Home Care for the 21st Century - Chester

“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 upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure the physician ordered plan of care to ensure pertinent diagnoses for one (1) out of three (3) CR’s reviewed (CR#1), failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR’s reviewed (CR#1), failed to ensure medications and treatments were provided in accordance with physician’s orders for two (2) out of three CR’s reviewed (CR #1 and CR#2); failed to ensure the plan of care was updated to include all medication orders for one (1) out of three (3) CR’s reviewed (CR#1); and failed to ensure the plan of care was updated to include all wound care orders for one (1) out of three CR’s reviewed (CR #1). Finding include: Cross Reference: 484.60 (a) Tag 0572 Plan of Care 484.60 (a)(2) Tag 0574 Plan of Care must include the following 484.60 (b)(1) Tag 0580 Drugs, services, and treatments are administered only as ordered by a physician 484.60 (c)(2) Tag 0592 Revised Plan of Care The cumulative effect of these systemic failures led to the agency’s inability to adequately plan care and coordinate services which led to a lower standard of care for the patients.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based upon policy and procedure review, review of IQIES OASIS reporting for calendar year 2025, interview with the agency administrator, and clinical record (CR) review, it was determined the agency failed to ensure the transmittal of OASIS data for agency patients receiving skilled services, over eighteen years of age, for three (3) out of three (3) clinical records (CR) reviewed and failed to ensure the agency’s OASIS policy to contain language regarding OASIS data transmittal for one (1) out of one (1) OASIS policy reviewed (OASIS policy #1). Review of agency policy titled “OASIS-E Policies” on February 17, 2026 states the following: The Agency gathers OASIS data for Medicare and Medicaid patients aged 18 and over who received skilled care, excluding those treated for pre-or post-natal conditions. THE POLICY DID NOT ADDRESS OASIS DATA TRANSMITTAL. CR#1 (Start of care 8/11/2018) on 2/17/2026 at approximately 9:30 AM revealed the following: Payor source: Medicaid, therefore, meeting criteria for transmittal. CR#2: (Start of care: 9/18/2025) on 2/19/2026 at approximately 9:00 AM revealed the patient to be receiving skilled nursing services, based on admission date, this meets criteria for transmittal regardless of payor source. CR#3: (Start of care: 6/21/2024) on 2/19/2026 at approximately 10:00 AM revealed the patient to be receiving skilled nursing services and a Medicaid payor source, therefore, meeting criteria for transmittal. An interview with the agency administrator on 2/19/26 at approximately 10:30 AM confirmed the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure the physician ordered plan of care contained pertinent diagnoses for one (1) out of three (3) CR’s reviewed (CR#1), and failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR’s reviewed (CR#1). Review of policy “5.17 PLAN OF CARE REQUIREMENTS” on 2/19/26 at approximately 4:15 PM states the following: “(APC.7. I) The patient’s care/service plan addresses needs identified in the assessment process. (APC.7.I.M1) Each patient must receive the home health services that are written in an individualized plan of care. The plan is developed, and evaluated, in partnership with the patient, representative (if any), and caregiver(s) and identifies patient-specific measurable outcomes and goals. (APC.7.I.M2) The individualized plan of care includes the following: 1. All pertinent diagnoses. 2. All patient care orders, including verbal orders.....4. The types of services, supplies, and equipment required.....11. All medications and treatments....17. Patient-specific interventions and education....20. Any additional items the organization, or physician or allowed practitioner, may choose to include.” Review of CR#1 (Start of care 8/11/2018) on 2/19/2026 at approximately 12:30 PM revealed the following: Patient is on an intermittent ventilator with a tracheostomy, receiving 24/7 skilled nursing services from the agency. Plan of care for the certification period 1/01/26-3/01/2026 revealed the following: Primary and secondary diagnosis left blankGoal stating: “Foley will remain patent during this certification period and be free from UTI.” THE PLAN OF CARE DID NOT INCLUDE ORDERS FOR FOLEY CATHETER CAREPhysician notification for vital signs was listed, given the following parameters: “Temperature greater than 99.0 or less than 97.0, pulse greater than 100 or less than 60, respirations greater than 18 or less than 10. Systolic BP greater than 140 or less than 80. Diastolic BP is greater than 100 or less than 70. O2 Sat less than 85%”. THERE WERE NO ORDERS ON THE PLAN OF CARE FOR THE FREQUENCY OF VITAL SIGN MONITORING FOR THE GIVEN PARAMETERS.”SN to perform finger stick for fasting blood sugar/random blood sugar if it has not been done or if patient reports signs and symptoms of hypo/hyper glycemia.” THERE WERE NO FURTHER ORDERS FOR BLOOD GLUCOSE PARAMETERS, INTERVENTIONS, FREQUENCY OR CLARIFICATION FOR “IF IT HAS NOT BEEN DONE”. An interview with the agency administrator on 2/19/25 at approximately 2:55 PM confirmed the above findings.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure the registered nurse resolved wound care orders with discrepancies in the plan of care for one (1) out of three (3) CR’s reviewed (CR#2) and failed to ensure the registered nurse resolved medication orders with discrepancies in the plan of care for two (2) out of three (3) CR’s reviewed (CR#1 and CR#3). Review of agency policies on 2/18/26 at 2:50 PM revealed the following: 5.23 PHYSICIAN’S PLAN OF TREATMENT AND ORDERS “Statement of Standard: (CDT.4. D) There are documented policies and procedures for the acceptance, documentation, verification, and authentication of required physician or other authorized practitioner orders. Policies address which personnel can receive and document orders, including the timeframes for documentation and authentication, in accordance with local, state, and federal law and regulation. (CDT.4. I) Physician (or other authorized practitioner) orders for services are obtained, as required, prior to the provision of care/services and in accordance with applicable state and federal law and regulation.” Review of CR#1 (Start of care 8/11/2018) on 2/19/2026 at approximately 12:30 PM revealed the following: Patient is on an intermittent ventilator with a tracheostomy, receiving 24/7 skilled nursing services from the agency. Plan of care for the certification period 1/01/26-3/01/2026: Order stating “Use oxygen gas by inhaling 2 liters/minute as needed.” THERE WERE NO PARAMETERS LISTED ON THE PLAN FOR “WHEN NEEDED” Review of CR#2 on 2/19/2026 at approximately 11:30 AM revealed the following: (Start of care: 9/18/2025): Plan of Care for certification period 1/16/26-3/16/2026: “Sacral Wound Tx:” FOLLOWING AREA LEFT BLANK. NO FURTHER WOUND CARE ORDER OR CLARIFICATION PROVIDED. Review of CR#3 on 2/19/2026 at approximately 10:30 AM revealed the following: (start of care 6/21/2024): Plan of Care for certification period 12/13/25-2/10/26: “Medications: Diazepam Rectal 20 mg 1 Take medication 20 mg per rectal as needed. Take 12.5 mg once seizures occur or for seizures lasting 2 minutes 30 seconds longer.” THERE WAS NO FURTHER CLARIFICATION OF THE SPECIFIC DOSAGE OR SPECIFIC PARAMETERS FOR ADMINISTRATION. DOSE AND PARAMETERS ON ORDER ARE CONFLICTING. An interview with the agency administrator on 2/19/25 at approximately 2:55 PM confirmed the above findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based upon clinical record (CR) review, and an interview with the agency administrator, it was determined the agency failed to ensure all entries in the clinical record to be legible for one (1) out of three (3) clinical records reviewed (CR#3). A policy pertaining to “Documentation” was requested from the agency on 2/19/2026. No policy was received. Review of CR#3 (Start of care: 6/21/2024) on 2/17/2026 at approximately 10:00 AM revealed the following: Nursing flow sheets from 2/3/26-2/10/26 were reviewed. Handwritten progress notes for this time period were not legible. An interview with the agency administrator on 2/19/2026 at approximately 8:35 AM confirmed the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure the physician ordered plan of care contained pertinent diagnoses for one (1) out of three (3) CR’s reviewed (CR#1), and failed to ensure the plan of care included clear treatment and intervention orders for one (1) out of three (3) CR’s reviewed (CR#1). Review of policy “5.17 PLAN OF CARE REQUIREMENTS” on 2/19/26 at approximately 4:15 PM states the following: “(APC.7. I) The patient’s care/service plan addresses needs identified in the assessment process. (APC.7.I.M1) Each patient must receive the home health services that are written in an individualized plan of care. The plan is developed, and evaluated, in partnership with the patient, representative (if any), and caregiver(s) and identifies patient-specific measurable outcomes and goals. (APC.7.I.M2) The individualized plan of care includes the following: 1. All pertinent diagnoses. 2. All patient care orders, including verbal orders.....4. The types of services, supplies, and equipment required.....11. All medications and treatments....17. Patient-specific interventions and education....20. Any additional items the organization, or physician or allowed practitioner, may choose to include.” Review of CR#1 (Start of care 8/11/2018) on 2/19/2026 at approximately 12:30 PM revealed the following: Patient is on an intermittent ventilator with a tracheostomy, receiving 24/7 skilled nursing services from the agency. Plan of care for the certification period 1/01/26-3/01/2026 revealed the following: Primary and secondary diagnosis left blankGoal stating: “Foley will remain patent during this certification period and be free from UTI.” THE PLAN OF CARE DID NOT INCLUDE ORDERS FOR FOLEY CATHETER CAREPhysician notification for vital signs was listed, given the following parameters: “Temperature greater than 99.0 or less than 97.0, pulse greater than 100 or less than 60, respirations greater than 18 or less than 10. Systolic BP greater than 140 or less than 80. Diastolic BP is greater than 100 or less than 70. O2 Sat less than 85%”. THERE WERE NO ORDERS ON THE PLAN OF CARE FOR THE FREQUENCY OF VITAL SIGN MONITORING FOR THE GIVEN PARAMETERS.”SN to perform finger stick for fasting blood sugar/random blood sugar if it has not been done or if patient reports signs and symptoms of hypo/hyper glycemia.” THERE WERE NO FURTHER ORDERS FOR BLOOD GLUCOSE PARAMETERS, INTERVENTIONS, FREQUENCY OR CLARIFICATION FOR “IF IT HAS NOT BEEN DONE”. An interview with the agency administrator on 2/19/25 at approximately 2:55 PM confirmed the above findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure medications and treatments were provided in accordance with physician’s orders for two (2) out of three CR’s reviewed (CR #1 and CR#2). Review of agency policy “5.23 PHYSICIAN’S PLAN OF TREATMENT AND ORDERS” on 2/18/26 at 2:50 PM revealed the following: (CDT.4. D) There are documented policies and procedures for the acceptance, documentation, verification, and authentication of required physician or other authorized practitioner orders. Policies address which personnel can receive and document orders, including the timeframes for documentation and authentication, in accordance with local, state, and federal law and regulation. (CDT.4. I) Physician (or other authorized practitioner) orders for services are obtained, as required, prior to the provision of care/services and in accordance with applicable state and federal law and regulation. (CDT.4.I.M1) Medications, services, and treatments are administered, only, as ordered, by a physician or allowed practitioner. Review of CR#1 (Start of care 8/11/2018) on 2/19/2026 at approximately 12:30 PM revealed the following: Patient is on an intermittent ventilator with a tracheostomy, receiving 24/7 skilled nursing services from the agency. Review of Plan of Care for the certification period 1/01/26-3/01/2026: Flow Sheets, MARS (Medication Administration Records), and Ventilator home monitoring form for the time period 1/21/26-1/30/26 revealed the following findings: Plan of care includes the following order: “Skilled nurse will provide tracheostomy care such as suctioning client as needed for excess mucus. SN to change inner canula every 24 hours and clean around trach area every shift and to change “necktie” (tracheostomy tie) once a day.” There was no documentation of tracheostomy care provided on the following dates and shifts: 1/21/2026 1400-2200, 1/21/26 2200-0600, 1/22/26 1400-2200, 1/23/26- 1400-2200, 1/23/26-2200-0600, 1/24/26- 0710-1445, 1/25/26- 0600-2400, 1/26/26-1658-2200, 1/27/26-1402-2200, 1/28/26- 1348-21:59, 1/28/2026- 2200-0600, 1/29/26-1400-2200 2. Plan of care includes the following order: “Skilled nurse to ensure vent setting remains as follows all the time: tidal volume 520 mL, respiratory rate 16 BPM, PEEP 5 CMH20, and inspiratory time 1.0 seconds.” There was no documentation of verification of any ventilator settings on the following shifts: 1/21/26 1400-2200, 1/22/26 1400-2200,1/23/26- 1400-2200, 1/24/26- 0710-1445, 1/26/26-1658-2200,1/27/26-1402-2200,1/28/26- 1348-21:59, 1/29/26-1400-2200 /Tidal volume setting verification on the Ventilator home monitoring form was left blank on the following dates and shifts: 1/21/2026 2200-0600, 1/22/26-2200-0600, 1/28/2026- 2200-0600, 1/29/26-2200-0600 /Inspiratory Time setting verification on the Ventilator home monitoring form was left blank on the following dates and shifts: 1/21/2026 2200-0600 , 1/22/26-2200-0600, 1/23/26-2200-0600, 1/25/26- 0600-2400,1/27/2026-2200-0600, 1/28/2026- 2200-0600, 1/29/26-2200-0600 / Machine Respiratory Rate Setting verification on the Ventilator home monitoring form was left blank on the following dates and shifts: 1/23/26-2200-0600, 1/25/26- 0600-2400,1/27/2026-2200-0600. 1/28/2026- 2200-0600, 1/29/26-2200-0600 / PEEP setting verification was left blank on the Ventilator home monitoring form was left blank on the following dates and shifts: 1/24/26-1444-0410 3. Plan of care includes the following order: “SN to change vent tubing once a week”-No weekly ventilatory tubing change documented per order on the plan of care in the time period reviewed (9 days) 4. Plan of care includes the following order: “Triad Hydrophilic wound dress external 1 apply topically 2 times a day on the skin to increase skin healing (left foot).” There was no documentation of PM wound care on the following dates and shifts: 1/21/26 1400-2200, 1/22/26 1400-2200, 1/23/26- 1400-2200, 1/25/26- 0600-2400, 1/26/26-1658-2200,1/27/26-1402-2200, 1/28/26- 1348-21:59,1/29/26-1400-2200 - There was no documentation of AM wound care on the following dates and shifts:1/24/26- 0710-1445, 1/25/26- 0600-2400 5. Additional order 12/10/2025- “clean posterior thigh wound due to scratching with soap and water then apply triad-hydrophilic external cream wound paste once a day.” There was no documentation of this wound care order having been provided on the following dates and shifts: 1/24/26- 0710-1445, 1/25/26- 0600-2400 6. Plan of care includes the following order: “Bumetanide Oral 1 mg 1 tab (s) take by mouth every 4 times in a week” There was no documentation on the MAR of the patient having received this medication in the time period reviewed 7. Plan of care includes the following order: “Ferrous Sulfate oral 325 (65(Fe) mg 1 tab (s) take by mouth every other day” There was no documentation on the MAR of the patient having received this medication in the time period reviewed 8. Plan of care includes the following order: “SN to perform finger stick for fasting blood sugar/random blood sugar if it has not been done or if patient reports signs and symptoms of hypo/hyper glycemia”. No documentation of the patient having received: any finger stick for fasting blood sugar/random blood sugar “if it has not been done” during the time period reviewed. 9. Plan of care includes the following order: “Sertraline HCL oral 100 mg 2 tabs Take 2 tablets by mouth once a day”- There was no documentation on the MAR of the patient having received this medication in the time period reviewed 10. Plan of care includes the following order: “Calcium Acetate (Phos Binder) Oral 667 mg 3 tabs. Take 3 caps 3x/day before meals”- There was no documentation on the MAR of the 2100 dose given between 1/21/2026-1/29/2026 or the 0800 dose on 1/25/2026 11. Plan of care includes the following order: “Sevelamer HCL oral 800 mg 4 tab(s) take 3200 mg 4 tablets by mouth 3 times a day before meals” There was no documentation on the MAR of the 0800-dose given on 1/25/2026 12. Plan of care includes the following order:” Metoprolol-hydrochlorothiazide oral 100-25 mg 1 tab (s). Take 25 mg by mouth once a day (hypertension)” There was no documentation on the MAR of administration on 1/24/26 and 1/25/26 13. Plan of care includes the following order: “Use oxygen gas by inhaling 2 liters/minute as needed” “SPO2 O2 LPM/continuous/prn” section left blank on flow sheets on the following dates and shifts: 1/21/2026 1400-2200, 1/21/2026 2200-0600, 1/22/26 1400-2200, 1/22/26-2200-0600, 1/23/26- 1400-2200, 1/23/26-2200-0600, 1/24/26- 0710-1445, 1/24/26 1444-0410, 1/25/26- 0600-2400, 1/26/26-1658-2200,1/27/2026-2200-0600, 1/27/26-1402-2200, 1/28/26- 1348-21:59,1/28/2026- 2200-0600, 1/29/26-1400-2200, 1/29/26-2200-0600 Review of CR#2 on 2/19/2026 at approximately 11:30 AM revealed the following: (Start of care: 9/18/2025): Visit flow sheets and MARs were reviewed for the time period 1/19/26-1/26/26 Plan of Care for certification period 1/16/26-3/16/2026 contains the following orders: “Sacral Wound Tx:” FOLLOWING AREA LEFT BLANK. NO FURTHER WOUND CARE ORDER OR CLARIFICATION PROVIDED. Sacral wound care was documented as completed per visit flow sheets on 1/19/26-1/26/26 “Novolog Injection 100 unit/mL give 4-16 units via subcutaneous as follow: 3 times daily when blood sugar is as follows BS 150-200 give 4 units, 201-250 give 8 units, 251-300 give 12 units, 300 give 16 units and blood sugar greater than 300 call Docter. Times were listed on MAR as 0800, 12 noon, and 1700. MAR section to list blood sugar and units of insulin given was left blank for dates reviewed 1/19/26-1/26/26. “Ostomy Care TX: Gently clean skin and stoma gently using warm water and paper towel to dry skin area. Do not use soap/baby wipes. Pat dry. Measure stoma and cut pouch wafer, then apply wafer and pouch. Hold pressure over pouch to allow wafer to mold to skin. Change pouch every 3-4 days and as needed.” THERE WAS NO DOCUMENTATION OF OSTOMY POUCH CHANGES BETWEEN 1/19/2026-1/26/2026.An interview with the agency administrator on 2/19/25 at approximately 2:55 PM confirmed the above findings.”

“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 upon clinical record (CR) review, policy and procedure review, and interview with the agency administrator, it was determined the agency failed to ensure the plan of care to be updated to include all medication orders for one (1) out of three (3) CR’s reviewed (CR#1) and failed to ensure the plan of care was updated to include all wound care orders for one (1) out of three CR’s reviewed (CR #1). Review of policy “5.17 PLAN OF CARE REQUIREMENTS” on 2/19/26 at approximately 4:15 PM states the following: “(APC.7. I) The patient’s care/service plan addresses needs identified in the assessment process. (APC.7.I.M1) Each patient must receive the home health services that are written in an individualized plan of care. The plan is developed, and evaluated, in partnership with the patient, representative (if any), and caregiver(s) and identifies patient-specific measurable outcomes and goals. (APC.7.I.M2) The individualized plan of care includes the following: 1. All pertinent diagnoses. 2. All patient care orders, including verbal orders.....4. The types of services, supplies, and equipment required.....11. All medications and treatments....17. Patient-specific interventions and education....20. Any additional items the organization, or physician or allowed practitioner, may choose to include.” Review of CR#1 (Start of care 8/11/2018) on 2/19/2026 at approximately 12:30 PM revealed the following: Patient is on an intermittent ventilator with a tracheostomy, receiving 24/7 skilled nursing services from the agency. Plan of care for the certification period 1/01/26-3/01/2026: Additional order 10/03/2025: Add Tums 750 mg take 2 chewables twice daily. THIS ORDER WAS NOT ADDED TO THE PLAN OF CARE.Additional order 12/10/2025- “clean posterior thigh (back of the thigh) wound due to scratching with soap and water then apply triad-hydrophilic external cream wound paste (A medication paste for wound care) once a day”. THIS ORDER WAS NOT ADDED TO THE PLAN OF CARE An interview with the agency administrator on 2/19/25 at approximately 2:55 PM confirmed the above findings.”

“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 upon personnel file review, policy and procedure review, and an interview with the agency administrator, it was determined the agency failed to ensure completed ventilator competency skills validation checklists for three (3) out of three (3) personnel files (PF) reviewed (PF#1-PF#3). Policy “Mechanical Ventilator Patients” reviewed on 2/19/2026 at approximately 2:15 PM states the following: “Care of patients requiring mechanical ventilation, on a planned basis, including a plan for healthcare emergencies, will be in accordance with existing organization policies with regard to patients’ rights, physician or allowed practitioner referral, management, and all other issues. Patients/clients requiring continuous mechanical ventilation will be managed by an RN.An RN, or a Registered Respiratory Therapist (RRT) (It is noted the agency does not employ an RRT), will provide such care and/or instruction, as ordered by the patient/client’s physician or allowed practitioner. PF#1-PF#3 were reviewed on 2/19/2026 from approximately 1:00 PM-2:00 PM, revealing the following: All three files contained a “Clinical Competency Checklist: Ventilator Skill Training Form” with a section for “Goals/Competencies” labeled #1 through #11. The bottom of the competency contained a signed area by the Registered nurse trainer and the clinician. Each of the three competencies contained various sections left blank: PF#1(No date of hire provided) -A form titled “Clinician Competency Checklist-Ventilator Skill Training” dated 9/5/2025 was left blank for the following “4. Attach to the O2 source…6. Assemble and connect the patient circuit. 8. View and change settings 9. Access monitoring screens PF#2 (No date of hire provided) -A form titled “Clinician Competency Checklist-Ventilator Skill Training” dated 9/5/2025 was left blank for the following “3. Attach to A/C or D/C power and explain power source indicators 4. Attach to the O2 source. 8. View and change settings 9. Access monitoring screens 10. Locate and explain alarm messages and alarm indicators PF#3 (No date of hire provided) -A form titled “Clinician Competency Checklist-Ventilator Skill Training” dated 11/3/2025 was left blank for the following “4. Attach to O2 source 9. Access monitoring screens An interview with the agency administrator on 2/19/2026 at approximately 2:55 PM confirmed the above findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based upon clinical record review, agency policy and procedure review, and email communication with the agency administrator, it was determined the agency failed to ensure the patient’s physician to be notified of change in patient’s condition for one (1) out of three (3) clinical records (CR) reviewed (CR#1). Findings include: Review of agency policy on 5/13/2025 at approximately 2:50 PM states: 5.23 PHYSICIAN’S PLAN OF TREATMENT AND ORDERS“Statement of Standard: (CDT.4.D) There are documented policies and procedures for the acceptance, documentation, verification, and authentication of required physician or other authorized practitioner orders. Policies address which personnel can receive and document orders, including the timeframes for documentation and authentication, in accordance with local, state, and federal law and regulation. (CDT.4.I) Physician (or other authorized practitioner) orders for services are obtained, as required, prior to the provision of care/services and in accordance with applicable state and federal law and regulation. (CDT.4.I.M1) Medications, services, and treatments are administered, only, as ordered, by a physician or allowed practitioner. (CDT.5.I) Orders, including verbal orders, are accepted, signed, and dated, by authorized personnel, as defined in organizational policy and local, state, or federal law and regulation. (CDT.5.I.M1) Physician or allowed practitioner verbal orders are documented in the patient’s record, by a nurse acting in accordance with state licensure requirements, or other authorized practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the organization’s policies. Orders are signed and dated and indicate the time the order was received. (CDT.5.I.M2) Verbal orders are authenticated and dated by the physician, or other ordering practitioner in accordance with the organization’s policies and state law and regulation. Responsibility of Organization: 1.The organization will notify the physician or allowed practitioner, either, verbally, and/or in writing, or fax of the patient/client’s condition, including, but not limited to, the following: After the initial visit to establish the plan of care/treatmentVital signs are outside of normal or pre-established rangesAll lab resultsNew clinical symptoms become evidentClinical symptoms are extending, to the point that the patient’s/client’s status has changedPatient/client, and/or caregivers, request notification of physician or allowed practitionerChanges occur in the patient/client’s expected response to treatmentMedications are ineffective, condition indicates adverse reactions, significant side effects are present, drug allergies are suspected, or contraindicated medications are being taken. Any confusion on medication regimen is reported to the physician or allowed practitioner, for clarification.Long term symptoms are present, without resolutionChanges occur in the patient/client’s environment or caregiver support. 2. Documentation of physician or allowed practitioner notification is maintained, in the patient/client’s clinical record, on, either, a communication form, or a verbal/telephone order form and includes: Date and time of all contact attempts Name of person taking messageName of physician or allowed practitionerAction taken and/or orders obtainedReason for notification Signature, and title, of individual making the contactPhysician or allowed practitioner’s response 3. If unable to notify the physician or allowed practitioner regarding changes in the patient’s/client’s condition, the supervisor or Clinical Manager should be notified. The supervisor, or the Clinical Manager, will attempt to contact the physician or allowed practitioner. “ Review of CR#1 on 5/08/2025 at approximately 9:30 AM revealed the following: Physician ordered plan of care for the certification period 3/07/2025-5/05/2025. Plan of care included an order stating the following: SN inspection of patient’s lower extremities every visit and report any alteration in skin integrity to physician.Nursing flow sheet dated 4/20/25, completed by EMP#1, stated the following: Pt has been scratching his foot and then asked to be “deep” in water. After left leg is washed, washing the right, and noticed peelings on leg, which patient says is dead skin, later it was burning while washed (misspelling) and refused to go to ER.” There was no documentation in the clinical record of physician notification of patient’s change in condition.Nursing flow sheet dated 4/21/25, written by EMP #2 states “Patient had left foot soles redness around 1600 and he refused to go to the ER according to report…” A second note dated 4/21/25 written by EMP#2 states “Patient had left foot soles burn around 1600 and refused to go to the ER according to the report.” There was no documentation in the clinical record of physician notification of patient’s change in condition.Notification to Physician revealed a patient communication form dated 4/22/25 written by Supervising RN Stating “This is to inform MD that CR#1 went to the ER yesterday and is admitted now for evaluation. It happed after his dialysis appointment. On Sunday 4/20/25 afternoon around 4:20 PM, nurse called and said that Randi was constantly scratching his foot with a sharp object stating that it’s itching him severely, so it must be washed with a lukewarm water. After rinsing his foot, nurse noticed some peeling and redness, so she recommended he goes to the hospital to get it checked due to him still scratching after the wash is done but he still refused to go. After his dialysis treatment, he was sent to the ER for further evaluation due to the condition of the foot. His service will be on hold until he comes home. The notification of the change in patient condition was not provided to the physician until after the patient was hospitalized.An email to the agency administrator on 5/13/2025 at approximately 10:04 AM confirmed the above findings.”