Guardian Healthcare

“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 record review and interview, the agency failed to ensure a patient’s right to be free from neglect by an agency employee (LVN 1) for one (Patient #2) out of 4 patient records reviewed for providing services ordered, in that LVN 1 failed to provide wound care for Patient #2 as ordered by Nurse Practitioner. (Identifier 100) As a result of the failure, the patient failed to receive wound care from LVN 1 as ordered by the Nurse Practitioner. The failure placed the patient at an increased risk of infection, interruption of intravenous therapy, and hospitalization. Findings include: During the presurvey on 07/20/2026, review of 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) revealed a self-reported incident (for intake number 1094817) dated 06/03/2026 and submitted by Administrator/Supervising Nurse. Further review revealed an unidentified pharmacist called on 06/02/2026 and reported that Patient #2’s peripherally inserted central catheter (a long, thin tube put into a vein in the arm and moved close to the heart) dressing had not been changed per Nurse Practitioner orders and it was unknown the last time it was changed. The self-reported incident also revealed that after agency investigations LVN 1 confirmed he did not complete the ordered dressing change. Review of TULIP during presurvey revealed a completed Provider Investigation Report. Patient #2 Record review of Patient #2’s clinical record revealed a plan of care with a start of care date of 10/28/2025 and resumption of care date of 05/20/2026 and a certification period of 04/26/2026 to 06/24/2026. Review of the plan of care revealed RN A and RN B signed and dated the plan of care on 04/22/2026. Continued review of the plan of care revealed a diagnosis of Pressure Ulcer of Sacral Region, Stage 4 (full-thickness tissue loss with exposed bone, muscle, or tendons in the lower back region located directly above the tailbone). Further review of Patient #2’s record revealed a resumption of care order dated and signed by RN C on 05/20/2026 and RN B on 06/01/2026 and included wound care orders for peripherally inserted central catheter line, “Cleanse access site with Chlorhexidine Gluconate (antiseptic wash) swabs for 30 seconds and allow to air dry. Then apply dressing Biopatch (a sterile, circular foam disk placed around a catheter insertion site to prevent infections, absorb small amounts of fluid, and continuously release medicine ) applied to access site, stat-lock (a sterile, suture-less stabilization device that locks the catheter wings onto a plastic retainer pad) applied, cover with transparent dressing, injection cap(a small, sterile, needleless connector attached to the end of the catheter to seal the line, block germs, and let nurses inject medicine or fluids safely) changed, extension tubing(a short, flexible secondary tube that attaches to the catheter) changed WEEKLY.” Further review of Patient #2’s record revealed a missed visit for skilled nursing on 05/25/2026 by LVN 1, a completed skilled nursing visit on 05/27/2026 that LVN 1 documented in the visit note, “no wound care performed due to not ordered this visit,” and another completed skilled nursing visit on 05/29/2026 that LVN 1 documented in the visit note, “SN (Skilled Nurse) performed wound care using aseptic technique per physicians orders.” Further review of the documentation for skilled nurse visit on 05/29/2026 revealed more detailed wound care documentation for Patient #2’s pressure ulcer, but wound care for the peripherally inserted central catheter line was not mentioned. Further review of Patient #2’s record revealed a completed skilled nurse visit on 06/02/2026 that included documentation for the peripherally inserted central catheter line orders, “SN changed peripherally inserted central catheter line dressing to left upper extremity per sterile technique as follows: SN carefully removed old peripherally inserted central catheter line dressing to left upper extremity. The central catheter line is in place, and site is without symptoms of infection or complication. Using sterile technique SN cleansed peripherally inserted central catheter line site with alcohol to skin. SN cleansed peripherally inserted central catheter line site with Chlorhexidine and allowed to penetrate skin for 4 minutes. SN covered site with sterile transparent dressing provided with sterile kit.” During a phone interview on 07/21/2026 at 11:20 AM with FM(family member) 1, Surveyor asked FM 1 to explain what happened with the peripherally inserted central catheter line wound care and FM 1 stated, “the pharmacy would call every week and would go over how much medicine was left and then the pharmacist asked if the dressing was changed on Patient #2’s catheter line and FM 1 told him no and that LVN 1 said it did not need to be changed all the time.” FM 1 stated, “the agency must have said something to LVN 1 because he came out to change it and said he had three other patients with these and he got them mixed up.” During a phone interview on 07/22/2026 at 0900 AM with LVN 1, Surveyor stated that Patient #2 had a missed visit on 05/25/2026 and LVN 1 stated that it was correct. LVN 1 stated he saw Patient #2 on 05/27/2026 and 05/29/2026. Surveyor stated the visit note on 05/29/2026 stated wound care was performed using aseptic technique per doctors’ orders, but it did not elaborate to include the peripherally inserted central catheter specifically. LVN 1 stated, “that was for Patient #2’s pressure ulcers only and I did not do the peripherally inserted central catheter dressing change that day because the visits changed so much and his orders changed that week.” LVN 1 stated, “As soon as I found out a few days later that it was not changed and should have been, I went to see the patient and changed it.” During an interview on 07/22/2026 at 10:50 AM with the Administrator/Supervising Nurse, the Surveyor asked what the agency’s policy was for providing services and interventions per the plan of care and doctors’ orders. Administrator/Supervising Nurse stated, “we gave the interventions and services that the doctor ordered. If they are in the plan of care or ordered, then they are to be done.” The Surveyor asked who is ultimately responsible for making sure the patients are getting all services and interventions that have been ordered and the Administrator/Supervising Nurse stated, “ The RN case manager and the Clinical Manager who reviews the plan of care and then ultimately me to make sure everyone is doing what they are supposed to be doing.” Surveyor asked how does the agency ensure wound care orders are followed and the Administrator/Supervising Nurse stated, “ we do chart reviews especially when an order comes in and we are putting it in the chart and we go back and look at the wound summary and see what is being documented and what orders are being done.” Surveyor asked what was the expected process if a scheduled dressing change could not be completed during a visit and the Administrator/Supervising Nurse stated, “the Clinician should call the doctor and let them know and leave a message if they don’t answer and submit a clinical note, so it can be faxed to the doctor so they are aware why it was not done or couldn’t be done that day and what steps were taken in place of it.” Surveyor asked how were missed treatments identified and the Administrator/Supervising Nurse stated, “through the electronic medical record Home Care Home Base with a clinical note that is checked daily throughout the day and depending on the level of missed treatment they can also do it through a phone call.” Surveyor asked how could not providing the weekly dressing change that was ordered have an adverse effect on Patient #2 and the Administrator/Supervising Nurse stated, “they could get an infection like Sepsis (a life-threatening medical emergency that happens when your body has an extreme, harmful response to an infection) and worse they could die.” Surveyor asked what could have LVN 1 done differently and the Administrator/Supervising Nurse stated, “the biggest issue was the orders in the chart were not reviewed by LVN 1 before the visit and I reiterated to the nurses it needs to be done before you see the patient every single week. LVN 1 knew Patient #2 had a peripherally inserted central catheter line and knew when Patient #2 was scheduled to be seen for wound care, so LVN 1 should have known the dressing change was due.” Review of agency policy titled, “Patient Rights and Responsibilities” revised on 02/05/2026 revealed the following, “PURPOSE: The agency recognizes, respects, and promotes the rights of each individual patient in accordance with fundamental human, civil, constitutional, and statutory rights. The agency also sets forth responsibilities for the patient/ family in order to facilitate coordination of care. (State Specific Patient Rights are located in the Patient Admission Guide). To protect and promote the patient’s right to be informed of his/her rights and to participate in the planning of his/her care to include choice of agency, treatment regimen, and advanced directives, as well as notification of established service/care rates and charges. To clearly state the “Rights and Responsibilities” of the patient and to make a written document available for review by patient, caregiver, and staff… Texas: RULE §558.282 Client Conduct and Responsibility and Client Rights.. f) A client has the following rights:.. (6) A client has the right to be free from abuse, neglect, and exploitation by an agency employee, volunteer, or contractor… TITLE 6. SERVICES FOR THE ELDERLY CHAPTER 102. RIGHTS OF THE ELDERLY Sec. 102.003. RIGHTS OF THE ELDERLY… (2) has the right to be free from abuse, neglect, and exploitation;…””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview the agency failed to transmit completed OASIS (a tool used by CMS to collect certain patient information) assessment to CMS within 30 days of completing the OASIS assessment, in that: from 01/01/2025 to 06/02/2025 there were 681 assessments transmitted greater than 30 days from the assessment completion date. This failure prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Pre-survey review of the report titled, “OASIS Error Detail Report” on 06/05/2025 taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 681 (patients 13, 14, 15, 16 and 17) assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” On 06/04/2025 at approximately 12:35 PM the surveyor conducted an interview with the Director of Operations. The Director of Operations was acting as the Administrator for the agency due to the agency not having an Administrator or Alternate Administrator at the time of the survey. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 01/01/2025 to 06/02/2025 the agency transmitted 681 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked who was responsible for transmitting the OASIS assessment to CMS. The Director of Operations explained the IT department submits the agency OASIS reports. The surveyor asked why the agency had 681 OASIS assessment that were transmitted past 30 days to CMS. The Director of Operations stated, “I didn’t know we had that many late OASIS.” Record review for Patient 13: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64328938 submission date 01/03/2025 with 21 total record processed. Record 7 (Patient 13) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 7 (Patient 13) of the OASIS Agency Final Validation report that was submitted on 01/03/2025 had a M0090 completion date of 11/20/2024. Record review for Patient 14: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64328938 submission date 01/03/2025 with 21 total records processed. Record 17 (Patient 14) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 17 (Patient 14) of the OASIS Agency Final Validation report that was submitted on 01/03/2025 had a M0090 completion date of 11/20/2024. Record review for Patient 15: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64328938 submission date 01/03/2025 with 21 total records processed. Record 20 (Patient 15) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 20 (Patient 15) of the OASIS Agency Final Validation report that was submitted on 01/03/2025 had a M0090 completion date of 11/20/2024. Record review for Patient 16: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64336693 submission date 01/06/2025 with 11 total records processed. Record 2 (Patient 16) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 2 (Patient 16) of the OASIS Agency Final Validation report that was submitted on 01/06/2025 had a M0090 completion date of 12/03/2024. Record review for Patient 17: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64336691 submission date 01/06/2025 with 18 total records processed. Record 6 (Patient 17) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 6 (Patient 17) of the OASIS Agency Final Validation report that was submitted on 01/06/2025 had a M0090 completion date of 12/04/2024. On 06/18/2025 at approximately 12:07 PM the surveyor conducted an interview with the Manager of Application Integration (Employee I). The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor asked Employee I if she was responsible for transmitting OASIS to CMS. Employee I stated, “My team does. I am the manager and I transmit some, but I have 2 other people that do it with me.” The surveyor explained that from 01/01/2025 to 06/02/2025 the agency transmitted 681 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked why the agency had 681 OASIS assessment that were transmitted past 30 days to CMS. Employee I stated, “I don’t really know.” The surveyor discussed the findings from the patient record reviews. The surveyor explained that during record review he found Patients 13, 14, 15, 16 and 17 had OASIS that were transmitted to CMS more than 30 days after the M0090 dates. The surveyor asked why the OASIS were transmitted past 30 days. The Employee I stated, “I don’t know, it was around the new year holiday but I don’t know why they were late.” The surveyor asked what the negative outcome could be for agency clients if the agency submits OASIS past 30 days. Employee I stated, “I’m not sure.” Review of Agency policy titled, “Oasis Outcome and Information Set” with a revision date of 09/26/2024 read in part: “PURPOSE: The agency will collect, encode, and electronically transmit OASIS data as stated in the CMS Federal Conditions of Participation…REGULATORY GUIDANCE:…(a)… transmit each completed OASIS assessment to the CMS system… within 30 days of completing the assessment…””

“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 observation, record review and interview, the agency failed to provide all services outlined in the plan of care in that the agency failed to order enough catheters (hollow tube used to drain urine from the bladder out of the body) for the patient to self-catheterize (patient inserting a catheter to drain urine from the bladder out of the body) at the physician ordered frequency of catheterization for 1 (#12) of 3 patient records reviewed where patients were performing self-catheterizations. The failure placed the patients at risk of infections, kidney problems, fluctuations in blood pressure, and heart problems when unable to drain urine from the bladder. Patient #12: Record review of Patient #12’s clinical record revealed a Plan of Care dated 12/21/2024 to 2/18/2025. The Plan of Care indicated that Patient #12 started on the agency’s services on 10/28/2023 The Plan of Care listed Localized Edema (swelling in a specific area of the body caused by an excessive buildup of fluid in the tissues) with an onset date of 12/5/2024 and Neuromuscular Dysfunction of Bladder (also known as Neurogenic bladder- condition where the nerves and muscles responsible for bladder (stores urine) control are not working together leading to problems with the storage and releasing of urine) diagnoses. The Plan of Care listed Furosemide (generic name for Lasix) 40 milligrams (diuretic medication that works by increasing the amount of urine the body produces to remove excess fluid from the body) by mouth daily for edema (excess fluid in the body) as a medication. The Patient Medication report indicated that Patient #12 started Furosemide 40 milligrams daily on 12/5/2024. Patient #12’s record contained a physician order dated 9/10/2024 that read in part; Patient’s Self-Cath (insertion of catheter into bladder to drain urine) order accidentally left off 485 (Plan of Care). Patient to Self-Cath 4-6 times daily and as needed using 16 French (size) catheter using sterile technique (practice that restricts microorganisms and contamination of surfaces of some objects that would be introduced into the body). Ref number for Self-Caths is 421911 (specific product to use, Urethral Catheter GentleCath Glide Coude Tip (urinary catheter with a curved or angled tip, designed to navigate around blockages or obstructions in the urethra, duct by which urine would drain from the bladder out of the body). Review of Patient #12’s clinical record revealed a 4-page document titled “Home Health-Patient Acknowledgement and Consent” that was signed by Patient #12 on 4/28/2023. The documented listed Patient #12’s payor source as Medicare. The document read in part;...”Provision of supplies and outpatient therapy - For those patients with traditional Medicare, it is the policy of [agency] to provide or arrange for all medically necessary physician-ordered routine and non-routine supplies...” Registered Nurse C conducted a skilled nurse visit on 12/5/2024. Registered Nurse C documented that Patient #12 went to the emergency room over the weekend for shortness of breath, chest pain, and edema of all extremities; Patient #12 was reported to Registered Nurse C that Patient #12 received intravenous (way of giving a medication through a needle or tube inserted into a vein) Lasix (generic name Furosemide -diuretic medication to remove excess fluid from the body by increasing urine production) and Patient #12 sent home with Lasix (Furosemide). Patient #12’s clinical record contained supply requisition reports indicating that 4 boxes of catheters, 30 catheters in each box, had been requested on 12/5/2024 and 12/30/2024 to equal 120 catheters in each request. Registered Nurse C conducted a skilled nurse visit on 1/24/2025 (Friday). Patient #12’s clinical record contained a supply requisition report indicating that 4 boxes of catheters, 30 catheters in each box, had been requested on 1/24/2025 for a total of 120 catheters (20 day supply for catheterizing 6 times each day). Review of the agency’s complaint investigation documentation revealed: -Documentation of a complaint report dated 1/28/2025 indicated that the Operational Manager had received a message on 1/27/2025 at 8:10 a.m. from Patient #12 that Patient #12 did not receive the catheters but received some gauze. The Operational Manager emailed Supply Staff Member on 1/27/2025 and received the following response from Supply Staff Member; “Need to contact [Supply Company] to track order. If patient got wound care supplies instead of catheters that was a packing error by [Supply Company] and they will reship supplies at their cost...” -The Operational Manager spoke to [Supply Company Employee with Supply Company] on 1/27/2025, Supply Company Employee had informed the Operational Manager that Patient #12 would not receive the catheters until Wednesday or Thursday (January 28 or 29th) because they were being shipped from Ohio and Corporate approval would be needed to overnight and gave email address to request overnight. Patient #12’s Family Member called on 1/27/2025 and requested Patient #12 be discharged from the agency and did not want an in-person discharge visit. Corporate had approved overnight shipping for 1 box of catheters and would be delivered by noon on 1/28/2025. During an interview on 6/12/2025 at 12:14 p.m. with Patient #12, Patient #12 informed the surveyor that the home health care company was supplying the catheters. Patient #12 informed the surveyor that they were not ordering the catheters Patient #12 needed or the appropriate amount. Patient #12 stated, “I ran out and was able to see the Urologist (doctor with special training in diagnosing and treating diseases of the urinary and reproductive organs) that day (1/27/2025).” Patient #12 informed the surveyor that the Urologist gave Patient #12 catheter samples. Patient #12 informed the surveyor that he was started on a diuretic (12/5/2025) and had to increase catheterizing to 8 times each day. During an interview on 6/16/2025 at 1:22 p.m. with Registered Nurse C, the surveyor discussed Patient #12 catheters. Registered Nurse was asked how many catheters Patient #12 had in the home when Registered Nurse C would reorder the catheters. Registered Nurse C informed the surveyor that Patient #12 would tell Registered Nurse C when he was down to a box. The surveyor asked how many boxes Patient #12 had in the home when Registered Nurse C reordered the catheters in January 2025. Registered Nurse C stated, “I couldn’t tell you for sure.” The surveyor asked the process for ordering Patient #12’s catheters. Registered Nurse C informed the surveyor that Patient #12’s catheters were non-formulary and Registered Nurse C could not order the catheters. Registered Nurse C informed the surveyor that Registered Nurse C had to go through Supply Staff Member, the supply person based in Louisiana. Patient #12 would tell Registered Nurse C that supplies were needed and Registered Nurse C would email Supply Staff Member. Supply Staff Member would respond back to Registered Nurse C, ordered, and approved. The surveyor asked if Patient #12 had been ordered a diuretic medication. Registered Nurse C informed the surveyor that Patient #12 was started on Lasix (Furosemide). When asked if Patient #12 had informed Registered Nurse C that Patient #12 had to catheterize more often, Registered Nurse C stated, “[Patient #12] didn’t think it (Lasix/Furosemide) was working. [Patient #12] did not tell me [Patient #12] had to catheterize more often.” The surveyor asked if Patient #12’s edema had improved and Registered Nurse C stated, “[Patient #12] edema was better.” The surveyor asked if Registered Nurse C would look at the catheter supply level at Patient #12’s home to see how many catheters Patient #12 had. Registered Nurse C stated, “No, I did not look at them.” The surveyor asked what the physician ordered frequency for Patient #12 to self-catheterize was. Registered Nurse C informed the surveyor that the order was for 4-6 times a day. The surveyor asked what effect this could have on Patient #12. Registered Nurse C stated, “[Patient #12] didn’t want to run out. [Patient #12] couldn’t pee without them.” A home visit with interview was conducted on 6/17/2025 at 2:00 p.m. with Patient #12 and Patient #12’s Family Member. The surveyor asked Patient #12 what the process was to order catheters. Patient #12 informed the surveyor that Patient #12 would tell the nurse and the nurse would put it in the tablet. It would go to the office to be requested, then go to Supply Staff Member. I would give them a week notice. Patient #12 informed the surveyor that Patient #12 would catheterize a minimum of 4 times each day until Patient #12 started on Lasix (Furosemide) and would have to catheterize 8 times per day. Patient #12 informed the surveyor that Patient #12 was currently taking Lasix (Furosemide) but now was only taking as needed for swelling. Patient #12 informed the surveyor that Patient #12 had to take a Lasix (Furosemide) today. Patient #12 informed the surveyor that things had been better with the ordering and obtaining of catheters until January 2025. Patient #12 informed the surveyor that Patient #12 had less than a box of catheters left when Registered Nurse C ordered the catheters in January 2025. Patient #12 informed the surveyor that on 1/25/2025 Patient #12 had texted Registered Nurse C that Patient #12 had only a day’s worth of catheters left and had not received the catheters. Patient #12 informed the surveyor that Registered Nurse C told Patient #12 that Registered Nurse C would check on the order. Registered Nurse C informed Patient #12 that [Staff Member] had not seen that [Supply Staff Member] had placed the order. Patient #12 informed the surveyor that Patient #12 went to the Urologist office to get catheter samples on 1/27/2025. Patient #12 informed the surveyor that Patient #12 had told Registered Nurse C that Patient #12 had to “cath a ton every day” after Patient #12 had started on Lasix (Furosemide). Patient #12 stated, “I used my last catheter in the morning on 1/27/2025. Patient #12 had less than a 4-week supply of catheters in the home when Registered Nurse C ordered catheters in January. Patient #12 would need 180 catheters to last 30 days. A text exchange between Registered Nurse C and Patient #12, dated 1/25/2025, was provided to the surveyor by Patient #12. The text exchange read in part as follows: 1/25/2024 4:12 p.m. (Saturday) Patient #12 -“Hey, sorry to bother you so late on Saturday. My catheters still haven’t arrived and I’m down to about a days worth left. Registered C- “I will check my email from [Staff Member] when I get home in a bit.’ Patient #12 - “lol, sorry and thank you.” Registered Nurse C - ‘Ok. Don’t freak. [Staff Member] didn’t see where [Supply Staff Member] placed the order so [Staff Member] did.’ Patient #12- “So what does that mean?” Registered Nurse C- “That they are on their way as of yesterday instead of when I emailed [Supply Staff Member].” Patient #12 had asked in the text exchange if there was a way to expedite shipping. Registered Nurse C texted, “I can email [Staff Member] but not sure [Staff Member] will get it until Monday (1/27/2025). Let me try. Patient #12 texted, “OK. Thanks.” Supply Staff Member was on leave and not available for interview. During an interview on 6/18/2025 at 8:00 a.m. with the Senior Clinical Supply Manager, Supply Staff Member’s supervisor. The surveyor discussed Patient #12 and catheter supplies. The surveyor asked what Senior Clinical Supply Manager job duties entailed. Senior Clinical Supply Manager informed the surveyor that Senior Clinical Supply Manager oversaw the non-formulary medical request. The surveyor asked if Senior Clinical Supply Manager would approve if a client could have a product. Senior Clinical Supply Manager informed the surveyor that they would try to send a comparable item. If there was not a comparable item and it was an item we can obtain, cost of the item, if not comparable in price to our item, we would reach out to the Assistant Vice President for approval. Senior Clinical Supply Manager informed the surveyor that they did not order supplies; they filled supply requisitions; the nurse would request the quantity; and we sent out the quantity requested. Senior Clinical Supply Manager informed the surveyor that Medical Supply did not limit the quantity that could be ordered. Senior Clinical Supply Manager informed the surveyor that if a client required long term catheter, then the catheters could be ordered for a month at a time. The surveyor asked how the nurses would be education on ordering supplies. Senior Clinical Supply Manager stated, “They have different trainings when they are on-boarded, quantities of the electronic medical record, appropriate recommendation, par levels in the system.” On 6/18/2025 at 10:51 a.m. the surveyor requested the agency’s policy on when the nurses were to reorder supplies. When would the agency want nurses to reorder catheters so clients would not run out, the par level of catheters in the home. During an interview on 6/18/2025 at 12:21 p.m. with the Operational Manager, who had knowledge regarding Patient #12’s catheters, the surveyor discussed Patient #12’s catheters. The surveyor asked what the process was to order Patient #12’s catheters. The Operational Manager informed the surveyor the Operational Manager approved the non-formulary catheters for Patient #12. The Operational Manager stated, “I thought we were ordering 4 cases (120 catheters) at a time.” The surveyor discussed that if Patient #12 catheterized 6 times per day, that would be enough for 20 days. The surveyor discussed that Patient #12 started on a diuretic medication on 12/5/2024 and was having to catheterize more often than 6 times per day. The Operational Manager stated, “I didn’t know, I will see if they increased more on cathing (catheterizing).” The surveyor asked if a month’s supply of Patient #12’s catheters could be ordered at a time. The Operational Manager stated “Yes.” The surveyor asked who would be responsible to make sure the clients have catheters. The Operational Manager informed the surveyor that it would be the nurses that make the visit. The nurses would make a supply requisition. Requests would go to a clinical manager in the office to make sure there was a physician order, it’s on the Plan of Care or new orders, make sure there was a current order. The surveyor asked how long it would take to approve the requisitions. The Operational Manager informed the surveyor if it was received before 2:00 p.m. it would be processed that day. The surveyor asked what if a requisition was sent in on Friday after 2:00 p.m., when would it be processed. The Operational Manager informed the surveyor that it would be processed on Monday, with delivery on Tuesday. The Operational Manager gave the surveyor a document titled “HCHB PointCare Supply Requisition Clinician- Home Health.” The Operational Manager and surveyor reviewed the document together that indicated that the par level for urological supplies in the home was a 4-week supply. On 6/18/2025 at 12:29 p.m. with the Operational Manager the surveyor asked if the par level would include non-formulary supplies. The Operational Manager stated, “Yes, par levels would be for non-formulary too.” The Operational Manager informed the surveyor that Registered Nurse C was new to case managing. During an interview on 6/18/2025 at 1:07 p.m. with Registered Nurse C, the surveyor asked Registered Nurse C about training on ordering supplies and par levels of supplies in the home. Registered Nurse C informed the surveyor that Registered Nurse C did not remember them (agency) verbalizing par levels. Registered Nurse C informed the surveyor that Registered Nurse C “should have been able to do the math (the number of catheters to equal a 4-week supply) but was hesitant due to issues with ordering supplies previously.” Registered Nurse C stated, “I know now that I can order enough (catheters) for a month at a time.” During an interview on 6/18/2025 at 1:34 p.m. with the Operational Manager and the Supervising Nurse, the surveyor discussed catheter supply ordering. The surveyor asked how the nurses were trained on ordering supplies. The Operational Manager informed the surveyor that the nurses were trained with orientation, computer led courses - self-paced and virtual. There would be a skills check-off, ride-along, have preceptor or mentor, complete module training - take through ordering supplies, entering orders. The nurse would have to complete and pass. The surveyor asked if the modules covered par levels when to order supplies. The Operational Manager and Supervising nurse informed the surveyor that the modules would mimic real time. May not have all supplies. The surveyor asked how the nurse would know to order a month of catheter supplies, par levels in the home. The Operational Manager informed the surveyor that it would be included in on-line training. The surveyor asked what effect a diuretic medication would have on the body. The Supervising Nurse and Operational Manager pull off excess fluid by diuresis (an increase in the amount of urine made by the kidney and passed from the body). The surveyor asked what effect of not emptying the bladder could have on the body. The Supervising Nurse and Operational Manager informed the surveyor that it could cause fluctuations in blood pressure, heart problems, and kidney problems. Registered Nurse C did not reorder catheter supplies when Patient #12’s catheter supply reached the home par level. Patient #12 ran out of catheters on 1/27/2025. Patient #12 went to the Urologist’s office on 1/27/2025 to get catheters samples. The Urologist ordered catheters for Patient #12 to be delivered to Patient #12’s home. Review of the agency’s policy titled “Patient Rights and Responsibilities,” labeled RI-001, and dated 7/2/2024 read in part; “Purpose: The agency recognizes, respects, and promotes the rights of each individual patient in accordance with fundamental human, civil, constitutional, and statutory rights...Regulatory Guidance...484.50(c)(5) Receive all services outlined in the plan of care...” Review of the agency’s policy titled “HCHB PointCare Supply Requisition Clinician- Home Health.” The policy was not dated and was given to the surveyor on 6/18/2025. The policy read in part; “A Physician’s order, including the supply category, is required to requisition a supply to a patient....Quantities: Requisition of supplies should accommodate up to 2 weeks of care... Exception: Ostomy, Trach, and Urological (surgical and medical diseases of the urine system) patients- up to 4 weeks of supplies may be appropriate...HCHB Par levels...exception: Ostomy, Trach, Urological supply par levels are set to 4 weeks...””