 PRN visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025. Review of referral orders dated 07/18/2025 revealed the following labs were to be obtained weekly while receiving TPN beginning Monday, 07/21/2025: Complete metabolic profile (CMP), magnesium, phosphorus and ionized calcium. Review of laboratory results revealed the above referenced laboratory studies were obtained on 08/08/2025. There was no documentation in the clinical record which provided evidence orders to obtain the aforementioned laboratory studies had been included on the initial POC. Patient #4: Between September 24, 2025 at approximately 11:06 AM and September 25, 2025 at approximately 3:09 PM, review of the clinical record revealed the SOC date was 09/04/2025, the primary diagnosis is cellulitis of the left lower limb, that SN services are to be provided for one (1) week with 10 PRN visits and that the following medications and wound care are to be administered/provided as documented on the original “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025: -Wound care: Utilize black or white foam and wound vacuum; and -Cefazolin (antibiotic) and normal saline (NSS) flushes to be administered IV every 8 hours: and -Heparin flush 10 units per milliliter (ml)--administer 2 ml every 8 hours. The electronic agency staff signature date documented on the original POC was 09/22/2025. Review of an updated “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025 revealed the following orders were included under “Locator 22 Patient/Family/Goals”: Heparin flush 10 units per milliliter (ml)-administer 5 ml. The electronic staff signature date entered on the updated POC was 09/24/2025. Review of SN “Service Note” documentation revealed wound care and IV medication administration/NSS flushes were completed on 09/06, 09/07, 09/10, 09/12 and 09/19/2025. There was no documentation in the clinical record which provided evidence the original POC included orders for the wound vac pressure setting nor the frequency of the wound vac change. There was no documentation in the clinical record which provided evidence the updated POC included orders for the frequency for administration of heparin 5ml. Patient #5: On September 24, 2025 at between the approximate times of 12:02 PM and 1:45 PM, review of the clinical record revealed the SOC date was 09/05/2025, the primary diagnosis is blood stream infection due to central venous catheter, subsequent visit, that SN is to provide tracheostomy (surgically created airway created in the front of the neck) care and that SN services are to be provided for 10 weeks with 10 PRN visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/05/2025 through 11/03/2025: Review of SN “Service Note” documentation revealed tracheostomy care was provided on 09/08 and 09/15/2025 but the type of tracheostomy care provided was not documented. There was no documentation in the clinical record which provided evidence the initial POC included orders for the type nor frequency of tracheostomy care to be provided by SN staff. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation in the clinical record which provided evidence the initial (original or updated) POC included the above referenced orders for the above identified patients.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure interim verbal orders related to skilled nursing (SN) interventions had been incorporated into the clinical record for one (1) of one (1) patients for whom a comprehensive assessment was completed due to a change in patient condition. (Patient #4) Findings include: On September 23, 2025 at approximately 5:09 PM, review of the agency policy titled “Plan of Care (POC) Policy” revealed the following: The agency will establish, implement and periodically review a patient-centered Plan of Care (POC) that meets the Medicare Conditions of Participation... Procedure...Development of the POC… The POC will be reviewed and updated at least every 60 days or sooner if there is a significant change in the patient condition and in accordance with the Medicare Conditions of Participation. Updates may include verbal orders obtained from the physician/allowed practitioner, followed by written confirmation. Patient #4: Between September 24, 2025 at approximately 11:06 AM and September 25, 2025 at approximately 3:09 PM, review of the clinical record revealed the SOC date was 09/04/2025, the primary diagnosis is cellulitis of the left lower limb, that SN interventions include peripherally inserted peripheral catheter (PICC-intravenous line inserted into the arm) assessment and dressing changes, and that SN services are to be provided for one (1) week with 10 PRN visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025. Review of SN “Service Note” documentation revealed PICC line dressing changes were documented as having been performed on 09/06, 09/07 and 09/10/2025. On 09/10/2025, the licensed practical nurse (LPN-Employee #14) documented the PICC line dressing change was performed at the patient request due to small amount of blood being present. Review of patient “Notes” documentation the following: -09/14/2025 revealed the patient required emergency room treatment for a leaking PICC line; and -09/16/2025: An agency Patient Care Coordinator (Employee #15) documented a staff member from the primary care physician’s office reported the PICC line could be discontinued after the last dose of the antibiotic. Review of the resumption of care “Service Note” dated 09/19/2025 revealed the comprehensive assessment was performed due to a change in the patient condition and that the RN (Employee #11) discontinued the PICC line due to completion of an antibiotic. There was no documentation in the clinical record which provided evidence an interim physician verbal order had been verified by, placed in writing by a licensed nurse nor incorporated into the clinical record prior to 09/24/2025. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation in the clinical record which provided evidence an interim physician verbal order had been verified by, placed in writing by a licensed nurse nor incorporated into the clinical record prior to 09/24/2025 for the PICC line removal completed on 09/19/2025 for patient #4.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure interim order changes were communicated to the primary care physician (PCP) for one (1) of one (1) patient for whom supplemental orders were provided by an infusion company. (Patient #1) Findings include: On September 23, 2025 at approximately 5:09 PM, review of the agency policy titled “Plan of Care (POC) Policy” revealed the following: The agency will establish, implement and periodically review a patient-centered Plan of Care (POC) that meets the Medicare Conditions of Participation... Procedure…Variations from the POC will be justified in the clinical record as clinically appropriate and communication to the physician/allowed practitioner when required. Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided for nine (9) weeks with 10 as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse entered on the aforementioned POC on 07/29/2025. Review of infusion company instructions dated 07/25/2025 revealed the following: -Access: Peripherally inserted central catheter (PICC); -Access Flushes: 5 to 10 ml of 0.9% normal saline solution (NSS) before and after therapy and heparin 10 units per ml-administer 5 ml after final saline flush and as directed; and -Laboratory: Basic metabolic profile (BMP) to be drawn one (1) week post discharge. Review of the “Prescription for Home Infusion/Certification of Medical Necessity” general prescription revealed the following order changes were provided by a registered pharmacist (RPh) on 07/31/2025: -Access flushes: Flush with 20 ml of saline before and after each lab draw and as needed; and -Laboratory studies: BMP every two (2) weeks. There was no documentation in the clinical record which provided evidence the aforementioned order changes had been communicated to the PCP. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation in the clinical record which provided evidence the above referenced order changes had been communicated to the PCP for patient #1.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of agency policies/procedures, clinical records, personnel files, and the 2021 Infusion Nurses Society (INS) Infusion Therapy Standards of Practice and based on interview with a licensed practical nurse (LPN-Employee #2) and the Regional/New Administrator (Employee #5), the agency failed to ensure skilled nursing (SN) assessments were performed in accordance with physician orders, agency policies/procedures and/or professional standards for five (5) of five (5) patients. (Patients #1, #2, #3, #4 and #5) Findings include: On September 23, 2025 at approximately 5:10 PM, review of the agency policy titled “Comprehensive and Ongoing Assessment Policy” revealed the following under “Procedure”: Ongoing assessments…Ongoing assessment will be performed by all involved disciplines… Each discipline will assess and document….Assessments will emphasize changes in condition, progress towards goals and emerging needs. On September 23, 2025 at approximately 11:49 AM, review of the agency policy titled “PICC Line Maintenance & Care Policy and Procedure” revealed the following regarding care of a peripherally inserted central catheter (PICC): Policy: The agency will ensure that all PICC (peripherally inserted central catheter-intravenous (IV) which is inserted into the arm) lines are maintained according to current evidenced based standards… Documentation: Each PICC care visit must include documentation of… Dressing condition… On September 23, 2025 at approximately 12:55 PM, review of the 2021 INS Infusion Therapy Standards of Practice revealed the following: Standard 10. Documentation in Health Record…10.1 10.1 Clinicians record their initial and ongoing assessments or collection of data, diagnosis or problem, intervention and monitoring, the patient’s response to that intervention, and plan of care for infusion therapy and vascular access in a patient-specific physical (paper) or electronic/digital document… Standard 42. Vascular Access Device Assessment (VAD), Care, Dressing and Changes: Practice Recommendations: C…2. Assess the VAD site and surrounding area, by palpation and inspection, including catheter pathway, for integrity of skin, dressing, and securement device…b. Measure the external CVAD (Central Access Device) length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion… D…3. In outpatient or home care settings, assess VAD at every visit… Standard 45. Vascular Access Device Removal…Practice Recommendations… Non-tunneled CAVD including PICCs… F. Assess the removed catheter to ensure it is fully intact, after planned or inadvertent CVAD removal. Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided three (3) times a week for one (1) week followed by one (1) time a week for eight (8) weeks with 10 as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse (RN) entered on the aforementioned POC on 07/29/2025. Review of infusion company instructions dated 07/25/2025 revealed the following: Access: Peripherally inserted central catheter (PICC); Review of the SN start of care “Service Note” dated 07/28/2025 revealed a double lumen (2 ports) PICC was present in the right upper arm and that the RN flushed both ports with NSS and that the red port was flushed with heparin. Review of SN “Service Note” documentation revealed PICC “change” and/or “care” was completed by SN staff on the following dates: -Employee #2 (LPN) on 08/03, 08/07, 08/14, 08/18, 08/20, 08/22, 08/31, 09/03 and 09/05/2025; and -Employee #3 (LPN) on 08/27/2025. SN “Service Note” documentation dated 09/08/2025 revealed the patient was transferred to the emergency department due to PICC line discomfort and open wound around PICC. Review of inpatient referral documentation revealed the following: -The patient was admitted to the hospital on 09/09/2025; -Superficial thrombophlebitis (inflammation of a vein caused by a blood clot) of the right upper extremity was identified; -Blood cultures findings revealed staphylococcus aureus bacteremia (blood stream infection and that an infectious disease consult was ordered; and -The PICC line required replacement. There was no documentation in the clinical record which provided evidence the LPN’s (Employees #2 and #3) assessed the PICC line insertion site appearance, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. During telephone interview conducted on September 23, 2025 at approximately 4:15 PM, the LPN (Employee #2) reported external PICC line length is not assessed during dressing changes and that insertion site appearance and dressing condition findings were not documented as only negative assessment findings are documented in the clinical record. Patient #2: Between September 22, 2025 at approximately 11:12 AM and September 24, 2025 at approximately 4:21 PM, review of the clinical record revealed the SOC date was 09/10/2025, the primary diagnosis is type-2 diabetes mellitus (diabetes) with foot ulcer, that SN is perform PICC line dressing changes weekly and that SN services are to be provided one (1) time a week for one (1) week followed by five (5) as needed (PRN) visits and that SN is to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/10/2025 through 11/08/2025: -Measure length of exposed catheter with each dressing change. Review of SN “Service Note” documentation dated 09/15/2025 revealed the registered nurse (RN-Employee #1) documented the following IV interventions were completed: Change dressing weekly and measure length of exposed catheter each dressing change and but there was no documentation in the clinical record which provided evidence the RN assessed the PICC line insertion site appearance and dressing condition on 09/15/2025. The RN failed to document the external PICC length on 09/15/2025. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the SOC date was 07/18/2025, the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that SN is to provide wound care to abdominal wound and change the PICC line dressing weekly, the that SN services were to be provided one (1) time a week for one (1) week, then two (2) times a week for eight (8) weeks, followed by one (1) time a week for one (1) week with 10 PRN visits and that SN was to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the following was provided by SN staff on the following dates: Employee #8 (LPN): Wound care on 08/05, 08/07 and 08/08/2025 and PICC line dressing change on 08/07/2025. Employee #11 (RN): Wound care and PICC line dressing change on 08/22 and 08/29/2025. There was no documentation in the clinical record which provided evidence the LPN (Employee #8) had assessed wound size nor the PICC line insertion site, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. There was no documentation in the clinical record which provided evidence the RN (Employee #11) had documented the wound size assessment nor the PICC line insertion site appearance, dressing condition nor external PICC length during the PICC line changes dressing changes and/or care performed on the above referenced dates. Patient #4: Between September 24, 2025 at approximately 11:06 AM and September 25, 2025 at approximately 3:09 PM, review of the clinical record revealed the SOC date was 09/04/2025, the primary diagnosis is cellulitis of the left lower limb, that SN is to provide wound care and perform PICC line dressing changes weekly, that SN services are to be provided one (1) time a week for one (1) week with 10 PRN visits and that SN is to assess the following as documented on the original “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the SN interventions were completed as follows on the following dates: Employee #2 (LPN): Wound care and PICC line change/care on 09/06 and 09/07,/2025: and Employee #14 (LPN): Wound care and PICC line dressing change on 09/10 and 09/12/2025. Employee #11 (RN): PICC line removal completed on 09/19/2025. There was no documentation in the clinical record which provided evidence the LPN (Employee #2) assessed the wound size nor PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. There was no documentation in the clinical record which provided evidence the LPN (Employee #14) had documented the wound size assessment findings nor the external PICC length and dressing appearance on 09/10 nor 09/12/2025. There was no documentation in the clinical record which provided evidence the RN (Employee #11) had assessed the integrity of the PICC line after the PICC line removal on 09/19/2025. Patient #5: On September 24, 2025 at between the approximate times of 12:02 PM and 1:45 PM, review of the clinical record revealed the SOC date was 09/05/2025, the primary diagnosis is blood stream infection due to central venous catheter, subsequent visit, that SN is to provide tracheostomy (surgically created airway created in the front of the neck) care and perform PICC line dressing changes weekly, that SN services are to be provided one (1) time a week for one (1) week, then four (4) times a week for one (1) week, followed by one (1) time a week for eight (8) weeks with 10 PRN visits and that SN is to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/05/2025 through 11/03/2025: -Measure length of exposed PICC catheter with each dressing change; and -Assess tracheostomy stoma for redness, odor or exudate. Review of SN “Service Note” documentation revealed tracheostomy care and PICC line dressing changes/care were provided/completed by the LPN (Employee #6) on 09/08/2025 and an SN (Employee #10) on 09/15/2025. There was no documentation in the clinical record which provided evidence the LPN and SN (Employees #6 and #10) had documented tracheostomy stoma assessment findings on the aforementioned dates. There was no documentation in the clinical record which provided evidence the LPN and SN had assessed PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. Between 09/23/2025 at approximately 3:44 PM and 09/26/2025 at approximately 1:50 PM and on 09/29/2025 at approximately 10:45 AM, review of personnel file documentation revealed the following: Employee #10: The date of hire of the SN was 08/04/2025 and the first date of assignment was 08/18/2025. Review of licensure documentation reveled the SN was licensed as an RN in the state of Illinois but not in Pennsylvania. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/ New Administrator confirmed there was no documentation in the clinical record which provided evidence ongoing SN assessments had been conducted in accordance with physician orders, agency policy and procedures nor professional standards for the above identified patients.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on review of agency policies/procedures and clinical records and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure skilled nursing (SN) services were provided in accordance with the visit frequency orders included on the “Home Health Certification and Plan of Care” (POC) for two (2) of five (5) patients. (Patients #1 and #3) Findings include: On September 23, 2025 at approximately 5:09 PM, review of the agency policy titled “Plan of Care (POC) Policy” revealed the following: The agency will establish, implement and periodically review a patient-centered Plan of Care (POC) that meets the Medicare Condition of Participation... Procedure...The POC will be based on patient-specific needs...The POC will include at minimum... Visit frequency (may be written in ranges to allow flexibility) ... Patients and caregivers will be involved in care planning to the extent they are willing and able... Documentation...Clinicians will document care provided in accordance with the POC, noting any variations or adjustments made... Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided three (3) times a week for one (1) week followed by one (1) time a week for eight (8) weeks with 10 as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse (RN) was entered on the aforementioned POC on 07/29/2025. Review of interim order documentation dated 08/10/2025 revealed effective 08/17/2025, the SN visit frequency was updated to three (3) times a week for five (5) weeks. Review of SN visit documentation failed to reveal SN services had been provided in accordance with the aforementioned SN visit frequencies as evidenced by the following: -Week one (1) of the certification period (Begin 07/28/2025): One (1) of three (3) SN visits were provided. -Week five (5) of the certification period (Begin 08/24/2025): One (1) of three (3) SN visits were provided. There was no documentation in the clinical record which provided evidence the patient had refused SN visits during the above referenced weeks. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the SOC date was 07/18/2025, the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that SN is to provide wound care to abdominal wound and change the PICC line dressing weekly, the that SN services were to be provided one (1) time a week for one (1) week, then two (2) times a week for eight (8) weeks, followed by one (1) time a week for one (1) week with 10 PRN visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025: Review of SN visit documentation failed to reveal SN services had been provided in accordance with the aforementioned SN visit frequency as evidenced by the following: -Week two (2) of the certification period (Begin 07/20/2025): Zero (0) of two (2) SN visits were provided. -Week three (3) of the certification period (Begin 07/27/2025): One (1) of two (2) SN visit were provided. -Week six (6) of the certification period (Begin 08/17/2025): One (1) of two (2) SN visits were provided. -Week seven (7) of the certification period (Begin 08/24/2025): One (1) of two (2) SN visits were provided. There was no documentation in the clinical record which provided evidence the patient had refused SN visits during the above referenced weeks. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation in the clinical record which provided evidence SN services were provided in accordance with the above referenced visit frequency orders for the above identified patients.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on review of agency documentation, clinical records and personnel files and based on interview with the Regional/New Administrator (Employee #5), the agency failed to ensure documentation was maintained which provided evidence a registered nurse (RN) supervised the skilled nursing (SN) services provided by four (4) of four (4) licensed practical nurses (LPN). (Employees #2, #3, #6 and #8) Findings include: On September 26, 2025 at approximately 8:50 AM, review of the job description titled “Licensed Practical Nurse” revealed the following under “Job Description Summary”: The licensed practical/vocational nurse is responsible for providing direct patient care under the supervision of a registered nurse. On September 29, 2025 at approximately 1:57 PM, review of the “Field Supervisor” crosswalk form revealed the following: Job Description Summary: The position is responsible for all nursing staff... Position Qualifications: Registered nurse with current licensure... On September 23, 2025 at approximately 3:44 PM, review of the agency job description titled “Local Administrator” revealed the following: Job Description Summary: The Local Administrator is responsible for the current overall direction of home health clinical services.... Position Qualifications: Masters in healthcare administration or may be a RN with current licensure to practice professional services in the State or possess Master’s degree in health care administration or other related field. Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided for nine (9) weeks with 10 as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse (RN) entered on the aforementioned POC on 07/29/2025. Review of infusion company instructions dated 07/25/2025 revealed the following: Access: Peripherally inserted central catheter (PICC); Review of SN “Service Note” documentation revealed PICC “change” and/or “care” was completed by SN staff on the following dates: -Employee #2 (LPN) on 08/03, 08/07, 08/14, 08/18, 08/20, 08/22, 08/31, 09/03 and 09/05/2025; and -Employee #3 (LPN) on 08/27/2025. SN “Service Note” documentation dated 09/08/2025 revealed the patient was transferred to the emergency department due to PICC line discomfort and open wound around PICC. Review of inpatient referral documentation revealed the following: -The patient was admitted to the hospital on 09/09/2025; -Superficial thrombophlebitis (inflammation of a vein caused by a blood clot) of the right upper extremity was identified; -Blood cultures findings revealed staphylococcus aureus bacteremia (blood stream infection and that an infectious disease consult was ordered; and -The PICC line required replacement. There was no documentation in the clinical record which provided evidence the LPN’s (Employees #2 and #3) assessed the PICC line insertion site appearance, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. During telephone interview conducted on September 23, 2025 at approximately 4:15 PM, the LPN (Employee #2) reported external PICC line length is not assessed during dressing changes and that insertion site appearance and dressing condition findings were not documented as only negative assessment findings are documented in the clinical record. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the SOC date was 07/18/2025, the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that SN is to provide wound care to abdominal wound and change the PICC line dressing weekly, that SN services were to be provided for 10 weeks with 10 PRN visits and that SN was to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the following was provided by SN staff on the following dates: Employee #8 (LPN): Wound care on 08/05, 08/07 and 08/08/2025 and PICC line dressing change on 08/07/2025. There was no documentation in the clinical record which provided evidence the LPN (Employee #8) had assessed wound size nor the PICC line insertion site, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. Patient #4: Between September 24, 2025 at approximately 11:06 AM and September 25, 2025 at approximately 3:09 PM, review of the clinical record revealed the SOC date was 09/04/2025, the primary diagnosis is cellulitis of the left lower limb, that SN is to provide wound care and perform PICC line dressing changes weekly, that SN services are to be provided for one (1) week with 10 PRN visits and that SN is to assess the following as documented on the original “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the SN interventions were completed as follows on the following dates: Employee #2 (LPN): Wound care and PICC line change/care on 09/06 and 09/07,/2025: and There was no documentation in the clinical record which provided evidence the LPN (Employee #2) assessed the wound size nor PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. Patient #5: On September 24, 2025 at between the approximate times of 12:02 PM and 1:45 PM, review of the clinical record revealed the SOC date was 09/05/2025, the primary diagnosis is blood stream infection due to central venous catheter, subsequent visit, that SN is to provide tracheostomy (surgically created airway created in the front of the neck) care and perform PICC line dressing changes weekly, that SN services are to be provided for 10 weeks with 10 PRN visits and that SN is to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/05/2025 through 11/03/2025: -Measure length of exposed PICC catheter with each dressing change; and -Assess tracheostomy stoma for redness, odor or exudate. Review of SN “Service Note” documentation revealed tracheostomy care and PICC line dressing changes/care were provided/completed by the LPN (Employee #6) on 09/08/2025. There was no documentation in the clinical record which provided evidence the LPN (Employees #6) had documented tracheostomy stoma assessment findings on the aforementioned dates. There was no documentation in the clinical record which provided evidence the LPN had assessed PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. On September 23, 2025 at approximately 4:15 PM, review of the first organizational chart (Chart 1) revealed the chart did not include a job title for a clinical manager nor supervising RN. The organizational chart did include job titles for a “Director of Professional Services” and “Clinical Supervisor” but staff names were for those positions were not included on the chart. On September 22, 20254 at approximately 12:06 PM and September 29,. 2025 at approximately 11:50 AM, review of the patient admission folder revealed an LPN (Employee #6) was identified as the Home Health Administrator/Clinical Manager to make complaints. Between 09/23/2025 at approximately 3:44 PM and 09/26/2025 at approximately 1:50 PM and on 09/29/2025 at approximately 10:45 AM, review of personnel file documentation revealed the following: Employee #6: The date of hire of the LPN was July 2019. The “Local Administrator” job description was signed by the LPN on 04/07/2025 and included a handwritten note which revealed the LPN was starting as assistant administrator for eight (8) months then will decide if full administrator is a good fit. Review of the post graduate diploma revealed the LPN obtained a Master’s Degree in Organizational Leadership on 07/09/2023. Employee #2: The date of hire of the LPN was 06/25/2025 and the first date of assignment to provide SN services was 07/18/2025. Employee #3: The date of hire of the LPN was 06/08/2021 and the first date of assignment to provide SN services was 06/21/2021. Review of performance evaluation documentation revealed Employee #6 was the reviewer listed on the LPN’s performance evaluation. Employee #8: The date of hire of the LPN was 08/30/2024 and the first date of assignment was 10/10/2024. There was no documentation in the above listed agency documentation, clinical records nor personnel files which provided evidence an RN supervised SN services provided to the above identified patients by the LPN’s (Employees #2, #3, #6 and #8). During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed employee #6 was not licensed as a RN; therefore, employee #6 is did not possess the qualifications to supervise SN services provided by LPN staff.”

“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 review of agency polices/procedures, documentation, clinical records and personnel files and the 2021 Infusion Nurses Society (INS) Infusion Therapy Standards of Practice and based on interview with the Regional/New Administrator (Employee #5), the Chief Executive Officer (CEO)/Alternate Administrator (Employee #12) failed to ensure documentation was maintained in the personnel file which provided evidence competency or qualification (licensure) verification was completed in accordance with agency policies/procedures for two (2) of three (3) registered nurses (RN) who provided skilled nursing (SN) services. (Employees #1 and #10) Findings include: On September 29, 2025 at approximately 8:20 AM, review of the agency policy titled “RN/LPN Clinical Staff Competency Evaluation Policy” revealed the following under “Purpose”: This policy ensures that staff are trained and evaluated through multiple avenues and that competency is verified in accordance with Medicare Conditions of Participation and Pennsylvania home health regulations... Final competency verification and sign-off by an RN to ensure compliance with regulatory requirements. This approach ensures that staff receives comprehensive training from diverse sources while maintaining RN oversight. On September 29, 2025 at approximately 8:41 AM, review of the registered nurse job description revealed the following under “Qualifications”: 2. Current licensure in the state... On September 23, 2025 at approximately 12:55 PM, review of the 2021 INS Infusion Therapy Standards of Practice revealed the following: Standard 10. Documentation in Health Record…10.1 10.1 Clinicians record their initial and ongoing assessments or collection of data, diagnosis or problem, intervention and monitoring, the patient’s response to that intervention, and plan of care for infusion therapy and vascular access in a patient-specific physical (paper) or electronic/digital document… Standard 42. Vascular Access Device Assessment (VAD), Care, Dressing and Changes: Practice Recommendations: C…2. Assess the VAD site and surrounding area, by palpation and inspection, including catheter pathway, for integrity of skin, dressing, and securement device…b. Measure the external CVAD (Central Access Device) length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion… D…3. In outpatient or home care settings, assess VAD at every visit… Standard 45. Vascular Access Device Removal…Practice Recommendations… Non-tunneled CAVD including PICCs… F. Assess the removed catheter to ensure it is fully intact, after planned or inadvertent CVAD removal. On September 23, 2025 at approximately 4:39 PM, review of an undated organizational chart (Chart 2) revealed the following: -The Alternate Administrator/DON is the CEO/Family Nurse Practitioner (Employee #12). Patient #2: Between September 22, 2025 at approximately 11:12 AM and September 24, 2025 at approximately 4:21 PM, review of the clinical record revealed the SOC date was 09/10/2025, the primary diagnosis is type-2 diabetes mellitus (diabetes) with foot ulcer, that SN is perform PICC line dressing changes weekly and that SN is to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/10/2025 through 11/08/2025: -Measure length of exposed catheter with each dressing change. Review of SN “Service Note” documentation dated 09/15/2025 revealed the registered nurse (RN-Employee #1) documented the following IV interventions were completed: Change dressing weekly and measure length of exposed catheter each dressing change and but there was no documentation in the clinical record which provided evidence the RN assessed the PICC line insertion site appearance and dressing condition on 09/15/2025. The RN failed to document the external PICC length on 09/15/2025. Patient #5: On September 24, 2025 at between the approximate times of 12:02 PM and 1:45 PM, review of the clinical record revealed the SOC date was 09/05/2025, the primary diagnosis is blood stream infection due to central venous catheter, subsequent visit, that SN is to provide tracheostomy (surgically created airway created in the front of the neck) care and perform PICC line dressing changes weekly and that SN is to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 09/05/2025 through 11/03/2025: -Measure length of exposed PICC catheter with each dressing change; and -Assess tracheostomy stoma for redness, odor or exudate. Review of SN “Service Note” documentation revealed tracheostomy care and PICC line dressing changes/care were provided/completed by a SN (Employee #10) on 09/15/2025. There was no documentation in the clinical record which provided evidence the SN (Employees #6 and #10) had documented tracheostomy stoma assessment findings on the aforementioned dates. There was no documentation in the clinical record which provided evidence the SN had assessed PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. Between 09/23/2025 at approximately 3:44 PM and 09/26/2025 at approximately 1:50 PM and on 09/29/2025 at approximately 10:45 AM, review of personnel file documentation revealed the following: Employee #1: The date of hire of the RN was 08/04/2025 and the first date of assignment was 08/18/2025. Review of the “Initial Competency Assessment Skills Checklist-Registered Nurse” revealed IV competency, including PICC line competency, was verified on 09/05/2025 by an unknown staff member as the initials and signature of the preceptor were illegible. There was no documentation on the aforementioned checklist which provided evidence a qualified RN verified competency to perform PICC line dressing changes and assessment prior to the assignment to provide SN services to patient #2. Employee #10: The date of hire of the SN was 08/04/2025 and the first date of assignment was 08/18/2025. Review of licensure documentation reveled the SN was licensed as an RN in the state of Illinois but not in Pennsylvania. There was no documentation in the personnel file which provided evidence the PA licensure status had verified prior to the assignment to provide SN services. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed there was no documentation on the “Initial Competency Assessment Skills Checklist-Registered Nurse” for employee #2 which provided evidence IV competency, including PICC line competency, was verified by a qualified RN prior to the assignment to provide SN services to patient #2 and that there was no documentation the personnel file which provided evidence the PA licensure status had verified prior to the assignment of employee #10 to provide SN services.”

“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 review of agency polices/procedures, documentation, clinical records and personnel files,2021 INS Infusion Therapy Standards of Practice and Pennsylvania (PA) State Board training requirements and based on interview with the Regional/New Administrator (Employee #5), the Chief Executive Officer/Alternate Administrator (Employee #12) failed to ensure two (2) of four (4) licensed practical nurses (LPN) completed a PA State Board of Nursing approved intravenous (IV) training program. (Employees #2 and #8) Findings include: On September 29, 2025 at approximately 8:20 AM, review of the agency policy titled “RN/LPN Clinical Staff Competency Evaluation Policy” revealed the following under “Purpose”: This policy ensures that staff are trained and evaluated through multiple avenues and that competency is verified in accordance with Medicare Conditions of Participation and Pennsylvania home health regulations... Final competency verification and sign-off by an RN to ensure compliance with regulatory requirements. This approach ensures that staff receives comprehensive training from diverse sources while maintaining RN oversight. On September 23, 2025 at approximately 12:55 PM, review of the 2021 INS Infusion Therapy Standards of Practice revealed the following: Standard 10. Documentation in Health Record…10.1 10.1 Clinicians record their initial and ongoing assessments or collection of data, diagnosis or problem, intervention and monitoring, the patient’s response to that intervention, and plan of care for infusion therapy and vascular access in a patient-specific physical (paper) or electronic/digital document… Standard 42. Vascular Access Device Assessment (VAD), Care, Dressing and Changes: Practice Recommendations: C…2. Assess the VAD site and surrounding area, by palpation and inspection, including catheter pathway, for integrity of skin, dressing, and securement device…b. Measure the external CVAD (Central Access Device) length at each dressing change or when catheter dislodgement is suspected and compare to the external CVAD length documented at insertion… D…3. In outpatient or home care settings, assess VAD at every visit… On September 29, 2025 at approximately 8:29 AM, review of the PA State Board of Nursing “Infusion Therapy Program Syllabus” revealed the training program includes the following as required on the PA State Board of Nursing Approved Education Forms: --Infusion Therapy Program Syllabus Page 2 and 3 Columns Requiring Trainer Documentation for Each of the Below Listed Objectives: Detailed Description of Content to Meet Each Objective (Lecture Hours and Lab Hours); Resources and Instruction Materials and Assignments/Testing. Detailed description of Content to Meet Each Objective 1. Practical Nursing Law and Regulations, 2. Definition of infusion therapy and indications. 3. Types of vascular access delivery devices, 4. Age-related considerations. 5. Legal implications for infusion therapy, 6. Anatomy and physiology 7. Fluid and electrolyte balance, 8. Components of infusion equipment 9. Parenteral solutions and their indications, 10. Infection control and safety considerations, 11. Insertion of peripheral short catheters 12. Complications, drug and solution incompatibilities, and appropriate nursing interventions, 13. Central and peripheral vascular devices. 14. Administration, maintenance and monitoring of infusion therapy, 15. Documentation, 16. Patient education On September 23, 2025 at approximately 4:39 PM, review of an undated organizational chart (Chart 2) revealed the following: -The administrator and the alternate to the DON was an RN (Employee #4); and -The alternate administrator and DON is the Chief Executive Officer (CEO)/Family Nurse Practitioner (Employee #12). On September 23, 2025 at approximately 12:22 PM, review of the email received from the RN/Administrator (Employee #4) revealed Employee #4 remained administrator in an advisory capacity and that the RN continues to provide guidance and oversight regarding compliance, ensuring quality care and services and strategic planning and project management. The RN documented that the LPN (Employee #6) has assumed increased office duties and reports and reports to the CEO (Employee #12). On September 29, 2025 at approximately 9:14 AM, review of agency documentation revealed the Administrator/RN (Employee #4) resigned effective 09/28/2025 and that the Regional/Alternate Administrator (Employee #5) was appointed new administrator effective 09/28/2025. Patient #1: Between September 22, 2025 at approximately 10:45 AM and September 23, 2025 at approximately 9:59 AM, review of the clinical record revealed the start of care (SOC) date was 07/28/2025, the primary diagnosis is hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4 CKD or unspecified CKD and that SN services are to be provided for nine (9) weeks with 10 as needed (PRN) visits as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/28/2025 through 09/25/2025. The electronic signature of the registered nurse (RN) entered on the aforementioned POC on 07/29/2025. Review of infusion company instructions dated 07/25/2025 revealed the following: Access: Peripherally inserted central catheter (PICC); Review of SN “Service Note” documentation revealed PICC “change” and/or “care” was completed by SN staff on the following dates: -Employee #2 (LPN) on 08/03, 08/07, 08/14, 08/18, 08/20, 08/22, 08/31, 09/03 and 09/05/2025; and -Employee #3 (LPN) on 08/27/2025. SN “Service Note” documentation dated 09/08/2025 revealed the patient was transferred to the emergency department due to PICC line discomfort and open wound around PICC. Review of inpatient referral documentation revealed the following: -The patient was admitted to the hospital on 09/09/2025; -Superficial thrombophlebitis (inflammation of a vein caused by a blood clot) of the right upper extremity was identified; -Blood cultures findings revealed staphylococcus aureus bacteremia (blood stream infection and that an infectious disease consult was ordered; and -The PICC line required replacement. There was no documentation in the clinical record which provided evidence the LPN’s (Employees #2 and #3) assessed the PICC line insertion site appearance, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. During telephone interview conducted on September 23, 2025 at approximately 4:15 PM, the LPN (Employee #2) reported external PICC line length is not assessed during dressing changes and that insertion site appearance and dressing condition findings were not documented as only negative assessment findings are documented in the clinical record. Patient #3 (Discharge): Between September 22, 2025 at approximately 11:02 AM and September 24, 2025 at approximately 8:50 AM, review of the clinical record revealed the SOC date was 07/18/2025, the primary diagnosis was diverticulitis of the large intestine with perforation and abscess without bleeding, that SN is to provide wound care to abdominal wound and change the PICC line dressing weekly, that SN services were to be provided for 10 weeks with 10 PRN visits and that SN was to assess the following as documented on the “Home Health Certification and Plan of Care” for the initial certification period of 07/18/2025 through 09/15/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the following was provided by SN staff on the following dates: Employee #8 (LPN): Wound care on 08/05, 08/07 and 08/08/2025 and PICC line dressing change on 08/07/2025. There was no documentation in the clinical record which provided evidence the LPN (Employee #8) had assessed wound size nor the PICC line insertion site, dressing condition nor external PICC length during the PICC line changes and/or care performed on the above referenced dates. Patient #4: Between September 24, 2025 at approximately 11:06 AM and September 25, 2025 at approximately 3:09 PM, review of the clinical record revealed the SOC date was 09/04/2025, the primary diagnosis is cellulitis of the left lower limb, that SN is to provide wound care and perform PICC line dressing changes weekly, that SN services are to be provided for one (1) week with 10 PRN visits and that SN is to assess the following as documented on the original “Home Health Certification and Plan of Care” for the initial certification period of 09/04/2025 through 11/02/2025: -Measure length of exposed PICC catheter with each dressing change; and -Measure wound at every visit. Review of SN “Service Note” documentation revealed the SN interventions were completed as follows on the following dates: Employee #2 (LPN): Wound care and PICC line change/care on 09/06 and 09/07,/2025: and There was no documentation in the clinical record which provided evidence the LPN (Employee #2) assessed the wound size nor PICC line insertion site, dressing condition nor external PICC length during the dressing changes/care performed on the above referenced dates. Between 09/23/2025 at approximately 3:44 PM and 09/26/2025 at approximately 1:50 PM and on 09/29/2025 at approximately 10:45 AM, review of personnel file documentation revealed the following: Employee #2: The date of hire of the LPN was 06/25/2025 and the first date of assignment to provide SN services was 07/18/2025. Review of IV therapy training documentation revealed the LPN completed the web-based CEUFast LPN IV Series: Central Venous Catheters and Arterial Catheters” course on 06/25/2025 and that the IV competency demonstration portion of the agency--based “Initial Competency Assessment Skills Checklist--Licensed Practical/Vocational Nurse” was completed on 06/28/2025. Employee #8: The date of hire of the LPN was 08/30/2024 and the first date of assignment was 10/10/2024.Review of IV therapy training documentation revealed the LPN completed the web-based CEUFast LPN IV Series: Central Venous Catheters and Arterial Catheters course on 09/10/2024 and the IV competency demonstration of the agency--based “Initial Competency Assessment Skills Checklist--Licensed Practical/Vocational Nurse” was completed on 10/09/2024. There was no documentation in the personnel file which provided evidence the web and agency-based LPN IV training program included the above referenced curriculum components required by the PA State Board of Nursing nor was documentation present between 09/23 and 09/26/2025 which provided evidence the above identified LPN’s completed a PA State Board of Nursing approved LPN infusion therapy program. During interviews conducted between September 22, 2025 at approximately 2:56 PM and September 26, 2025 at approximately 10:58 AM and on September 29, 2025 at approximately 2:22 PM, the Regional/New Administrator confirmed that between 09/23 and 09/26/2025 there was no documentation in the personnel file which provided evidence the above referenced web and agency-based LPN IV training program included the curriculum components required by the PA State Board of Nursing nor was documentation present between 09/23 and 09/26/2025 which provided evidence the above identified LPN’s completed a PA State Board of Nursing approved LPN infusion therapy program.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the administrator (Employee #9) and the co-director/nurse practitioner (CD/NP-Employee #10), the agency failed to ensure a registered nurse (RN) completed an initial (start of care) assessment for one (1) of two (2) patients for whom a referral was received and accepted by the agency. (Patient #1) Findings include: On November 22, 2024 at approximately 11:42 AM, review of agency policy 2-004, titled “Intake Process” revealed the following under “Procedure”: D. The Scheduling Coordinator will assign personnel and schedule and assessment visit. The initial visit will be performed either within 48 hours of the order, or within 48 hours of the patient’s return home with order, or on the start of care date ordered by the licensed independent contractor. If the patient is not seen within 48 hours of order or the patient’s return home with order or on the physician-ordered start of care date, documentation will be present in the medical record describing the circumstances surrounding the delay in the patient’s start of care. Patient #1: On November 13, 2024 at approximately 12:14 PM, review of the clinical record revealed the referral facsimile forwarded to the agency by a skilled inpatient facility was dated 09/13/2024. The Review of “Patient Quick Note” documentation dated 10/01/2024 revealed an agency patient care coordinator (PCC-Employee #1) contacted the patient by telephone on 10/01/2024 to verify the patient’s address and physician, that the patient’s physician was contacted on10/01/2024 to verify that the physician will sign (home health) orders and that the patient agreed to the start of care. There was no documentation on the “Patient Quick Note” which provided evidence that the patient was advised of the start of care date nor was documentation present which provided evidence the physician provided a verbal start of care date. Review of “Patient Quick Note: documentation revealed the three (3) follow-up calls were placed to the patient on 10/09/2024. The follow-up calls were placed eight (8) days after the above referenced patient and physician calls. The call details on 10/09/2024 at 12:39 PM revealed the call was being placed to schedule a start of care visit. During the third call dated 10/09/2024 at 4:55 PM, the patient notified the agency that the patient was hospitalized. There was no documentation in the clinical record which provided evidence a registered nurse performed an initial assessment of the patient after the patient agreed to the start of care during the 10/01/2024 call. During interview conducted on November 22, 2024 at approximately 11:14 PM the administrator and the CD/NP confirmed an initial nursing assessment was not completed by a registered nurse for the above identified patient.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the administrator (Employee #9) and the co-director/nurse practitioner (CD/NP-Employee #10), the agency failed to ensure an initial (start of care) assessment was conducted in accordance with agency policy/procedure for two (2) of two (2) patients for whom therapy services were ordered on the home health plan of care. (Patients #2 and #3) Findings include: On November 22, 2024 at approximately 11:42 AM, review of agency policy 2-004, titled “Intake Process” revealed the following under “Procedure”: D. The Scheduling Coordinator will assign personnel and schedule and assessment visit. The initial visit will be performed either within 48 hours of the order, or within 48 hours of the patient’s return home with order, or on the start of care date ordered by the licensed independent contractor. If the patient is not seen within 48 hours of order or the patient’s return home with order or on the physician-ordered start of care date, documentation will be present in the medical record describing the circumstances surrounding the delay in the patient’s start of care. Patient #2: On November 13, 2024 at approximately 1:23 PM, review of the clinical record revealed the start of care date was 10/11/2024 and that physical therapy (PT) and occupational therapy (OT) services are to be provided as ordered on the “Revision to Plan of Care” for the initial certification period of 10/11/2024 through 12/09/2024. Review of the “Printable Discharge Form” revealed the agency accepted the referral on 10/08/2024, that the patient’s projected inpatient discharge date was 10/08/2024 and that the start of care was scheduled for the next day. Review of the clinical record revealed a PT (Employee #3) performed the start of care assessment on 10/111/2024 and that the PT documented that the inpatient discharge date was unknown. There was no documentation in the clinical record which provided evidence the initial PT assessment was completed with 48 hours of the referral date nor was documentation present which provided an explanation for the delay in the start of care. Patient #3: On November 13, 2024 at approximately 2:00 PM, review of the clinical record revealed the start of care date was 10/10/2024 and that physical therapy (PT) and occupational therapy (OT) services are to be provided as ordered on the “Home Health Certification and Plan of Care” for the initial certification period of 10/10/2024 through 12/08/2024. Review of the facsimile documentation dated revealed patient information was forwarded to the agency on 09/27/2024. Review of “Patient Quick Note” documentation dated 09/28/2024 revealed a patient care coordinator (PCC-Employee 13) documented that the welcome call was placed to the patient was unsuccessful and that a voicemail was left for a PT to confirm patient information. “Patient Quick Note” documentation revealed the next attempt to contact the patient occurred on 10/07/2024 at which time the patient agreed to a start of care date of 10/10/2024. There was no documentation in the clinical record which provided evidence the agency attempted to contact the patient between 09/29/2024 and 10/06/2024. Review of the clinical record revealed a PT (Employee #4) performed the start of care assessment on 10/10/2024 and that the PT documented that the inpatient discharge date was unknown. There was no documentation in the clinical record which provided evidence the initial PT assessment was completed in accordance with the above referenced policy/procedure nor was documentation present which provided an explanation for the delay in the start of care. During interview conducted on November 22, 2024 at approximately 11:14 PM the administrator and the CD/NP confirmed an initial therapy assessment was not completed in accordance with agency policies/procedures and that there was no documentation in the clinical record which provided an explanation for the delay in the start of care for the above identified patients.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policies/procedures, personnel documentation and clinical records and based on interview with the administrator (Employee #9) and the co-director/nurse practitioner (CD/NP-Employee #10), the agency failed to ensure documentation was maintained in the personnel file which provided evidence a licensed staff member obtained and documented verbal physician orders for two (2) of three (3) patients. (Patients #2 and #4) Findings include: On November 22, 2024 at approximately 11:46 AM, review of agency policy 2.020, titled “Verification of Physician/Authorized Licensed Independent Practitioner Orders”, revealed the following under “Policy”: Verbal orders will be taken only by professional, licensed home health personnel but may be transcribed into the patient record by paraprofessional staff. On November 22, 2024 at approximately 11:47 AM, review of the job description titled “Patient Care Coordinator” (PCC) revealed the position qualifications did not require the staff member to be a licensed staff member. On November 19, 2024 at approximately 8:04 AM, review of personnel file documentation revealed the following: Employee #7: The date of hire of the PCC was 09/03/2024. Patient #2: On November 13, 2024 at approximately 1:23 PM, review of the clinical record revealed a PCC (Employee #7) documented that a verbal order (V.O.) was obtained from the physician for a physical and occupational therapy frequency of one (1) time a day for one (1) day on 10/10/2024. There was no documentation in the clinical record which provided evidence the V.O. had been obtained by a licensed professional staff member. Patient #4: On November 13, 2024 at approximately 2:31 PM, review of the clinical record revealed a PCC (Employee #7) documented that a V.O. was obtained from the physician for a skilled nursing visit frequency of skilled nursing one (1) time a day for one (1) day on 10/03/2024. There was no documentation in the clinical record which provided evidence the V.O. had been obtained by a licensed professional staff member. During interview conducted on November 22, 2024 at approximately 11:14 PM the administrator and the CD/NP confirmed there was no documentation in the clinical record which provided evidence a licensed professional obtained the aforementioned verbal orders for the above identified patients.”

“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 agency policies/procedures and clinical records, Centers for Medicare/Medicaid (CMS) qualification guidelines, Nurse Licensure Compact licensure requirements and professional license details, and based on interview with the Administrator (Employee #8) and the Regional Administrator (Employee #9), the agency failed to ensure a qualified practitioner provided plan of care/treatment orders for one (1) of four (4) patients. (Patient #2) Findings include: On July 26, 2024 at approximately 3:34 PM, review of agency policy 2-020, titled “Verification of Physician/Authorized Licensed Independent Practitioner Orders” revealed the following under “Purpose”: To ensure that accurate physician (or other authorized independent practitioner) orders...are obtained in accordance with the state and Federal law and regulation. On July 31, 2024 at approximately 8:10 AM, review of Title 42, Chapter IV, Subchapter B —Medicare Program Part 410 —Supplementary Medical Insurance (SMI) Benefits revealed the following under “§ 410.75 Nurse practitioners’ services”: Qualifications...a nurse practitioner must be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law… Patient #2: On July 16, 2024 at approximately 2:06 PM, July 22, 2024 at approximately 10:35 AM, July 26, 2024 at approximately 3:37 PM, July 29, 2024 at approximately 3:25 PM and July 31, 2024 at approximately 8:00 AM, review of the clinical record revealed the orders included on the “Home Health Certification and Plan of Care” (POC-plan of care/treatment) for the initial certification period of 06/26/2024 through 08/24/2024 were provided by a Family Nurse Practitioner (FNP) whose address was located in New York state. On July 22, 2024 at approximately 11:15 AM revealed the following regarding the NCL on the Pennsylvania Department of Health (PA DOH) website ( https://www.health.pa.gov/topics/facilities/Pages/Nurse-Licensure-Compact.aspx ): Act 68 of 2021 authorizes the Commonwealth of Pennsylvania’s entrance into the interstate Nurse Licensure Compact (Compact)...In accordance with the Pennsylvania Department of State’s announcement, the Commonwealth is partially implementing the Compact by permitting RNs and LPNs residing in other Compact states and holding an active MSL (eligible MSL nurses) to practice in Pennsylvania. On July 22, 2024 at approximately 11;13 AM, review of the NLC information included on the National Council of State Board of Nursing website ( https://nursecompact.com/index.page#map ) revealed New York state had not yet enacted the NLC as NLC legislation was pending. On July 22, 2024 at approximately 11:19 AM, review of the New York state licensure verification website ( https://eservices.nysed.gov/professions/verification-search ) revealed the above referenced FNP was licensed in New York as a Nurse Practitioner in Family Health. There was no evidence the New York license for the FNP was an MLS. On July 22, 2024 at approximately 11:17 AM, review of licensure details included on the PA Department of State website failed to reveal the above referenced FNP obtained a license to practice as a nurse practitioner in Pennsylvania. During telephone interview conducted on July 31, 2024 at approximately 3:30 PM, the Administrator and Regional Administrator confirmed there was no documentation which provided evidence the above referenced FNP met the aforementioned qualification requirements to provide the POC orders for Patient #2.”