Abundant Home Health LLC

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record reviews, and interviews the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect and report patient information for quality improvement and monitoring) to the CMS system within 30 days of completing the patient’s assessment for 207 of 3148 OASIS assessments submitted from 8/1/2024 to 7/31/2025. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Findings: Review of the OASIS Error Detail report in IQIES (CMS system to manage provider and patient information and ensure quality healthcare) on 7/31/2025 revealed 207 late OASIS submissions with error code 3330 (code for a late submission greater than 30 days after the patient’s assessment completion date) for report period 8/1/2024 to 7/31/2025. An entrance conference and interview were conducted with the Administrator (Adm) and Director of Nurses (DON) on 8/7/2025 at 9:30am. The surveyor asked about the agency’s policy and procedure for OASIS submissions. The Adm stated “the nurse has 24 to 48 hours to complete the admission.” The DON stated, after the admissions are completed, the Alternate Director of Nurses (ADON) completes the QA review and submits the OASIS data within 5 days of the M0090 date (date assessment is completed). The DON stated the ADON “checked the list daily” for late submissions. The surveyor shared the findings of the 207 late OASIS submissions and asked why the agency’s policy was not followed. The Adm stated, the agency had “issues” with contracted nurses not completing documentation on time and notifying management (Adm, Alt Adm, DON and ADON) “they had already discharged the patient.” The DON stated, “we had some contracted nurses that were not submitting documentation.” The surveyor asked about the potential patients’ outcomes for late OASIS submissions. The DON stated, “it’s delaying the claims (request for payment) … data (OASIS assessment information) can just be delayed.” An interview was conducted with the ADON on 8/14/2025 at 10:45am. The surveyor asked about the agency’s policy on the timeliness of OASIS submissions. The ADON stated, “Nursing or physical therapy should be 24 to 48 hours submission of the notes and OASIS.” The surveyor shared the findings of the 207 late OASIS submissions. The ADON stated,” some (late submissions) are non-admits (patients that were not admitted to home health).” The ADON stated patient’s names are entered in the agency’s EMR system and are counted as “delayed…without any confirmations and verifications” the patient was not admitted. The ADON stated he “exported data (OASIS) every day, two to five times a day.” When asked about OASIS submission tracking, the ADON stated he tracks submissions “sometimes I do it monthly.” When asked about late OASIS discharge submissions, the ADON stated “sometimes the discharges were delayed and caused the exporting to be late.” Review of agency’s policy “Timelines, IM.35,” revision 07/01/2025 reads in part “The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”

“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 observations, record reviews and interviews the agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for 2 (Patients 5 and 9) of 12 active patients’ records reviewed. This failure placed patients at risk of not receiving interventions and treatments ordered by a physician, which could lead to poor patients’ health outcomes. Findings: Record review of Patient 5 revealed a plan of care for period 07/29/2025 to 09/26/2025 signed by RN A. The POC contained a SOC date of 07/29/2025 and an admitting diagnosis of “Encounter for surgical aftercare following surgery on the skin.” The POC contained a nurse frequency of 1 visit for the first week, then 3 times a week for 8 weeks with 2 prn visits. Records contained a RN-Skilled Nursing visit dated 7/29/2025 and signed by RN A which stated: Wound 1 - Location right leg. Treatment: removed old dressing, washed wound with saline (solution of sterile water and salt). Pat dried. Applied non sting barrier to periwound (surrounding skin that extends outward from the wound’s edge). Draped (Adhesive covering helps maintain negative pressure wound therapy) periwound. Applied nonadherent dressing made of knitted cellulose and petrolatum. Packed wound with black foam. Secured black foam with wound vac drape. Attached trackpad (connects the dressing to the wound vac pump) and hooked to wound vac machine (a medical device that uses suction to remove fluid to help wounds heal). Turned on machine and maintained at 125 mmHg (pressure setting to promote wound healing), however was showing a leak (of pressure) … troubleshooting done, machine not working. Replaced dressing with wet to dry (a piece of gauze moistened with saline, is placed on the wound and is removed when it dries) and secured with tape. The POC did not contain any orders for wound care treatments. The physician contact section of the nursing visit note was blank with no evidence the physician was contacted for an order for a wet to dry dressing. An interview was conducted with Patient 5 during a home visit on 8/12/2025 at 10:35am. When asked about the wound care that was completed on 7/29/2025, Patient 5 stated RN A came to her home twice on 7/29/2025, initially for the SOC visit and the second time for a wound vac battery malfunction and wound care. Patient 5 stated the wound vac orders were obtained from the hospital after surgery on her right leg and when the wound vac malfunctioned, RN A called her supervisor for the wet to dry dressing. Patient 5 stated RN A returned the next day when the new wound vac machine arrived and completed the wound care as ordered by the hospital. Record review of Patient 9 revealed a plan of care for period 06/25/2025 to 08/23/2025 signed by RN A. The POC contained a SOC date of 10/24/2025 and an admitting diagnosis of “Pressure ulcer of sacral region (bedsore or pressure sore on lower back and spine).” The POC contained a nurse frequency of 3 times a week for 9 weeks. Records contained a RN Skilled Nursing Visit dated 06/27/2025 signed by RN A which stated, “Catheter: Suprapubic (a tube inserted through a small incision in the lower abdomen, just above the pubic bone, to drain urine from the bladder) , Last Changed: 06/09/2025, Tube Feeding Bolus (a single dose of feeding formula given at once): 200 milliliters every 4 hours, Comments: dysphagia (difficulties swallowing), PEG (a feeding tube inserted through the abdominal wall directly into the stomach).” Records also contained a transfer summary dated 7/20/2025 for patient’s hospitalization for a PEG tube replacement. The POC did not contain orders for the suprapubic catheter, PEG tube and PEG tube feedings. The resumption of care “SN Assessment” dated 08/04/2025 completed by RN A stated, wound 1 - Location: Sacrum, Treatment: Removed old dressing. Washed wound with antimicrobial wound cleanser (cleansing agent that removes debris and kills a wide range of bacteria and fungi) Applied skin protectant (containing menthol and zinc oxide) then blue antibacterial foam dressing. Covered with silicone foam dressing. Patient’s records did not contain an updated POC for the resumption of care with the new wound care orders. Observation, and interview were conducted with Patient 9 and FM #1 during a home visit on 8/14/2025 at 11:45am. When asked about the suprapubic catheter. FM #1 stated the catheter is changed once a month by RN A. When asked about the PEG tube. FM #1 stated Patient 9 received 1 carton of tube feeding formula 4 times a day. The daughter showed the surveyor the carton of 250 milliliters of tube feeding formula. When asked about Patient 9’s wound care. FM #1 stated wound care is done “daily,” 3 times a week by the nurse and 4 times a week by FM #2. FM #1 stated the nurse “packs the wound. I have not seen the whole process yet.” FM #1 stated FM #2 “communicates with the nurse and does the wound care.” A phone interview was conducted with RN A on 8/13/2025 at 1:39pm. When asked about the agency’s policy and process of updating the POC. RN A stated, “if the plan of care changes let’s say I’m going to increase wound care visits I will sometimes call the doctor. If the patient has a wound care doctor, usually I give them a heads up (an update) and then write the order.” RN A stated, “sometimes the patient will go home, and we will not receive any orders from the doctors regarding wound care. I call the doctor’s office right there with the patient and then document it and then when I get home, I write or create a physician’s order.” When asked if the written order transfers to the POC, RN A stated, “Yes.” The surveyor shared the findings of Patients 5 and 9 and asked why the agency’s policy on updating the POC was not followed. RN A stated, on Patient 5 the wound vac orders were “on the attachment of the patient’s history and physical (comprehensive medical evaluation) and “I forgot to add it” to the POC. RN A stated, the wet to dry dressing was a “standard protocol if the patient is having problems with the wound vac… I did not write the order because it was a onetime need.” RN A stated, Patient 9 returned from the hospital with no wound orders and the wound worsened during hospitalization. RN A stated, “I tried to reach out to the hospital but there was no response. I made a decision until they (wound care provider) came. That’s why I didn’t write the order. I did contact her wound care specialist right away… they had scheduled a visit with the patient on Monday and had not seen the patient. I had no one else to call so I decided to upgrade the wound care of the patient because I could not wait for them (wound care specialist).” The surveyor asked if Patient 9’s primary care physician had been notified. RN A stated “Yes”, and the provider gave her approval to change the wound care based on RN A’s recommendations. When asked about the missing orders on the POC for the suprapubic catheter, PEG tube and PEG tube feedings, RN A stated, “probably just forgot to include it.” The surveyor asked about the potential patients’ outcomes for missing treatments and interventions on the POC. RN A stated, “I know that I have several plans of cares that are not updated. Even though those things were not written… I go over everything (assessment, treatments, interventions and education) during my visit... I make sure they(patients) got everything covered and nothing is left out.” An interview was conducted with the ADON on 8/14/2025 at 10:45am. The surveyor asked about the agency’s policy and process of updating the POC. The ADON stated, if the patient is in the middle of a certification period “an extra assessment” is done by the RN to verify the changes of the patient and to add the changes to the POC. The surveyor asked about standing orders for wound vac malfunctions. The ADON stated, “They (physician or provider) always have a standard for that. They’re (the nurses are) informed if there’s a malfunction of the wound vac, a wet to dry dressing is use and the physician notified… In the patient’s plan of care, it has the instructions on the wound care. It should have a stipulation saying if wound vac malfunctions, then may use wet to dry dressing.” An interview was conducted with the DON and Adm on 8/15/2025 at 2:05pm. The surveyor asked about the agency’s policy and process for updating a POC. The DON stated, “if there’s a significant change, they’ll (agency nurses) contact the doctor. We (agency nurses) sometimes perform OASIS follow up visits and we can use that to generate an updated plan of care for the patient.” The DON stated orders are added to the POC during the patient’s SOC, recertification or follow-up OASIS and “interim physician orders are addendums to these orders and are continued through the recertification period.” When asked about the agency’s process of adding continuing orders to the POC during the patients’ recertification for home health. The DON stated, “If our QA department working with the nurses notice that those orders were added on to the previous planning of care. Those orders would be incorporated in the plan of care for the recert moving into the next episode.” The surveyor shared the findings for Patients 5 and 9 and the interviews with RN A and the ADON. When asked about the potential patients’ outcomes for missing treatments and interventions on the POC. The DON stated, “Prescribed treatments and interventions might not be performed” by the nurses. Review of agency’s policy “Plan of Care, PC.35,” revision 05/02/2024, reads in part “The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. Procedure. Each patient/client 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/client-specific needs as identified in the comprehensive assessment… The individualized Plan of Care must include the following: Nutritional requirements; All medications and treatments.””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure services and treatments are administered only as ordered by a physician or allowed practitioner for 2 (Patients 6 and 17) of 17 active and discharged patients’ records reviewed. This failure could potentially place patients at risk for poor health outcomes and decreased patient satisfaction and trust. Findings: Record review of Patient 6 revealed a plan of care for period 07/12/2025 to 09/09/2025 signed by RN B. The POC contained a SOC date of 07/12/2025 with admitting diagnosis of Hemarthrosis (bleeding into a joint space) left knee. The POC contained a nurse frequency of 4 visits in the first month then once a week for 6 weeks plus 2 prn visits. The “Skilled Nurse visit with Aide Supervision” dated 07/29/2025 signed by RN B stated, Wound 1 location: sacral (lower back and spine) area. Onset date 07/26/2025, Type: Pressure injury (bedsore or pressure sore). The physician contact section of the nursing visit note dated 07/29/2025 was blank with no evidence the physician was contacted for wound orders. An unsigned Patient Communication note dated 07/29/2025 stated “Supplies order placed for the following items: Gauze, skin protectant ointment (that contains menthol and zinc oxide), triple antibiotic ointment, border foam dressing and wound cleanser. The RN skilled Nursing Visit dated 08/01/2025 and signed by RN B stated: Wound 1 - Location: sacral area, Treatment: Removed old dressing. Cleansed wound with wound cleanser, patted dry, applied triple antibiotic ointment on the wound bed. applied skin protectant ointment (that contains menthol and zinc oxide) on the area of the wound and covered with absorbent foam dressing. Patient 6’s records did not contain an order for wound care. The physician contact section of the nursing visit note dated 8/01/2025 was blank with no evidence the physician was contacted for an order for wound care. A phone interview was conducted with FM #4 on 8/12/2025 at 12:22pm. The surveyor asked about Patient 6’s wound care. FM #4 stated wound care was completed by RN B twice a week and the “wound closed last week.” The surveyor asked about the type of wound care done and RN B’s coordination with Patient 6’s primary care physician, FM #4 replied, “I don’t know.” A phone interview was conducted with RN B on 8/13/2025 at 12:25pm. The surveyor asked about the agency’s policy and process on obtaining and documenting physician’s orders. RN B stated, “most of our orders are sent to us through fax, but if it’s a verbal order the nurse or clinician has to confirm it. I always call the doctor to verify if the order was actually given to us by the doctor.” When asked about the process of obtaining new wound orders. RN B stated “I always ask the patients if they have a wound care doctor. If not, I call the primary care doctor. If they (the patients) are seeing a wound care doctor, they (the patients) call the doctor and then they (the patients) would give me an order with instructions on the wound care.” The surveyor shared the findings on Patient 6 and asked about the missing order for wound care. RN B stated,” I believe that we as nurses can assess on our own…If it’s (the wound care is) not very complicated, we can give an order for those kinds of wounds. So that’s what I did.” The surveyor asked about the potential patient outcome for not obtaining a physician’s order. RN B stated, “The wound is already healed and closed.” Record review of Patient 17 revealed a POC for period 06/06/2025 to 08/04/2025 signed by RN E. The POC contained a SOC date of 04/07/2025 with admitting diagnosis of “Non-pressure chronic ulcer (sore or break in the skin) of left ankle.” The POC contained a nurse frequency of 6 visits in the first month, 4 visits the second month and 2 prn visits. Records contained 10 nursing visits for wound care in the first month dated 6/6, 6/9,6/11, 6/16, 6/18, 6/20, 6/23, 6/25, 6/27 and 6/30. Records did not contain an order to increase nursing visits for the month of June 2025. A phone interview was conducted with RN E on 8/14/2025 at 3:59pm. The surveyor asked about the agency’s policy and process of increasing visit frequency. RN E stated, “we update the doctor first to get a confirmation then we tell the schedulers (agency staff that plots visits for patients) about it.” When asked if an order was written to change the visit frequency. RN B stated, “some of them (visit frequency) are written…sometimes verbal with the office.” The surveyor shared the findings on Patient 17 and asked why an order was not written to increase the nurse visit frequency. RN E stated, “I think it was either miscommunicated or was not communicated to me.” The surveyor asked about coordination and communication between the agency’s LVN’s. RN E stated, “I tried to communicate with the LVN’s, and they also communicate with me if there’s an update or there’s any changes on the patients.” When asked about the potential patient outcome if orders to increase visit frequency are not obtained. RN E stated, “there could be some complications due to missed visits or if something is missing on the POC.” An interview was conducted with the DON and Adm on 8/15/2025 at 2:05pm. When asked about the agency’s policy and process of obtaining new wound orders, the DON stated, the nurses “get the verbal order from the doctor and type it up as a physician order” and the agency faxes the order to the doctor. “When asked about the agency’s policy and process of adding discipline’s frequency, the DON stated, the nurses “reach out to the doctor” and the doctor will “send the order to our office.” The DON stated the nurses also use a template with the visit frequencies and will create an order to send to the physician or provider. The surveyor shared the findings for Patients 6 and 17, and the interviews with RN B and RN E. When asked about the potential patient outcome for services and treatments performed without a doctor’s order, the DON stated, “all sorts of things can happen if you’re not given permission by the doctor, potential patient injury, infection risk, or maybe regression (a decline) of the patient.” Review of agency’s policy “Implementing Care and Treatment, PC.40,” revision 05/02/2024, reads in part, “Agency staff providing patient/client care and treatment will be competent to the level of care and treatment needed, and the care provided will be within the frequency parameters established on the care planning document(s). Review of agency’s policy “Orders for Care, PC.30,” revision 04/14/2023 reads in part, “The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care and reviewed/revised by the physician and/or non-physician practitioner every sixty (60) days and as needed. Orders may be accepted and put into writing by personnel authorized to do so by applicable state and federal laws and regulations as well as by the Agency’s internal policies. The order will be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. Procedure. All orders are kept current and renewed or updated as appropriate when: Changes in the patient’s/client’s condition occur. The ordered care is ineffective. Changes in diagnosis, treatment (including procedures and medications), and equipment occur. Desired goals are not being achieved. Required by applicable law and regulation.”

“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 record reviews and interviews the Home Health Agency failed to ensure when services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse or other qualified practitioner responsible for furnishing or supervising the ordered services, must document the orders in the patient’s clinical record, and sign, date, and time the orders for 1 (Patient 17) of 17 active and discharged patients’ records reviewed. This failure placed patients at risk of not receiving treatments ordered by a physician or practitioner, which could lead to poor patient health outcomes. Findings: Record review of Patient 17 revealed a POC for period 06/06/2025 to 08/04/2025 signed by RN E. The POC contained a SOC date of 04/07/2025 with admitting diagnosis of “Non-pressure chronic ulcer (sore or break in the skin) of left ankle.” The POC contained a nurse frequency of 6 visits month 1, 4 visits month 2 and 2 prn visits. The POC contained wound orders which stated, “Wound cleansed with normal saline (solution of salt and water), patted dry. Gentamycin (antibiotic used to reduce bacteria and prevent infection) ointment to wound bed. Covered with gauze pad and sterile gauze wrap, secured well with tape. Elastic bandage wrap and compression applied.” Records contained a skilled nursing visit dated 6/25/25 signed by LVN F which stated, “Wound 3 Location: left lateral (a body part or side of the body that’s farther from the body’s center or middle) ankle, Treatment: Wound cleansed with normal saline, and patted dry. Iodine (substance applied to a wound or skin to reduce the risk for infection) ointment to wound bed. Covered with bordered foam (foam bandage with adhesive edges).” The physician contact section of the nursing visit note dated 6/25/2025 was blank with no evidence the physician was contacted for a change in wound orders. Records did not contain a communication note to the doctor regarding the change in wound care for 6/25/2025. A phone interview was conducted with LVN F on 8/14/2025 at 3:33pm. The surveyor asked about the agency’s policy and process on obtaining new wound care orders. LVN F stated, “most of the times they (physicians or provider) give us (agency nurses) verbal orders, but I make sure they (physician or provider) fax an order. Sometimes they (physician or provider) forget stuff and I write a telephone order and communication.” The surveyor shared the findings of Patient 17 and asked why the agency’s policy was not followed. LVN F stated,” I don’t know, I think I might have missed that one…I remember the patient got home from the doctor’s and he said we’re just doing iodine, so I called the doctor.” LVN F stated, she was expecting the order to be faxed from the doctor’s office, and she did not write the verbal order. When asked about the potential patient outcome for not writing the verbal order, LVN F stated, “The RN would not be aware of the order.” An interview was conducted with the DON and Adm on 8/15/2025 at 2:05pm. When asked about the agency’s policy and process of obtaining new wound orders, the DON stated, the nurses “get the verbal order from the doctor and type it up as a physician order” and the agency faxes the order to the doctor” for their signature. The surveyor shared the findings of Patient 17 and the interview with LVN F. When asked about the potential patient outcome for missing written verbal orders, the DON stated, “Prescribed treatments and interventions might not be performed.” Review of agency’s policy “Orders for Care, PC.30,” revision 04/14/2023 reads in part, “The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care and reviewed/revised by the physician and/or non-physician practitioner every sixty (60) days and as needed. Orders may be accepted and put into writing by personnel authorized to do so by applicable state and federal laws and regulations as well as by the Agency’s internal policies. The order will be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. Procedure. All orders are kept current and renewed or updated as appropriate when: Changes in the patient’s/client’s condition occur. The ordered care is ineffective. Changes in diagnosis, treatment (including procedures and medications), and equipment occur. Desired goals are not being achieved. Required by applicable law and regulation. Supplemental verbal orders may be obtained before care is provided and are written within twenty-four (24) hours of receiving the orders. The verbal orders may be accepted and put into writing by personnel authorized to do so by applicable state and federal laws and regulations with co-signature by the RN, a PT, OT, ST, or an MSW responsible for furnishing or supervising the ordered services. When services are provided on the basis of a physician’s and/or non-physician practitioners 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 Agency’s policies, must document the orders in the patient’s/client’s clinical record, and sign, date, and time the orders”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record reviews and interviews the Home Health Agency failed to 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 for 2 (Patients 6 and 8) of 17 active and discharged patients’ records reviewed. This failure placed patients at risk for not receiving adequate care, treatments and interventions, which could potentially affect the agency’s ability to meet the patients’ needs. Findings: Record review of Patient 6 revealed a plan of care for period 07/12/2025 to 09/09/2025 signed by RN B. The POC contained a SOC date of 07/12/2025 with admitting diagnosis of Hemarthrosis (bleeding in a joint space) left knee. The POC contained a nurse frequency of 4 visits in the first month then once a week for 6 weeks plus 2 prn visits. The “Skilled Nurse visit with Aide Supervision” dated 07/29/2025 signed by RN B stated, Wound 1 location: sacral (lower back and spine) area. Onset date 07/26/2025, Type: Pressure injury (bedsore or pressure sore). The physician contact section of the nursing visit note dated 07/29/2025 was blank with no evidence the physician was contacted regarding the new wound. An unsigned Patient Communication note dated 07/29/2025 stated “Supplies order placed for the following items: Gauze, skin protectant ointment (that contains menthol and zinc oxide), triple antibiotic ointment, border foam dressing and wound cleanser. The RN skilled Nursing Visit dated 08/01/2025 and signed by RN B stated: Wound 1 - Location: sacral area, Treatment: Removed old dressing. Cleansed wound with wound cleanser, patted dry, applied triple antibiotic ointment on the wound bed, applied skin protectant ointment (that contains menthol and zinc oxide) on the area of the wound and covered with absorbent foam dressing. Patient 6’s records did not contain an order for wound care. The physician contact section of the nursing visit note dated 8/01/2025 was blank with no evidence the physician was contacted for an order for wound care. A phone interview was conducted with FM #4 on 8/12/2025 at 12:22pm. The surveyor asked about Patient 6’s wound care. FM # 4 stated wound care was completed by RN B twice a week and the “wound closed last week.” The surveyor asked about the type of wound care done and RN B’s coordination with Patient 6’s primary care physician, FM #4 replied, “I don’t know.” Record review of Patient 8 revealed a plan of care for period 06/18/2025 to 08/16/2025 signed by RN C. The POC contained a SOC date of 06/18/2025 with admitting diagnosis of Hypertensive Heart Disease (heart problems caused by high blood pressure) with Heart Failure (heart is unable to pump blood effectively to meet the body’s needs). The POC contained a nurse frequency of twice a week for 3 weeks, then once a week for 6 weeks, 2 prn visits and PT to evaluate and treat. The POC stated, “Notify physician of: Systolic blood pressure (the top number of a blood pressure reading, representing the force of blood against artery walls when the heart contracts and pumps blood out) greater than 170 or less than 90, and pulse (number of times the heart beats within a minute) greater than 100 or less than 60.” Records contained a RN Skilled Nursing Visit assessment dated 07/09/2025 signed by RN C with a documented systolic blood pressure of 178 and a pulse of 57. The physician contact section of the RN Skilled Nursing Visit assessment was blank with no evidence the physician was contacted for a systolic blood pressure greater than 170 and pulse less than 60. Records did not contain a communication note to the doctor regarding the elevated blood pressure and decreased pulse. An interview was conducted with RN C on 8/13/2025 at 11:34am. When asked about the agency’s policy and process of notification of the primary care physician for a patient change in condition or need. RN C stated, “any changes, situations, or change in condition of the patient I put in a communication note and send an e-mail to our whole team (nurses, therapists and management) … I have to call not just the PCP I also have to communicate with whoever signs the orders.” When asked about the process of documenting communication with the doctor. RN C stated documentation is done under the “communication note tab” that transfers to the agency’s EMR system. The surveyor shared the findings on Patient 8 and asked why the agency’s policy on doctor notification was not followed. RN C stated, “I didn’t notify the doctor for the elevated blood pressure because during the beginning of care the physician told me to call if patient was symptomatic only.” When asked if the initial conversation with the doctor was documented. RN C stated, “Yes, through email.” The surveyor asked if the email was attached to the patient’s medical records in the agency’s EMR system. RN C stated, “I really don’t know how to do that.” When asked about the potential patient outcome for not notifying the PCP based on the blood pressure and pulse parameters listed on the POC, RN C stated, patient “hospitalization.” A phone interview was conducted with RN B on 8/13/2025 at 12:25pm. When asked about the agency’s policy and process on coordination and communication with patients’ physicians, RN B stated, “all of our reports go to the primary care doctors and also to the referring doctor.” The surveyor shared the findings on Patient 6 and asked about the notification of patient’s primary care doctor. RN B stated on 7/29/25 the wound “was an abrasion or something like that...Maybe I just forgot to inform the doctor, but it was a superficial thing (skin surface wound) and that’s why I did not inform the doctor.” When asked why the agency’s policy on doctor notification was not followed. RN B stated,” I believe that we as nurses can assess on our own… If it’s (wound care is) not very complicated, we (nurses) can give an order for those kinds of wounds (skin surface wounds). So that’s what I did.” When asked about the potential patient outcome for not notifying the physician, RN B stated, “The wound is already healed and closed.” An interview was conducted with the DON and Adm on 8/15/2025 at 2:05pm. When asked about the agency’s policy and procedure on coordination and communication with patients’ physicians, the DON stated, the nurses and therapy (PT, OT and ST) contact the physicians “by phone” with “new developments (new patient conditions or symptoms)” and “an update or continuation of care or any kind of skills like wound care, will be in the communication notes.” The surveyor shared the findings of Patients 6 and 8, and the interviews with RN B and RN C. When asked about the potential patients’ outcomes for lack of coordination and communication with the physician, the DON stated, “skills, treatments, and interventions might not be executed… Correct medications might not be prescribed, and treatments, feedings, or any kind of labs might not be performed.” Review of agency’s policy “Monitoring Patient/Client Care/Coordination of Care, PC.45,” revision 05/01/2024 reads in part, “The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or nonphysician practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care. Procedure. The Agency will: Assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient/client. When other organizations are involved in the patient’s/client’s care, agency staff members will notify them of significant changes in the patient’s/client’s overall care. This communication will be documented in the medical record. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care. Skilled professionals who provide services to agency patients/clients directly or under arrangement must participate in the coordination of care. Communication and collaboration regarding the patient’s/client’s progress may occur through a formal case conference, and/or it may include informal verbal and written communication among all staff members providing care.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observations, record reviews and interviews the Home Health Agency failed to provide the patient and caregiver with a copy of written instructions outlining the visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for 6 (Patients 2, 3, 5,7, 9, and 12) of 7 patients, in which a home visit was conducted. This failure placed patients at risk of missed visits by the agency’s staff when visits were not scheduled and conflicted with the availability of the patients. Findings: Record review of Patient 2 revealed a plan of care for period 6/17/2025 to 08/15/2025 signed by RN A. The POC revealed a SOC of 04/18/2025 and an admitting diagnosis of Gastrointestinal hemorrhage (bleeding in the digestive tract). The POC contained a nurse frequency of 1 visit in June, 3 visits in July and 1 visit in August with 2 prn visits. The POC also contained an order “to continue POC based on PT reevaluation.” Observation, record review, and interview with Patient 2 during a home visit on 8/12/2025 at 12:50pm revealed no written calendar with scheduled nursing or therapy visits in patient’s undated home health booklet. Patient 2 stated the agency’s home health nurse comes once every other week, and the physical therapist comes twice a week. When asked if the agency provided a written calendar of scheduled visits for the nurse and physical therapist. Patient 2 stated a written calendar was not provided and the nurse “calls a day ahead” to schedule a visit and time. Patient 2 stated the Physical Therapist has a set schedule of Mondays and Fridays and calls if he needs to reschedule. Record review of Patient 3 revealed a plan of care for period 05/21/2025 to 07/19/2025 signed by RN G. The POC revealed a SOC of 01/21/2025 and an admitting diagnosis of Cerebral Palsy (group of disorders that affect muscle control and movement due to damage to the developing brain). The POC contained a nurse frequency of once a week for 9 weeks. The POC also contained an order “to continue POC based on OT reevaluation.” Observation, record review, and interview with Patient 3 during a home visit on 8/12/2025 at 10:00am revealed no written calendar with scheduled nursing or therapy visits in patient’s undated home health booklet. When asked if the agency provided a written calendar of scheduled visits for the nurse and occupational therapy. Patient 3 stated a written calendar was not provided and the agency’s home health nurse comes twice a week, and the occupational therapist (OT) or certified occupational therapist assistant (COTA) comes twice a week. Patient 3 stated the nurse, OT and COTA usually texts him the day before their scheduled visit. Record review of Patient 5 revealed a plan of care for period 07/29/2025 to 09/26/2025 signed by RN A. The POC revealed a SOC of 07/29/2025 and an admitting diagnosis of “Encounter for surgical aftercare following surgery on the skin.” The POC contained a nurse frequency of 1 visit for the first week, then 3 times a week for 8 weeks with 2 prn visits. Observation, record review, and interview with Patient 5 during a home visit on 8/12/2025 at 10:35am revealed no written calendar with scheduled nursing visits in patient’s undated home health booklet. When asked if the agency provided a written calendar of scheduled visits for the nurse. Patient 5 stated a written calendar was not provided and the agency’s home health nurse comes 3 times a week on Mondays, Wednesdays and Fridays and calls before she visits. Record review of Patient 7 revealed a plan of care for period 06/11/2025 to 08/09/2025 signed by the ADON. The POC revealed a SOC of 12/13/2024 and an admitting diagnosis of Heart Failure (heart is unable to pump blood effectively to meet the body’s needs). The POC contained a nurse frequency of 2 visits a month and “to continue POC based on PT reevaluation.” Observation, record review, and interview with Patient 7 during a home visit on 8/12/2025 at 11:10am revealed no written calendar with scheduled nursing or physical therapy visits in patient’s undated home health booklet. When asked if the agency provided a written calendar of scheduled visits for the nurse and PT. Patient 7 stated she could not recall and everything the agency provided was in the home health booklet. Patient 7 stated the nurse visited every other week usually on Saturdays and PT visited twice a week on Mondays and Wednesdays. Patient 7 stated the nurse and PT called her prior to their visits. Record review of Patient 9 revealed a plan of care for period 06/25/2025 to 08/23/2025 signed by RN A. The POC contained a SOC date of 10/24/2025 and an admitting diagnosis of “Pressure ulcer of sacral region (bedsore or pressure sore on lower back and spine).” The POC contained a nurse frequency of 3 times a week for 9 weeks. Observation, record review, and interview with Patient 9 and FM #1 during a home visit on 8/14/2025 at 11:45am revealed no written calendar with scheduled nursing visits in patient’s undated home health booklet. When asked if the agency provided a written calendar of scheduled nurse visits. FM #1 stated the nurse comes 3 times a week and a written calendar was not provided. FM #1 stated, FM #2 “texts me when the nurse is arriving, and the nurse always shows up on time.” Record review of Patient 12 revealed a plan of care for period 07/17/2025 to 09/14/2025 signed by RN B. The POC contained a SOC date of 07/17/2025 and an admitting diagnosis “Alzheimer’s Disease (progressive brain disorder that affects memory, thinking and the ability to perform simple tasks).” The POC contained a nurse frequency of one visit the first week, 2 visits the second week, one visit the third week then twice a month, plus 2 prn visits, and “PT to evaluate and treat.” Observation, record review, and interview with Patient 12 and FM #3 during a home visit on 8/14/2025 at 12:55pm revealed no written calendar with scheduled nursing or physical therapy visits in patient’s undated home health booklet. When asked if the agency provided a written calendar of scheduled visits for the nurse and PT. FM #3 stated, “No, they (nurse and PT) text me when they are coming.” An interview was conducted with RN B on 8/13/2025 at 12:25 pm. The surveyor shared the findings for Patient 12. When asked about the communication with patients regarding scheduling visits and if a written calendar/schedule of visits is provided to the patients, RN B stated, he calls or texts the patients and a written schedule is not provided to the patients. An interview was conducted with RN A on 8/13/2025 at 1:39pm. The surveyor shared the findings for Patient’s 2,5, and 9. When asked about the communication with patients regarding scheduling visits and if a written calendar/schedule of visits is provided to the patients, RN A stated “I usually call them (patients) a day before my visit. I never call and then come at the same day... No, there’s not a written calendar.” An interview was conducted with the ADON on 8/14/2025 at 10:45am with the ADON. The surveyor shared the findings of Patient 7. When asked about the agency’s policy on providing a written calendar/schedule to the patients, the ADON stated, “Normally we call the patients and inform them with the number of visits.” The ADON stated, patients were not provided a written calendar or schedule “because the business (home health nursing) I have done, I haven’t seen any calendars at all.” When asked about the potential patients’ outcomes for not receiving a written calendar/schedule, the ADON stated, “that they (patients) are not directed properly when it comes to care, and not be aware when someone is coming.” An interview was conducted with RN G on 8/15/2025 at 9:02am. The surveyor shared the findings for Patient 3. When asked about the communication with patients regarding scheduling visits and if a written calendar/schedule of visits is provided to the patients, RN G stated, a written calendar and schedule is not provided and “the agency normally does the scheduling, we (the agency staff) communicate with the patient that we are going to be visiting twice or three times a week” at a convenient time for the patient. An interview was conducted with the DON and Adm on 8/15/2025 at 2:05pm. When asked about the agency’s policy on providing a written calendar/schedule to the patients, the DON stated, the agency staff is advised to write their frequency in a “9-week planner” that is provided to the patients. The surveyor shared the findings on Patients 2,3,5,7,9 and 12, and the interviews with the ADON, RN A, RN B, and RN G. When asked about the potential patient outcome for not providing a written schedule/calendar to the patient, the DON stated, “Barrier to visitation. Patients are better equipped to open the door if they know somebody’s coming. Patient expectations, because sometimes patients get anxious when they’re not being visited or are unaware of the schedule.” Review of agency’s policy “Implementing Care and Treatment, PC.40,” revision 05/02/2024 reads in part, “Agency staff providing patient/client care and treatment will be competent to the level of care and treatment needed, and the care provided will be within the frequency parameters established on the care planning document(s). Procedure. Written information to the patient/client. The Agency must provide the patient/client, and caregiver, with a copy of written instructions outlining: The visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency.”