Vitalcaring Group

“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 interview and record review the home health agency failed to ensure the patient’s individualized plan was followed by agency staff, failed to promptly notify the physician of changes in the patient’s condition, and failed to coordinate care across multiple disciplines for 1 of 5 clinical records reviewed (Patient #1). 1) The HHA failed to ensure Patient #1’s individualized plan of care was followed by RN A and LVN A for wound care orders; 2) The HHA failed to promptly notify the physician of changes in patient #1’s wound condition; and 3) The HHA failed to ensure coordination of care was conducted by RN A and LVN A to the patient’s physician This failure placed Patient #1 at risk for severe harm, such as skin deterioration and infection that necessitated an emergency hospital admission. Based on interview and record review, the agency failed to ensure that care was provided as ordered by a physician or health care provider for 1 of 5 patients with wounds (Patient #1), in that wound care was not provided to the patients as ordered in the physician referral order for home health services and plan of care (POC). Patient #1’s POC orders included for the SN to notify the physician of skin changes. LVN A failed to notify to physician or healthcare provider and documented wound care provided. (Refer to G0580) Based on clinical record review and interview, the agency failed to ensure the physician revised the patients’ plan of care as frequently as the patient needed or at least every 60 days for 1 of 5 patients (Patient #1) whose record was reviewed. This failure places the patients at risk of harm from services being provided without the approval and supervision of their physicians or health care provider. (Refer to G0588) Based on record review and interview, RN A and LVN A failed to inform the physician promptly when 1 of 5 (Patient #1) patients had a change in condition, in that: RN A did not notify the physician that Patient #1 had a change in skin integrity in that blisters to the left leg were no longer intact. LVN A did not notify the physician of worsening skin condition and performed wound care to the right great toe, which had no wound care orders. RN A did not notify the physician of ankle circumference greater than 33. LVN A did not notify the physician of Patient’s #1 verbal statement of maggots to the left leg wound. This failure placed Patient #1 at risk of receiving inadequate care and services and a decline in wound status. (Refer to G0590).”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a patient’s right to be free from neglect by the agency’s employees, for 1 of 5 patients reviewed for patient rights.( Patient #1) LVN A failed to ensure a full assessment of all body systems on 05-15-2026 for Patient #1 and document Patient #1’s verbal statement of maggots in a left leg wound. LVN A failed to notify the health care provider of Patient #1’s verbal statement of maggots in the left leg wound. LVN A failed to follow up on pending orders for blisters to left leg and performed wound care without obtaining treatment orders. This failure placed the patient at risk for severe harm, such as skin deterioration and infection that necessitated an emergency hospital admission. Findings include: During presurvey record review in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 5-21-2026 at 8:33 A.M., revealed a self-reported incident #1091905 that was called in by the agency’s Admin/DON on 05/20/2026 at 3:05 P.M. Further review of the self-reported incident report showed Patient #1 was admitted to the hospital on 05-18-2026 for maggots in a left foot wound. Case Manager A called the agency on 05-19-2026 to report the incident. Patient #1 was under the care of LVN A. Record review of an incident report dated 05-19-2026 and completed by Admin/DON indicated that the office of Nurse Practitioner A was notified of Patient #1’s admission to Hospital A. Admin/DON spoke with Family A who reported EMS was called on 05-18-2026 to assist with a transfer, but transported Patient #1 to the hospital when they (EMS) noticed the flies. The incident report indicated LVN A was terminated by the agency on 05-20-2026. Review of job description titled, “Licensed Practical/Vocational Nurse (LVN- Home Health”, dated 02/01/25, read in part”… is responsible for providing direct care under the supervision of a registered nurse…” “Communication 4) Communicates plan of care to referring physician and other agency professionals 5) Maintains contact/communication with other personnel involved in the patient’s care to promote coordinated, efficient care.” Record review of LVN A’s personnel file showed she signed the job description policy on 02-17-2026; LVN A’s hire date according to her personnel file was 02-16-2026. Further review of LVN A’s records showed she completed competency tests for “Patient Rights in Home Health and “Preventing and Reporting Elder Abuse on 02-18-2026. Review of Patient #1’s clinical record revealed a POC for certification period 03-24-2026 to 05-22-26. SOC for Patient #1 was on 03-24-2026, which included diagnoses of Type 2 Diabetes with Foot Ulcer(high blood sugar level caused nerve damage and poor blood circulation, leading to open wound on foot), Blister Left Lower Leg, Lymphedema (swelling in the leg), Heart Failure (condition where the heart muscle is too weak to pump blood efficiently), Chronic Kidney Disease (damaged kidneys), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes breathing difficult), Morbid Obesity (excessive amount of body fat), and Repeated Falls. The visit frequency for skilled nursing was 1wk1,3wk8 Further review of the POC revealed the “skilled nurse/caregiver to perform wound care to site located 2nd toe rt foot. “Cleanse with hibiclens (antiseptic skin cleanser), apply iodosorb paste (paste/gel used to infected wound) and calcium alginate (a gel used for highly draining/bleeding wound), wrap with kerlix gauze (woven cotton gauze/dressing) , using clean/aseptic technique. Change dressing every MWF.” Continued review of the plan of care revealed “SN to perform a comprehensive assessment…,plan of care developed in coordination between agency staff, physician, PT, SN to assess/evaluate co-morbid conditions including diabetic wound 2nd toe rt foot,…and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications… Licensed professional to report…ankle…>33” LVN A completed visits on 3/28/2026, 3/30/2026, 4/1/2026, 4/3/2026, 4/6/2026, 4/8/2026, 4/10/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/24/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, 5/8/2026, 5/11/2026, 5/13/2026, and 5/15/2026. Review of patient coordination note by LVN A on 05-20-2026 revealed an “Addendum to SN11 visits for the following dates 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/1/26 [sic], 4/15/26, 4/17/26, 4/20/26, 4/24/26, 4/27/25 [sic], 4/29/26, 5/1/26, 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26. SN performed first aid to open blister to LLE shin area as follows: Using clean technique wound cleansed with wound cleanser, pat dried with gauze, covered with dry gauze and secured with tape...” Review of visit note report completed by LVN A, dated 05-15-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial (the shin bone), Lt, blister”. Onset date for both wounds was 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” and “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-15-2026, LVN A documented wound care provided to “multi/scat-prox pretibial(the shin bone), Lt, blister” and “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-15-2026 revealed …“Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, no s/sx of infection noted. BLE with noted swelling, with dark discoloration to both… doesn’t get up out of recliner much… imapired [sic]skin integrity…” Review of Hospital A admission records, dated 05-18-2026, revealed primary diagnosis of severe sepsis (a life-threatening condition that happens when the body’s immune system has an extreme response to an infection) and cellulitis (bacteria/infection of the skin and the tissues beneath it) lower legs. On 05-18-2026, Patient #1 was transported by EMS and arrived with several wounds with purulent (pus) foul-smelling drainage noted on the bandages. Patient #1 had maggot infestation on his foot. Maggots were present between the toes on the left foot surrounded with moist denuded skin ulcers (open sore on skin). Further review of hospital medical records revealed Patient #1 to have an unstageable pressure ulcer (severe bedsore or pressure injury) to the right buttock and chronic venous stasis (veins in the legs have trouble sending blood back to the heart) and lymphedema stage III (a chronic condition marked by extreme swelling in the leg caused by a buildup of lymph, or clear watery fluid that has leaked in the tissues to bilateral(both) legs, multiple ulcers (break in the skin) to the dorsum (the back) of the toes on the right fourth toe, second toe, and first toe, and candidal intertrigo (a rash that develops when yeast infects skin folds) to the perineum (in males, the bottom of the pelvis, between the scrotum and the anus) and abdominal fold(extra layers of skin and fat on the stomach). Patient #1 had wound care consult on 05-18-2026. Labwork was obtained and revealed Patient #1 had: -Leukocytosis( higher than normal number of white blood cells) -Elevated WBC(immune system working to defend the body) 31.1 (normal 4.5-12.5) -Elevated lactic acid (body tissues deprived of oxygen)2.2 (normal range 0.50-2.0) An interview was held with Family A on 5/22/2026 at 11:55A.M. Surveyor introduced self and explained the reason for the call. The Surveyor asked Family A when he first noticed maggots in Patient #1’s left leg wound. Family A stated that he noticed it less than a week from today’s date. Family A was asked if he could try to recall the exact date, but he could not. Family A stated there were flies in the house. He would see the flies around the outside of the left leg; the maggots were first noticed when Patient #1 was getting cleaned up. Family A was asked what happened after the maggots were discovered. He stated Patient #1 wanted to wait until the next visit with LVN A. Family A stated the home health agency and the doctor were not notified after maggots were seen in and around the left leg wound. Family A was asked if the left leg was covered by anyone after cleaning up Patient #1 and he stated it was not. Family A was asked to describe the exact location on the left leg where the maggots were seen. Per Family A, it was on top of the left thigh and the left lower leg. Family A stated that Patient #1 always had blisters to the left leg that “come and go.” Surveyor asked Family A to clarify “come and go” and he stated the blisters would heal, then come back. This was ongoing. He explained that LVN A was aware and dressed the wounds during her visits. He further went on to explain that Patient #1 had “lymphedema and a bad infection in his legs.” Per Family A, Patient #1 said he told LVN A about the maggots in the open area to the left leg and LVN A said, “it was alright.” Family A stated that he does not know if LVN A actually assessed the area, but he believed she misunderstood Patient #1. Per Family A, Family B also spoke with LVN A during the visit and LVN A told her the leg was alright. Family A believed that the words of LVN A were probably taken out of context because his father is hard of hearing. Family A was asked if the maggots were on or around Patient #1’s skin when LVN A last visited on 05-15-2026 and he stated that he did not know. Family A was not present during the skilled nurse visit on 5-15-2026. He further went on to say that Family B was there and could provide more information. Surveyor asked if Patient #1 was still admitted to Hospital A and he said he was. On 5/22/2026 at 1:14 P.M. An interview was held with the Admin/DON. Admin/DON stated that she became aware of the incident after Case Manager A from Hospital A notified her on 05-19-2026. She did meet with RN A and LVN A on 05-20-2026 as they were the skilled nurses assigned to Patient #1. During the meeting, LVN A admitted that she did not do a full head-to-toe assessment on Patient #1. It was the expectation for LVN A to do a thorough assessment on Patient #1. Admin/DON stated that LVN A and RN A were provided with the opportunity to write a late addendum for the visits made. After meeting with LVN A, the agency decided to terminate her that same day. Per Admin/DON, she began the paperwork to report LVN A to Organization A. Admin/DON stated that after careful review, it was decided not to terminate RN A. Instead, she was placed on disciplinary action. In addition, the agency took immediate action by removing RN A from the case and assigned additional in-service trainings for her to complete by a deadline established by the agency. On 05-22-2026 at 2:05P.M., an interview with Case Manager A from Hospital A was held. Case Manager A confirmed that Patient #1 was admitted to the hospital on 05-18-2026. Case Manager stated Patient #1 was admitted for sepsis (“a life-threatening condition that happens when the body’s immune system has an extreme response to an infection, causing organ dysfunction”) and cellulitis (bacteria/infection of the skin and the tissues beneath it). She stated Patient #1 was brought to the hospital by EMS because they were concerned about the flies flying around Patient #1. Upon assessment by the hospital physician, Patient #1 was noted with left leg infestation of maggots. Case Manager A stated she notified the home health agency on 05-19-2026 when she became aware that Patient #1 was receiving wound care at home from skilled nurses three times a week. On 05-22-26 at 5:07 P.M, Surveyor called Patient #1 and there was no answer. The Surveyor left a voice message with call back number. An interview was held with Family B on 05-25-2026 at 09:49AM. Surveyor introduced self and explained the reason for the call. Family B stated she placed the phone on speaker because she felt more comfortable speaking with Family A present. Family B stated that Patient #1 and LVN A had a good relationship. She did not stay in the room as LVN A did the wound dressing change on 05-15-2026 because Patient #1 was comfortable with LVN A. She stated there was no issue with how she did the wound care. Family B was asked if she spoke with LVN A on 05-15-2026 regarding the maggots on the left leg and she said she did not. Per Family B, it was not a wound. Rather, it was an open blister or blisters that popped open. Family B was asked if the open area that had the maggots were located on the upper or the lower left leg. She stated that it was located on top of the upper left leg and Patient #1’s “stomach flapped over it.” Family B was asked to clarify the location of left wound (open blisters) as the medical record stated that the blisters were located on the left shin, which meant that the wound (open blisters) would be below the knee. Family A stated, “well, that is all I can tell you. It was located on the top left leg and the stomach flapped over it.” Family B was asked why EMS was called on Monday, May 18, 2026. She stated that they needed help with transferring Patient #1. Per Family B, Patient #1 was “a very big guy.” They did not call regarding the wound, open area, or the maggots. She said EMS noticed the flies flying around Patient #1 and checked out his skin. EMS noticed the left upper leg had maggots and said they were taking Patient #1 to the hospital. Family B stated that she did not notify the agency or the doctor about the maggots. Family B was asked if there was anything else she would like to add. She stated that Patient #1 was still admitted to Hospital A and would possibly be discharged this week to a rehabilitation center. On 5/25/26 Surveyor called Patient #1 at 10:02 A.M. A voice message was left as there was no answer. On 5/26/26 at 8:55AM- Called LVN A and left a voice message. On 5/26/2026 at 8:57 A.M Surveyor called and spoke with Patient #1. Surveyor introduced self and explained the reason for the call. Patient #1 was able to state his full name, his date of birth, and today’s date without difficulty or any cues. Patient #1 stated that he was still admitted to the hospital. Patient #1 stated the “little bugs” (maggots) were noticed on a Thursday. He stated he remembered the date because it was the day before the nurse came to visit him. Patient #1 stated that Family A noticed the “little worms” as he was getting cleaned up and said, “it was bad.” Per Patient #1, he told Family A he would ask LVN A about it on Friday because he knew she was coming. Patient #1 stated that he also saw the “little worms” on him too. Patient #1 was asked what part of his body had the open area with maggots. He stated he did not know because it was hard for him to see his legs, but the “little worms” were crawling on both legs. Patient #1 stated that he did tell LVN A about the maggots and she told him not to worry. Patient #1 was asked if the nurse saw the maggots and he said she did. Patient #1 stated that LVN A cleaned the left leg and covered it. Patient #1 did not know what solution LVN A used to clean the left wound. Patient #1 was asked if LVN A stated that she would contact the physician, and he stated he did not remember her saying that. Patient #1 was asked if he contacted the physician and he laughed and stated, “I never get to speak with a doctor when I call, but no, I did not call.” Patient #1 was asked again if LVN A saw the maggots on her visit with him on Friday, May 15th and he replied, “ma’am, she did see the “little worms.” Patient #1 went on to say that he really liked LVN A and did not want her to get in trouble. On 5/26/26 at 12:30PM- Surveyor called the clinic to speak to Nurse Practitioner A, and the call was answered by Clinic LVN A. Surveyor explained the reason for the call and provided Patient #1’s name and date of birth. Clinic LVN A was asked if she had any record from the period of 3/24/2026 to present that showed any nurse from Home Health Agency A called regarding wound care orders or any change in condition. Clinic LVN A stated she did not have any record of such. Clinic LVN A stated that Patient #1 was last seen in the clinic on 03-19-2026. Clinic LVN A was asked to confirm if the last visit was in person or virtual and she stated that it was an in-person visit. Clinic LVN A was asked if there was a record of Patient #1 being noncompliant with his follow-up appointments and she stated there was no record of such. Clinic LVN A was asked to notify Nurse Practitioner A of the call. There was no return call from Nurse Practitioner A. On 05-26-2026 at 12:46 P.M, Surveyor spoke with LVN A. LVN A stated that she could not remember if anyone else was home when she did the visit on Friday, May 15th, 2026. Surveyor asked how she entered the home and she stated it was through the garage as the door was open. LVN A was asked if Patient #1 told her about the maggots on his leg and she stated he did. LVN A stated the room was dark, so she turned on the light from her phone to see better. She stated she looked on the bed, lifted up the sheets, and assessed the left and the right leg, but she did not see any maggots. LVN A stated she did not look at the left foot and did not recall if Patient #1 was wearing socks. After that, LVN A stated she performed wound care as ordered to the right toes, 2nd and great toe. Surveyor asked LVN A if she reviewed the plan of care and physician orders before she performed wound care and she stated she did. LVN A stated she washed the right great toe and 2nd toe with hibiclens, applied calcium alginate, and wrapped right foot with kerlix gauze. She stated that Patient #1 was noted with blisters that had popped open near the admission date on services. LVN A could not recall the exact date when the blister popped open. LVN stated she did not have orders for the blisters to the left shin, so she cleansed it with normal saline and covered it with a dry dressing. LVN A was asked to describe exactly where the opened blisters were located and she said it was on Patient #1’s left shin and above his knee on his left thigh. LVN A was asked who was responsible for coordinating with the physician to obtain orders when there was a change in condition. Per LVN A, she called and left a voice message with the physician office near the SOC to obtain orders, but she did not get a call back. She said it was some sort of answering service. LVN A stated she placed this call when the blisters opened, but she could not recall what date that was. Per LVN A, the wound care section in her tablet read there were pending orders, so she did a clean dry dressing at the visits as she awaited orders. LVN A stated she did not try to reach out to physician office again for orders since the SOC. LVN A was asked why she didn’t reach out to the physician office on her visit with Patient #1 on 5/15/2026, especially since he informed her about the maggots to the left leg. She stated, “I did not see maggots, no bugs, no flies.” LVN A was asked if the left wound looked infected and she stated it did not. She stated the open blisters looked pink and it was getting smaller. LVN A was asked if she did a full skin assessment and she stated that she did not. LVN A was asked if she coordinated with RN A to inform her of the change in condition and she stated she did not. LVN stated she continued doing clean and dry dressing to the left shin at each visit without physician orders. When LVN A was asked why she didn’t continue to follow up with the physician to obtain wound care orders as she visited with Patient #1 three times per week, LVN A stated she assumed the admitting nurse (RN A) did it. LVN A was asked if she notified Clinical Manager A regarding the open blisters, and she stated she did not. LVN A was asked to describe Patient #1’s home environment. She stated that the home was not disheveled and “everything was good.” LVN A was asked what harm the patient could have for delaying the coordination of care. She replied, “there was no neglect, no, bugs, no flies, so there was nothing to report.” LVN A was asked if she had anything else to add and she stated she did not. On 5-26-2026 at 1:19 P.M., the Surveyor was unable to continue an interview with the Admin/DON as she is out of the office on vacation. On 0-26-2026 at 1:19 P.M., RD stated the Admin/DON was not available by phone; however, she (RD)was involved in the investigation and could answer any questions. RD stated RN A was aware of the blister upon admission and documented that. She stated that LVN A did a dry dressing change as nurses are protected by the Organization A/ Practice Act A to do a First-Aid dressing. LVN A failed to do a head-to-toe assessment after being notified of the maggots and did not notify the doctor. RD agreed that LVN A had an opportunity to contact the doctor for orders regarding the open blister and failed to do so. The Alt Admin was present, but she stated that she was not involved in the investigation. Surveyor did ask the Alt Admin how often the RNs should do supervisory visits on the LVNs and she stated it was twice per episode. On 5/26/2026 at 4:18 P.M. Surveyor spoke with RN A. RN A stated she remembered doing the SOC for Patient #1. She stated Patient #1 had wound care orders for his right toe. She stated that Patient #1 did have fluid-filled blisters to his left leg and she called the doctor’s office to report her findings. RN A stated that she did not document who she spoke with nor did she document her attempt to contact the physician on the care coordination note. RN A was asked was there ever a time the LVN A reached out to her to let her know the blisters were open and she stated she did not. RN A was asked how often she was expected to perform supervisory visits on the LVNs and she stated every 4-5 weeks or 2 times for each episode. RN A stated she did notice that the blisters were open during the supervisory visit on 04-22-26. RN A stated she did not recall if she tried to contact the physician about the open blister or any change in condition. RN A stated that she did not remember if she coordinated with Clinical Nurse A or LVN A to discuss her findings on the change in condition. RN A was asked to describe the home where Patient #1 lived and she stated that it was unkempt, cluttered and unclean. RN A stated that she never saw flies in the home or maggots. RN A was asked if she tried to coordinate with the physician to get an order for a social worker. She stated that it did cross her mind at the time of admission, but she did not. She stated that Patient #1 stayed in his recliner chair in the living room all day. He slept in the recliner chair as well because it was difficult for him to walk or stand. It took about 4 family members to get him to stand up. She stated that Patient #1 did not like to stand up and she documented his refusal to assess his bottom in a late entry dated 05-20-2026. RN A went on further to explain that her documentation stated several family members was needed to help Patient #1 to stand up, then one family member would put a bed side commode from behind so that he could use the bathroom. RN A stated that she spoke with Patient #1 about physical therapy, but he refused. This was later documented as the late entry on 05-20-2026. Surveyor asked RN A if she felt like she had enough lighting in the living room to perform his wound care and assess his skin and she stated yes. RN A was asked if she ever had to use additional lighting from her phone or any other device to see better and she stated she did not. RN A was asked if she called the office to give report of her findings after she completed the SOC for Patient #1 and she stated she did. Per RN A, it was agency protocol to call in report to the RN in the office. She was assigned to Clinical Manager A. RN A was asked if there was anything else she would like to add and she stated that she wished she did more supervisory visits for Patient #1. When asked what harm could be caused for delay in patient coordination, she stated hospital admission. On 05-27-26 at 8:20am Surveyor called Patient #1 and the call was answered by Family A. Family A stated Patient #1 only had 15 minutes to talk because he was going to surgery for a procedure. Family A stated the procedure was to put in a device for Patient #1 to begin receiving dialysis (treatment that helps body remove extra/waste when kidneys are failing). Family A stated Patient #1 has never received dialysis; this would be new. Family A stated that Patient #1 would not be discharged to rehabilitation today. Family A put the call on speaker and Patient #1 greeted Surveyor. Surveyor informed Patient #1 that the purpose of the call was to ask a few follow-up questions. Patient #1 was asked if he refused Physical Therapy. Patient #1 stated that the nurses did speak with him about getting Physical Therapy, but he said no because when he needed it in the past, but his health insurance declined to pay for it. Patient #1 was asked if he ever refused for the nurse to assess his bottom. Patient #1 stated that RN A and LVN A never asked to look at his bottom. He went on to explain that the nurses came to the house to do his right foot wound. That was the focus. Patient #1 stated that LVN A did not do anything wrong. He went on to further explain that she would not have known anything was wrong with his bottom because she was there to take care of his foot. Patient #1 A stated “I feel like you people want to put the blame on LVN A and that’s not right.” Surveyor assured Patient #1 that the reason for the call was to ensure the skilled nurses were proving quality care. Patient #1 was asked if he was having pain or discomfort to his bottom while he was home at home and he stated he did not. He went on to say, “I wish I did say I had pain there to get the nurses to look there to avoid all of this.” Patient #1 went on to say LVN A was a good nurse, and he did not want anything to happen to her. Surveyor asked Patient #1 if he wore socks when he was home. Patient #1 did not answer but Family A stated Patient #1 did wear socks all the time. It was yellow socks. When surveyor asked Patient #1 if RN A and LVN A ever removed the socks to look at his feet he mumbled some words, but it was unclear. There was no answer from Patient #1 to determine if LVN A removed his socks on 05-15-2026 to assess his left foot. Family A did not know as he was not present during the dressing change on 05-15-2026. On 05-27-2026 at 9:19 A.M, Surveyor held a follow up interview with RN A. Per RN A, she did not apply a dressing to the blisters noted at the SOC, but she did apply a dry dressing during the second visit on 04-22-2026. RN A stated that the blister was intact at the SOC. She educated the family on how to care for it by not popping the blisters on the left leg and keeping the area clean and dry. RN A stated that by the time she did the follow up visit, the blister had popped. Surveyor asked if the doctor was called to report the changes and she stated that she did not recall. Surveyor asked if she updated the plan of care and she said she did not. RN A stated she just did a basic dressing, which she cleaned the area with NS and covered it. RN A went on to explain that Patient #1 did not want to stand up and refused an assessment of his bottom because he was afraid of falling. RN A stated at the SOC, multiple family members were present, but Patient #1 continued to refuse a full skin assessment. During the second visit on 04-22-2026, RN A was alone with Patient #1 and it was unsafe for Patient #1 to stand. Per RN A, Patient #1 did not have a Hoyer lift (mechanical device used to transfer individuals with limited mobility) in the home. RN A stated that Patient #1 also refused PT because he only wanted wound care. RN A stated she did not recall if she told Clinical Manager A that she was unable to assess Patient #1’s bottom and refused PT. RN A was asked did she inform Clinical Manager A that Patient #1 required more than 1 person assistance to stand and requested to have extra help (another clinician) to co-visit with Patient #1. RN A stated that it did not cross her mind. She stated that she only remembered reporting to Clinical Manager A that Patient #1 spent most of the time in his recliner chair. Surveyor asked RN A when she became aware Patient #1 had a pressure ulcer and she stated right after he went to the hospital. RN A was asked if she recalled Patient #1 wearing socks when she visited with him. She stated, “he may have had socks on. If he did have socks on, it would have been only on the left foot”. RN A stated she may have removed the socks at the SOC but didn’t at the supervisory follow up visit. RN A was asked if the doctor was notified about Patient #1’s ankle circumference of 38 and was also asked did she document coordination with the doctor in the coordination note. RN A stated she did not recall. RN A was asked if she attended case conference for Patient #1 held this episode. She stated that she attended but left before giving report on Patient #1. RN A stated that she did not know if LVN A attended the case conference. RN A was asked who all attended case conference and she said all the disciplines, the Branch Director, Clinical Manager, and the Palliative team. RN A stated patients were discussed in case conference every Tuesday. Because RN A left case conference before discussing Patient #1, Surveyor asked if she had to provide a written report for Clinical Manager A and she said she did not. RN A stated, “it was not verbally asked to provide a written report for case conference.” She just had to make sure her documentation was completed so the notes could be reviewed at the case conference. On 5/27/2026 at 2:33P.M., an interview was held with Clinical Manager A. Clinical Manager A stated she needed to review the PAR (Post Admission/Recertification) note. Clinical Manager A explained that PAR was used when the nurses called in report. Clinical Manager A stated that she received report from RN A on 03-24-2026. RN A informed Clinical Manager A that Patient#1 was homebound and the discipline required was skilled nursing. There was no report of Patient #1 needing physical therapy or refusing. Clinical Manager A stated she did not remember what RN A reported about the wounds. Clinical Manager A was asked who was responsible for following up on pending orders. She stated that it was the responsibility of the clinician who did the assessment, but she would remind the clinician at the end of the call to follow up. Clinical Manager A did not receive a call from LVN A to report any changes in Patient #1’s condition. Clinical Manager A stated she attended the case conferences and there was no report of a change in condition for Patient #1. An interview was held with RD and Alt Admin on 05-29-2026 to discuss concerns about the care RN A and LVN A provided for Patient #1. Surveyor asked if there were additional orders or updated orders as RN A did not follow up with the health care provider regarding the blisters to the left leg nor did she contact the doctor when the blisters opened. Surveyor also voiced concerned that LVN A continued to document wound to the right great toe and second toe, but the orders were only for the second right great toe. RD checked Patient #1’s medical record and stated that she did not see additional wound care orders apart from the original wound care orders initiated at the SOC. RD and Alt Admin were made aware of concerns copied and pasted clinical narrative notes. Surveyor reminded BD of her statement from the previous interview that the Organization A and Practice Act A protected nurses to do a “First-Aid dressings”, but the concern was how many “First-Aid dressings” was too much and when was RN A and LVN A going to coordinate with the doctor regarding Patient #1’s change in condition. Surveyor asked what harm could be done to patients for not notifying the health care provider in a change of condition. RD stated the wound could worsen and cause a hospital admission. Alt Admin stated she agreed with what RD said, and in addition, a patient could lose a limb. Review of the agency’s policy titled, “Patient Bill of Rights”, dated 12/2024. Read in part, Procedure…H…receives all services outlined in the plan of care…I …right to be free from…physical…including injuries of unknown source…neglect…” Review of agency’s policy titled, “Assessment of Possible Abuse/Neglect” dated 12/2024, “7:Individual Mandated to Report: A professional…who is engaged in the care of patients…who had knowledge of the…neglect of a patient… knowledge that a patient has sustained a physical injury…Procedure 1. Any clinician who discovers, within the course of rendering care, …any suspected neglect will immediately…report such occurrences to his/her immediate supervisor.” Review of agency’s policy no.5-005.2 titled, “Incident Reporting”, dated 12/2024, read in part”Incident: An unusual event involving…a patient…When an incident occurs…Notify their supervisor immediately…Follow-up with the patient…patient’s physican”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide all services outlined in the plan of care for 1 of 5 patients (Patient #1), in that: LVN A did not notify the physician of client’s change in condition and performed wound care to the right great toe without wound care orders. LVN A failed to complete a head-to-assessment after Patient #1’s verbal statement of maggots to the left leg wound. RN A failed to identify barriers and notify the physician about Patient #1’s refusal for physical therapy. This failure placed Patient #1 at risk of inadequate care and improper treatment of not progressing towards their potential skilled/rehabilitation goals, negative impact due to admission to hospital for infected wound. Findings include: Review of Patient #1’s clinical record revealed a POC for certification period 03-24-2026 to 05-22-26. SOC for Patient #1 was on 03-24-2026, which included diagnoses of Type 2 Diabetes with Foot Ulcer(high blood sugar level caused nerve damage and poor blood circulation, leading to open wound on foot), Blister Left Lower Leg, Lymphedema (swelling in the leg), Heart Failure (condition where the heart muscle is too weak to pump blood efficiently), Chronic Kidney Disease (damaged kidneys), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes breathing difficult), Morbid Obesity (excessive amount of body fat), and Repeated Falls. The visit frequency for skilled nursing was 1wk1,3wk8. Further review of the POC revealed the “skilled nurse/caregiver to perform wound care to site located 2nd toe rt foot. “Cleanse with hibiclens (antiseptic skin cleanser), apply iodosorb paste (paste/gel used to infected wound) and calcium alginate (a gel used for highly draining/bleeding wound), wrap with kerlix gauze (woven cotton gauze/dressing) , using clean/aseptic technique. Change dressing every MWF.” Continued review of the plan of care revealed “SN to perform a comprehensive assessment…,plan of care developed in coordination between agency staff, physician, PT, SN to assess/evaluate co-morbid conditions including diabetic wound 2nd toe rt foot,…and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications… Licensed professional to report…ankle…>33” RN A completed the SOC on 3/24/2026 for Patient #1. RN A visited with Patient #1 again on 04-22-2026 to complete a supervisory visit on LVN A. LVN A completed visits on 3/28/2026, 3/30/2026, 4/1/2026, 4/3/2026, 4/6/2026, 4/8/2026, 4/10/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/24/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, 5/8/2026, 5/11/2026, 5/13/2026, and 5/15/2026. Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum to visit note 04-22-2026 that read”…Only pt was present for SN visit, no other CG available. On LLE blisters SN cleansed with NS, patted dry, then covered with foam dressing. SN encouraged pt to consider working with physical therapy, Pt refused stating hes [sic] only worried about healing his wounds. SN did not assess Pt’s back side or bottom as pt cannot stand without 4-5 person assist, too dangerous to try as pt is large in weight.” Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum for SOC on 03-24-2026 that read “SN did not assess pt’s backside or bottom due to pt refusing to stand because of safety concerns and there not being enough people to assist as pt requires 4-5 assist to stand. …reported…that pt has no skin breakdown on his back side or bottom. SN asked pt about physical therapy, pt refused physical therapy…” Review of patient coordination note by LVN A on 05-20-2026 revealed an “Addendum to SN11 visits for the following dates 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/1/26 [sic], 4/15/26, 4/17/26, 4/20/26, 4/24/26, 4/27/25 [sic], 4/29/26, 5/1/26, 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26. SN performed first aid to open blister to LLE shin area as follows: Using clean technique wound cleansed with wound cleanser, pat dried with gauze, covered with dry gauze and secured with tape. Instructed patients son on need to provide wound care daily, keep clean and dry and covered at all times, understanding voiced.” Review of visit note report completed by LVN A, dated 05-15-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” and “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-15-2026, LVN A documented wound care provided to “multi/scat-prox pretibial(the shin bone), Lt, blister” and “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-15-2026 revealed …“Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, no s/sx of infection noted. BLE with noted swelling, with dark discoloration to both… doesn’t get up out of recliner much… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-13-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-13-2026LVN A documented “multi/scat-prox pretibial, Lt, blister”…” “Wound care not provided awaiting orders” The narrative note completed by LVN A, dated 05-13-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic] skin integrity…” Review of visit note report completed by LVN A, dated 05-11-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-11-2026 LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-11-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic] skin integrity…” Review of supervisory visit note completed by RN A, dated 04-22-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” Continued review of visit noted revealed an ankle circumference reading of 38 “lower limit 23 upper limit 33…comments MD notified.” There was no coordination note according to agency’s policy to reveal coordination with health care provider. RN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by RN A, dated 04-22-2026 revealed… “pt with rt toe wound. Recently infected. Pt with scattered blisters to LLE…Supervisory visit completed…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary…” Review of SOC visit note completed by RN A, dated 03-24-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Woundcare performed with available supplies. Pt tolerated well.” RN A documented “multi/scat-prox pretibial, Lt, blister” measured “3.2x4x0.1”…” “Wound care not provided”awaiting orders” The narrative note completed by RN A, dated 03-24-2026 revealed…pt with rt toe wound. Recently infected. Pt with scattered blisters to LL…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary…” On 5/26/26 at 12:30PM- Surveyor called the clinic to speak to Nurse Practitioner A, and the call was answered by Clinic LVN A. Surveyor explained the reason for the call and provided Patient #1’s name and date of birth. Clinic LVN A was asked if she had any record from the period of 3/24/2026 to present that showed any nurse from Home Health Agency A called regarding wound care orders or any change in condition. Clinic LVN A stated she did not have any record of such. Clinic LVN A stated that Patient #1 was last seen in the clinic on 03-19-2026. Clinic LVN A was asked to confirm if the last visit was in person or virtual and she stated that it was an in-person visit. Clinic LVN A was asked if there was a record of Patient #1 being noncompliant with his follow-up appointments and she stated there was no record of such. Clinic LVN A was asked to notify Nurse Practitioner A of the call. There was no return call from Nurse Practitioner A. On 05-26-2026 at 12:46 P.M, Surveyor spoke with LVN A. LVN A stated that she could not remember if anyone else was home when she did the visit on Friday, May 15th, 2026. Surveyor asked how she entered the home and she stated it was through the garage as the door was open. LVN A was asked if Patient #1 told her about the maggots on his leg and she stated he did. LVN A stated the room was dark, so she turned on the light from her phone to see better. She stated she looked on the bed, lifted up the sheets, and assessed the left and the right leg, but she did not see any maggots. LVN A stated she did not look at the left foot and did not recall if Patient #1 was wearing socks. After that, LVN A stated she performed wound care as ordered to the right toes, 2nd and great toe. Surveyor asked LVN A if she reviewed the plan of care and physician orders before she performed wound care and she stated she did. LVN A stated she washed the right great toe and 2nd toe with hibiclens, applied calcium alginate, and wrapped right foot with kerlix gauze. She stated that Patient #1 was noted with blisters that had popped open near the admission date on services. LVN A could not recall the exact date when the blister popped open. LVN stated she did not have orders for the blisters to the left shin, so she cleansed it with normal saline and covered it with a dry dressing. LVN A was asked to describe exactly where the opened blisters were located and she said it was on Patient #1’s left shin and above his knee on his left thigh. LVN A was asked who was responsible for coordinating with the physician to obtain orders when there was a change in condition. Per LVN A, she called and left a voice message with the physician office near the SOC to obtain orders, but she did not get a call back. She said it was some sort of answering service. LVN A stated she placed this call when the blisters opened, but she could not recall what date that was. Per LVN A, the wound care section in her tablet read there were pending orders, so she did a clean dry dressing at the visits as she awaited orders. LVN A stated she did not try to reach out to physician office again for orders since the SOC. LVN A was asked why she didn’t reach out to the physician office on her visit with Patient #1 on 5/15/2026, especially since he informed her about the maggots to the left leg. She stated, “I did not see maggots, no bugs, no flies.” LVN A was asked if the left wound looked infected and she stated it did not. She stated the open blisters looked pink and it was getting smaller. LVN A was asked if she did a full skin assessment and she stated that she did not. LVN A was asked if she coordinated with RN A to inform her of the change in condition and she stated she did not. LVN stated she continued doing clean and dry dressing to the left shin at each visit without physician orders. When LVN A was asked why she didn’t continue to follow up with the physician to obtain wound care orders as she visited with Patient #1 three times per week, LVN A stated she assumed the admitting nurse (RN A) did it. LVN A was asked if she notified Clinical Manager A regarding the open blisters, and she stated she did not. LVN A was asked to describe Patient #1’s home environment. She stated that the home was not disheveled and “everything was good.” LVN A was asked what harm the patient could have for delaying the coordination of care. She replied, “there was no neglect, no, bugs, no flies, so there was nothing to report.” LVN A was asked if she had anything else to add and she stated she did not. On 5-26-2026 at 1:19 P.M., RD stated RN A was aware of the blister upon admission and documented that. She stated that LVN A did a dry dressing change as nurses are protected by the Organization A/ Practice Act A to do a First-Aid dressing. LVN A failed to do a head-to-toe assessment after being notified of the maggots and did not notify the doctor. RD agreed that LVN A had an opportunity to contact the doctor for orders regarding the opened blister and failed to do so. The Alt Admin was present, but she stated that she was not involved in the investigation. Surveyor did ask the Alt Admin how often the RNs should do supervisory visits on the LVNs and she stated it was twice per episode. On 5/26/2026 at 4:18 P.M. Surveyor spoke with RN A. RN A stated she remembered doing the SOC for Patient #1. She stated Patient #1 had wound care orders for his right toe. She stated that Patient #1 did have fluid-filled blisters to his left leg and she called the doctor’s office to report her findings. RN A stated that she did not document who she spoke with nor did she document her attempt to contact the physician on the care coordination note. RN A was asked was there ever a time the LVN A reached out to her to let her know the blisters were open and she stated she did not. RN A was asked how often she was expected to perform supervisory visits on the LVNs and she stated every 4-5 weeks or 2 times for each episode. RN A stated she did notice that the blisters were open during the supervisory visit on 04-22-26. RN A stated she did not recall if she tried to contact the physician about the open blister or any change in condition. RN A stated that she did not remember if she coordinated with Clinical Nurse A or LVN A to discuss her findings on the change in condition. RN A was asked to describe the home where Patient #1 lived and she stated that it was unkempt, cluttered and unclean. RN A stated that she never saw flies in the home or maggots. RN A was asked if she tried to coordinate with the physician to get an order for a social worker. She stated that it did cross her mind at the time of admission, but she did not. She stated that Patient #1 stayed in his recliner chair in the living room all day. He slept in the recliner chair as well because it was difficult for him to walk or stand. It took about 4 family members to get him to stand up. She stated that Patient #1 did not like to stand up and she documented his refusal to assess his bottom in a late entry dated 05-20-2026. RN A went on further to explain that her documentation stated several family members was needed to help Patient #1 to stand up, then one family member would put a bed side commode from behind so that he could use the bathroom. RN A stated that she spoke with Patient #1 about physical therapy, but he refused. This was later documented as the late entry on 05-20-2026. Surveyor asked RN A if she felt like she had enough lighting in the living room to perform his wound care and assess his skin and she stated yes. RN A was asked if she ever had to use additional lighting from her phone or any other device to see better and she stated she did not. RN A was asked if she called the office to give report of her findings after she completed the SOC for Patient #1 and she stated she did. Per RN A, it was agency protocol to call in report to the RN in the office. She was assigned to Clinical Manager A. RN A was asked if there was anything else she would like to add and she stated that she wished she did more supervisory visits for Patient #1. When asked what harm could be caused for delay in patient coordination, she stated hospital admission. On 05-27-2026 at 9:19 A.M, Surveyor held a follow up interview with RN A. Per RN A, she did not apply a dressing to the blisters noted at the SOC, but she did apply a dry dressing during the second visit on 04-22-2026. RN A stated that the blister was intact at the SOC. She educated the family on how to care for it by not popping the blisters on the left leg and keeping the area clean and dry. RN A stated that by the time she did the follow up visit, the blister had popped. Surveyor asked if the doctor was called to report the changes and she stated that she did not recall. Surveyor asked if she updated the plan of care and she said she did not. RN A stated she just did a basic dressing, which she cleaned the area with NS and covered it. RN A went on to explain that Patient #1 did not want to stand up and refused an assessment of his bottom because he was afraid of falling. RN A stated at the SOC, multiple family members were present, but Patient #1 continued to refuse a full skin assessment. During the second visit on 04-22-2026, RN A was alone with Patient#1 and it was unsafe for Patient #1 to stand. Per RN A, Patient #1 did not have a Hoyer lift (mechanical device used to transfer individuals with limited mobility) in the home. RN A stated that Patient #1 also refused PT because he only wanted wound care. RN A stated she did not recall if she told Clinical Manager A that she was unable to assess Patient #1’s bottom and refused PT. RN A was asked did she inform Clinical Manager A that Patient #1 required more than 1 person assistance to stand and requested to have extra help (another clinician) to co-visit with Patient #1. RN A stated that it did not cross her mind. She stated that she only remembered reporting to Clinical Manager A that Patient #1 spent most of the time in his recliner chair. Surveyor asked RN A when she became aware Patient #1 had a pressure ulcer and she stated right after he went to the hospital. RN A was asked if she recalled Patient #1 wearing socks when she visited with him. She stated, “he may have had socks on. If he did have socks on, it would have been only on the left foot”. RN A stated she may have removed the socks at the SOC but didn’t at the supervisory follow up visit. RN A was asked if the doctor was notified about Patient #1’s ankle circumference of 38 and was also asked did she document coordination with the doctor in the coordination note. RN A stated she did not recall. RN A was asked if she attended case conference for Patient #1 held this episode. She stated that she attended but left before giving report on Patient #1. RN A stated that she did not know if LVN A attended the case conference. RN A was asked who all attended case conference and she said all the disciplines, the Branch Director, Clinical Manager, and the Palliative team. RN A stated patients were discussed in case conference every Tuesday. Because RN A left case conference before discussing Patient #1, Surveyor asked if she had to provide a written report for Clinical Manager A and she said she did not. RN A stated, “it was not verbally asked to provide a written report for case conference.” She just had to make sure her documentation was completed so the notes could be reviewed at the case conference. On 5/27/2026 at 2:33P.M., an interview was held with Clinical Manager A. Clinical Manager A stated she needed to review the PAR(Post Admission/Recertification) note. Clinical Manager A explained that PAR was used when the nurses called in report. Clinical Manager A stated that she received report from RN A on 03-24-2026. RN A informed Clinical Manager A that Patient#1 was homebound and the discipline required was skilled nursing. There was no report of Patient#1 needing physical therapy or refusing. Clinical Manager A stated she did not remember what RN A reported about the wounds. Clinical Manager A was asked who was responsible for following up on pending orders. She stated that it was the responsibility of the clinician who did the assessment, but she would remind the clinician at the end of the call to follow up. Clinical Manager A did not receive a call from LVN A to report any changes in Patient #1’s condition. Clinical Manager A stated she attended the case conferences and there was no report of a change in condition for Patient #1. Per Clinical Manager A, it was also the responsibility of the field clinicians to ensure Patient #1 was receiving orders according to the plan of care. “If changes are not reported, then we do not know.” An interview was held with RD and Alt Admin on 05-29-2026 to discuss concerns about the care RN A and LVN A provided for Patient #1. Surveyor asked if there were additional orders or updated orders as RN A did not follow up with the health care provider regarding the blisters to the left leg nor did she contact the doctor when the blisters opened. Surveyor also voiced concerned that LVN A continued to document wound to the right great toe and second toe, but the orders were only for the second right great toe. RD checked Patient #1’s medical record and stated that she did not see additional wound care orders apart from the original wound care orders initiated at the SOC. RD and Alt Admin were made aware of concerns copied and pasted clinical narrative notes. Surveyor reminded BD of her statement from the previous interview that the Organization A and Practice Act A protected nurses to do a “First-Aid dressings”, but the concern was how many “First-Aid dressings” was too much and when was RN A and LVN A going to coordinate with the doctor regarding Patient #1’s change in condition. Surveyor asked what harm could be done to patients for not notifying the health care provider in a change of condition. RD stated the wound could worsen and cause a hospital admission. Alt Admin stated she agreed with what RD said, and in addition, a patient could lose a limb. Review of policy titled, “Patient Bill of Rights”, dated 12/2024, read in part…patient rights…to assist patients in making decisions regarding care…Procedure…The organization shall ensure that the patient receives all services outlined in the plan of care…right to be free from…injuries of unknown source, neglect…M. Be informed, verbally…before care is initiated…1. Payment may be expected from Medicare, Medicaid…Charges for services that will not be covered by Medicare, Medicaid…””

“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 interview and record review, the agency failed to ensure that care was provided as ordered by a physician or health care provider for 1 of 5 patients with wounds (Patient #1), in that wound care was not provided to the patients as ordered in the physician referral order for home health services and plan of care (POC). Patient #1’s POC orders included for the SN to notify the physician of skin changes. LVN A failed to notify to physician or healthcare provider and documented wound care provided. Failure of the agency to ensure that care provided was in conformance with physician orders resulted in the deterioration of Patient #1’s wound. This failed practice may potentially have negative outcomes on agency patients due to deterioration in existing condition, and delay in healing or rehabilitation of the patient. The agency currently has 223 patients on services whose care could be affected. Findings: Review of Patient #1’s clinical record revealed a POC for certification period 03-24-2026 to 05-22-26. SOC for Patient #1 was on 03-24-2026, which included diagnoses of Type 2 Diabetes with Foot Ulcer(high blood sugar level caused nerve damage and poor blood circulation, leading to open wound on foot), Blister Left Lower Leg, Lymphedema (swelling in the leg), Heart Failure (condition where the heart muscle is too weak to pump blood efficiently), Chronic Kidney Disease (damaged kidneys), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes breathing difficult), Morbid Obesity (excessive amount of body fat), and Repeated Falls. The visit frequency for skilled nursing was 1wk1,3wk8 Further review of the POC revealed the “skilled nurse/caregiver to perform wound care to site located 2nd toe rt foot. “Cleanse with hibiclens (antiseptic skin cleanser), apply iodosorb paste (paste/gel used to infected wound) and calcium alginate (a gel used for highly draining/bleeding wound), wrap with kerlix gauze (woven cotton gauze/dressing) , using clean/aseptic technique. Change dressing every MWF.” Continued review of the plan of care revealed “SN to perform a comprehensive assessment…,plan of care developed in coordination between agency staff, physician, PT, SN to assess/evaluate co-morbid conditions including diabetic wound 2nd toe rt foot,…and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications… Licensed professional to report…ankle…>33” RN A completed the SOC on 3/24/2026 for Patient #1. RN A visited with Patient #1 again on 04-22-2026 to complete a supervisory visit on LVN A. LVN A completed visits on 3/28/2026, 3/30/2026, 4/1/2026, 4/3/2026, 4/6/2026, 4/8/2026, 4/10/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/24/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, 5/8/2026, 5/11/2026, 5/13/2026, and 5/15/2026. Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum to visit note 04-22-2026 that read” … Only pt was present for SN visit, no other CG available. On LLE blisters SN cleansed with NS, patted dry, then covered with foam dressing. SN encouraged pt to consider working with physical therapy, Pt refused stating hes [sic] only worried about healing his wounds. SN did not assess Pt’s back side or bottom as pt cannot stand without 4-5 person assist, too dangerous to try as pt is large in weight.” Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum for SOC on 03-24-2026 that read “SN did not assess pt’s backside or bottom due to pt refusing to stand because of safety concerns and there not being enough people to assist as pt requires 4-5 assist to stand. …reported…that pt has no skin breakdown on his back side or bottom. SN asked pt about physical therapy, pt refused physical therapy…” Review of patient coordination note by LVN A on 05-20-2026 revealed an “Addendum to SN11 visits for the following dates 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/1/26 [sic], 4/15/26, 4/17/26, 4/20/26, 4/24/26, 4/27/25 [sic], 4/29/26, 5/1/26, 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26. SN performed first aid to open blister to LLE shin area as follows: Using clean technique wound cleansed with wound cleanser, pat dried with gauze, covered with dry gauze and secured with tape…” Review of visit note report completed by LVN A, dated 05-15-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial (the shin bone), Lt, blister”. Onset date for both wounds was 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” and “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-15-2026, LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” and “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-15-2026 revealed …“Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, no s/sx of infection noted. BLE with noted swelling, with dark discoloration to both… doesn’t get up out of recliner much… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-13-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-13-2026LVN A documented “multi/scat-prox pretibial, Lt, blister”…” “Wound care not provided awaiting orders” The narrative note completed by LVN A, dated 05-13-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-11-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-11-2026 LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-11-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of supervisory visit note completed by RN A, dated 04-22-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” Continued review of visit noted revealed an ankle circumference reading of 38 “lower limit 23 upper limit 33…comments MD notified.” There was no coordination note according to agency’s policy to reveal coordination with health care provider. RN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by RN A, dated 04-22-2026 revealed… “pt with rt toe wound. Recently infected. Pt with scattered blisters to LLE…Supervisory visit completed…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” Review of SOC visit note completed by RN A, dated 03-24-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Woundcare performed with available supplies. Pt tolerated well.” RN A documented “multi/scat-prox pretibial, Lt, blister” measured “3.2x4x0.1”…” “Wound care not provided”awaiting orders” The narrative note completed by RN A, dated 03-24-2026 revealed…pt with rt toe wound. Recently infected. Pt with scattered blisters to LL…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” On 5/26/26 at 12:30PM- Surveyor called the clinic to speak to Nurse Practitioner A, and the call was answered by Clinic LVN A. Surveyor explained the reason for the call and provided Patient #1’s name and date of birth. Clinic LVN A was asked if she had any record from the period of 3/24/2026 to present that showed any nurse from Home Health Agency A called regarding wound care orders or any change in condition. Clinic LVN A stated she did not have any record of such. Clinic LVN A stated that Patient #1 was last seen in the clinic on 03-19-2026. Clinic LVN A was asked to confirm if the last visit was in person or virtual and she stated that it was an in-person visit. Clinic LVN A was asked if there was a record of Patient #1 being noncompliant with his follow-up appointments and she stated there was no record of such. Clinic LVN A was asked to notify Nurse Practitioner A of the call. There was no return call from Nurse Practitioner A. On 05-26-2026 at 12:46 P.M, Surveyor spoke with LVN A. LVN A stated that she could not remember if anyone else was home when she did the visit on Friday, May 15th, 2026. Surveyor asked how she entered the home and she stated it was through the garage as the door was open. LVN A was asked if Patient #1 told her about the maggots on his leg and she stated he did. LVN A stated the room was dark, so she turned on the light from her phone to see better. She stated she looked on the bed, lifted up the sheets, and assessed the left and the right leg, but she did not see any maggots. LVN A stated she did not look at the left foot and did not recall if Patient #1 was wearing socks. After that, LVN A stated she performed wound care as ordered to the right toes, 2nd and great toe. Surveyor asked LVN A if she reviewed the plan of care and physician orders before she performed wound care and she stated she did. LVN A stated she washed the right great toe and 2nd toe with hibiclens, applied calcium alginate, and wrapped right foot with kerlix gauze. She stated that Patient #1 was noted with blisters that had popped open near the admission date on services. LVN A could not recall the exact date when the blister popped open. LVN stated she did not have orders for the blisters to the left shin, so she cleansed it with normal saline and covered it with a dry dressing. LVN A was asked to describe exactly where the opened blisters were located and she said it was on Patient #1’s left shin and above his knee on his left thigh. LVN A was asked who was responsible for coordinating with the physician to obtain orders when there was a change in condition. Per LVN A, she called and left a voice message with the physician office near the SOC to obtain orders, but she did not get a call back. She said it was some sort of answering service. LVN A stated she placed this call when the blisters opened, but she could not recall what date that was. Per LVN A, the wound care section in her tablet read there were pending orders, so she did a clean dry dressing at the visits as she awaited orders. LVN A stated she did not try to reach out to physician office again for orders since the SOC. LVN A was asked why she didn’t reach out to the physician office on her visit with Patient #1 on 5/15/2026, especially since he informed her about the maggots to the left leg. She stated, “I did not see maggots, no bugs, no flies.” LVN A was asked if the left wound looked infected and she stated it did not. She stated the open blisters looked pink and it was getting smaller. LVN A was asked if she did a full skin assessment and she stated that she did not. LVN A was asked if she coordinated with RN A to inform her of the change in condition and she stated she did not. LVN stated she continued doing clean and dry dressing to the left shin at each visit without physician orders. When LVN A was asked why she didn’t continue to follow up with the physician to obtain wound care orders as she visited with Patient #1 three times per week, LVN A stated she assumed the admitting nurse (RN A) did it. LVN A was asked if she notified Clinical Manager A regarding the open blisters, and she stated she did not. LVN A was asked to describe Patient #1’s home environment. She stated that the home was not disheveled and “everything was good.” LVN A was asked what harm the patient could have for delaying the coordination of care. She replied, “there was no neglect, no, bugs, no flies, so there was nothing to report.” LVN A was asked if she had anything else to add and she stated she did not. On 5-26-2026 at 1:19 P.M., RD stated RN A was aware of the blister upon admission and documented that. She stated that LVN A did a dry dressing change as nurses are protected by the Organization A/ Practice Act A to do a First-Aid dressing. LVN A failed to do a head-to-toe assessment after being notified of the maggots and did not notify the doctor. RD agreed that LVN A had an opportunity to contact the doctor for orders regarding the opened blister and failed to do so. The Alt Admin was present, but she stated that she was not involved in the investigation. Surveyor did ask the Alt Admin how often the RNs should do supervisory visits on the LVNs and she stated it was twice per episode. On 5/26/2026 at 4:18 P.M. Surveyor spoke with RN A. RN A stated she remembered doing the SOC for Patient #1. She stated Patient #1 had wound care orders for his right toe. She stated that Patient #1 did have fluid-filled blisters to his left leg and she called the doctor’s office to report her findings. RN A stated that she did not document who she spoke with nor did she document her attempt to contact the physician on the care coordination note. RN A was asked was there ever a time the LVN A reached out to her to let her know the blisters were open and she stated she did not. RN A was asked how often she was expected to perform supervisory visits on the LVNs and she stated every 4-5 weeks or 2 times for each episode. RN A stated she did notice that the blisters were open during the supervisory visit on 04-22-26. RN A stated she did not recall if she tried to contact the physician about the open blister or any change in condition. RN A stated that she did not remember if she coordinated with Clinical Nurse A or LVN A to discuss her findings on the change in condition. RN A was asked to describe the home where Patient #1 lived and she stated that it was unkempt, cluttered and unclean. RN A stated that she never saw flies in the home or maggots. RN A was asked if she tried to coordinate with the physician to get an order for a social worker. She stated that it did cross her mind at the time of admission, but she did not. She stated that Patient #1 stayed in his recliner chair in the living room all day. He slept in the recliner chair as well because it was difficult for him to walk or stand. It took about 4 family members to get him to stand up. She stated that Patient #1 did not like to stand up and she documented his refusal to assess his bottom in a late entry dated 05-20-2026. RN A went on further to explain that her documentation stated several family members was needed to help Patient #1 to stand up, then one family member would put a bed side commode from behind so that he could use the bathroom. RN A stated that she spoke with Patient #1 about physical therapy, but he refused. This was later documented as the late entry on 05-20-2026. Surveyor asked RN A if she felt like she had enough lighting in the living room to perform his wound care and assess his skin and she stated yes. RN A was asked if she ever had to use additional lighting from her phone or any other device to see better and she stated she did not. RN A was asked if she called the office to give report of her findings after she completed the SOC for Patient #1 and she stated she did. Per RN A, it was agency protocol to call in report to the RN in the office. She was assigned to Clinical Manager A. RN A was asked if there was anything else she would like to add and she stated that she wished she did more supervisory visits for Patient #1. When asked what harm could be caused for delay in patient coordination, she stated hospital admission. On 05-27-2026 at 9:19 A.M, Surveyor held a follow up interview with RN A. Per RN A, she did not apply a dressing to the blisters noted at the SOC, but she did apply a dry dressing during the second visit on 04-22-2026. RN A stated that the blister was intact at the SOC. She educated the family on how to care for it by not popping the blisters on the left leg and keeping the area clean and dry. RN A stated that by the time she did the follow up visit, the blister had popped. Surveyor asked if the doctor was called to report the changes and she stated that she did not recall. Surveyor asked if she updated the plan of care and she said she did not. RN A stated she just did a basic dressing, which she cleaned the area with NS and covered it. RN A went on to explain that Patient #1 did not want to stand up and refused an assessment of his bottom because he was afraid of falling. RN A stated at the SOC, multiple family members were present, but Patient #1 continued to refuse a full skin assessment. During the second visit on 04-22-2026, RN A was alone with Patient #1 and it was unsafe for Patient #1 to stand. Per RN A, Patient #1 did not have a Hoyer lift (mechanical device used to transfer individuals with limited mobility) in the home. RN A stated that Patient #1 also refused PT because he only wanted wound care. RN A stated she did not recall if she told Clinical Manager A that she was unable to assess Patient #1’s bottom and refused PT. RN A was asked did she inform Clinical Manager A that Patient #1 required more than 1 person assistance to stand and requested to have extra help (another clinician) to co-visit with Patient #1. RN A stated that it did not cross her mind. She stated that she only remembered reporting to Clinical Manager A that Patient #1 spent most of the time in his recliner chair. Surveyor asked RN A when she became aware Patient #1 had a pressure ulcer and she stated right after he went to the hospital. RN A was asked if she recalled Patient #1 wearing socks when she visited with him. She stated, “he may have had socks on. If he did have socks on, it would have been only on the left foot”. RN A stated she may have removed the socks at the SOC but didn’t at the supervisory follow up visit. RN A was asked if the doctor was notified about Patient #1’s ankle circumference of 38 and was also asked did she document coordination with the doctor in the coordination note. RN A stated she did not recall. RN A was asked if she attended case conference for Patient #1 held this episode. She stated that she attended but left before giving report on Patient #1. RN A stated that she did not know if LVN A attended the case conference. RN A was asked who all attended case conference and she said all the disciplines, the Branch Director, Clinical Manager, and the Palliative team. RN A stated patients were discussed in case conference every Tuesday. Because RN A left case conference before discussing Patient #1, Surveyor asked if she had to provide a written report for Clinical Manager A and she said she did not. RN A stated, “it was not verbally asked to provide a written report for case conference.” She just had to make sure her documentation was completed so the notes could be reviewed at the case conference. On 5/27/2026 at 2:33P.M., an interview was held with Clinical Manager A. Clinical Manager A stated she needed to review the PAR(Post Admission/Recertification) note. Clinical Manager A explained that PAR was used when the nurses called in report. Clinical Manager A stated that she received report from RN A on 03-24-2026. RN A informed Clinical Manager A that Patient #1 was homebound and the discipline required was skilled nursing. There was no report of Patient #1 needing physical therapy or refusing. Clinical Manager A stated she did not remember what RN A reported about the wounds. Clinical Manager A was asked who was responsible for following up on pending orders. She stated that it was the responsibility of the clinician who did the assessment, but she would remind the clinician at the end of the call to follow up. Clinical Manager A did not receive a call from LVN A to report any changes in Patient #1’s condition. Clinical Manager A stated she attended the case conferences and there was no report of a change in condition for Patient #1. Per Clinical Manager A, it was the responsibility of the field clinicians to reassess any change in condition and report it to the doctor. An interview was held with RD and Alt Admin on 05-29-2026 to discuss concerns about the care RN A and LVN A provided for Patient #1. Surveyor asked if there were additional orders or updated orders as RN A did not follow up with the health care provider regarding the blisters to the left leg nor did she contact the doctor when the blisters opened. Surveyor also voiced concerned that LVN A continued to document wound to the right great toe and second toe, but the orders were only for the second right great toe. RD checked Patient #1’s medical record and stated that she did not see additional wound care orders apart from the original wound care orders initiated at the SOC. RD and Alt Admin were made aware of concerns copied and pasted clinical narrative notes. Surveyor reminded BD of her statement from the previous interview that the Organization A and Practice Act A protected nurses to do a “First-Aid dressings”, but the concern was how many “First-Aid dressings” was too much and when was RN A and LVN A going to coordinate with the doctor regarding Patient #1’s change in condition. Surveyor asked what harm could be done to patients for not notifying the health care provider in a change of condition. RD stated the wound could worsen and cause a hospital admission. Alt Admin stated she agreed with what RD said, and in addition, a patient could lose a limb. Review of agency policy No. 4-023.1 titled Monitoring Patient’s Response/Reporting to Physician”, dated 12/2024, read in part, “…Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit…maintain ongoing communication with the physician (or allowed practitioner) to ensure safe and appropriate care for the patient…Procedure…The patient’s physician (or allowed practitioner) will be contacted on the same day when…A. Changes in patient’s condition…D. Inability to achieve goals within a specified time frame…H. There is any problem implementing the plan of care…4. All…attempts to communicate with physician will be documented in the clinical record…5. When unable to contact the patient’s physician (or allowed practitioner) for medical consultation warranted by change in patient’s condition, the following procedures will be followed:…A… The nurse…will immediately notify the Clinical Care Manager…””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the physician revised the patients’ plan of care as frequently as the patient needed or at least every 60 days for 1 of 5 patients (Patient #1) whose record was reviewed. This failure places the patients at risk of harm from services being provided without the approval and supervision of their physicians or health care provider. Findings include: Review of Patient #1’s clinical record revealed a POC for certification period 03-24-2026 to 05-22-26. SOC for Patient #1 was on 03-24-2026, which included diagnoses of Type 2 Diabetes with Foot Ulcer(high blood sugar level caused nerve damage and poor blood circulation, leading to open wound on foot), Blister Left Lower Leg, Lymphedema (swelling in the leg), Heart Failure (condition where the heart muscle is too weak to pump blood efficiently), Chronic Kidney Disease (damaged kidneys), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes breathing difficult), Morbid Obesity (excessive amount of body fat), and Repeated Falls. The visit frequency for skilled nursing was 1wk1,3wk8 Further review of the POC revealed the “skilled nurse/caregiver to perform wound care to site located 2nd toe rt foot. “Cleanse with hibiclens (antiseptic skin cleanser), apply iodosorb paste (paste/gel used to infected wound) and calcium alginate (a gel used for highly draining/bleeding wound), wrap with kerlix gauze (woven cotton gauze/dressing) , using clean/aseptic technique. Change dressing every MWF.” Continued review of the plan of care revealed “SN to perform a comprehensive assessment…,plan of care developed in coordination between agency staff, physician, PT, SN to assess/evaluate co-morbid conditions including diabetic wound 2nd toe rt foot,…and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications… Licensed professional to report…ankle…>33” RN A completed the SOC on 3/24/2026 for Patient #1. RN A visited with Patient #1 again on 04-22-2026 to complete a supervisory visit on LVN A. LVN A completed visits on 3/28/2026, 3/30/2026, 4/1/2026, 4/3/2026, 4/6/2026, 4/8/2026, 4/10/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/24/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, 5/8/2026, 5/11/2026, 5/13/2026, and 5/15/2026. Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum to visit note 04-22-2026 that read”… Only pt was present for SN visit, no other CG available. On LLE blisters SN cleansed with NS, patted dry, then covered with foam dressing. SN encouraged pt to consider working with physical therapy, Pt refused stating hes [sic]only worried about healing his wounds. SN did not assess Pt’s back side or bottom as pt cannot stand without 4-5 person assist, too dangerous to try as pt is large in weight.” Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum for SOC on 03-24-2026 that read “SN did not assess pt’s backside or bottom due to pt refusing to stand because of safety concerns and there not being enough people to assist as pt requires 4-5 assist to stand. …reported…that pt has no skin breakdown on his back side or bottom. SN asked pt about physical therapy, pt refused physical therapy…” Review of patient coordination note by LVN A on 05-20-2026 revealed an “Addendum to SN11 visits for the following dates 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/1/26 [sic], 4/15/26, 4/17/26, 4/20/26, 4/24/26, 4/27/25 [sic], 4/29/26, 5/1/26, 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26. SN performed first aid to open blister to LLE shin area as follows: Using clean technique wound cleansed with wound cleanser, pat dried with gauze, covered with dry gauze and secured with tape. Instructed patients son on need to provide wound care daily, keep clean and dry and covered at all times, understanding voiced.” Review of visit note report completed by LVN A, dated 05-15-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial (the shin bone), Lt, blister”. Onset date for both wounds was 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” and “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-15-2026, LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” and “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-15-2026 revealed …“Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, no s/sx of infection noted. BLE with noted swelling, with dark discoloration to both… doesn’t get up out of recliner much… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-13-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-13-2026LVN A documented “multi/scat-prox pretibial, Lt, blister”…” “Wound care not provided awaiting orders” The narrative note completed by LVN A, dated 05-13-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-11-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-11-2026 LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-11-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of supervisory visit note completed by RN A, dated 04-22-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” Continued review of visit noted revealed an ankle circumference reading of 38 “lower limit 23 upper limit 33…comments MD notified.” There was no coordination note according to agency’s policy to reveal coordination with health care provider. RN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by RN A, dated 04-22-2026 revealed… “pt with rt toe wound. Recently infected. Pt with scattered blisters to LLE…Supervisory visit completed…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” Review of SOC visit note completed by RN A, dated 03-24-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Woundcare performed with available supplies. Pt tolerated well.” RN A documented “multi/scat-prox pretibial, Lt, blister” measured “3.2x4x0.1”…” “Wound care not provided”awaiting orders” The narrative note completed by RN A, dated 03-24-2026 revealed…pt with rt toe wound. Recently infected. Pt with scattered blisters to LL…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” On 5/26/26 at 12:30PM- Surveyor called the clinic to speak to Nurse Practitioner A, and the call was answered by Clinic LVN A. Surveyor explained the reason for the call and provided Patient #1’s name and date of birth. Clinic LVN A was asked if she had any record from the period of 3/24/2026 to present that showed any nurse from Home Health Agency A called regarding wound care orders or any change in condition. Clinic LVN A stated she did not have any record of such. Clinic LVN A stated that Patient #1 was last seen in the clinic on 03-19-2026. Clinic LVN A was asked to confirm if the last visit was in person or virtual and she stated that it was an in-person visit. Clinic LVN A was asked if there was a record of Patient #1 being noncompliant with his follow-up appointments and she stated there was no record of such. Clinic LVN A was asked to notify Nurse Practitioner A of the call. There was no return call from Nurse Practitioner A. On 05-26-2026 at 12:46 P.M, Surveyor spoke with LVN A. LVN A stated that she could not remember if anyone else was home when she did the visit on Friday, May 15th, 2026. Surveyor asked how she entered the home and she stated it was through the garage as the door was open. LVN A was asked if Patient #1 told her about the maggots on his leg and she stated he did. LVN A stated the room was dark, so she turned on the light from her phone to see better. She stated she looked on the bed, lifted up the sheets, and assessed the left and the right leg, but she did not see any maggots. LVN A stated she did not look at the left foot and did not recall if Patient #1 was wearing socks. After that, LVN A stated she performed wound care as ordered to the right toes, 2nd and great toe. Surveyor asked LVN A if she reviewed the plan of care and physician orders before she performed wound care and she stated she did. LVN A stated she washed the right great toe and 2nd toe with hibiclens, applied calcium alginate, and wrapped right foot with kerlix gauze. She stated that Patient #1 was noted with blisters that had popped open near the admission date on services. LVN A could not recall the exact date when the blister popped open. LVN stated she did not have orders for the blisters to the left shin, so she cleansed it with normal saline and covered it with a dry dressing. LVN A was asked to describe exactly where the opened blisters were located and she said it was on Patient #1’s left shin and above his knee on his left thigh. LVN A was asked who was responsible for coordinating with the physician to obtain orders when there was a change in condition. Per LVN A, she called and left a voice message with the physician office near the SOC to obtain orders, but she did not get a call back. She said it was some sort of answering service. LVN A stated she placed this call when the blisters opened, but she could not recall what date that was. Per LVN A, the wound care section in her tablet read there were pending orders, so she did a clean dry dressing at the visits as she awaited orders. LVN A stated she did not try to reach out to physician office again for orders since the SOC. LVN A was asked why she didn’t reach out to the physician office on her visit with Patient #1 on 5/15/2026, especially since he informed her about the maggots to the left leg. She stated, “I did not see maggots, no bugs, no flies.” LVN A was asked if the left wound looked infected and she stated it did not. She stated the open blisters looked pink and it was getting smaller. LVN A was asked if she did a full skin assessment and she stated that she did not. LVN A was asked if she coordinated with RN A to inform her of the change in condition and she stated she did not. LVN stated she continued doing clean and dry dressing to the left shin at each visit without physician orders. When LVN A was asked why she didn’t continue to follow up with the physician to obtain wound care orders as she visited with Patient #1 three times per week, LVN A stated she assumed the admitting nurse (RN A) did it. LVN A was asked if she notified Clinical Manager A regarding the open blisters, and she stated she did not. LVN A was asked to describe Patient #1’s home environment. She stated that the home was not disheveled and “everything was good.” LVN A was asked what harm the patient could have for delaying the coordination of care. She replied, “there was no neglect, no, bugs, no flies, so there was nothing to report.” LVN A was asked if she had anything else to add and she stated she did not. On 5-26-2026 at 1:19 P.M., RD stated RN A was aware of the blister upon admission and documented that. She stated that LVN A did a dry dressing change as nurses are protected by the Organization A/ Practice Act A to do a First-Aid dressing. LVN A failed to do a head-to-toe assessment after being notified of the maggots and did not notify the doctor. RD agreed that LVN A had an opportunity to contact the doctor for orders regarding the opened blister and failed to do so. The Alt Admin was present, but she stated that she was not involved in the investigation. Surveyor did ask the Alt Admin how often the RNs should do supervisory visits on the LVNs and she stated it was twice per episode. On 5/26/2026 at 4:18 P.M. Surveyor spoke with RN A. RN A stated she remembered doing the SOC for Patient #1. She stated Patient#1 had wound care orders for his right toe. She stated that Patient #1 did have fluid-filled blisters to his left leg and she called the doctor’s office to report her findings. RN A stated that she did not document who she spoke with nor did she document her attempt to contact the physician on the care coordination note. RN A was asked was there ever a time the LVN A reached out to her to let her know the blisters were open and she stated she did not. RN A was asked how often she was expected to perform supervisory visits on the LVNs and she stated every 4-5 weeks or 2 times for each episode. RN A stated she did notice that the blisters were open during the supervisory visit on 04-22-26. RN A stated she did not recall if she tried to contact the physician about the open blister or any change in condition. RN A stated that she did not remember if she coordinated with Clinical Nurse A or LVN A to discuss her findings on the change in condition. RN A was asked to describe the home where Patient #1 lived and she stated that it was unkempt, cluttered and unclean. RN A stated that she never saw flies in the home or maggots. RN A was asked if she tried to coordinate with the physician to get an order for a social worker. She stated that it did cross her mind at the time of admission, but she did not. She stated that Patient #1 stayed in his recliner chair in the living room all day. He slept in the recliner chair as well because it was difficult for him to walk or stand. It took about 4 family members to get him to stand up. She stated that Patient #1 did not like to stand up and she documented his refusal to assess his bottom in a late entry dated 05-20-2026. RN A went on further to explain that her documentation stated several family members was needed to help Patient #1 to stand up, then one family member would put a bed side commode from behind so that he could use the bathroom. RN A stated that she spoke with Patient #1 about physical therapy, but he refused. This was later documented as the late entry on 05-20-2026. Surveyor asked RN A if she felt like she had enough lighting in the living room to perform his wound care and assess his skin and she stated yes. RN A was asked if she ever had to use additional lighting from her phone or any other device to see better and she stated she did not. RN A was asked if she called the office to give report of her findings after she completed the SOC for Patient #1 and she stated she did. Per RN A, it was agency protocol to call in report to the RN in the office. She was assigned to Clinical Manager A. RN A was asked if there was anything else she would like to add and she stated that she wished she did more supervisory visits for Patient #1. When asked what harm could be caused for delay in patient coordination, she stated hospital admission. On 05-27-2026 at 9:19 A.M, Surveyor held a follow up interview with RN A. Per RN A, she did not apply a dressing to the blisters noted at the SOC, but she did apply a dry dressing during the second visit on 04-22-2026. RN A stated that the blister was intact at the SOC. She educated the family on how to care for it by not popping the blisters on the left leg and keeping the area clean and dry. RN A stated that by the time she did the follow up visit, the blister had popped. Surveyor asked if the doctor was called to report the changes and she stated that she did not recall. Surveyor asked if she updated the plan of care and she said she did not. RN A stated she just did a basic dressing, which she cleaned the area with NS and covered it. RN A went on to explain that Patient #1 did not want to stand up and refused an assessment of his bottom because he was afraid of falling. RN A stated at the SOC, multiple family members were present, but Patient #1 continued to refuse a full skin assessment. During the second visit on 04-22-2026, RN A was alone with Patient #1 and it was unsafe for Patient #1 to stand. Per RN A, Patient #1 did not have a Hoyer lift (mechanical device used to transfer individuals with limited mobility) in the home. RN A stated that Patient #1 also refused PT because he only wanted wound care. RN A stated she did not recall if she told Clinical Manager A that she was unable to assess Patient #1’s bottom and refused PT. RN A was asked did she inform Clinical Manager A that Patient #1 required more than 1 person assistance to stand and requested to have extra help (another clinician) to co-visit with Patient #1. RN A stated that it did not cross her mind. She stated that she only remembered reporting to Clinical Manager A that Patient #1 spent most of the time in his recliner chair. Surveyor asked RN A when she became aware Patient #1 had a pressure ulcer and she stated right after he went to the hospital. RN A was asked if she recalled Patient #1 wearing socks when she visited with him. She stated, “he may have had socks on. If he did have socks on, it would have been only on the left foot”. RN A stated she may have removed the socks at the SOC but didn’t at the supervisory follow up visit. RN A was asked if the doctor was notified about Patient #1’s ankle circumference of 38 and was also asked did she document coordination with the doctor in the coordination note. RN A stated she did not recall. RN A was asked if she attended case conference for Patient #1 held this episode. She stated that she attended but left before giving report on Patient #1. RN A stated that she did not know if LVN A attended the case conference. RN A was asked who all attended case conference and she said all the disciplines, the Branch Director, Clinical Manager, and the Palliative team. RN A stated patients were discussed in case conference every Tuesday. Because RN A left case conference before discussing Patient #1, Surveyor asked if she had to provide a written report for Clinical Manager A and she said she did not. RN A stated, “it was not verbally asked to provide a written report for case conference.” She just had to make sure her documentation was completed so the notes could be reviewed at the case conference. On 5/27/2026 at 2:33P.M., an interview was held with Clinical Manager A. Clinical Manager A stated she needed to review the PAR(Post Admission/Recertification) note. Clinical Manager A explained that PAR was used when the nurses called in report. Clinical Manager A stated that she received report from RN A on 03-24-2026. RN A informed Clinical Manager A that Patient #1 was homebound and the discipline required was skilled nursing. There was no report of Patient #1 needing physical therapy or refusing. Clinical Manager A stated she did not remember what RN A reported about the wounds. Clinical Manager A was asked who was responsible for following up on pending orders. She stated that it was the responsibility of the clinician who did the assessment, but she would remind the clinician at the end of the call to follow up. Clinical Manager A did not receive a call from LVN A to report any changes in Patient #1’s condition. Clinical Manager A stated she attended the case conferences and there was no report of a change in condition for Patient #1. Per Clinical Manager A, it was the responsibility of the field clinicians to reassess any change in condition and report it to the doctor. An interview was held with RD and Alt Admin on 05-29-2026 to discuss concerns about the care RN A and LVN A provided for Patient #1. Surveyor asked if there were additional orders or updated orders as RN A did not follow up with the health care provider regarding the blisters to the left leg nor did she contact the doctor when the blisters opened. Surveyor also voiced concerned that LVN A continued to document wound to the right great toe and second toe, but the orders were only for the second right great toe. RD checked Patient #1’s medical record and stated that she did not see additional wound care orders apart from the original wound care orders initiated at the SOC. RD and Alt Admin were made aware of concerns copied and pasted clinical narrative notes. Surveyor reminded BD of her statement from the previous interview that the Organization A and Practice Act A protected nurses to do a “First-Aid dressings”, but the concern was how many “First-Aid dressings” was too much and when was RN A and LVN A going to coordinate with the doctor regarding Patient #1’s change in condition. Surveyor asked what harm could be done to patients for not notifying the health care provider in a change of condition. RD stated the wound could worsen and cause a hospital admission. Alt Admin stated she agreed with what RD said, and in addition, a patient could lose a limb. Review of agency policy titled “Home Health Plan of Care Process”, dated 12/2024, read in part, “A written plan of care…updated at least every sixty days for Home Health…or as patient’s condition warrants…”the plan of care will be reviewed more frequently than every sixty (60) days when a patient…a significant change occurs in the patient’s condition…” “Procedure 2.All clinicians will consider the conclusions of…ongoing assessments in their care planning process… B. Changes in patient’s condition K. Actions to be taken to meet patient goals W. All patient care orders, including verbal. 11. Clinicians will inform the patient’s physician (or allowed practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes. 13. Problems and or needs related to patient’s condition,…will be included in the plan of care.” Review of the agency’s policy No :4-006.1 titled, “Ongoing Assessments”, dated 12/2024, read in part, “ …During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter…the clinician will reassess the patient for…Current treatment related to the identified symptoms and the patient’s response…Skin integrity…Progress toward goals and patient needs and problems…The physician will be notified to verify…treatment/interventions that require physician approval.” Review of agency policy No. 4-023.1 titled Monitoring Patient’s Response/Reporting to Physician”, dated 12/2024, read in part, “…Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit…maintain ongoing communication with the physician (or allowed practitioner) to ensure safe and appropriate care for the patient…Procedure…The patient’s physician (or allowed practitioner) will be contacted on the same day when…A. Changes in patient’s condition…D. Inability to achieve goals within a specified time frame…H. There is any problem implementing the plan of care…4. All…attempts to communicate with physician will be documented in the clinical record…5. When unable to contact the patient’s physician (or allowed practitioner) for medical consultation warranted by change in patient’s condition, the following procedures will be followed:…A… The nurse…will immediately notify the Clinical Care Manager…””

“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 review and interview, RN A and LVN A failed to inform the physician promptly when 1 of 5 ( Patient #1) patients had a change in condition, in that: RN A did not notify the physician that Patient #1 had a change in skin integrity in that blisters to the left leg were no longer intact. LVN A did not notify the physician of worsening skin condition and performed wound care to the right great toe, which had no wound care orders. RN A did not notify the physician of ankle circumference greater than 33. LVN A did not notify the physician of Patient’s #1 verbal statement of maggots to the left leg wound. This failure placed Patient #1 at risk of receiving inadequate care and services and a decline in wound status. The findings include: Review of Patient #1’s clinical record revealed a POC for certification period 03-24-2026 to 05-22-26. SOC for Patient #1 was on 03-24-2026, which included diagnoses of Type 2 Diabetes with Foot Ulcer(high blood sugar level caused nerve damage and poor blood circulation, leading to open wound on foot), Blister Left Lower Leg, Lymphedema (swelling in the leg), Heart Failure (condition where the heart muscle is too weak to pump blood efficiently), Chronic Kidney Disease (damaged kidneys), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes breathing difficult), Morbid Obesity (excessive amount of body fat), and Repeated Falls. The visit frequency for skilled nursing was 1wk1,3wk8 Further review of the POC revealed the “skilled nurse/caregiver to perform wound care to site located 2nd toe rt foot. “Cleanse with hibiclens (antiseptic skin cleanser), apply iodosorb paste (paste/gel used to infected wound) and calcium alginate (a gel used for highly draining/bleeding wound), wrap with kerlix gauze (woven cotton gauze/dressing) , using clean/aseptic technique. Change dressing every MWF.” Continued review of the plan of care revealed “SN to perform a comprehensive assessment…,plan of care developed in coordination between agency staff, physician, PT, SN to assess/evaluate co-morbid conditions including diabetic wound 2nd toe rt foot,…and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications… Licensed professional to report…ankle…>33” RN A completed the SOC on 3/24/2026 for Patient #1. RN A visited with Patient #1 again on 04-22-2026 to complete a supervisory visit on LVN A. LVN A completed visits on 3/28/2026, 3/30/2026, 4/1/2026, 4/3/2026, 4/6/2026, 4/8/2026, 4/10/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/20/2026, 4/24/2026, 4/27/2026, 4/29/2026, 5/1/2026, 5/4/2026, 5/6/2026, 5/8/2026, 5/11/2026, 5/13/2026, and 5/15/2026. Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum to visit note 04-22-2026 that read”… Only pt was present for SN visit, no other CG available. On LLE blisters SN cleansed with NS, patted dry, then covered with foam dressing. SN encouraged pt to consider working with physical therapy, Pt refused stating hes [sic] only worried about healing his wounds. SN did not assess Pt’s back side or bottom as pt cannot stand without 4-5 person assist, too dangerous to try as pt is large in weight.” Review of patient coordination note by RN A on 05-20-2026 revealed a late entry addendum for SOC on 03-24-2026 that read “SN did not assess pt’s backside or bottom due to pt refusing to stand because of safety concerns and there not being enough people to assist as pt requires 4-5 assist to stand…reported…that pt has no skin breakdown on his back side or bottom. SN asked pt about physical therapy, pt refused physical therapy…” Review of patient coordination note by LVN A on 05-20-2026 revealed an “Addendum to SN11 visits for the following dates 3/30/26, 4/1/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/13/26, 4/1/26 [sic], 4/15/26, 4/17/26, 4/20/26, 4/24/26, 4/27/25 [sic], 4/29/26, 5/1/26, 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26. SN performed first aid to open blister to LLE shin area as follows: Using clean technique wound cleansed with wound cleanser, pat dried with gauze, covered with dry gauze and secured with tape. Instructed patients son on need to provide wound care daily, keep clean and dry and covered at all times, understanding voiced.” Review of visit note report completed by LVN A, dated 05-15-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial (the shin bone), Lt, blister”. Onset date for both wounds was 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” and “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-15-2026, LVN A documented wound care provided to “multi/scat-prox pretibial(the shin bone), Lt, blister” and “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-15-2026 revealed …“Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, no s/sx of infection noted. BLE with noted swelling, with dark discoloration to both… doesn’t get up out of recliner much… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-13-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-13-2026LVN A documented “multi/scat-prox pretibial, Lt, blister”…” “Wound care not provided awaiting orders” The narrative note completed by LVN A, dated 05-13-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of visit note report completed by LVN A, dated 05-11-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. LVN A documented wound care provided for “2nd toe Rt, Diab Ulcer” was “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” On 05-11-2026 LVN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by LVN A, dated 05-11-2026 revealed”…”Pt states he feels ok… SN assessment performed…patient presents with wounds to right second toe and great toes with weeping (leaking clear fluid), slow progression due to weeping. SN performed wound care per orders, patient tolerated well. Patient with open blisters to LLE no wound care orders at present, both OTA, … BLE with noted swelling, with dark discoloration to both… imapired [sic]skin integrity…” Review of supervisory visit note completed by RN A, dated 04-22-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Tolerated well” Continued review of visit noted revealed an ankle circumference reading of 38 “lower limit 23 upper limit 33…comments MD notified.” There was no coordination note according to agency’s policy to reveal coordination with health care provider. RN A documented wound care provided to “multi/scat-prox pretibial, Lt, blister” was “skilled nurse/caregiver to perform wound care to site located left pretibial, using clean/aseptic technique. Change dressing every MWF. Tolerated well” The narrative note completed by RN A, dated 04-22-2026 revealed… “pt with rt toe wound. Recently infected. Pt with scattered blisters to LLE…Supervisory visit completed…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” Review of SOC visit note completed by RN A, dated 03-24-2026, revealed wound assessment of “2nd toe Rt, Diab Ulcer” and “multi/scat-prox pretibial, Lt, blister”. Onset date for both wounds was on 03-24-2026. RN A documented “skilled nurse/caregiver to perform wound care to site located 2nd toe Rt foot, Cleanse with hibiclens, apply iodosorb paste and calcium alginate, wrap with kerlix gauze, using clean/aseptic technique. Change dressing every MWF. Woundcare performed with available supplies. Pt tolerated well.” RN A documented “multi/scat-prox pretibial, Lt, blister” measured “3.2x4x0.1”…” “Wound care not provided”awaiting orders” The narrative note completed by RN A, dated 03-24-2026 revealed…pt with rt toe wound. Recently infected. Pt with scattered blisters to LL…head to toe assessment completed…Pt with diabetic wound to 2nd toe on rt foot along with scattered blisters on his LLE. Woundcare orders given for the toe wound, awaiting orders for blisters…impaired integumentary (skin)…” On 5/26/26 at 12:30PM- Surveyor called the clinic to speak to Nurse Practitioner A, and the call was answered by Clinic LVN A. Surveyor explained the reason for the call and provided Patient #1’s name and date of birth. Clinic LVN A was asked if she had any record from the period of 3/24/2026 to present that showed any nurse from Home Health Agency A called regarding wound care orders or any change in condition. Clinic LVN A stated she did not have any record of such. Clinic LVN A stated that Patient #1 was last seen in the clinic on 03-19-2026. Clinic LVN A was asked to confirm if the last visit was in person or virtual and she stated that it was an in-person visit. Clinic LVN A was asked if there was a record of Patient #1 being noncompliant with his follow-up appointments and she stated there was no record of such. Clinic LVN A was asked to notify Nurse Practitioner A of the call. There was no return call from Nurse Practitioner A. On 05-26-2026 at 12:46 P.M, Surveyor spoke with LVN A. LVN A stated that she could not remember if anyone else was home when she did the visit on Friday, May 15th, 2026. Surveyor asked how she entered the home and she stated it was through the garage as the door was open. LVN A was asked if Patient #1 told her about the maggots on his leg and she stated he did. LVN A stated the room was dark, so she turned on the light from her phone to see better. She stated she looked on the bed, lifted up the sheets, and assessed the left and the right leg, but she did not see any maggots. LVN A stated she did not look at the left foot and did not recall if Patient #1 was wearing socks. After that, LVN A stated she performed wound care as ordered to the right toes, 2nd and great toe. Surveyor asked LVN A if she reviewed the plan of care and physician orders before she performed wound care and she stated she did. LVN A stated she washed the right great toe and 2nd toe with hibiclens, applied calcium alginate, and wrapped right foot with kerlix gauze. She stated that Patient #1 was noted with blisters that had popped open near the admission date on services. LVN A could not recall the exact date when the blister popped open. LVN stated she did not have orders for the blisters to the left shin, so she cleansed it with normal saline and covered it with a dry dressing. LVN A was asked to describe exactly where the opened blisters were located and she said it was on Patient #1’s left shin and above his knee on his left thigh. LVN A was asked who was responsible for coordinating with the physician to obtain orders when there was a change in condition. Per LVN A, she called and left a voice message with the physician office near the SOC to obtain orders, but she did not get a call back. She said it was some sort of answering service. LVN A stated she placed this call when the blisters opened, but she could not recall what date that was. Per LVN A, the wound care section in her tablet read there were pending orders, so she did a clean dry dressing at the visits as she awaited orders. LVN A stated she did not try to reach out to physician office again for orders since the SOC. LVN A was asked why she didn’t reach out to the physician office on her visit with Patient #1 on 5/15/2026, especially since he informed her about the maggots to the left leg. She stated, “I did not see maggots, no bugs, no flies.” LVN A was asked if the left wound looked infected and she stated it did not. She stated the open blisters looked pink and it was getting smaller. LVN A was asked if she did a full skin assessment and she stated that she did not. LVN A was asked if she coordinated with RN A to inform her of the change in condition and she stated she did not. LVN stated she continued doing clean and dry dressing to the left shin at each visit without physician orders. When LVN A was asked why she didn’t continue to follow up with the physician to obtain wound care orders as she visited with Patient #1 three times per week, LVN A stated she assumed the admitting nurse (RN A) did it. LVN A was asked if she notified Clinical Manager A regarding the open blisters, and she stated she did not. LVN A was asked to describe Patient #1’s home environment. She stated that the home was not disheveled and “everything was good.” LVN A was asked what harm the patient could have for delaying the coordination of care. She replied, “there was no neglect, no, bugs, no flies, so there was nothing to report.” LVN A was asked if she had anything else to add and she stated she did not. On 5-26-2026 at 1:19 P.M., RD stated RN A was aware of the blister upon admission and documented that. She stated that LVN A did a dry dressing change as nurses are protected by the Organization A/ Practice Act A to do a First-Aid dressing. LVN A failed to do a head-to-toe assessment after being notified of the maggots and did not notify the doctor. RD agreed that LVN A had an opportunity to contact the doctor for orders regarding the opened blister and failed to do so. The Alt Admin was present, but she stated that she was not involved in the investigation. Surveyor did ask the Alt Admin how often the RNs should do supervisory visits on the LVNs and she stated it was twice per episode. On 5/26/2026 at 4:18 P.M. Surveyor spoke with RN A. RN A stated she remembered doing the SOC for Patient #1. She stated Patient #1 had wound care orders for his right toe. She stated that Patient #1 did have fluid-filled blisters to his left leg and she called the doctor’s office to report her findings. RN A stated that she did not document who she spoke with nor did she document her attempt to contact the physician on the care coordination note. RN A was asked was there ever a time the LVN A reached out to her to let her know the blisters were open and she stated she did not. RN A was asked how often she was expected to perform supervisory visits on the LVNs and she stated every 4-5 weeks or 2 times for each episode. RN A stated she did notice that the blisters were open during the supervisory visit on 04-22-26. RN A stated she did not recall if she tried to contact the physician about the open blister or any change in condition. RN A stated that she did not remember if she coordinated with Clinical Nurse A or LVN A to discuss her findings on the change in condition. RN A was asked to describe the home where Patient #1 lived and she stated that it was unkempt, cluttered and unclean. RN A stated that she never saw flies in the home or maggots. RN A was asked if she tried to coordinate with the physician to get an order for a social worker. She stated that it did cross her mind at the time of admission, but she did not. She stated that Patient #1 stayed in his recliner chair in the living room all day. He slept in the recliner chair as well because it was difficult for him to walk or stand. It took about 4 family members to get him to stand up. She stated that Patient #1 did not like to stand up and she documented his refusal to assess his bottom in a late entry dated 05-20-2026. RN A went on further to explain that her documentation stated several family members was needed to help Patient #1 to stand up, then one family member would put a bed side commode from behind so that he could use the bathroom. RN A stated that she spoke with Patient #1 about physical therapy, but he refused. This was later documented as the late entry on 05-20-2026. Surveyor asked RN A if she felt like she had enough lighting in the living room to perform his wound care and assess his skin and she stated yes. RN A was asked if she ever had to use additional lighting from her phone or any other device to see better and she stated she did not. RN A was asked if she called the office to give report of her findings after she completed the SOC for Patient #1 and she stated she did. Per RN A, it was agency protocol to call in report to the RN in the office. She was assigned to Clinical Manager A. RN A was asked if there was anything else she would like to add and she stated that she wished she did more supervisory visits for Patient #1. When asked what harm could be caused for delay in patient coordination, she stated hospital admission. On 05-27-2026 at 9:19 A.M, Surveyor held a follow up interview with RN A. Per RN A, she did not apply a dressing to the blisters noted at the SOC, but she did apply a dry dressing during the second visit on 04-22-2026. RN A stated that the blister was intact at the SOC. She educated the family on how to care for it by not popping the blisters on the left leg and keeping the area clean and dry. RN A stated that by the time she did the follow up visit, the blister had popped. Surveyor asked if the doctor was called to report the changes and she stated that she did not recall. Surveyor asked if she updated the plan of care and she said she did not. RN A stated she just did a basic dressing, which she cleaned the area with NS and covered it. RN A went on to explain that Patient #1 did not want to stand up and refused an assessment of his bottom because he was afraid of falling. RN A stated at the SOC, multiple family members were present, but Patient #1 continued to refuse a full skin assessment. During the second visit on 04-22-2026, RN A was alone with Patient#1 and it was unsafe for Patient #1 to stand. Per RN A, Patient #1 did not have a Hoyer lift (mechanical device used to transfer individuals with limited mobility) in the home. RN A stated that Patient #1 also refused PT because he only wanted wound care. RN A stated she did not recall if she told Clinical Manager A that she was unable to assess Patient #1’s bottom and refused PT. RN A was asked did she inform Clinical Manager A that Patient #1 required more than 1 person assistance to stand and requested to have extra help (another clinician) to co-visit with Patient #1. RN A stated that it did not cross her mind. She stated that she only remembered reporting to Clinical Manager A that Patient #1 spent most of the time in his recliner chair. Surveyor asked RN A when she became aware Patient #1 had a pressure ulcer and she stated right after he went to the hospital. RN A was asked if she recalled Patient #1 wearing socks when she visited with him. She stated, “he may have had socks on. If he did have socks on, it would have been only on the left foot”. RN A stated she may have removed the socks at the SOC but didn’t at the supervisory follow up visit. RN A was asked if the doctor was notified about Patient #1’s ankle circumference of 38 and was also asked did she document coordination with the doctor in the coordination note. RN A stated she did not recall. RN A was asked if she attended case conference for Patient #1 held this episode. She stated that she attended but left before giving report on Patient #1. RN A stated that she did not know if LVN A attended the case conference. RN A was asked who all attended case conference and she said all the disciplines, the Branch Director, Clinical Manager, and the Palliative team. RN A stated patients were discussed in case conference every Tuesday. Because RN A left case conference before discussing Patient #1, Surveyor asked if she had to provide a written report for Clinical Manager A and she said she did not. RN A stated, “it was not verbally asked to provide a written report for case conference.” She just had to make sure her documentation was completed so the notes could be reviewed at the case conference. On 5/27/2026 at 2:33P.M., an interview was held with Clinical Manager A. Clinical Manager A stated she needed to review the PAR(Post Admission/Recertification) note. Clinical Manager A explained that PAR was used when the nurses called in report. Clinical Manager A stated that she received report from RN A on 03-24-2026. RN A informed Clinical Manager A that Patient #1 was homebound and the discipline required was skilled nursing. There was no report of Patient #1 needing physical therapy or refusing. Clinical Manager A stated she did not remember what RN A reported about the wounds. Clinical Manager A was asked who was responsible for following up on pending orders. She stated that it was the responsibility of the clinician who did the assessment, but she would remind the clinician at the end of the call to follow up. Per Clinical Manager A, it was also the responsibility of the field clinicians to ensure Client #1 was receiving orders according to the plan of care. “If changes are not reported, then we do not know.” Clinical Manager A did not receive a call from LVN A to report any changes in Patient #1’s condition. Clinical Manager A stated she attended the case conferences and there was no report of a change in condition for Patient #1. An interview was held with RD and Alt Admin on 05-29-2026 to discuss concerns about the care RN A and LVN A provided for Patient #1. Surveyor asked if there were additional orders or updated orders as RN A did not follow up with the health care provider regarding the blisters to the left leg nor did she contact the doctor when the blisters opened. Surveyor also voiced concerned that LVN A continued to document wound to the right great toe and second toe, but the orders were only for the second right great toe. RD checked Patient #1’s medical record and stated that she did not see additional wound care orders apart from the original wound care orders initiated at the SOC. RD and Alt Admin were made aware of concerns copied and pasted clinical narrative notes. Surveyor reminded BD of her statement from the previous interview that the Organization A and Practice Act A protected nurses to do a “First-Aid dressings”, but the concern was how many “First-Aid dressings” was too much and when was RN A and LVN A going to coordinate with the doctor regarding Patient #1’s change in condition. Surveyor asked what harm could be done to patients for not notifying the health care provider in a change of condition. RD stated the wound could worsen and cause a hospital admission. Alt Admin stated she agreed with what RD said, and in addition, a patient could lose a limb. Review of agency policy titled “Home Health Plan of Care Process”, dated 12/2024, read in part, “A written plan of care…updated at least every sixty days for Home Health…or as patient’s condition warrants…”the plan of care will be reviewed more frequently than every sixty (60) days when a patient…a significant change occurs in the patient’s condition…” “Procedure 2.All clinicians will consider the conclusions of…ongoing assessments in their care planning process… B. Changes in patient’s condition K. Actions to be taken to meet patient goals W. All patient care orders, including verbal. 11. Clinicians will inform the patient’s physician (or allowed practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes. 13. Problems and or needs related to patient’s condition,…will be included in the plan of care.” Review of the agency’s policy No :4-006.1 titled, “Ongoing Assessments”, dated 12/2024, read in part, “ …During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter…the clinician will reassess the patient for…Current treatment related to the identified symptoms and the patient’s response…Skin integrity…Progress toward goals and patient needs and problems…The physician will be notified to verify…treatment/interventions that require physician approval.” Review of agency policy No. 4-023.1 titled Monitoring Patient’s Response/Reporting to Physician”, dated 12/2024, read in part, “…Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit…maintain ongoing communication with the physician (or allowed practitioner) to ensure safe and appropriate care for the patient…Procedure…The patient’s physician (or allowed practitioner) will be contacted on the same day when…A. Changes in patient’s condition…D. Inability to achieve goals within a specified time frame…H. There is any problem implementing the plan of care…4. All…attempts to communicate with physician will be documented in the clinical record…5. When unable to contact the patient’s physician (or allowed practitioner) for medical consultation warranted by change in patient’s condition, the following procedures will be followed:…A… The nurse…will immediately notify the Clinical Care Manager…” Review of the agency’s policy No :4-030.1 titled, “Care/Service Coordination”, dated 12/2024, read in part, “…It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned employees. Timely and ongoing communication is the responsibility of each member of the IDG…Procedure…Care coordination will include,…E. Timely documentation of coordinated of care activities…H. Proper communication…of patient, including the opportunity for questions between the giver and receiver of information…J. Coordination of care delivery to meet the patient’s needs…6….communicate changes in a timely manner…7. Documentation of all communications will be included in the clinical record on a communication note…will include… A. Date and time of communication, B. Individuals involved with the communication, C. Information discussed, and D. Outcome of communication””