Ariel Home Healthcare

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to meet the Condition of Participation 484.60 Care planning, Coordination, and Quality of Care as evidenced by: Refer to G572: Based on record reviews and interviews, the agency failed to ensure that each patient received the home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, and which was established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration, in three (Patient # 3, 4, and 5) of four records reviewed in which the patients received a home visit or telephone interview, in that: the home health agency failed to provide skilled nursing services, home health aide services, physical therapy services, or occupational services as written in the plan of care (physician’s orders). The failure caused the patients to not receive home health services as ordered in the plan of care. The failure placed the patients at increased risk for decline in physical health, for poor personal hygiene (bathing and grooming), unmet activities of daily living needs (including meal preparation and household tasks), falls and injuries, decline in functional, and mobility status. Refer to G574: Based on record review, observation, and interviews, the agency failed to ensure that the individualized plan of care (POC) included the required elements in four of four patient records reviewed who received a home visit or telephone interview, in that: for (Patient # 1, 3, 4, and 5) the POC failed to include the frequency and duration of visits to be made, all medications and treatments, or both. The failure placed the patient at increased risk of having poor physical health and safety outcomes when skilled nursing visits and therapy visits were missed or not implemented and when all medications and medication instructions were not included in the plan of care. Refer to G588: Based on record reviews, observation, and interview, the agency failed to ensure that the patient’s individualized plan of care (POC) had been reviewed and revised by the patient’s physician no less frequently than once every 60 days, in three (Patients # 1, 3, and 4) of five active patient records reviewed. The failure placed the patients’ physical health at increased risk of declining due to lack of physician oversight if there were changes in the patient’s condition or if there was a need for additional care and services. Refer to G616: Based on record reviews, observation, and interviews the agency failed to ensure that the patient’s medication schedule and administration instructions were written and provided to three (Patient # 1 and 5) of four records reviewed in which the patients received a home visit or telephone interview, in that: Patient’s # 1 and 5 did not receive a written medication schedule and instructions that included medication name (Insulin), dosage and frequency, and if the medication would be administered by HHA personnel. The failure resulted in the patients not receiving necessary guidance for safe medication administration. The failure placed the patient at increased risk for medication errors, adverse drug events, improper administration, and decline in health status.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that each patient received the home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, and which was established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration, in three (Patient # 3, 4, and 5) of four records reviewed in which the patients received a home visit or telephone interview, in that: the home health agency failed to provide skilled nursing services, home health aide services, physical therapy services, or occupational services as written in the plan of care (physician’s orders). The failure caused the patients to not receive home health services as ordered in the plan of care. The failure placed the patients at increased risk for decline in physical health, for poor personal hygiene (bathing and grooming), unmet activities of daily living needs (including meal preparation and household tasks), falls and injuries, decline in functional, and mobility status. Findings include: Patient record review # 3: During record review of Patient # 3’s EHR revealed a plan of care with a start of care date of 02/12/2026 for certification period 02/12/2026-04/12/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 02/12/2026 and physician (Physician 1) signed and dated the POC on 03/11/2026. Continued review of the POC revealed a principal diagnosis of Chronic Kidney Disease Stage 3b (moderate to severe loss of kidney function); orders for skilled nurse visits one time per week for nine weeks beginning the week of 02/12/2026 and home health aide visits one time per week for nine weeks beginning the week of 02/12/2026. Further review of Patient # 3’s record revealed an admit/referral order dated 02/02/2026 and signed by RN A and Physician 2 on 02/02/2026. Review of the order revealed the following ordered services: Skilled Nursing Care, Physical Therapy, Occupational Therapy and Home Health Aide with no frequencies listed. Further review of the order revealed “additional orders: SN Visit [two times per week for one week and one time per week for five weeks] PT/OT to [evaluate] and treat.” During a home visit and interview conducted on 04/23/2026 at approximately 2:10 p.m. with Patient # 3 and Family Member # 1, the Surveyor B asked what services were currently being provided by the agency. Patient # 3 stated (Patient # 3) was supposed to receive nursing services, but it took over one month for a nurse to initiate visits and that nursing staff had only visited a few times since admission (admitted 02/12/2026). Patient # 3 further stated that although the agency contacted (Patient # 3) by phone, but staff frequently did not arrive for scheduled visits. Patient # 3 stated that home health aide services were ordered as part of the plan of care; however, the agency had not provided any home health aide visits to date and stated the agency was still waiting for an order. Patient # 3 stated she knew that the agency had the order and knew that insurance was approved a few hours a week. Patient # 3 stated after admission to the home health agency, the agency sent an order for physical and occupational therapy, but nobody had been out to date to start those services. Patient record review # 4: During record review of Patient 4’s EHR revealed a plan of care with a start of care date of 12/15/2025 for certification period 02/13/2026 to 04/13/2026. Review of the plan of care (POC) revealed that (RN A) signed and dated the POC on 12/12/2026 and was not signed or dated by Family Nurse Practitioner (FNP 1). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks beginning week of 02/09/2026, home health aide to assist with activities of daily living (personal care and hygiene needs) according to RN care plan, and PT one visit one time monthly to evaluate and treat. The record did not include a home health aide care plan and did not include frequency of visits. Continued review of Patient # 4’s record did not reveal any home health aide visit notes. The record included an admit/referral order dated 07/23/2025. DON A signed and dated the order on 07/23/2025. The order included visit frequency for SN as one time weekly and home health aide services for eight hours per week. The record included a PT re-evaluation dated 03/12/2026 with orders for PT visits one time per week for five weeks. PT A signed and dated the order on 03/12/2026 and FNP 1 signed and dated the order on 03/24/2026. During a telephone interview conducted on 04/23/2026 at 12:15 p.m. with Patient # 4’s (Family Member 4), Surveyor A asked what services were currently being provided by the agency. Family Member 4 stated (Patient # 4) was receiving nursing one time weekly, home health aide two times weekly, and therapy services one time weekly. Family Member 4 stated that PT had been visiting since original admission (07/25/2025). Family Member 4 stated that the agency staff had been helpful, but voiced concern that nursing services had not been “up to par.” Family Member 4 stated that (RN A) did not assess (Patient # 4) that (RN A) just wrote down the family’s blood pressure and heart rate readings when (RN A visited). Family Member 4 stated that (RN A) could have been more diligent in monitoring Patient # 4’s medication. Family Member 4 stated that there had been inconsistent in agency visit schedules. Surveyor A asked if Patient # 4 was receiving home health aide services. Family member 4 stated that Patient # 4 was receiving home health aide services two times weekly to assist with personal care tasks. Surveyor A asked how long Patient # 4 had been receiving home health aide services. Family Member 4 stated that Patient # 4 had been receiving home health aide services since original start of care (07/25/2025). Patient record review # 5: During record review of 5’s EHR revealed a plan of care with a start of care date of 04/03/2026 for certification period 04/03/2026-06/01/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 04/03/2026 and was not signed or dated by physician (Physician 3). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus and a secondary of Long term (current) use of insulin (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood; currently using insulin to help manage the condition). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks for medication administration, teaching, training, observation, and assessment. The POC did not list any medication. Further review of Patient # 5’s record revealed an admit/referral order dated 04/02/2026 and signed by RN A on 04/02/2026 and was not signed by Physician 3. Review of the order revealed the following ordered services: Skilled Nursing Care with “additional orders: SN visits [one time per week for nine weeks beginning 04/03/2026]” Continued review of Patient # 5’s record revealed a SOC initial assessment that was electronically signed with RN A’s initials and dated 04/03/2026. The record included a SN visit note, ADON B signed and dated the visit note on 04/21/2026. Further review of the patient record did not reveal any other skilled nursing care visits (SN visits were due week of 04/10/2026 and 04/17/2026). During a telephone interview conducted on 04/24/2026 at 9:36 a.m. with Patient # 5, Surveyor A asked what services were currently being provided by the agency. Patient # 5 stated (Patient # 5) was supposed to receive nursing services, but (Patient # 5) had one in person visit (4/03/3036) and one telephone visit on (4/21/2026). Patient # 5 further stated that when RN A visited (RN A) “we talked [RN A] did not touch me or anything.” Patient # 5 stated that RN A did not assess or review medications or assess [Patient # 5]. Patient # 5 stated, “I have not had a lot of contact with [the agency], no paperwork or anything.” During an interview with Office Mgr. on 04/22/2026 at 12:00 p.m., the Office Mgr. stated that RN A no longer worked for the agency. The surveyor attempted to call RN A on 04/22/2026 at 12:00 p.m. and did not receive an answer or a return call. The Office Mgr. also stated that DON A was out of the office receiving medical treatments. On 04/24/2026 at 11:16 a.m. and 11:21 a.m. the surveyor attempted to call QA Supervisor, Contractor A. There were no answer and no return call. On 04/24/2026 at 10:29 a.m., and 12:44 p.m. the surveyor attempted to call DON A. There was no answer or return call. During an interview on 04/24/2026 at 1:38 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A or ADON B had returned calls. Admin and Office Mgr. stated that they had not received any return calls. Office Mgr. stated that ADON B worked at the hospital and was only working for the agency three days per week. During an interview conducted on 04/24/2026 at approximately 3:30 p.m. with the Admin, Office Mgr., and Surveyors A and B, Surveyor B asked how the agency ensured that all services ordered and included in the plan of care were provided to patients. The Office Mgr. stated that all documents were reviewed by office staff to ensure patients receive all the services ordered and if services were not provided, the office coordinator was responsible for documenting the reason. The Admin stated that the office coordinator was a contracted employee (QA Supervisor, Contractor A) who was terminated on 04/23/2026 after it was determined she was not performing her job duties appropriately. The Office Mgr. further stated that the RN case manager (RN A) was responsible for notifying the physician when services were not provided and documenting the reason. Surveyor B asked why a patient (Patients # 3) ordered home health aide services were not receiving them and why there was no documentation in the clinical record, the Office Mgr. stated that Alt Admin had visited the patient’s home to assist with Medicaid application due to lack of coverage for home health aide services under her insurance. Surveyor B asked what the agency policy was for documenting such visits and communication, the Office Mgr. stated that Alt Admin verbally informed office staff, who then document the visit in the patient’s EHR. The Admin and Office Mgr. subsequently stated that Alt Admin should have entered a communication in the patient’s EHR. Surveyor B asked how the failure to provide ordered services (home health aide and therapy services) could negatively impact patients and the Admin stated that it could negatively impact the patients’ health, mobility and independence. Surveyor B asked what should have been done differently and the Admin stated that he should have provided more oversight and follow-up rather than relying solely on office staff and focusing primarily on growing the business. Admin states he should have been more involved in ensuring the health and safety of patients. During a phone interview conducted on 04/24/2026 at approximately 4:00 p.m. with Alt Admin, Surveyor B asked about documentation of a visit related to Medicaid assistance for Patient # 3. Alt Admin stated that she had documented a communication in the EHR regarding the visit. Surveyor A informed Alt Admin that no such documentation was present in the clinical record and asked for clarification. Alt Admin stated that she would go into the record and add any missing communications. Surveyor asked if Alt Admin could explain why the documentation was not in the patient’s record. Alt Admin did not answer the question and remained silent. During an interview on 04/24/2026 at approximately 4:30 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A, ADON A, RN A, and ADON B were available for phone interviews. Admin stated that they were not available and had not returned the agency’s calls. During an on 04/24/2026 at 4:30 p.m. interview with Admin, Office Mgr., and Surveyors A and B, Surveyor A reviewed the findings and asked what the agency’s process was for ensuring that services (nursing and home health aide services) were provided as ordered in the plan of care. Office Mgr. stated that the agency’s process was to communicate to the patient if there was duplication of services (between home health aide and personal assistance services). Surveyor A asked what the agency’s policy was for notifying the physician if services were not provided as written in the plan of care. Office Mgr. stated that the agency would send an order to the physician that the services were “dropped” (not provided). Surveyor A asked who was responsible for ensuring that the agency processes were followed. Office Mgr. stated that DON A and Admin were responsible. Admin stated that DON A was not available for interview. Admin approved Office Mgr. providing answer to interview questions. Surveyor A asked why nursing and home health aide services not provided as ordered in the plan of care for Patient # 4 and 5. Office Mgr. stated that the agency could not recruit on time for the location of the patients. Office Mgr. stated that Patient # 4 was receiving personal assistance services from their personal assistance service agency (with a different state license number). Surveyor A asked why the agency did not notify the patients physician and document the notification. Office Mgr. replied, “I thought the office staff, QA Supervisor (Contractor A) was doing it. I just did not follow-up with them.” The surveyor asked what should have been done to ensure compliance with regulation and agency policy. Office Mgr. stated that the physician should have been notified, patient and family should have been notified, and coordination of care should have been documented. Review of agency policy titled, “Plan of Care” last reviewed 01/01/2026 read in part: “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems… A. A registered nurse (RN) initiates the Plan of Care for skilled nursing care and for personal hygiene/activities of daily living care… II. An RN is responsible for coordinating the Plan of Care when multiple disciplines are involved, or when more than one agency is involved, to decrease the possibility of duplication or conflict and to identify responsibilities… III. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s)…V. Each patient/client must receive the home health services that are written in an individualized Plan of Care…””

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that the client received all services as outlined in the plan of care in three (Patient # 3, 4, and 5) of four records reviewed in which the patients received a home visit or telephone interview, in that: the home health agency failed to provide skilled nursing services, home health aide services, physical therapy services, or occupational services as outlined in the plan of care (physician’s orders). The failure violated the patients’ right to receive home health services as outlined in the plan of care. The failure placed the patients at increased risk for decline in physical health, for poor personal hygiene (bathing and grooming), unmet activities of daily living needs (including meal preparation and household tasks), falls and injuries, decline in functional, and mobility status. Findings include: Patient record review # 3: During record review of Patient # 3’s EHR revealed a plan of care with a start of care date of 02/12/2026 for certification period 02/12/2026-04/12/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 02/12/2026 and physician (Physician 1) signed and dated the POC on 03/11/2026. Continued review of the POC revealed a principal diagnosis of Chronic Kidney Disease Stage 3b (moderate to severe loss of kidney function); orders for skilled nurse visits one time per week for nine weeks beginning the week of 02/12/2026 and home health aide visits one time per week for nine weeks beginning the week of 02/12/2026. Further review of Patient # 3’s record revealed an admit/referral order dated 02/02/2026 and signed by RN A and Physician 2 on 02/02/2026. Review of the order revealed the following ordered services: Skilled Nursing Care, Physical Therapy, Occupational Therapy and Home Health Aide with no frequencies listed. Further review of the order revealed “additional orders: SN Visit [two times per week for one week and one time per week for five weeks] PT/OT to [evaluate] and treat.” During a home visit and interview conducted on 04/23/2026 at approximately 2:10 p.m. with Patient # 3 and Family Member # 1, the Surveyor B asked what services were currently being provided by the agency. Patient # 3 stated (Patient # 3) was supposed to receive nursing services, but it took over one month for a nurse to initiate visits and that nursing staff had only visited a few times since admission (admitted 02/12/2026). Patient # 3 further stated that although the agency contacted (Patient # 3) by phone, but staff frequently did not arrive for scheduled visits. Patient # 3 stated that home health aide services were ordered as part of the plan of care; however, the agency had not provided any home health aide visits to date and stated the agency was still waiting for an order. Patient # 3 stated she knew that the agency had the order and knew that insurance was approved a few hours a week. Patient # 3 stated after admission to the home health agency, the agency sent an order for physical and occupational therapy, but nobody had been out to date to start those services. Patient record review # 4: During record review of Patient 4’s EHR revealed a plan of care with a start of care date of 12/15/2025 for certification period 02/13/2026 to 04/13/2026. Review of the plan of care (POC) revealed that (RN A) signed and dated the POC on 12/12/2026 and was not signed or dated by Family Nurse Practitioner (FNP 1). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks beginning week of 02/09/2026, home health aide to assist with activities of daily living (personal care and hygiene needs) according to RN care plan, and PT one visit one time monthly to evaluate and treat. The record did not include a home health aide care plan and did not include frequency of visits. Continued review of Patient # 4’s record did not reveal any home health aide visit notes. The record included an admit/referral order dated 07/23/2025. DON A signed and dated the order on 07/23/2025. The order included visit frequency for SN as one time weekly and home health aide services for eight hours per week. The record included a PT re-evaluation dated 03/12/2026 with orders for PT visits one time per week for five weeks. PT A signed and dated the order on 03/12/2026 and FNP 1 signed and dated the order on 03/24/2026. During a telephone interview conducted on 04/23/2026 at 12:15 p.m. with Patient # 4’s (Family Member 4), Surveyor A asked what services were currently being provided by the agency. Family Member 4 stated (Patient # 4) was receiving nursing one time weekly, home health aide two times weekly, and therapy services one time weekly. Family Member 4 stated that PT had been visiting since original admission (07/25/2025). Family Member 4 stated that the agency staff had been helpful, but voiced concern that nursing services had not been “up to par.” Family Member 4 stated that (RN A) did not assess (Patient # 4) that (RN A) just wrote down the family’s blood pressure and heart rate readings when (RN A visited). Family Member 4 stated that (RN A) could have been more diligent in monitoring Patient # 4’s medication. Family Member 4 stated that there had been inconsistent in agency visit schedules. Surveyor A asked if Patient # 4 was receiving home health aide services. Family member 4 stated that Patient # 4 was receiving home health aide services two times weekly to assist with personal care tasks. Surveyor A asked how long Patient # 4 had been receiving home health aide services. Family Member 4 stated that Patient # 4 had been receiving home health aide services since original start of care (07/25/2025). Patient record review # 5: During record review of 5’s EHR revealed a plan of care with a start of care date of 04/03/2026 for certification period 04/03/2026-06/01/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 04/03/2026 (Physician 3). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus and a secondary of Long term (current) use of insulin (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood; currently using insulin to help manage the condition). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks for medication administration, teaching, training, observation, and assessment. The POC did not list any medication. Further review of Patient # 5’s record revealed an admit/referral order dated 04/02/2026 and signed by RN A on 04/02/2026 and was not signed by Physician 3. Review of the order revealed the following ordered services: Skilled Nursing Care with “additional orders: SN visits [one time per week for nine weeks beginning 04/03/2026]” Continued review of Patient # 5’s record revealed a SOC initial assessment that was electronically signed with RN A’s initials and dated 04/03/2026. The record included a SN visit note, ADON B signed and dated the visit note on 04/21/2026. Further review of the patient record did not reveal any other skilled nursing care visits (SN visits were due week of 04/10/2026 and 04/17/2026). During a telephone interview conducted on 04/24/2026 at 9:36 a.m. with Patient # 5, Surveyor A asked what services were currently being provided by the agency. Patient # 5 stated (Patient # 5) was supposed to receive nursing services, but (Patient # 5) had one in person visit (4/03/3036) and one telephone visit on (4/21/2026). Patient # 5 further stated that when RN A visited “we talked [RN A] did not touch me or anything.” Patient # 5 stated that RN A did not assess or review medications or assess [Patient # 5]. Patient # 5 stated, “I have not had a lot of contact with [the agency], no paperwork or anything.” During an interview with Office Mgr. on 04/22/2026 at 12:00 p.m., the Office Mgr. stated that RN A no longer worked for the agency. The surveyor attempted to call RN A on 04/22/2026 at 12:00 p.m. and did not receive an answer or a return call. The Office Mgr. also stated that DON A was out of the office receiving medical treatments. On 04/24/2026 at 11:16 a.m. and 11:21 a.m. the surveyor attempted to call QA Supervisor, Contractor A. There was no answer and no return call. On 04/24/2026 at 10:29 a.m., and 12:44 p.m. the surveyor attempted to call DON A. There was no answer or return call. During an interview on 04/24/2026 at 1:38 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A or ADON B had returned calls. Admin and Office Mgr. stated that they had not received any return calls. Office Mgr. stated that ADON B worked at the hospital and was only working for the agency three days per week. During an interview conducted on 04/24/2026 at approximately 3:30 p.m. with the Admin, Office Mgr., and Surveyors A and B, Surveyor B asked how the agency ensured that all services ordered and included in the plan of care were provided to patients. The Office Mgr. stated that all documents were reviewed by office staff to ensure patients receive all the services ordered and if services were not provided, the office coordinator was responsible for documenting the reason. The Admin stated that the Office Coordinator was a contracted employee (QA Supervisor, Contractor A) who was terminated on 04/23/2026 after it was determined she was not performing her job duties appropriately. The Office Mgr. further stated that the RN case manager (RN A) was responsible for notifying the physician when services were not provided and documenting the reason. Surveyor B asked why a patient (Patient # 3) ordered home health aide services were not receiving them and why there was no documentation in the clinical record, the Office Mgr. stated that Alt Admin had visited the patient’s home to assist with Medicaid application due to lack of coverage for home health aide services under her insurance. Surveyor B asked what the agency policy was for documenting such visits and communication, the Office Mgr. stated that Alt Admin verbally informs office staff, who then document the visit in the Patient # 3’s EHR. The Admin and Office Mgr. subsequently stated that Alt Admin should have entered a communication in the patient’s EHR. Surveyor B asked how the failure to provide ordered services (home health aide and therapy services) could negatively impact patients and the Admin stated that it could negatively impact the patients’ health, mobility and independence. Surveyor B asked what should have been done differently and the Admin stated that he should have provided more oversight and follow-up rather than relying solely on office staff and focusing primarily on growing the business. Admin states he should have been more involved in ensuring the health and safety of patients. During a phone interview conducted on 04/24/2026 at approximately 4:00 p.m. with Alt Admin, Surveyor B asked about documentation of a visit related to Medicaid assistance for Patient # 3. Alt Admin stated that she had documented a communication in the EHR regarding the visit. Surveyor A informed Alt Admin that no such documentation was present in the clinical record and asked for clarification. Alt Admin stated that she would go into the record and add any missing communications. Surveyor asked if Alt Admin could explain why the documentation was not in the patient’s record. Alt Admin did not answer the question and remained silent. During an interview on 04/24/2026 at approximately 4:30 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A, ADON A, RN A, and ADON B were available for phone interviews. Admin stated that they were not available and had not returned the agency’s calls. During an interview on 04/24/2026 at 4:30 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A reviewed the findings and asked what the agency’s process was for ensuring that services (nursing and home health aide services) were provided as ordered in the plan of care. Office Mgr. stated that the agency’s process was to communicate to the patient if there is duplication of services (between home health aide and personal assistance services). Surveyor A asked what the agency’s policy was for notifying the physician if services were not provided as outlined in the plan of care. Office Mgr. stated that the agency would send an order to the physician that the services were dropped. Surveyor A asked who was responsible for ensuring that the agency processes were followed. Office Mgr. stated that DON A and Admin were responsible. Admin stated that DON A was not available for interview. Admin approved Office Mgr. providing answer to interview questions. Surveyor A asked why nursing and home health aide services were not provided as outlined in the plan of care for Patient # 4 and 5. Office Mgr. stated that the agency could not recruit on time for the location of the patients. Office Mgr. stated that Patient # 4 was receiving personal assistance services from their personal assistance service agency (with a different state license number). Surveyor A asked why the agency did not notify the patients physician and document the notification. Office Mgr. replied, “I thought the office staff was doing it. I just did not follow-up with them.” The surveyor asked what should have been done to ensure compliance with regulation and agency policy. Office Mgr. stated that the physician should have been notified, patient and family should have been notified, and coordination of care should have been documented. Review of agency policy titled, “Patient/Client Rights and Responsibilities” last reviewed 05/01/24 read in part: “Purpose To ensure all patients/clients, representatives (if any), and agency staff acknowledge, observe, and implement the patient’s/client’s rights and responsibilities… Procedure I. Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct, and patient/client responsibilities on a continuous basis… VI. The patient/client has the right to… E. Receive all services outlined in the plan of care…””

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure that the patient’s comprehensive assessment/individualized plan of care (POC) had been updated the last five days of every 60 days beginning with the start-of-care date, in that: for three (Patients # 1, 3, and 4) of five active patient records reviewed the agency failed to ensure that the patients had current comprehensive assessments/POCs. The failure placed the patients’ physical health at increased risk of declining due to lack of physician oversight if there were changes in the patient’s condition or if there was a need for additional care and services. Findings Included: Patient #1: Record review of Patient # 1’s EHR revealed a plan of care (POC) with a start of care date 12/12/2025 for the certification period 02/10/2026 to 04/10/2026. Review of the POC revealed it was signed and dated by (RN A) on 02/09/2026 and by physician (Physician 4) on 03/04/2026. The POC included a principal diagnosis is Essential (primary) Hypertension (high blood pressure without a specific single medical cause) and a secondary diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Continued review of the record revealed a recertification order for certification period of 04/11/2026 to 06/10/2026. DON A signed and dated the recertification order on 04/09/2026. Further review of the record did not reveal that an RN recertification assessment had been completed for certification period of 04/11/2026 to 06/10/2026. Record review for Patient # 1 did not reveal a current POC, for certification period of 04/11/2026 to 06/10/2026, that had been reviewed and revised by Physician 4 at least every 60 days (due no later than 04/10/2026). Patient # 3: Record review of Patient # 3’s EHR revealed a plan of care with a start of care date of 02/12/2026 for certification period 02/12/2026-04/12/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 02/12/2026 and physician (Physician 1) signed and dated the POC on 03/11/2026. Continued review of the POC revealed a principal diagnosis of Chronic Kidney Disease Stage 3b (moderate to severe loss of kidney function); orders for skilled nurse visits one time per week for nine weeks beginning the week of 02/12/2026 and home health aide visits one time per week for nine weeks beginning the week of 02/12/2026. Continued review of the record revealed a recertification order for certification period of 04/13/2026 to 06/11/2026. DON A signed and dated the recertification order on 04/09/2026. Further review of the record did not reveal that a RN recertification assessment had been completed for certification period of 04/13/2026 to 06/11/2026. Record review for Patient # 3 did not reveal a current POC, for certification period of 04/13/2026 to 06/11/2026, that had been reviewed and revised by Physician 4 at least every 60 days (due no later than 04/12/2026). Patient # 4: Record review of Patient 4’s EHR revealed a plan of care with a start of care date of 12/15/2025 for certification period 02/13/2026 to 04/13/2026. Review of the plan of care (POC) revealed that (RN A) signed and dated the POC on 12/12/2026 and was not signed or dated by Family Nurse Practitioner (FNP 1). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Further review of the POC revealed orders for skilled nurse visits one time per week for nine beginning week of 02/09/2026 and home health aide to assist with activities of daily living (personal care and hygiene needs) according to RN care plan. The record did not include a home health aide care plan. Continued review of Patient # 4’s record did not reveal any home health aide visit notes. Continued review of the record revealed a recertification order for certification period of 04/14/2026 to 06/12/2026. DON A signed and dated the recertification order on 04/13/2026. Further review of the record revealed that a RN recertification visit had been completed for certification period of 04/14/2026 to 06/12/2026. The recertification included DON A’s initials and was dated 04/13/2026. Record review for Patient # 4 did not reveal a current POC, for certification period of 04/14/2026 to 06/12/2026, that had been reviewed and revised by Physician 4 at least every 60 days (due no later than 04/13/2026). During an interview with the Admin, Office Mgr., and Surveyors A and B, on 04/24/2026 at 4:20 p.m., Surveyor A reviewed the findings and asked who was responsible for the POC(s) were completed for Patients # 1, 3, and 4. Office Mgr. stated that the agency’s office staff was responsible for completing the process of creating the POC from the RN OASIS assessment (standard data elements home health agencies integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services). Surveyor A asked what the process was for ensuring the POC was completed. Office Mgr. stated that after the office staff completed the electronic transfer of data from the OASIS, the agency’s DON reviewed the POC, and the office staff sent it to the patient’s physician for review and signature. Surveyor A asked why Patients # 1, 3, and 4 did not have individualized plan of care (POCs) that had been reviewed and revised by the patient’s physician at least every 60 days. Office Mgr. stated that she just became aware that the patients did not have current POC (s) after the surveyor arrived at the agency on 04/21/2026. Admin replied, “Because I did not replace my DON soon enough and did not follow-up it was not noticed.” The surveyor asked what should have been done differently. Admin replied, “We should have had the DON review the OASIS so the POC could be completed. We should have had a valid replacement.” Review of the agency policy titled; “Plan of Care” last reviewed 01/01/2026 read in part: “ ... VI. The individualized Plan of Care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health Plan of Care and the Agency as frequently as the patient’s/client’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date…””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record reviews, observation, and interviews, the agency failed to ensure that the individualized plan of care (POC) included the required elements in four of four patient records reviewed who received a home visit or telephone interview, in that: for (Patient # 1, 3, 4, and 5) the POC failed to include the frequency and duration of visits to be made, all medications and treatments, or both. The failure placed the patient at increased risk of having poor physical health and safety outcomes when skilled nursing visits and therapy visits were missed or not implemented and when all medications and medication instructions were not included in the plan of care. Findings included: Patient record review #1 Record review of Patient # 1’s EHR revealed a plan of care (POC) with a start of care date 12/12/2025 for the certification period 02/10/2026 to 04/10/2026. Review of the POC revealed it was signed and dated by admitting nurse, (RN A) on 02/09/2026 and by physician (Physician 4) on 03/04/2026. The POC included a principal diagnosis is Essential (primary) Hypertension (high blood pressure without a specific single medical cause) and a secondary diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Continued review of the POC revealed that it read in part: “Summary/Progress: [Patient] educated on fall precautions, importance of checking [blood pressure and blood glucose] before taking medications and insulin, performed finger stick using aseptic technique with blood sugar level of 98 milligrams per deciliter [measurement of sugar in the blood]. …” The plan of care included medication orders for (a liquid laxative) 15 milliliters (used for measurement of liquid medication doses) by mouth three times daily, (a laxative capsule) 145 micrograms (used for measurement in precise drug dosing) by mouth every morning, and (a cream for arthritis pain) 1% topical gel, 4 grams applied topically four times daily. The POC did not list any insulin medication name, instructions for insulin, or who would administer the insulin. Further review of Patient # 1’s POC revealed that it included orders for skilled nursing visits one time per week for nine weeks beginning the week of 02/10/2026, and physical therapy one time per month for one month to evaluate, treat and establish a plan of care. During home visit, interview, and observation conducted on 04/23/2026 at approximately 09:30 a.m. with Patient # 1, Family member 2, ADON B, and Surveyors A and B, the surveyors observed ADON B performing an assessment of Patient # 1. Patient # 1’s blood glucose at 369 (high blood glucose reading). ADON B then began looking at Patient # 1’s medications list and stated that the list was incorrect (did not include all medications that Patient # 1 was taking). Surveyor B asked ADON B if she had access to look up Patient # 1’s clinical record to check for an updated list and ADON B stated she did not have a way to access the EHR and would have to contact the office. ADON B contacted the agency’s Quality Assurance Supervisor, (Contractor A) and Contractor A confirmed that the agency did not have any additional medications other than the three listed on the medication list for Patient # 1. Review of Patient # 1’s “Medication Profile” in the home folder included the following medications: (a liquid laxative) 15 milliliters (used for measurement of liquid medication doses) by mouth three times daily, (a laxative capsule) 145 micrograms (used for measurement in precise drug dosing) by mouth every morning, and (a cream for arthritis pain) 1% topical gel, 4 grams applied topically four times daily. DON A signed the medication profile, and it was not dated. The medication profile did not list any insulin medication name, instructions for insulin, or who would administer the insulin. ADON B stated that she was unaware Patient # 1 was on insulin. Patient # 1 stated that (Patient # 1) checked her blood glucose daily and administered her insulin daily. Patient record review # 3: During record review of Patient # 3’s EHR revealed a plan of care with a start of care date of 02/12/2026 for certification period 02/12/2026-04/12/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 02/12/2026 and physician (Physician 1) signed and dated the POC on 03/11/2026. Continued review of the POC revealed a principal diagnosis of Chronic Kidney Disease Stage 3b (moderate to severe loss of kidney function); orders for skilled nurse visits one time per week for nine weeks beginning the week of 02/12/2026 and home health aide visits one time per week for nine weeks beginning the week of 02/12/2026. Further review of Patient # 3’s record revealed an admit/referral order dated 02/02/2026 and signed by RN A and Physician 2 on 02/02/2026. Review of the order revealed the following ordered services: Skilled Nursing Care, Physical Therapy, Occupational Therapy and Home Health Aide with no frequencies listed. Further review of the order revealed “additional orders: SN Visit [two times per week for one week and one time per week for five weeks] PT/OT to [evaluate] and treat.” During a home visit and interview conducted on 04/23/2026 at approximately 2:10 p.m. with Patient # 3 and Family Member # 1, the Surveyor B asked what services were currently being provided by the agency. Patient # 3 stated (Patient # 3) was supposed to receive nursing services, but it took over one month for a nurse to initiate visits and that nursing staff had only visited a few times since admission (admitted 02/12/2026). Patient # 3 further stated that although the agency contacted (Patient # 3) by phone, but staff frequently did not arrive for scheduled visits. Patient # 3 stated that home health aide services were ordered as part of the plan of care; however, the agency had not provided any home health aide visits to date and stated the agency was still waiting for an order. Patient # 3 stated she knew that the agency had the order and knew that insurance was approved a few hours a week. Patient # 3 stated after admission to the home health agency, the agency sent an order for physical and occupational therapy, but nobody had been out to date to start those services. Patient record review # 4: During record review of 4’s EHR revealed a plan of care with a start of care date of 12/15/2025 for certification period 02/13/2026 to 04/13/2026. Review of the plan of care (POC) revealed that (RN A) signed and dated the POC on 12/12/2026 and was not signed or dated by Family Nurse Practitioner (FNP 1). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Further review of the POC revealed orders for skilled nurse visits one time per week for nine beginning week of 02/09/2026 and home health aide to assist with activities of daily living (personal care and hygiene needs) according to RN care plan. The POC did not include a frequency or duration for the home health aide visits. During a telephone interview conducted on 04/23/2026 at 12:15 p.m. with Patient # 4’s (Family Member 4), Surveyor A asked what services were currently being provided by the agency. Family Member 4 stated (Patient # 4) was receiving nursing one time weekly, home health aide two times weekly, and therapy services one time weekly. Family Member 4 stated that the agency staff had been helpful, but voiced concern that nursing services had not been “up to par.” Family Member 4 stated that (RN A) did not assess (Patient # 4) that (RN A) just wrote down the family’s blood pressure and heart rate readings when (RN A visited). Family Member 4 stated that (RN A) could have been more diligent in monitoring Patient # 4’s medication. Family Member 4 stated that there had been inconsistent in agency visit schedules. Surveyor A asked if Patient # 4 was receiving home health aide services. Family member 4 stated that Patient # 4 was receiving home health aide services two times weekly to assist with personal care tasks. Surveyor A asked how long Patient # 4 had been receiving home health aide services. Family Member 4 stated that Patient # 4 had been receiving home health aide services since admission (07/25/2025). Patient record review # 5: During record review of 5’s EHR revealed a plan of care with a start of care date of 04/03/2026 for certification period 04/03/2026-06/01/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 04/03/2026 and was not signed or dated by physician (Physician 3). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus and a secondary of Long term (current) use of insulin (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood; currently using insulin to help manage the condition). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks for medication administration, teaching, training, observation, and assessment. The POC did not list any medication. During a telephone interview conducted on 04/24/2026 at 9:36 a.m. with Patient # 5, Surveyor A asked what services were currently being provided by the agency. Patient # 5 stated (Patient # 5) was supposed to receive nursing services, but (Patient # 5) had one in person visit (4/03/3036) and one telephone visit on (4/21/2026). Patient # 5 further stated that when RN A visited (RN A) “we talked [RN A] did not touch me or anything.” Patient # 5 stated that RN A did not assess or review medications or assess [Patient # 5]. Patient # 5 stated, “I have not had a lot of contact with [the agency], no paperwork or anything.” During an interview with Office Mgr. on 04/22/2026 at 12:00 p.m., the Office Mgr. stated that RN A no longer worked for the agency. The surveyor attempted to call RN A on 04/22/2026 at 12:00 p.m. and did not receive an answer or a return call. The Office Mgr. also stated that DON A was out of the office receiving medical treatments. On 04/24/2026 at 11:16 a.m. and 11:21 a.m. the surveyor attempted to call QA Supervisor, Contractor A. There were no answer and no return call. On 04/24/2026 at 10:29 a.m., and 12:44 p.m. the surveyor attempted to call DON A. There was no answer or return call. During an interview conducted on 04/24/2026 at approximately 4:30 p.m. with the Admin and Office Mgr., Surveyor A reviewed the findings and asked who was responsible for ensuring that the patient’s medication schedule and administration instructions were current, written and provided to the patients. Office Mgr. stated that Contractor A, QA Supervisor and DON A were responsible. The surveyor asked what the agency’s process was for ensuring that the patient’s medication schedule and administration instructions were current, written and provided to patients. Office Mgr. stated that weekly Contractor A sent the OASIS (standard data elements home health agencies integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services) to DON A for review, after reviewing if the OASIS is not correct (did not include the frequency and duration of visits to be made and all medications and instructions) the DON sent the OASIS back to the nurses for correction. Surveyor A asked why Patient # 3 and 4 did not have frequency and duration of home health aide visits to be made Patient and why Patients # 2 and 5 did not have a written medication schedule and administration instructions for the insulin that they were using. Admin replied, “My failure was that I did not follow-up properly to ensure that everything was being done. Review of agency policy titled, “Plan of Care” last reviewed 01/01/2026 read in part: “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems… A. A registered nurse (RN) initiates the Plan of Care for skilled nursing care and for personal hygiene/activities of daily living care… II. An RN is responsible for coordinating the Plan of Care when multiple disciplines are involved, or when more than one agency is involved, to decrease the possibility of duplication or conflict and to identify responsibilities… III. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s)… A. The individualized Plan of Care must include the following… 4. The frequency and duration of visits to be made… 10. All medications and treatments… V. Each patient/client must receive the home health services that are written in an individualized Plan of Care…””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record reviews, observation, and interviews the agency failed to ensure that the patient’s medication schedule and administration instructions were written and provided to three (Patient # 1 and 5) of four records reviewed in which the patients received a home visit or telephone interview, in that: Patient’s # 1 and 5 did not receive a written medication schedule and instructions that included medication name (Insulin), dosage and frequency, and if the medication would be administered by HHA personnel. The failure resulted in the patients not receiving necessary guidance for safe medication administration. The failure placed the patient at increased risk for medication errors, adverse drug events, improper administration, and decline in health status. Findings include: Patient record review #1 Record review of Patient # 1’s EHR revealed a plan of care (POC) with a start of care date 12/12/2025 for the certification period 02/10/2026 to 04/10/2026. Review of the POC revealed it was signed and dated by admitting nurse, (RN A) on 02/09/2026 and by physician (Physician 4) on 03/04/2026. The POC included a principal diagnosis is Essential (primary) Hypertension (high blood pressure without a specific single medical cause) and a secondary diagnosis of Type 2 diabetes mellitus (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood). Continued review of the POC revealed that it read in part: “Summary/Progress: [Patient] educated on fall precautions, importance of checking [blood pressure and blood glucose] before taking medications and insulin, performed finger stick using aseptic technique with blood sugar level of 98 milligrams per deciliter [measurement of sugar in the blood]. …” The plan of care included medication orders for (a liquid laxative) 15 milliliters (used for measurement of liquid medication doses) by mouth three times daily, (a laxative capsule) 145 micrograms (used for measurement in precise drug dosing) by mouth every morning, and (a cream for arthritis pain) 1% topical gel, 4 grams applied topically four times daily. The POC did not list any insulin medication name, instructions for insulin, or who would administer the insulin. Further review of Patient # 1’s POC revealed that it included orders for skilled nursing visits one time per week for nine weeks beginning the week of 02/10/2026, and physical therapy one time per month for one month to evaluate, treat and establish a plan of care. The POC also included orders for SN to assess Patient # 1’s blood sugar levels and report abnormal or pertinent findings (a random blood sugar level above 350 milligrams per deciliter) to physician (Physician 4). During home visit, interview, and observation conducted on 04/23/2026 at approximately 09:30 a.m. with Patient # 1, Family member 2, ADON B, and Surveyors A and B, the surveyors observed ADON B performing an assessment. Patient # 1’s blood glucose at 369 (high blood glucose-outside of parameter) . ADON B then began looking at Patient # 1’s medications list and stated that the list was incorrect. Surveyor B asked ADON B if she had access to look up Patient # 1’s clinical record to check for an updated list and ADON B stated she did not have a way to access the EHR and would have to contact the office. ADON B contacted the agency’s Quality Assurance Supervisor, (Contractor A) and Contractor A confirmed that the agency did not have any additional medications other than the three listed on the medication list for Patient # 1. Review of Patient # 1’s “Medication Profile” in the home folder included the following medications: (a liquid laxative) 15 milliliters (used for measurement of liquid medication doses) by mouth three times daily, (a laxative capsule) 145 micrograms (used for measurement in precise drug dosing) by mouth every morning, and (a cream for arthritis pain) 1% topical gel, 4 grams applied topically four times daily. DON A signed the medication profile, and it was not dated. The medication profile did not list any insulin medication name, instructions for insulin, or who would administer the insulin. ADON B stated that she was unaware Patient # 1 was on insulin. Surveyor B asked ADON B what the reporting parameters were for the patient’s vital signs (blood sugar), and ADON B stated she did not know and had not received training beyond virtual instruction on the charting system. Surveyor B asked ADON B what the protocol would be for a blood glucose of 369 and ADON B stated she would provide the patient with saltine crackers for carbohydrates and recheck her blood glucose in 15 minutes. ADON B further stated she was unsure how to respond in a home health setting, as her experience was limited to the hospital setting. Surveyor B asked ADON B who she would contact in the field with clinical questions and ADON B stated she was told by the office her supervisor was unavailable, and that office staff could only assist with EHR tasks. Surveyor B asked ADON B what she would do in a hospital setting and ADON B stated she would administer insulin and fluids. ADON B then asked Family member 2 whether Patient # 1 had a sliding scale insulin order (a fast-acting insulin dosing method used to manage variation in blood sugar levels); Family member 2 stated he was unaware and stated Patient # 1’s Family member 3 managed insulin administration. Family member 2 contacted Family member 3, and ADON B spoke with Family Member 3 regarding the elevated blood glucose. Family member 3 stated that he managed Patient # 1’s diabetes on his own judgement. Family member 3 instructed that no intervention be taken until lunchtime, at which time Patient # 1 should receive her usual insulin dose. ADON B stated she would contact Patient # 1’s physician to report the elevated blood glucose and obtain further instructions and subsequently left a message with (Physician 4’s) office staff. Patient # 1 rechecked [Patient # 1’s] blood glucose, which had increased to 392. ADON B stated she would like to send Patient # 1 to the emergency room; however, Family member 2 refused, stating the family would manage the situation and would seek emergency care if the blood glucose did not decrease after the lunchtime insulin dose. ADON B complied with the refusal. Patient # 1 stated that (Patient # 1) checked her blood glucose daily and administered her insulin daily. Patient record review # 5: During record review of Patient # 5’s EHR revealed a plan of care with a start of care date of 04/03/2026 for certification period 04/03/2026-06/01/2026. Review of the plan of care (POC) revealed that admitting nurse (RN A) signed and dated the POC on 04/03/2026 and was not signed or dated by physician (Physician 3). Continued review of the POC revealed a principal diagnosis of Type 2 diabetes mellitus and a secondary of Long term (current) use of insulin (chronic condition in which the body fails to produce enough insulin or does not utilize insulin causing high levels of glucose or sugar in the blood; currently using insulin to help manage the condition). Further review of the POC revealed orders for skilled nurse visits one time per week for nine weeks for medication administration, teaching, training, observation, and assessment. The POC did not list any medication. Further review of Patient # 5’s record revealed an admit/referral order dated 04/02/2026 and signed by RN A 0n 04/02/2026 and was not signed by Physician 3. Review of the order revealed the following ordered services: Skilled Nursing Care with “additional orders: SN visits [one time per week for nine weeks beginning 04/03/2026]” Continued review of Patient # 5’s record revealed a SOC initial assessment that was electronically signed with RN A’s initials and dated 04/03/2026. The record included a SN visit note, ADON B signed and dated the visit note on 04/21/2026. Review of SN telephone visit note dated 04/21/2026 revealed that it read in part: “Able to self-administer insulin…” Patient # 5’s record did not list any insulin medication name or instructions for insulin. During an interview with Office Mgr. on 04/22/2026 at 12:00 p.m., the Office Mgr. stated that RN A no longer worked for the agency. The surveyor attempted to call RN A on 04/22/2026 at 12:00 p.m. and did not receive an answer or a return call. The Office Mgr. also stated that DON A was out of the office receiving medical treatments. During a telephone interview conducted on 04/24/2026 at 9:36 a.m. with Patient # 5, Surveyor B asked what services were currently being provided by the agency. Patient # 5 stated (Patient # 5) was supposed to receive nursing services, but (Patient # 5) had one in person visit (4/03/2026) and one telephone visit on (4/21/2026). Patient # 5 further stated that when RN A visited “we talked [RN A] did not touch me or anything.” Patient # 5 stated that RN A did not assess or review medications or assess [Patient # 5]. Surveyor B asked if Patient # 5 had received a written medication schedule with instructions from the agency. Patient # 5 stated, “I have not had a lot of contact with [the agency], no paperwork or anything.” Surveyor B asked if Patient # 5 was using insulin to help manage her diabetes. Patient # 5 stated that (Patient # 5) was using an intermediate-acting insulin that was just increased from 15 to 23 units twice daily to 30 units twice daily. Patient # 5 stated that (Patient # 5) checked her blood glucose daily and administered her insulin daily. On 04/24/2026 at 11:16 a.m. and 11:21 a.m. the surveyor attempted to call QA Supervisor, Contractor A. There were no answer and no return call. On 04/24/2026 at 10:29 a.m., and 12:44 p.m. the surveyor attempted to call DON A. There was no answer or return call. During an interview conducted on 04/24/2026 at approximately 4:30 p.m. with the Admin and Office Mgr., Surveyor B asked what the agency process was for medication reconciliation. The Office Mgr. stated that physician orders were received in the office and uploaded into the patient’s chart by the QA Supervisor (Contractor A), who was terminated on 04/23/2026. The Office Mgr. further stated that the RN case manager (RN A) was responsible for comparing the physician ordered medication list with the medications in the home and contacting the physician if discrepancies are identified. Surveyor B asked who was responsible for medication reconciliation and the Office Mgr. stated that the RN reported any discrepancies to the office, and the Director of Nursing audits the chart, contacts the physician as needed, and updates the clinical record. Survey asked who was ultimately responsible for ensuring this process was completed and why it was not done. Admin stated that he is ultimately responsible and acknowledged the process was not followed due to his focus on marketing and growing the business, as he had relied on office staff to manage operations in his absence. Surveyor B then asked what potential impact improper medication documentation could have on the agency’s patients. Admin stated that inaccurate or incomplete medication information in the clinical record could place the patients at risk for harm, particularly if a new nurse relied on incorrect information. Surveyor B asked what could have been done differently. Admin stated that emotional considerations impacted decision making, as the Director of Nursing had been undergoing cancer treatment since January, and he delayed replacing her in hopes she would return to her role. The Admin acknowledged that the delay contributed to lapses in oversight and stated that, in hindsight, he should have separated emotions from operational decisions and ensured timely replacement to maintain safe patient care practices. In a continued interview with the Admin and Office Mgr., Surveyor A reviewed the findings and asked who was responsible for ensuring that the patient’s medication schedule and administration instructions were current, written and provided to the patients. Office Mgr. stated that Contractor A, QA Supervisor and DON A were responsible. The surveyor asked what the agency’s process was for ensuring that the patient’s medication schedule and administration instructions were current, written and provided to patients. Office Mgr. stated that weekly Contractor A sent the OASIS to DON A for review, after reviewing if the OASIS was not correct (did not include all medications and instructions) the DON sent the OASIS back to the nurses for correction. Surveyor A asked why Patient # 1 and 5 did not have a written medication schedule and administration instructions for the insulin that they were using. Admin replied, “My failure was that I did not follow-up properly to ensure that everything was being done. Review of agency policy titled, “Medication Management” last reviewed 01/01/26 read in part: “…Policy I. Medication assessments will identify all medications, both prescription, non-prescription and as needed (PRN) that the patient/client is taking and document in the clinical record. II. The Agency will ensure that assessments of a patient/client include a review of the medication regimen. This will include… III. The Agency will define the high-risk medications and subsequent standards of care that include patient/client education and monitoring. At a minimum high-risk medications will include… f. Hypoglycemics, including insulin… Procedure I. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. II. All qualified clinicians will initially and routinely evaluate the medication regimen. A complete and accurate medication profile will be established and monitored as part of the Plan of Care… VI. A prescription medication found in the home is considered an order from a physician or allowed practitioner that has been transcribed by the pharmacist. The medication will be documented in the medical record and added to the Plan of Care. VII. The Agency will maintain a current, accurate list of all prescription and nonprescription (over-the counter (OTC) medications) taken by the patient/client. Qualified clinical staff will update the medication list with any changes in the medication regimen, per orders… IX. The Agency will provide to the patient/client and caregiver (if any) written information regarding the patient’s/client’s medication regimen based on the results of the medication assessment. A. The medication administration instructions must be written in plain language that does not use medical abbreviations. B. Patient/client medication schedule/instructions will include: medication name, dosage and frequency and which medications will be administered by agency/contract personnel…””

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation, record review, and interviews the administrator failed to ensure that a clinical manager was available during all operating hours, in that for two (DON A and ADON B) two active clinical mangers were not available by phone or in person during the agency’s operating hours. The failure resulted in the agency’s patients not receiving necessary guidance from a clinical manager for safe medication monitoring and instructions; and resulted in patients not having current plans of care. The failure placed the patient at increased risk for medication errors, adverse drug events, improper administration, and decline in physical health status. Findings include: On 04/21/2026 at 9:00 a.m. the Surveyor A arrivedat the agency’s suite located in an office building. Surveyor A observed a note hanging on the agency’s door that indicated the agency’s operating hours were from 9:00 a.m. to 5:00 p.m. Monday through Friday. During the entrance conference with Admin, Office Mgr., and ADON B on 04/21/2026 at 11:25 a.m., Surveyor A asked who the agency’s DON and ADON (clinical managers) were. Office Mgr. identified DON A as the clinical manager and ADON B as the alternate clinical manager. Office Mgr. confirmed the agency’s operating hours. During an interview with Office Mgr. on 04/22/2026 at 12:00 p.m. Office Mgr. stated that DON A was out of the office receiving medical treatments. During a home visit and interviews with Patient # 1, ADON B, and Surveyors A and B on 04/23/3036 at approximately 9:30 a.m., Surveyor B asked ADON B who she would contact in the field with clinical questions and ADON B stated she was told by the office her supervisor (DON A) was unavailable, and that office staff could only assist with EHR tasks. During an interview with ADON B on 04/23/2024 at approximately 10:30 a.m. Surveyor A asked how long she had worked for the agency. ADON B stated that her first day was 04/21/2026. The surveyor asked if ADON B had accepted the position of ADON (clinical manager) and was made aware that DON A was not available. ADON B stated that she was not aware that she had accepted the position of ADON. ADON B stated that she had not signed any papers except an application. ADON B stated that she applied to the agency to work part time because she worked night shifts at a hospital. DON A: Review of DON A’s personnel record revealed a hire date of 12/19/2022. The record included a signed application for the position of nursing supervisor dated 12/16/2022. The record also included a signed job description for Director of Nursing dated 12/30/2023. ADON B: Review of ADON B’s personnel record revealed a hire date of 04/21/2026. The record included a signed application for the position of RN. Review of the application revealed that ADON B had four months’ RN experience in a hospital setting (no home health nursing experience). Review of ADON B’s RN license revealed that she received her original license on 12/16/2025 (ADON B had four months nursing experience). The record did not include a signed job description for RN or assistant director of nursing. The record did not include any record of competency assessment for the position of clinical manager, orientation to agency, or training in the position of clinical manager. During a phone interview with Office Mgr. on 04/23/2026 at 1:22 p.m. Surveyor A requested the telephone number for DON A. Office Mgr. provided the telephone number and stated that DON A was receiving medical treatments and might not be able to answer. On 04/24/2026 at 10:29 a.m., and 12:44 p.m. Surveyor A attempted to call DON A. There was no answer or return call. During an interview on 04/24/2026 at 12:54 p.m. with the Admin, Office Mgr., and Surveyors A and B, Surveyor A asked who the agency’s active DON was. Office Mgr. stated the DON was DON A, but “[DON A] has been going through [medical treatments]. We are trying to replace [DON A].” Surveyor A asked who the DON on-call was when DON A was not available in person or by phone. Office Mgr. stated that ADON B was the assistant DON (clinical manager). Surveyor A stated that Surveyor A needed to speak with ADON B. 04/24/2026 At 12:56 p.m. Office Mgr. attempted to call ADON B twice with no answer or return call. Surveyor B asked when the last ADON (ADON A) left the agency. Office Mgr. replied, “[ADON A] left last week. [ADON B] started last Friday [04/17/2026].” Surveyor A requested Admin and Office Mgr. to attempt to contact DON A, ADON A, RN A, and ADON B. Admin stated that DON A was in the hospital receiving medical treatment and had been receiving medical treatment since January. On 04/24/2026 at 1:15 p.m. Surveyor A attempted to call ADON B. There was no answer or return call. During an interview on 04/24/2026 at 1:38 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A or ADON B had returned calls. Admin and Office Mgr. stated that they had not received any return calls. Office Mgr. stated that ADON B worked at the hospital and was only working for the agency three days per week. During phone interview on 04/24/2026 at 2:48 p.m. with ADON B, Surveyor A asked again if ADON B realized that the agency hired her as ADON. ADON B stated that she was not aware. ADON B stated that she did not accept the position of ADON because she did not have enough experience. Surveyor A asked if ADON B was aware that DON A was not available in person or by phone. ADON B stated that she was not aware that DON A was not available by phone. ADON B stated that the agency told her that she had a supervisory (DON A), but she was just on leave. Surveyor B asked again when ADON B’s first day to work was. ADON B stated 04/21/2026 was her first day. ADON B stated that she conducted a virtual visit with Patient # 5 on 04/21/2026. ADON B stated that (ADON B) was confused she was told by the agency that other nurses would go with her to conduct a home visit with Patient # 1 and Surveyors A and B on 04/23/2026. ADON B stated that she was not aware that (ADON B) was assigned to conduct the visit alone. Surveyor A asked what training ADON B received. ADON B stated that she received a virtual training on the agency’s EHR system. QA Supervisor (Contractor A) provided the training. The surveyor asked if ADON B went to any patient visits with an RN. ADON B stated that she did not do any visits or training with an RN from the agency. During an interview on 04/24/2026 at approximately 4:30 p.m. with Admin, Office Mgr., and Surveyors A and B, Surveyor A asked if DON A, ADON A, RN A, and ADON B were available for phone interviews. Admin stated that they were not available and had not returned the agency’s calls. Surveyor A reviewed the findings and asked why the agency did not have a qualified clinical manager available in person or by phone during the agency’s business hours. Admin stated that he and Office Mgr. were emotional towards the DON A because she had been getting medical treatments since January and did not want to replace her. Admin stated he let things slip because he hoped DON A would get better and return back to her position and stated he should have left emotions out of it and replaced her sooner. Surveyor A asked what the current process was for training and verifying previous employment and experience for agency staff. Office Mgr. stated there was currently no training other than virtual for the EMR system. Office Mgr. stated the agency verified two references and required nurses to have 2 years of home health experience for the position of clinical manager (DON). Surveyor A asked how ADON B’s employment history and experience were verified since she had only been licensed since 12/16/2025. Office Mgr. stated that ADON B’s family member (Family Member 5) was a home health nurse and ADON B had been going out with her since she was little, so ADON B knew what she was doing. Admin stated the agency made an exception because ADON B was the administrator of Family Member # 5’s home health company and Admin and Office Mgr. assumed ADON B knew what she was doing since they hired her as the alternate DON. Surveyor A asked how having an inexperienced RN seeing patients in the position of alternate DON could negatively impact patient care. Admin stated it could impact patient care if she did not know what to do for a patient and did not have the training required to assess properly. Surveyor A asked what should have been done differently. Admin stated (Admin and Office Mgr.) were in a bind because ADON B was the only RN the agency had and state surveyors showed up to do a survey, so they had no choice but to send ADON B out untrained. Admin stated the he had hired another RN today that had 20 years’ experience, she would become the DON (DON B), and ADON B would become a RN care manager, DON B would be training ADON B for a minimum of 4 months before ADON B would be able to go on her own to see patients. Review of agency policy titled, “Responsibilities of the Clinical Manager” last reviewed on 05/01/2024 read in part: “Purpose [:] To define the responsibilities of the Clinical Manager to ensure safe and appropriate delivery of patient/client care. Definition The Clinical Manager is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or Registered Nurse responsible for supervising skilled services provided by the Agency, and who meets the qualifications defined by regulation. This person may also be known as the Director of Nurses, Director of Clinical Services, Director of Home Health Services, or a similar title. Policy [:] The Clinical Manager, appointed by the Administrator, is responsible for the oversight of all patient/client care services and personnel, and participates in activities relevant to the professional services furnished. Procedure [:] I. The Agency defines the responsibilities of the Clinical Manager to include, but not be limited to: A. Making patient/client and personnel assignments. B. Coordinating patient/client care. C. Coordinating referrals. D. Assuring patient/client needs are continually assessed. E. Assuring the development, implementation, and updating of the individualized plan of care. F. Participating in activities relevant to professional services furnished, including the assignment of agency personnel. G. Coordinating and integrating care provided by agency staff, including contractual providers. H. Collaborating on the development and implementation of policies and procedures, which guide and support the provision of care. I. Recommending resources needed to provide care J. Collaborating with agency leadership and appropriate staff to develop the organizational plan as it pertains to patient/client care. K. Ensuring the care offered by the Agency, including any branches, is consistently available to all patients/clients. L. Participating in the development and implementation of the Quality Assessment Performance Improvement Program. M. Being available at all times in person or via telecommunications during operating hours (Clinical Manager or Alternate). N. Assuring a reassessment of a patient’s/client’s needs is performed by the appropriate healthcare professional: 1. When there is a significant health status change in the patient’s/client’s condition; 2. At the physician’s request; 3. After hospital discharge. II. The Clinical Manager will identify resources needed to implement responsibilities and will notify the Administrator of these needs. III. The Clinical Manager will notify the Administrator immediately if unable to fulfill responsibilities. IV. Administrator will designate, in writing, the appropriate qualified person to perform the responsibilities of the position in the absence of the Clinical Manager.”