UT Southwestern Home Health Care

“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, observation, and interview the agency failed to ensure a patient’s right to be free from neglect by the agency’s employees for one (Patients # 16 and 3) of two patients, in that: for Patient # 3 RN D did not timely follow up on urinary catheter care, urinary catheter change orders, RN E did not clarify, validate, and write verbal order for urinary catheter size, and RN E did not timely address the client’s complaint of severe pain after urinary catheter inserted; and Patient # 16 did not receive care for PICC line (is a flexible, long, thin tube that is placed in a vein in the upper arm and threaded into a large vein close to the heart; it is used for long term medication delivery and to draw blood for testing) dressing changes, as ordered, timely follow-up of the patient’s concern for status of the PICC line, and blood collection for laboratory testing as ordered from RN A, RN B, and Alt Admin/Former DON/RN Clinical Mgr. The failure placed the patients at risk of physical and emotional harm and at increased risk of infection due to delayed follow-up for complaints and delayed service provision. Findings include: During the entrance conference interview on 05/20/2026 at 10:20 a.m., the surveyor requested the agency’s complaint logs, incident reports, and records since 05/16/2023. Review of the agency’s complaint record “…Patient Grievance Form…” revealed a complaint report dated 01/02/2026 for Patient # 16. Review of the 01/02/2026 patient grievance form for Patient # 16 revealed that the form read in part: “…Patient would like to end home health service because she does not feel confident in the care. She tried to get someone to see her earlier this week for her bandages, but the agency cancelled. She expected someone today, but nobody came.” Discharged Clinical Record # 16: Record review of the clinical record for Patient # 16 revealed a POC for the certification period of 12/14/2025 to 02/11/2026. Review of the POC revealed a start of care date of 12/14/2025 with a principal diagnosis of acquired deformity of nose. RN A signed and dated the POC on 12/18/2025. The POC contained an order for skilled nursing visits three times per week for one week; two times per week for one week, and one time per week for seven weeks. The POC included orders for SN visits to monitor and teach self-management of intravenous antibiotic therapy with an anticipated end date of 01/22/2026. Patient # 16 and caregiver (CG 2) administered the intravenous antibiotic therapy. Continued review of the POC revealed the following orders: SN to change the PICC line dressing and caps to the ports on the PICC line one time weekly and as needed; and SN to collect a laboratory blood specimen of blood from the PICC line for laboratory testing each visit. Review of SN visit notes revealed the following: SOC visit dated 12/14/2025 did not reveal that RN A changed the PICC line dressing or collected a laboratory blood specimen of blood from the PICC line for lab testing. SN visit dated 12/16/2025 revealed that RN A collected a laboratory blood specimen of blood from the PICC line for lab testing but did not reveal that RN A changed the PICC line dressing. RN A signed the note on 12/22/2025. SN visit dated 12/17/2025 did not reveal that RN A collected a laboratory blood specimen of blood from the PICC line for lab testing and did not reveal that RN A changed the PICC line dressing. The note stated, “SN to…” change the dressing and collect the blood specimen. RN B signed the note on 12/21/1025. Patient # 16’s record included a missed visit note dated 12/22/2025. RN B signed the note on 01/01/2026 SN visit note dated 12/26/25 revealed that RN B changed the PICC line dressing and collected a laboratory blood specimen of blood from the PICC line for lab testing. RN B signed the note on 01/01/2026. Review of the note revealed the following: “Blue lumen (port on PICC line) unable to obtain blood return but flushed without difficulty…IV (in the vein) antibiotic was connected to the blue lumen…” Patient # 16’s record included a SN missed visit note dated 01/02/2026. RN B signed the note on 01/07/2026. Review of the note revealed the following: “Patient was scheduled for a skilled nursing visit on this date. Prior to initiating the visit, skilled nurse reviewed the patient’s chart and noted an active order from the radiologist (a medical doctor who specializes in treating and diagnosing injuries and diseases using x-rays and other medical imaging) directing home health to reschedule the nursing visit for the patient to report to radiology for further [PICC line placement) evaluation. Skilled nurse contacted the patient and informed her of the radiology order and the need to attend the radiology appointment as directed. Patient insisted that skilled nurse come to home to perform a PICC line dressing change. Patient sent SN a photograph of the PICC line site. Upon review of the image, SN observed that the bio patch (a protective disc that is placed around a medical device insertion site and includes medication to inhibit infection) appeared displaced and the PICC line appeared to have shifted…one lumen/port had reportedly not been functioning for the past five days…Patient…stated she had previously gone to emergency department, where she reported staff were “not concerned.” Patient…stated she would…go to the infectious disease department to have the PICC line dressing changed…” Patient # 16’s record did not include a copy of the photograph of the PICC line site. Continued review of Patient # 16’s record revealed and emergency department visit dated 12/26/2025 to 12/27/2025. Review of the visit note revealed that it read in part: “…[Patient # 16] States today when she was having home health come obtain her blood work from her right upper extremity PICC line they were unable to access one of the ports and when they got the labs she was found to be hypoglycemic with a blood sugar of 25. She states she has eaten and drink sweet tea/sugar cookies since then which brought her blood sugar up. She states that around the time of getting her blood results she began experiencing sharp chest pain worse with deep breaths that was persistent and has recently become the pressure sensation…” Patient # 16’s record did not include any records or documentation from the home health agency of the low blood sugar. Further review of Patient # 16’s record revealed an “Infectious Disease Clinic Note” dated 12/31/2025. Review of the clinic note revealed that it read in part: “…[Patient # 16] reports that her continuous infusion is clogged and expresses dissatisfaction with [Agency] Home Health Care. She had a no-show from one of the nurses and another nurse who came the day after Christmas did not put on the little blue caps. The next morning, she noticed that the bulb was still 3/4 full and had turned a yellow brown, amber color. Then another nurse attempted to draw blood and flush the line but reported it was clogged. They put the line into the blood draw one, and she has not seen anyone since. The last change was on Friday [12/26/2025] she reports pain at the site which has been presence since the procedure and is worsening... She received a call from a doctor regarding her blood draw advising her to go to the emergency room because her blood sugar was 25, they believe it was a bad blood draw…” Patient # 16’s record did not include any records or documentation from the home health agency of the of follow-up of Patient # 16’s expressed dissatisfaction. During an interview with Patient # 16 on 05/28/2026 at 11:51 a.m. the surveyor asked Patient # 16 to describe her dissatisfaction with the agency. Patient # 16 stated that she went eight to nine days without a dressing change to her PICC line site. She stated that the first dressing change was on 12/26/2025. She stated that the lady who changed it did not have “a clue what she was doing. She did not even know how to lay a sterile field. She did not do a good job.” She stated that she called the agency on Saturday 12/27/2026 (she stated that she was not exactly sure of the date) with an emergency because there was “blood backflow all over” from the PICC line. She stated that Alt Admin/Former DON/RN Clinical Mgr. said that she was with a patient and she would have to call her back. Patient # 16 stated, “She called back and had me send a picture. She said it was normal.” She stated that RN B called her one day and refused to come change her dressing. She stated that RN B wanted her to get a sonogram (visual medical imaging). She stated that she was not driving at the time and unable to get a sonogram. “They were awful and unprofessional. I never had anything (PICC line) like this before.” She stated that she felt emotionally anxious and concerned that it would get infected. She stated that she had a new facility that was overseeing her antibiotic infusions and dressing changes, “They are amazing.” Patient # 16 stated that the agency refused to change her PICC Line dressing, and she told the agency staff if they were not going to change the dressing there was no need for them to come to her home. Patient # 16 texted the picture to the Surveyor of her PICC line with the blood backflow to the on 05/28/2026 at 5:47 p.m. The pictures did not include a date, but Client # 16 stated that she sent the pictures to Alt Admin/Former DON/RN Clinical Mgr. on the weekend of 12/27/2026. Review of the Client # 16’s record did not include any records or any documentation related to the incident of the blood backflow on Client # 16’s PICC line. During an interview with RN A on 05/29/2026 at 10:02 a.m. the surveyor asked if RN A had provided PICC line dressing changes and collected a laboratory blood specimen of blood from the PICC line for lab testing for Patient # 16. RN A stated, “I did not do much. I was still just learning. I think there was a rush (in RN A’s training).” RN A was no longer employed with the agency and declined to answer any further questions. During interview on 05/29/2026 at 11:09 a.m. with RN B the Surveyor asked if RN B provided care for and conduct visits with Patient# 16. RN B stated that she was seeing Patient# 16 with her preceptor (LVN A). She stated that she did not see the patient by herself. The Surveyor asked if RN B collected blood for laboratory testing and changed the dressing on Patient# 16’s PICC line on 12/26/2025. RN B stated that she changed the dressing under the directions of her preceptor (LVN A). The surveyor asked if Patient# 16 called RN B about concerns with and sent a picture (documented on case note 01/02/2026) of her PICC line site on 12/27/2025. RN B replied, “Yes, she did on a Saturday.” The surveyor requested a copy of the picture. RN B replied, “Let me see if I still have it.” The Surveyor asked what RN B did when Patient# 16 called the weekend of 12/27/2026, with concerns about the PICC line. RN B stated that she directed Patient# 16 to call the on-call nurse. RN B stated that she believed the on-call nurse was Alt Admin/Former DON/RN Clinical Mgr. The surveyor asked what RN B did with pictures that were received from patients. RN B stated that she would upload it to the media folder of the client’s electronic record, but back then she did not know to (that she was supposed to) upload it. The surveyor asked what RN B was trained to do when patients call with concerns. She stated that she redirected Patient# 16 to person on-call.” The Surveyor asked if RN B reported Patient# 16’s concern concerns about the PICC Line. RN B replied, “I told my preceptor (LVN A) and supervisor (Alt Admin/Former DON/RN Clinical Mgr.).” RN B texted a picture to Surveyor of Patient # 16’s PICC line on 05/29/2026 at 2:58 p.m. Review of the picture of Client # 16’s PICC line did not reveal a date that it was sent to RN B and was not clear enough to determine if the PICC line looked displaced. The picture showed Client # 16’s arm with the PICC line inserted. The picture was not the same picture that Patient # 16 sent to the surveyor. The line did not have any blood in or around the tube. During an interview on 05/29/2026 4:15 p.m. with the Admin, Alt Admin/Former DON/RN Clinical Mgr., DON, and QA Nurse A surveyor reviewed the findings and asked what Alt Admin/Former DON/RN Clinical Mgr. could tell the surveyor about Patient # 16. She replied, “I remember the patient now.” She stated that the patient had a medical doctor’s visit and the caps were not replaced to the PICC line. The surveyor asked if Alt Admin/Former DON/RN Clinical Mgr. conducted a visit (on 12/27/2025) with Patient # 16. She stated that she was trying to instruct the patient to look through the supplies for caps for the PICC line. “I did not do a visit. I just dropped off supplies (the caps).” The Surveyor asked why Alt Admin/Former DON/RN Clinical Mgr. did not document the visit and communication with Patient # 16 and RN B about the clients concerns on 12/27/2025. She stated that she should have documented it. The surveyor requested a copy of the picture that Patient # 16 sent Alt Admin/Former DON/RN Clinical Mgr. The surveyor asked why the picture was not uploaded into the Patient clinical record. She replied, “I did not upload it.” The surveyor asked if the agency self-reported the incident of the client’s complaints. Admin stated, “it is our responsibility to report.” The surveyor asked why the agency did not investigate and self-report. Admin stated that she did not know what was going on. “It should have been reported.” The surveyor asked Alt Admin/Former DON/RN Clinical Mgr. why she did not self-report. She stated, “I don’t recall. I’m trying to remember. I remember [Patient # 16] reaching out about her concern about times of visits.” Alt Admin/Former DON/RN Clinical Mgr. texted pictures of ports for Patient #16 the PICC line to surveyor on 05/29/2026 at 4:54 p.m. Review of the pictures revealed that Client # 16 sent the pictures to Alt Admin/Former DON/RN Clinical Mgr. at 3:40 p.m. on 12/27/2025. Further review of revealed “I am on my way.” The pictures were not the same as the picture that Patient # 16 sent to the Surveyor. The pictures did not include Patient # 16’s arm with the PICC line and blood backflow. During a follow up interview on 06/04/2026 at 11:37 a.m. with RN B’s preceptor (LVN A) the surveyor asked what LVN A remembered about the weekend of 12/27/2025 related to Patient# 16’s PICC line concerns. LVN A stated that on the weekend of 12/27/2025 RN B received a call from Patient# 16 about her PICC line being clogged. RN B directed Patient # 16 to on call person (Alt Admin/Former DON/RN Clinical Mgr.). Review of a text thread between Patient # 16 and RN B revealed the following: The top of the thread listed RN B’s name, the date 12/28/2025 (with no time visible), and Patient # 16’s name. Patient # 16 text RN B and said, “Just got off the phone with [Alt Admin/Former DON/RN Clinical Mgr.]. She is coming to unclog the purple line, and I have antibiotic going through the red line. RN B texted (at 3:37 p.m.) Patient # 16 to ask if Alt Admin/Former DON/RN Clinical Mgr. was able to “troubleshoot” the PICC line. Client # 16 text “…[Alt Admin/Former DON/RN Clinical Mgr.] came yesterday to try to get the purple line cleared but was not able to…” Review of another text thread between LVN A and Alt Admin/Former DON/RN Clinical Mgr. revealed the following: Alt Admin/Former DON/RN Clinical Mgr.’s name at the top of the thread, date 12/28/2025, and time 5:45 p.m. LVN A text Alt Admin/Former DON/RN Clinical Mgr., “Hello I’m with [RN B] and [Patient # 16] said that her line malfunctioned this weekend and you were unable to unclog and she was need a solution [solution that breaks us clots in PICC lines to restore function] I’m assuming -Did you call in for [the solution] or do we need to call for it? Alt Admin/Former DON/RN Clinical Mgr. text, “I will reach out to the provider in the morning. [Patient] also reported an [emergency room] visit [due to ] lab results. Her red line is working. Was going to update [RN B] tomorrow…” Active Clinical Record # 3: Record review of the clinical record for Patient # 3 revealed a resumption of care POC dated 01/14/2026 with a start of care date of 12/25/2025 and a certification period of 12/25/2025 to 02/22/2026. Review of the POC revealed a principal diagnosis of Acute post hemorrhagic anemia (a drop in hemoglobin and red blood cells caused by a significant and rapid loss of blood). The POC included an assessment date of 01/14/2026 that was completed by RN D. Continued review of the POC revealed the following” “Problem: Risk of Infection Patient has been assessed to be at high risk for infection as evidenced by… urinary catheter….Problem: Urinary Catheter Patient requires urinary catheter changes. [Skilled nurse] to assess genitourinary (combined body system of the urinary and reproductive organs) status and identify any signs and symptoms of impaired urinary function. Intervention: Urinary Catheter Frequency: [as needed] Patient was [discharged, no discharged date was provided] from hospital with a [urinary] catheter, no order for care of [urinary] catheter. Patient gets [urinary catheter] changed at …Urology Clinic…” catheter. Continued review of Patient # 3’s record revealed a POC for the certification period of 12/25/2025 to 02/22/2026. Review of the POC revealed a start of care date of 12/25/2025 with a principal diagnosis of Acute post hemorrhagic anemia. RN C signed and dated the POC on 12/25/2025. The POC contained an order for skilled nursing visits two times per week for one week and three times per week for eight weeks. Continued review of the POC revealed the following” “Problem: Risk of Infection Patient has been assessed to be at high risk for infection as evidenced by… urinary catheter….Problem: Urinary Catheter Patient requires urinary catheter changes. [Skilled nurse] to assess genitourinary status and identify any signs and symptoms of impaired urinary function. Intervention: Urinary Catheter Frequency: [as needed] Patient was [discharged, no discharge date was provided] from hospital with a [urinary] catheter, no order for care of [urinary] catheter. Instructed [caregiver] to follow up with provider…” Patient # 3’s record did not include any caregiver or agency follow-up for the urinary catheter care or a size of the urinary catheter. The POC included orders for wound care to the left foot three times per week. Review of SN visit note (12/27/2025) revealed that RN C signed and dated the note. Continued review of the SN visit note revealed under the genitourinary section that Patient # 3 had a size “# 16 [French urinary] catheter in place. (Higher numbered catheters, indicates the thicker and larger the external diameter of the catheter will be).” Review of case communication note dated 01/16/2026 revealed that RN D signed the note. Continued review of the case note read in part: “…Home Health will need orders for indwelling (urinary) catheter care to change catheter at home.[Patient is currently home bound and would benefit from it. CG (caregiver # 1) stated that she will be reaching out to [Physician # 1’s] office to request the orders…” Further review of Patient # 3’s record did not reveal a physician’s order for urinary catheter care or urinary catheter change. Review of SN visit note (01/19/2026) revealed that RN E signed and filed the note on 01/22/2026. Review of the SN note read in part: “…Upon entering the room foul odor from the urinary drainage bag was noted. Therapist met nurses and informed that the catheter was leaking to the point that the patient had to be cleaned and changed…[Patient]…Does finally admit that he has flank (located on the side of body between bottom of ribs and top of hip) “pain at 12 of 10.” Call to triage for doctor order to possibly change the catheter…Complains of pain in urethra and burning…Triage gave recommendation to transport to [emergency department]. Ambulance called for transport of patient…” Review of SN visit note (01/21/2026) revealed that RN E signed and filed the note on 01/24/2026. Review of the SN note read in part: “…[Patient] States that he feels 100% better that the pain is gone from the urinary tract infection and having the catheter changed out… Family informed that the patient was also dehydrated and was given 3 liters of fluid in the [emergency department]. There was no documentation in the note of an order for urinary catheter care, change, or size of current urinary catheter. Review of SN visit note (01/30/2026) revealed that RN E signed the note on 02/01/2026. Review of the SN note read in part: “…it was noted that patient was soaked in with urine. Foul smell noted when covers were pulled back…Called urologist (a medical who specializes in treating diseases of the urinary tract in women and men and treating male reproductive system) and received order to change the catheter every 4 weeks and [as needed]…[urinary] catheter was changed with an 18 [French]…catheter immediately started to drain cloudy yellow urine…” Further review of Patient # 3’s record did not reveal a written verbal order for the catheter change or for the catheter size change from # 16 to # 18. Review of SN visit note (02/09/2026) revealed that RN E signed the note on 02/09/2026. Review of the SN note read in part: “… [Urinary catheter] changed... Used 18 [French urinary] catheter and inserted until resistance and urine obtained. Urine has a small amount of blood noted. Patient complaints of pain of 12 out of 10 came down to 5 after a couple of [minutes]. Up to 20 [minutes] patient denied pain…” Further review of Patient # 3’s record did not include any documentation that RN E followed up with Patient # 3, his family, or agency supervisor related to blood in the urine and complaint of pain. Review of OT transfer assessment and OT Home visit note dated 02/09/2026 revealed that OT A signed and dated the transfer assessment and note on 02/10/2026. Review of the transfer assessment revealed that Patient # 3 was transferred to emergency department and admitted to hospital for blood in his urine and urinary catheter and elevated troponin levels (shows the amount of a protein found in the heart muscle that is in the bloodstream). Review of home visit note read in part: “…[Patient] Is not feeling well and shows very poor motivation today… during visit [patients family member] called therapist to report [patient] had [skilled nurse] earlier today and was having some cramping and blood in [urinary] tube… [Patient] had done well last two visits with OT and was showing more progress, motivation and endurance. It is possible [patient] is becoming more frustrated with multiple sets backs re: catheter problems. Later in the day [patients family member] contacted therapist to report he was in the [emergency room]…” During a home visit, observation and interview with Patient # 3, CG # 1, and RN F on 05/27/2026 at 12:00 p.m. the surveyor observed RN F provided wound care to Patient # 3’s left foot blister. RN F provided the treatment in accordance with physician’s orders and using standard infection control procedures. RN F removed Patient # 3’s urinary catheter, but Patient # 3 requested privacy and the Surveyor did not observe the procedure. RN F stated that she had been employed with the agency since January 2026. Patient # 3 stated that RN F was his favorite nurse. Durning an interview with CG # 1 the surveyor asked if the Patient or family had any concerns about the care that Patient # 3 had received from the agency. CG # 1 stated that Patient # 3 was afraid to complain or voice any concerns because he was afraid of retaliation. CG # 1 stated that in or around November 2025 a nurse (CG # 1 could not remember the name of the nurse) would use the same gloves for applying new wound dressings that were used to remove old wound dressings. CG # 1 stated that Patient # 3 soon after got an infection and had sepsis in the blood and had to be hospitalized and had a toe amputation. CG # 1 stated that on 02/09/2026 RN E changed Patient # 3’s urinary catheter and he started bleeding and was in pain; GC # 1 called the agency the same day to notify of the bleeding and the pain; and Patient # 3 went to the emergency department the same day. CG # 1 stated that a new urinary catheter was replaced at the emergency department. GC # 1 stated that it was explained to “us” that the previous urinary catheter was inflated in the urethra (tube that carries urine from the bladder to outside of the body) and not in the bladder. CG # 1 stated that Patient # 3 had a suprapubic (an opening created surgically that connects the urinary bladder and the skin to drain urine) urinary catheter placed on 05/13/2026 in outpatient surgery. Surveyor asked if CG # 1 spoke with RN E on 02/09/2026 about the bleeding and the pain. She stated, “we had a lot of contact with nurse [RN E]. He was in so much pain. The bleeding was what concerned us the most.” CG # 1 state that the urologist was called. Patient # 3 was still in pain and bleeding, and nurse [RN E] called the ambulance.” GC # 1 stated that since the home health took over changing the urinary catheter for Patient # 3 the leaking and bladder spasms got worse. During an interview with RN E on 05/29/2026 at 9:08 a.m. , the surveyor asked how long RN E had worked for the agency. RN E stated that she had worked for the agency for five months. The surveyor asked RN E to describe her training after hire. RN E stated that it was here and there. She would get started with training and something would come up. Christmas, New Year’s, state audit, and the training would be placed on hold, but the training was ongoing. The surveyor asked if RN E could find the agency’s resources for clinical procedures (i.e., urinary catheter changes). RN E stated that she could not say exactly that she could find the agency’s resources for the agency’s clinical procedures. She stated that she would call the Alt Admin/Former DON/RN Clinical Mgr. The surveyor asked when RN E was in a client’s home and received an order from a physician where the order was documented. RN E stated that she just put it in the (SN) note and went to the intervention and changed the intervention (on the POC). The surveyor asked what RN E what her role was in following up on needed urinary catheter care and catheter change orders for Patient # 3. RN E stated that shortly after she took over Patient # 3’s care his urinary catheter leaked and there was no order for the nurses to change it (until 02/09/2026). RN E stated that on 02/09/2026 she changed Patient # 3’s urinary catheter. She stated after the catheter was inserted there was a little bit of blood. She stated that she came back in about an hour and it was draining urine but did have some blood. She stated that after and while she was inserting the urinary catheter Patient # 3 complained of 12 out of 10 pain. She stated that when she came back to Patient # 3’s home (later on 02/09/2026) he stated that he was in minimal pain, so that was why she thought everything was okay. She stated that she stayed in constant contact with Patient # 3’s family. She stated that she did not remember if (the emergency department or hospital) figured out what happened. There was no documentation in Patient # 3’s record of RN E’s follow-up with Patient # 3 and his family. During a follow-up interview with RN E on 06/04/2026 at 12:43 p.m. the surveyor asked RNE if Patient # 3’s urologist, on 01/30/2026, specified a size for the urinary catheter for Patient #3. RN E stated that she did not think the urologist specified but she thought it was an 18 French. She stated that she just put back what he had in. The surveyor asked RN E why she did not write a verbal order for the catheter care and change for Patient #3. RN E stated that she believed the agency’s office staff were putting in the physician’s order. On 05/29/2026 at approximately 4:20 p.m. the surveyor conducted an interview with the Admin, Alt Admin/Former DON/RN Clinical Mgr., DON, and QA Nurse A. The surveyor reviewed the findings and asked what RN E reported to Alt Admin/Former DON/RN Clinical Mgr. about Patient # 3’s urinary catheter change and emergency department visit on 02/09/2026. Alt Admin/Former DON/RN Clinical Mgr. stated that she remembered that RN E called about the bloody urine. She stated that RN E had contacted Patient # 3’s provider and was instructed to send Patient # 3 to the emergency department. Alt Admin/Former DON/RN Clinical Mgr. stated RN E should have written the follow up in Patient # 3’s clinical record. She stated that the documentation was not complete. RN E should have documented the incident follow up. Review of agency policy titled, “Patient Rights” dated 2024 read in part: “…Procedure…VI. Rights of the Patient. The patient has a right to…B. Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect…C. Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for…person by anyone who is furnishing services on behalf of the HHA…J. The home health agency shall investigate complaints made by a patient or the patient’s family… regarding treatment or care that is (or fails to be) furnished…by anyone furnishing service on behalf of the home health agency, and must document both the insistence of the complaint and the resolution of the complaint...L. Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity…” Review of Agency policy titled, “Clinical Records Addendum_ dated 2024 read in part: “…I. In accordance with accepted principles of practice, an agency must establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible...i. Complete documentation of all known services and significant events. Documented action must show that an effective interchange, reporting, and coordination of care occurs…””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in one (Patients # 16) of three discharged patient records reviewed, where the patient required a written notice. The agency failed to provide Patient # 16 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistency and continuing care in the patient’s post discharge needs. The failure caused the patient to not have written advance notice to appeal the discharge decision if desired. Findings include: Discharged Clinical Record # 16: Record review of the clinical record for Patient # 16 revealed a POC for the certification period of 12/14/2025 to 02/11/2026. Review of the POC revealed a start of care date of 12/14/2025 with a principal diagnosis of acquired deformity of nose. RN A signed and dated the POC on 12/18/2025. The POC contained an order for skilled nursing visits three times per week for one week; two times per week for one week, and one time per week for seven weeks. Continued review of the record revealed a discharge OASIS (is a group of standard data elements home health agencies include into their comprehensive patient assessments, to collect and report quality data to the Centers for Medicare & Medicaid Services dated) 01/07/2026. RN B signed and dated the discharge OASIS on 01/07/2026. Further review of Patient # 16’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 01/07/2026. The record did not include a 2-day written NOMNC. During an interview with Patient # 16 on 05/28/2026 at 11:51 a.m. the surveyor asked if the client had requested to be discharged on 01/07/2026. Client # 16 stated that she did not request to be discharged from the agency. The surveyor asked if Client # 16 received a written notice of discharge from the agency. Client # 16 stated that she did not receive a written notice, “They did not tell me that they were going to discharge me.” Client # 16 stated that the agency refused to change her PICC Line (is a flexible, long, thin tube that is placed in a vein in the upper arm and threaded into a large vein close to the heart; it is used for long term medication delivery and to draw blood for testing) dressing and she told the agency staff if they were not going to change the dressing there was no need for them to come to her home. During an interview on 05/29/2026 at 11:09 a.m. with RN B, the surveyor asked if RN B had provided Patient # 16 a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 01/07/2026. RN B stated that she did not provide the notice because the patient requested to be discharged. During an interview on 05/29/2026 at 3:51 p.m. with the Admin, Alt Admin, DON, and QA Nurse A the surveyor reviewed the findings and asked why a written notice was not provided to Client # 16. Admin stated that it was hard to know. QA Nurse A stated because they (nursing staff) have been trained. During a follow up telephone interview with the Admin on 06/03/2026 at 9:02 a.m. the surveyor asked who at the agency was responsible for ensuring the patients received the 2-day written notification of the agency’s intent to discharge. Admin stated the clinician (RN or PT) who completed the discharge was responsible for providing the notice. The surveyor asked what the agency’s process was for ensuring that the notices were provided. Admin stated that the agency did audits and provided training to ensure that the notices were provided. Review of agency policy titled, “Transfer, Discharge and Discharge Planning” dated 2025 revealed that it read in part: “ Policy: The agency will maintain and implement an effective transfer and discharge planning process in compliance with the CMS Conditions of Participation. Both transfer and discharge planning will ensure safe, coordinated transitions of care and uphold patient rights. Purpose: To ensure safe, effective, and patient-centered transfer and discharge from home health services consistent with regulatory requirements and best practices…Procedure…XIX. A Notice of Medicare Non-Coverage (NOMNC) will be given to patients whose care will no longer be covered by Medicare, on the next to last visit (at minimum) when the frequency is less than daily, or at least two calendar days prior to the end of Medicare or Medicare HMO covered services with daily visits. A. The NOMNC explains the patient’s right to an immediate independent review of the proposed discontinuation of services…””

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interview the agency failed to document both the existence of the complaint and the resolution of the complaint for one (Patients # 16) of two clients whose records were reviewed and who experienced adverse events, in that: the agency did not document the existence and resolution of Patient # 16’s complaint that the agency staff was not concerned about dressing changes to her PICC line (is a flexible, long, thin tube that is placed in a vein in the upper arm and threaded into a large vein close to the heart; it is used for long term medication delivery and to draw blood for testing) site, that her PICC line was clogged, and there was blood backflow in her PICC line. The failure placed the patient at an increased risk of physical and emotional harm and at increased risk of infection or blood clots due to delayed resolution of the complaint. Findings include: During the entrance conference interview on 05/20/2026 at 10:20 a.m., the surveyor requested the agency’s complaint logs, incident reports, and records since 05/16/2023. Review of the agency’s complaint record “…Patient Grievance Form…” revealed a complaint report dated 01/02/2026 for Patient # 16. Review of the 01/02/2026 patient grievance form for Patient # 16 revealed that the form read in part: “…Patient would like to end home health service because she does not feel confident in the care. She tried to get someone to see her earlier this week for her bandages, but the agency cancelled. She expected someone today, but nobody came.” Discharged Clinical Record # 16: Record review of the clinical record for Patient # 16 revealed a POC for the certification period of 12/14/2025 to 02/11/2026. Review of the POC revealed a start of care date of 12/14/2025 with a principal diagnosis of acquired deformity of nose. RN A signed and dated the POC on 12/18/2025. The POC contained an order for skilled nursing visits three times per week for one week; two times per week for one week, and one time per week for seven weeks. The POC included orders for SN visits to monitor and teach self-management of intravenous antibiotic therapy with an anticipated end date of 01/22/2026. Patient # 16 and caregiver (CG 2) administered the intravenous antibiotic therapy. Continued review of the POC revealed the following orders: SN to change the PICC line dressing and caps to the ports on the PICC line one time weekly and as needed; and SN to collect a laboratory blood specimen of blood from the PICC line for laboratory testing each visit. Review of SN visit notes revealed the following: SOC visit dated 12/14/2025 did not reveal that RN A changed the PICC line dressing or collected a laboratory blood specimen of blood from the PICC line for lab testing. SN visit dated 12/16/2025 revealed that RN A collected a laboratory blood specimen of blood from the PICC line for lab testing but did not reveal that RN A changed the PICC line dressing. RN A signed the note on 12/22/2025. SN visit dated 12/17/2025 did not reveal that RN A collected a laboratory blood specimen of blood from the PICC line for lab testing and did not reveal that RN A changed the PICC line dressing. The note stated, “SN to…” change the dressing and collect the blood specimen. RN B signed the note on 12/21/1025. Patient # 16’s record included a missed visit note dated 12/22/2025. RN B signed the note on 01/01/2026 SN visit note dated 12/26/25 revealed that RN B changed the PICC line dressing and collected a laboratory blood specimen of blood from the PICC line for lab testing. RN B signed the note on 01/01/2026. Review of the note revealed the following: “Blue lumen (port on PICC line) unable to obtain blood return but flushed without difficulty…IV (in the vein) antibiotic was connected to the blue lumen…” Patient # 16’s record included a SN missed visit note dated 01/02/2026. RN B signed the note on 01/07/2026. Review of the note revealed the following: “Patient was scheduled for a skilled nursing visit on this date. Prior to initiating the visit, skilled nurse reviewed the patient’s chart and noted an active order from the radiologist (a medical doctor who specializes in treating and diagnosing injuries and diseases using x-rays and other medical imaging) directing home health to reschedule the nursing visit for the patient to report to radiology for further [PICC line placement) evaluation. Skilled nurse contacted the patient and informed her of the radiology order and the need to attend the radiology appointment as directed. Patient insisted that skilled nurse come to home to perform a PICC line dressing change. Patient sent SN a photograph of the PICC line site. Upon review of the image, SN observed that the bio patch (a protective disc that is placed around a medical device insertion site and includes medication to inhibit infection) appeared displaced and the PICC line appeared to have shifted…one lumen/port had reportedly not been functioning for the past five days…Patient…stated she had previously gone to emergency department, where she reported staff were “not concerned.” Patient…stated she would…go to the infectious disease department to have the PICC line dressing changed…” Patient # 16’s record did not include a copy of the photograph of the PICC line site. Continued review of Patient # 16’s record revealed and emergency department visit dated 12/26/2025 to 12/27/2025. Review of the visit note revealed that it read in part: “…[Patient # 16] States today when she was having home health come obtain her blood work from her right upper extremity PICC line they were unable to access one of the ports and when they got the labs she was found to be hypoglycemic with a blood sugar of 25. She states she has eaten and drink sweet tea/sugar cookies since then which brought her blood sugar up. She states that around the time of getting her blood results she began experiencing sharp chest pain worse with deep breaths that was persistent and has recently become the pressure sensation…” Patient # 16’s record did not include any records or documentation from the home health agency of the low blood sugar. Further review of Patient # 16’s record revealed an “Infectious Disease Clinic Note” dated 12/31/2025. Review of the clinic note revealed that it read in part: “…[Patient # 16] reports that her continuous infusion is clogged and expresses dissatisfaction with [Agency] Home Health Care. She had a no-show from one of the nurses and another nurse who came the day after Christmas did not put on the little blue caps. The next morning, she noticed that the bulb was still 3/4 full and had turned a yellow brown, amber color. Then another nurse attempted to draw blood and flush the line but reported it was clogged. They put the line into the blood draw one, and she has not seen anyone since. The last change was on Friday [12/26/2025] she reports pain at the site which has been presence since the procedure and is worsening... She received a call from a doctor regarding her blood draw advising her to go to the emergency room because her blood sugar was 25, they believe it was a bad blood draw…” Patient # 16’s record did not include any records or documentation from the home health agency of the of follow-up of Patient # 16’s expressed dissatisfaction. During an interview with Patient # 16 on 05/28/2026 at 11:51 a.m. the surveyor asked Patient # 16 to describe her dissatisfaction with the agency. Patient # 16 stated that she went eight to nine days without a dressing change to her PICC line site. She stated that the first dressing change was on 12/26/2025. She stated that the lady who changed it did not have “a clue what she was doing. She did not even know how to lay a sterile field. She did not do a good job.” She stated that she called the agency on Saturday 12/27/2026 (she stated that she was not exactly sure of the date) with an emergency because there was “blood backflow all over” from the PICC line. She stated that Alt Admin/Former DON/RN Clinical Mgr. said that she was with a patient and she would have to call her back. Patient # 16 stated, “She called back and had me send a picture. She said it was normal.” She stated that RN B called her one day and refused to come change her dressing. She stated that RN B wanted her to get a sonogram (visual medical imaging). She stated that she was not driving at the time and unable to get a sonogram. “They were awful and unprofessional. I never had anything (PICC line) like this before.” She stated that she felt emotionally anxious and concerned that it would get infected. She stated that she had a new facility that was overseeing her antibiotic infusions and dressing changes, “They are amazing.” Patient # 16 texted the picture to the Surveyor of her PICC line with the blood backflow to the on 05/28/2026 at 5:47 p.m. The pictures did not include a date, but Client # 16 stated that she sent the pictures to Alt Admin/Former DON/RN Clinical Mgr. on the weekend of 12/27/2026. Review of the Client # 16’s record did not include any records or any documentation related to the incident of the blood backflow on Client # 16’s PICC line. During an interview with RN A on 05/29/2026 at 10:02 a.m. the surveyor asked if RN A had provided PICC line dressing changes and collected a laboratory blood specimen of blood from the PICC line for lab testing for Patient # 16. RN A stated, “I did not do much. I was still just learning. I think there was a rush (in RN A’s training).” RN A was no longer employed with the agency and declined to answer any further questions. During interview on 05/29/2026 at 11:09 a.m. with RN B the Surveyor asked if RN B provided care for and conduct visits with Patient# 16. RN B stated that she was seeing Patient# 16 with her preceptor (LVN A). She stated that she did not see the patient by herself. The Surveyor asked if RN B collected blood for laboratory testing and changed the dressing on Patient# 16’s PICC line on 12/26/2025. RN B stated that she changed the dressing under the directions of her preceptor (LVN A). The surveyor asked if Patient# 16 called RN B about concerns with and sent a picture (documented on case note 01/02/2026) of her PICC line site on 12/27/2025. RN B replied, “Yes, she did on a Saturday.” The surveyor requested a copy of the picture. RN B replied, “Let me see if I still have it.” The Surveyor asked what RN B did when Patient# 16 called the weekend of 12/27/2026, with concerns about the PICC line. RN B stated that she directed Patient# 16 to call the on-call nurse. RN B stated that she believed the on-call nurse was Alt Admin/Former DON/RN Clinical Mgr. The surveyor asked what RN B did with pictures that were received from patients. RN B stated that she would upload it to the media folder of the client’s electronic record, but back then she did not know to (that she was supposed to) upload it. The surveyor asked what RN B was trained to do when patients call with concerns. She stated that she redirected Patient# 16 to person on-call.” The Surveyor asked if RN B reported Patient# 16’s concern concerns about the PICC Line. RN B replied, “I told my preceptor (LVN A) and supervisor (Alt Admin/Former DON/RN Clinical Mgr.).” RN B texted a picture to Surveyor of Patient # 16’s PICC line on 05/29/2026 at 2:58 p.m. Review of the picture of Client # 16’s PICC line did not reveal a date that it was sent to RN B and was not clear enough to determine if the PICC line looked displaced. The picture showed Client # 16’s arm with the PICC line inserted. The picture was not the same picture that Patient # 16 sent to the surveyor. The line did not have any blood in or around the tube. During an interview on 05/29/2026 4:15 p.m. with the Admin, Alt Admin/Former DON/RN Clinical Mgr., DON, and QA Nurse A surveyor reviewed the findings and asked what Alt Admin/Former DON/RN Clinical Mgr. could tell the surveyor about Patient # 16. She replied, “I remember the patient now.” She stated that the patient had a medical doctor’s visit and the caps were not replaced to the PICC line. The surveyor asked if Alt Admin/Former DON/RN Clinical Mgr. conducted a visit (on 12/27/2025) with Patient # 16. She stated that she was trying to instruct the patient to look through the supplies for caps for the PICC line. “I did not do a visit. I just dropped off supplies (the caps).” The Surveyor asked why Alt Admin/Former DON/RN Clinical Mgr. did not document the visit and communication with Patient # 16 and RN B about the clients concerns on 12/27/2025. She stated that she should have documented it. The surveyor requested a copy of the picture that Patient # 16 sent Alt Admin/Former DON/RN Clinical Mgr. The surveyor asked why the picture was not uploaded into the Patient clinical record. She replied, “I did not upload it.” The surveyor asked if the agency self-reported the incident of the client’s complaints. Admin stated, “it is our responsibility to report.” The surveyor asked why the agency did not investigate and self-report. Admin stated that she did not know what was going on. “It should have been reported.” The surveyor asked Alt Admin/Former DON/RN Clinical Mgr. why she did not self-report. She stated, “I don’t recall. I’m trying to remember. I remember [Patient # 16] reaching out about her concern about times of visits.” Alt Admin/Former DON/RN Clinical Mgr. texted pictures of ports for Patient #16 the PICC line to surveyor on 05/29/2026 at 4:54 p.m. Review of the pictures revealed that Client # 16 sent the pictures to Alt Admin/Former DON/RN Clinical Mgr. at 3:40 p.m. on 12/27/2025. Further review of revealed “I am on my way.” The pictures were not the same as the picture that Patient # 16 sent to the Surveyor. The pictures did not include Patient # 16’s arm with the PICC line and blood backflow. During a follow up interview with the Admin on 06/03/2026 at 9:02 a.m. the surveyor asked who at the agency was responsible for incident reporting, investigating, and documenting. Admin stated that any individual staff can report and document. Admin stated that the Admin is responsible for all things with the agency. The surveyor asked what the agency process was for reporting, investigating and documenting incident, complaints, and grievances. Admin stated that they should be routed to the clinical managers for follow-up, then to patient safety team; the patient safety team and clinical managers to determine reporting needs. The surveyor asked why the agency’s processes, policies, and regulations were not followed. Admin stated that the ones that happened in December of 2025, Alt Admin/Former DON/RN Clinical Mgr., was the nurse manager and she did not follow through. Admin stated that Alt Admin/Former DON/RN Clinical Mgr. admitted that she did not follow through and did not ensure that the nurses did so. The surveyor asked how the failure could adversely affect the agency’s patients. Admin stated that it could cause harm, “This is a safety event. It is a very serious condition and affects patient safety.” During a follow up interview on 06/04/2026 at 11:37 a.m. with RN B’s preceptor (LVN A) the surveyor asked what LVN A remembered about the weekend of 12/27/2025 related to Patient# 16’s PICC line concerns. LVN A stated that on the weekend of 12/27/2025 RN B received a call from Patient# 16 about her PICC line being clogged. RN B directed Patient # 16 to on call person (Alt Admin/Former DON/RN Clinical Mgr.). Review of a text thread between Patient # 16 and RN B revealed the following: The top of the thread listed RN B’s name, the date 12/28/2025 (with no time visible), and Patient # 16’s name. Patient # 16 text RN B and said, “Just got off the phone with [Alt Admin/Former DON/RN Clinical Mgr.]. She is coming to unclog the purple line, and I have antibiotic going through the red line. RN B texted (at 3:37 p.m.) Patient # 16 to ask if Alt Admin/Former DON/RN Clinical Mgr. was able to “troubleshoot” the PICC line. Client # 16 text “…[Alt Admin/Former DON/RN Clinical Mgr.] came yesterday to try to get the purple line cleared but was not able to…” Review of another text thread between LVN A and Alt Admin/Former DON/RN Clinical Mgr. revealed the following: Alt Admin/Former DON/RN Clinical Mgr.’s name at the top of the thread, date 12/28/2025, and time 5:45 p.m. LVN A text Alt Admin/Former DON/RN Clinical Mgr., “Hello I’m with [RN B] and [Patient # 16] said that her line malfunctioned this weekend and you were unable to unclog and she was need a solution [solution that breaks us clots in PICC lines to restore function] I’m assuming -Did you call in for [the solution] or do we need to call for it? Alt Admin/Former DON/RN Clinical Mgr. text, “I will reach out to the provider in the morning. [Patient] also reported an [emergency room] visit [due to ] lab results. Her red line is working. Was going to update [RN B] tomorrow…” The agency’s complaint and incident records did not include documentation of the existence of the complaint, incident, or resolution of the complaint, incident. Review of agency policy titled, “Complaint/Grievance Internal and External” dated 2025 read in part: “…Purpose: To ensure that all concerns and complaints are promptly and thoroughly evaluated and addressed to resolve issues, improve care and service delivery, and take corrective action as needed. The agency is committed to preventing further occurrences and protecting patients and staff from retaliation or service through disruption during the complaint investigation process… Definitions: Grievance: Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and the agency concerning, but not limited to, the application of policies or procedures, or any aspect of services including care that is not furnished, inconsistently furnished, are inappropriately furnished…Complaint Process I. Any staff member receiving a concern/complaint shall document on agency form or electronically in the medical record if available. Documentation will include any action taken and shared take me to his/her supervisor or (Administrator…) who ensures the notification of appropriate management personnel. II. The supervisor shall investigate the grievance and shall make every effort to resolve the agreements to the patient satisfaction…VIII. The Administrator or designee shall ensure that the concern/complaint has been addressed in a timely manner and resolved, if possible…” Review of agency policy titled, “Complaint/Grievance Internal and External Addendum” dated 2024 read in part: “IV. Agency complaint investigations. A. An agency must investigate complaints made by a client, a client’s family or guardian, our client’s health care provider, in accordance with this subsection, regarding: i. Treatment or care that was furnished by the agency; treatment or care that the agency failed to furnish…b. An agency must: i. Document receipt of the complaint and initiate A complaint investigation within 10 days after the agencies receipt of the complaint; and ii. document all components of the investigation. Review of agency policy titled, “Incidents and Adverse Events” dated 2025 read in part: “Policy: The organization shall monitor, investigate, and report incidents and adverse events that pose a risk to the health and safety of patients and/ R employees, or that may expose the organization to actual or potential liability. This includes but is not limited to…Variances in care delivery, Unusual occurrences impacting service quality or safety. The process shall include identification, monitoring, reporting, investigation, and documentation of all adverse events, incidents, accidents, variances, are unusual occurrences involving patient care or services. Purpose… This process supports regulatory compliance, promotes continuous quality improvement, and helps prevent recurrence of similar events…Definitions: Incident/Adverse Event: Any event occurring in the patient Care environment, office setting, or during official business hours that deviates from routine operations and threatens or affects the health, safety, comfort, or property of patients, employees, or visitors. Sentinel Event: An unexpected occurrence involving…serious physical or psychological injury, or the risk thereof…Procedure: I. The incidents shall be reported as soon as possible by the person who observes or becomes aware of the event. A. Verbal notifications shall be made to the immediate supervisor or designated after-hours personnel. B. Written or electronic documentation shall be completed preferably within 24 hours of the event…D. Documentation shall include: i. reporter’s name ii. date, time, and location iii. description of the incident iv. Witnesses v. notifications made vi. immediate actions taken and follow-up measures. Review of agency policy titled, “Documentation Requirements” dated 2024 read in part: “…III. Documentation is expected to be completed on the day of the patient contact. IV. Employees or contractors who do not submit required documentation in the manner described above will be disciplined according to policy and may be reported to the respective licensing board…””

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to designate a governing body to assume full legal authority and responsibility of the agency’s overall operation of services and performance improvement program as evidenced by: No direct governing body was assigned to the agency. This failure placed the agency’s clients for inadequate care on a systemic level. Findings include: Record Review of the agency’s organizational chart on 1/7/2026, untitled, revealed the reporting structure, in part, “[CNO, AVPBPO, Administrator, Director of Home Health (empty), Alternate Administrator].” Further record review revealed that the Director of Home Health, was terminated on 1/5/2026. During an interview with AVPBPO on 1/12/2026 at 11:00 am, the AVPBPO was informed of the above findings. The AVPBPO further stated that he wasis the direct report to the Administrator. When asked if he governs the home health agency, the AVPBPO stated, “I am not involved with the day to day operations of the agency.” During an interview with the CNO on 1/14/2026 at 11:00 am, the CNO was informed of the above findings. The CNO stated that she wasis the direct report to the AVPBPO. The CNO also stated that she acknowledged the systemic issues in the agency has been directly correlated with the lack of direct governance of the agency. The CNO stated that the deficiency was ultimately her responsibility. During an interview with the Administrator on 1/20/2026 at 2:00 p.m., the Administer was informed of the above findings. The Administrator stated she acknowledged the above findings and stated that direct governance was important for continual quality improvement. Record Review of the agency policy titled, “Governing Body”, dated 2024, revealed in part,” A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program... The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes,””

“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 client’s right to be free from neglect by the agency’s employees for 2 of 27 Clients (Client #6, #16), whose records were reviewed. This failure placed the agency’s clients at risk for neglect deterioration of the client’s wounds. Findings include: 1. Record Review of Client #16’s clinical records reveal start of care date of 8/22/2025 with a certification period of 12/20/2025 to 2/17/2026 with a diagnosis of left foot open wound. Further record review of Client #16’s plan of care revealed that skilled nursing services was ordered at three times weekly for wound care to Patient #16’s left foot. Further record review to the agency’s complaint log on 10/10/2025, documented unresolved complaint made by Client #16 revealed,” On 10/10/25, the patient called to report that the RN had not visited her home on either Wednesday, 10/08/25, or today, 10/10/25. The patient expressed concern regarding her wound care, stating that she was scheduled to be seen three times a week. She mentioned that she had not been seen since Monday, 10/06/25, and was upset by the lack of visits. Upon reviewing the situation…patient became highly distressed and insisted that she was supposed to be seen three times a week…” During an interview with Client #16 on 1/12/20215 at 10:00 a.m., Client #16 stated Client #16 rights were not protected and her needs were not addressed. Client #16 stated that she received wound care twice weekly when she is ordered. Client #16 stated that she was neglected on 12/25/2025-1/1/2026 when she was not seen for a week for her ordered wound care. Client #16 stated that the wound has deteriorated since not being cared for during 12/25/2025-1/1/2025. Client #16 stated that missed nursing visits were regularly experienced by the agency. During a record review of Client #16’s nursing visits schedule revealed no nursing visits were completed between 12/22/2025-12/26/2025. 2. Record Review of Client #6’s clinical records reveal start of care date of 12/20/2025, with a certification period of 12/20/2025 – 2/17/2026 with a diagnosis of right foot wound. Further record review revealed that with skilled nursing services ordered at three times weekly and as needed for wound dressing change. Further record review revealed that no nursing visits were made between 12/29/2025-1/16/2026. During an interview with FM of Client #6 on 1/16/2026 at 10:00 a.m., FM of Client #6 stated that Client #6 rights were not protected. FM of Client #6 stated that she has not seen a nurse for two weeks for Client #6 wound dressing changes due to the holiday season. FM of Client #6 stated that she changed the dressings when the nurses didn’t did not treat Client #6 wounds. FM of Client #6 stated that Client #6 attended dialysis (mechanical filtering of the blood in lieu of the low functioning kidneys) on Mondays, Wednesdays, and Fridays. FM of Client #6 stated that she informed the Alternate Administrator that she prefers Thursdays and Fridays because Client #6 was tired after dialysis. FM of Client #6 stated that the Alternate Administrator disregarded Client #6’s request. During an interview with AN #1 on 1/18/2026 at 9:00 a.m., AN #1 stated that the Alternate Administrator stated that no nursing visits for wound care were scheduled because half of the nursing staff were on vacation during the holiday week of 12/25/2025-1/1/2026. AN #1 stated that the Alternate Administrator was aware of the results of not scheduling nursing for wound care and wound management, but it was consciously disregarded. During an interview with the Alternate Administrator on 1/16/2025 at 2:00p.m., the Alternate Administrator was informed of the above findings. The Alternate Administrate stated that she was responsible for scheduling the nurses to clients as well assigning the clients. The Alternate Administrator stated she understood the importance of prioritizing wound care clients to decrease the instances of wound deterioration. She also stated that she has taken the annual ANE coursework provided by the agency. During an interview with the Administrator on 1/16/2026 at 2:00 p.m., the Administered was informed of the above findings. The Alternate Administrator stated she did not report these finding the HHSC. The Administrator stated she attended the annual ANE training provided by the agency. The Administrator stated that the Alternate Administrator was responsible for scheduling clients for services. During a record review of the Alternate Administrator and Administrator’s training records revealed that the Alternate Administrator and Administrator has attended annual ANE training. Record Review of the agency policy titled, “Abuse Neglect and Exploitation”, dated 2023, revealed in part,” Neglect: failure to provide the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain…” …Client Rights…An agency must protect and promote the rights of all clients...” Record Review of the agency policy titled, “Scheduled Time of Off SOP”, dated 7/1/2025, revealed in part,” Scheduling calls all patients to let them know that the [agency] working to reassign…Scheduling may reschedule per the patients’ request, if within the plan of care…scheduling identifies visit types to ensure compliance with visit timelines…””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to administer proper written notice to 1 of 27 patients (Patient #5), in advance of the home health agency termination of on-going care in that: 1) The agency failed to administer Notice of Medicare Non-Coverage to Patient #5 prior to Patient #5’s discharge. This failure could place the agency’s patients at risk due to inadequate continuation of care and patient preparation prior to patient discharge. The findings included: During a record review of Patient #5 clinical records, records reveal a start of care date of 12/9/2025, with a certification period of 12/9/2025-2/6/2026, with an admitting diagnosis of a neck fracture and wound care vac therapy(a vacuum connected to a sponge attached to the wound to promote healing) to right leg. Patient #5 was receiving skilled nursing visits twice weekly. Further review of clinical records reveal Patient #5 was discharged on 1/9/2026 due to change of insurance. Further record review revealed no evidence of the Notice of Medicare Non-Coverage was given to Patient #5. During an interview on 1/12/2026 at 2:30 p.m., with the Patient #5, Patient #5 stated that she was discharged on 1/9/2025 by RN D due to change of insurance for 2026. Patient #5 stated she was never given Notice of Medicare Non-Coverage prior to discharge. Patient #5 further stated she was discharged with the wound vac in place. Patient #5 stated that although she does not want to be billed for services, she was not given discharge instructions at the time of discharge. RN D was unavailable for interview. During an interview on 1/12/2026 at 2:30 p.m., with the Alternate Administrator, the Alternate Administrator was informed of the findings and acknowledged responsibility. The Alternate Administrator stated that at the time she didn’t think the Notice of Medicare Non-Coverage was needed because Patient #5 had a change of insurance but understood that the notice was necessary to provide written notice of intent to discharge Patient #5 an informed choice to continue non-covered services from the agency. Record review of an agency policy titled, “Notification of Noncovered Care,” dated 2022, revealed, in part,” Agency personnel will: A. Provide the notification information to the patient in plain language and in a manner that is accessible and timely; B. Discuss alternate plans for care with the patient, family, and/or physician/practitioner, including the possibility of charity services, as appropriate, C. Implement alternate plan of care, as ordered by the physician/practitioner, D. Submit a demand bill if requested by the patient; and/or E. Provide referral to other care sources as available and appropriate...””