Seniors Home Healthcare Services

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patient) for 56.25% (9 of 16) of assessments transmitted during 09/03/2024-09/03/2025. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 09/03/2025: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 09/03/2024-09/03/2025. The HHA Error Summary by Agency report included 9 of 16 OASIS assessments (56.25%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/LVN on 09/10/2025 at 2:30 PM. The Alt Adm/LVN stated the CFO was responsible for submitting OASIS assessments to the CMS system. During an interview with the CFO on 09/12/2025 at 3:00 PM, the surveyor asked who was responsible for submitting OASIS assessments to CMS and why agency policy was not followed. The CFO stated the agency’s electronic health vendor, Identifier A, submitted the OASIS assessments for the agency, but the CFO was responsible for overseeing it. The CFO stated the agency had issues with [Identifier A], and when they called [Identifier A] about the issues, [Identifier A] gave them reasons about technical issues when submitting the assessments. The CFO stated the failure affected the agency because they were not getting paid on time by CMS and the payments were lowered by percentages if assessments were submitted late. During an interview with the Adm/LVN on 09/12/2025 at 10:45 AM, the surveyor asked why OASIS assessments were submitted past 30 days of completion date and why agency policy was not followed. The Adm/LVN stated they were having issues with [Identifier A] who submitted the assessments for them. Agency policy titled, “MEDICAL RECORD INFORMATION TIMELINES IM.10” with a revision date of 05/01/2011 read in part, “… PURPOSE To establish timely parameters for all medical record information… PROCEDURE… 1.11 Completed and encoded OASIS data will be transmitted to the state within 30 days of the M0090 [completion] date…””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document performance improvement projects for two of two calendar years (2023 and 2024) that were reviewed and failed to have at least one performance improvement project in development or ongoing for calendar year 2025 that reflected the scope, complexity and past performance of the agency’s services and operations and the measurable progress achieved on the projects. This failure could prevent the agency from identifying weaknesses and making improvements in patient care. Findings Included: In an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the Adm/LVN stated the CFO was responsible for the agency’s overall quality assessment performance improvement activities and performance improvement projects. Record review at of the agency’s quality assessment performance improvement binder, available for review upon surveyor arrival to the agency on 09/12/2025, did not include any reports, reviews or documentation that indicated the agency conducted performance improvement projects for calendar year 2023 and 2024 or had a performance improvement project in development or ongoing for calendar year 2025. In an interview with the CFO on 09/12/2025 at 11:40 AM, the surveyor asked why performance improvement projects had not been done for calendar year 2023 and 2024 and in development or ongoing for calendar year 2025. The CFO stated they had been done and he would locate them. On 09/12/2025 at 12:20 PM, the CFO gave a report titled, “Final Validation Report” to the surveyor and asked if the report was what the surveyor was looking for. The surveyor reviewed the report and stated, “No.” The CFO stated the agency paid their consultant to prepare the performance improvement projects, but the consultant had not yet given them to the agency. The surveyor again requested the projects for 2023 and 2024 and in development or ongoing for calendar year 2025 and the CFO stated he was trying to get them from the consultant. In an interview with the Adm/LVN and the CFO on 09/12/2025 at 12:27 PM, the surveyor asked the Adm/LVN what the agency’s performance improvement projects were for calendar year 2023 and 2024 and in development or ongoing for calendar year 2025. The Adm/LVN stated she knew what they were but was unable to recall them. The Adm/LVN stated she would go look for them, but they were not aware they were missing and therefore, did not know what the reports would have included. The Adm/LVN and CFO both stated they did not know the projects were not included in the binder until the surveyor asked for them. The surveyor asked how the agency could follow the reports if they didn’t have them or know what was included in the reports. The CFO stated he did not know. In an interview with the CFO on 09/12/2025 at 12:35 PM, the CFO stated the agency paid their consultant lots of money to prepare all of their reports, but the consultant either did not complete the performance improvement projects or the consultant couldn’t find them. In an interview with the Adm/LVN and the CFO on 09/12/2025 at 12:45 PM, the surveyor asked how this failure could affect the patients and why the agency did not follow its policy. The CFO stated the patients could be affected by the agency not following through or giving them proper care. The CFO further stated that agency policy was not followed because they were not aware they did not have the performance improvement projects. The Adm/LVN nodded her head up and down in agreement.”

“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 provide the completed written Notice of Medicare Non-Coverage notice at least two days in advance of terminating on-going care in three of three patient (Patients 6, 8 and 9) discharged records reviewed. The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patients from exercising their right to appeal the discharge decision if they chose to appeal. Findings included: A discharge roster was provided to the surveyor by the CFO on 09/09/2025 at 3:10 PM that included the reason for discharge. During an interview with the CFO on 09/04/2025 at 11:20 AM and with the Adm/LVN at 11:45 AM, the CFO and Adm/LVN stated the DON and the ADON were out of the country and were not available in person or by telephone. During an interview with the CFO on 09/09/2025 at 11:15 AM, the CFO stated the agency hired a new ADON. In an interview on 09/12/2025 at 2:55 PM, the CFO stated the hire date for the new ADON was 09/08/2025. During an interview with the ADON on 09/09/2025 at 11:15 AM, the ADON stated she probably would not know the answers to clinical questions since she was a new employee and did not make any of the prior nursing visits that were under review. During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the Adm/LVN stated the DON was responsible for giving patients discharge notices. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The record included a discharge OASIS assessment dated 12/05/2022 signed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The record included a discharge summary signed and dated by the Alt Adm/DON on 12/05/2022. The discharge summary included the patient was discharged due to no authorization. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 12/05/2022 The reason for this discharge is: Pt ran out of authorization… Notified: 11/30/2022 By: [Adm/LVN]… Phone call date 11/30/2022 Patient/SO acknowledges awareness of discharge…” The discharge roster included the patient was discharged on 12/05/2022 with a discharge reason of goals met and discharged to home or self-care (routine discharge). During an interview with the Adm/LVN and ADON on 09/11/2025 at 2:30 PM, the surveyor asked why the discharge list included goals were met but the 5-day discharge notice included the patient ran out of authorization. The Adm/LVN stated the discharge reason was the patient no longer had insurance authorization for visits. The Adm/LVN stated the discharge list was wrong. The record did not include the form Notice of Medicare Non-Coverage. Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The record included a discharge OASIS assessment dated 07/25/2024 signed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The discharge OASIS included the patient remained in the community with formal assistive services at discharge. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 07/25/2024 The reason for this discharge is: Pt has different insurance… Notified: 07/20/2024 By: [Adm/LVN]… Phone call date 07/20/2024 Patient/SO acknowledges awareness of discharge…” The 5-day discharge notice was not signed by the patient. The record included a discharge summary initialed and dated by the Alt Adm/DON on 07/25/2024. The discharge summary read in part, “… Reason for discharge… non-compliance… Circumstances of Discharge… when the patient or payer could no longer pay for the services provided by the HHA…” The record included discharge order signed and dated by the Alt Adm/DON on 07/25/2024 that listed the discharge reason as the patient signed up with a new provider. The discharge roster included Patient 8 was discharged on 07/25/2024 with a discharge reason of discharged/transferred to a short-term general hospital for inpatient care/transfer to hospital. During an interview with the Adm/LVN and ADON on 09/11/2025 at 3:00 PM, the surveyor asked why the patient was discharged from the agency. The Adm/LVN stated the patient was discharged from the agency because the agency could not bill Medicaid for home health services. The Adm/LVN stated the discharge roster was wrong due to a mistake on the agency’s part. The record did not include the form Notice of Medicare Non-Coverage. Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The record included a discharge OASIS assessment dated 05/28¬/2023 and initialed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The discharge OASIS included the patient remained in the community with formal assistive services at discharge. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 05/28/2023 The reason for this discharge is: The patient switched to another agency… Notified: 05/23/2023 By: [Adm/LVN]… Phone call date 05/23/2023 Patient/SO acknowledges awareness of discharge…” The record included a discharge summary initialed and dated by the Alt Adm/DON on 05/23/2023 and a second discharge summary initialed and dated by the Alt Adm/DON on 05/28/2023. The discharge summaries read in part, “… Reason for discharge… recovered (goals achieved)…” The discharge roster included the patient was discharged on 05/28/2023 with a discharge reason of discharged to home or self-care (routine discharge). During an interview with the Adm/LVN and ADON on 09/11/2025 at 3:25 PM, the surveyor asked why the patient was discharged from the agency. The Adm/LVN stated goals were met. During an interview with the Adm/LVN, ADON and CFO on 09/11/2025 at 11:17 AM, the surveyor asked why the Notice of Medicare Non-Coverage was not given to Patients 6, 8 and 9 at least 2 days in advance of agency discharge. The Adm/LVN stated she was not aware of the Notice of Medicare Non-Coverage form and it was an oversight none of the discharged patients received the notice. The CFO stated it was because their electronic health record vendor [Identifier A], did not give the agency the notice. The ADON stated she could not answer for the agency since she was a new employee. Agency policy titled, “Patient Discharge PE.6” with a revision date of 04/01/2011 read in part, “PURPOSE To assess each patient’s discharge planning and/or continuing care needs prior to discharge from Agency. To provide for continuity of care as well as appropriate and timely post-discharge care and documentation… POLICY Agency will provide appropriate discharge planning and notification, per regulations… PROCEDURE… B. Termination Notice… 1. Agency staff will provide valid delivery notice (involves both delivery and completion) of the generic notice to the beneficiary when the end of all covered care is foreseen, even if the beneficiary agrees with the discharge… No later than two (2) days before the proposed end of covered services. Agency representative will provide generic notice to patient (or authorized representative)… If Agency fails to give valid notice, patient coverage continues for at least 2 days after notice is received… 1.3 Agency representative will assure the patient (or authorized representative) understands that the purpose and contents of the notice is to notify the patient that: End of covered care is imminent, and Patient (or authorized representative) may appeal the termination decision… 1.4 Agency will have patient (or authorized representative) complete and sign generic notice. Patient or authorized representative should sign and date two copies, keep one, and return a copy to Agency…””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patients’ health status for seven of nine Patients (Patient 1, 2, 5, 6, 7, 8 and 9) whose records were reviewed in that: Patient 1, 2, 5, 6, 7, 8 and 9’s comprehensive assessment included an inaccurate diagnosis of hemiplegia (paralysis) affecting the right dominant side. This failure placed patients at risk of receiving inadequate care and services due to inaccurate clinical information. Findings Included: During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the surveyor asked who was responsible for ensuring the plan of cares included all required elements. The Adm/LVN stated the Adm/LVN and the DON. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 03/03/2025 to 05/01/2025 signed by the Alt Adm/DON on 03/03/2025 with a start of care date of 03/03/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 03/03/2025. The plan of care included a diagnosis of diabetes (high blood sugar levels), heart disease, high blood pressure, and arthritis in the right knee (joint pain and swelling). The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 03/03/2025 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 2: Record review of the electronic and paper medical record included a plan of care dated 11/18/2024 to 01/16/2025 signed by the Alt Adm/DON on 11/18/2024 with a start of care date of 09/19/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/18/2024. The plan of care included a diagnosis of arthritis, pain, back pain and high blood pressure. The record included a comprehensive assessment (used to generate the plan of care dated 11/18/2024 to 01/16/2025) signed and dated by the Alt Adm/DON on 11/17/2024 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 5: Record review of the electronic and paper medical record included a plan of care dated 01/21/2025 to 03/21/2025 signed by the Alt Adm/DON on 01/21/2025 with a start of care date of 01/21/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 01/28/2025. The plan of care included a diagnosis of high blood pressure, diabetes and heart disease. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 01/21/2025 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/07/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 11/07/2022 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 7: Record review of the electronic and paper medical record included a plan of care dated 06/05/2023 to 08/03/2023 signed by the Alt Adm/DON on 04/06/2023 (sic) with a start of care date of 04/06/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 06/04/2022. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 06/03/2023 (used to generate the plan of care dated 06/05/2023 to 08/03/2023) that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/19/2024. The plan of care included a diagnosis of diabetes, high blood pressure, heart disease, heart failure and kidney failure. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 07/18/2024 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 04/30/2023. The plan of care included a diagnosis of knee pain and high blood pressure. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 04/29/2023 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” During an interview with the Adm/LVN on 09/12/2025 at 2:35 PM, the surveyor asked if Patients 1, 2, 5, 6, 7, 8 or 9 had hemiplegia affecting the right side. The Adm/LVN stated none of the patients had that diagnosis. The surveyor asked why the information was included on the comprehensive assessments. The Adm/LVN stated she did not know because the Alt Adm/DON checked the plan of cares, but the Alt Adm/DON and the person that was the ADON during the time period the assessments were completed (Prior ADON), were both out of the country and not available. The surveyor asked how the inaccurate information could affect the patients and why agency policy was not followed. The Adm/LVN stated patients could be greatly affected because the agency nurses might treat the patient for the wrong cause. Agency policy titled, “Medical Record Content IM.8” with a revision date of 10/01/2011 read in part, “…Policy Agency will initiate and maintain an individual and accurate medical record for each patient receiving care…””

“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: This is a repeated violation cited at G574 on 09/07/2022. Based on record review and interview, the agency failed to ensure the plan of cares included all pertinent diagnoses; psychosocial and cognitive status; all medications; 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; patient-specific interventions; and information related to advanced directives (medical power of attorney) in nine of nine records reviewed (Patient 1, 2, 3, 4, 5, 6, 7, 8 and 9) in that: a. In one of nine records reviewed (Patient 1), the plan of care did not include the psychosocial and cognitive status; Hydrocodone/Acetaminophen (strong prescription pain medication) and Acetaminophen (pain medication); 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; and pain parameters to report to the physician. b. In one of nine records reviewed (Patient 2), the plan of care did not include the psychosocial and cognitive status; pain parameters to report to the physician; and information related to a medical power of attorney. c. In one of nine records reviewed (Patient 3), the plan of care did not include Insulin (an injectable medicine used to lower blood sugar levels); 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; and pain parameters to report to the physician. d. In one of nine records reviewed (Patient 4), the plan of care did not include the psychosocial and cognitive status; Hydrocodone; 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; and pain parameters to report to the physician. e. In one of nine records reviewed (Patient 5), the plan of care did not include insulin and a strong prescription pain medication; 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; pain parameters to report to the ordering clinician; and orders for the nurse to monitor blood sugar levels. f. In one of nine records reviewed (Patient 6), the plan of care did not include 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; and pain parameters to report to the physician. g. In one of nine records reviewed (Patient 7), the plan of care did not include the frequency of administration or the as needed reason to take Tramadol (strong prescription pain medication); 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; orders for the nurse to monitor blood sugar levels; and information related to advanced directives. h. In one of nine records reviewed (Patient 8), the plan of care did not include 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; orders for the nurse to monitor blood sugar levels; and pain parameters to report to the physician. i. In one of nine records reviewed (Patient 9), the plan of care did not include Tylenol (pain medication); psychosocial and cognitive status; 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. These failures placed patients in jeopardy of harm from agency staff who could not address the patient’s risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 03/03/2025 to 05/01/2025 signed by the Alt Adm/DON on 03/03/2025 with a start of care date of 03/03/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 03/03/2025. The plan of care included a diagnosis of diabetes (high blood sugar levels), heart disease, high blood pressure, and arthritis in the right knee (joint pain and swelling). The plan of care read in part, “… Reason Homebound… Pt have increase pain to lower back… Pt c/o increase pain to joints when sitting for more than 30 mins… Pt have a hx of right hip pain… Patient is homebound due to unsteady, painful ambulation with extremely poor balance and current use of pain medications to address pain issues. Side effects of the pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses…” The Psychosocial/Cognitive section was blank and incomplete. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 03/03/2025 and a recertification nurse assessment electronically signed by the Alt Adm/DON on 04/28/2025. The two assessments read in part, “… Patient is homebound due to unsteady, painful ambulation with extremely poor balance and current use of pain medications to address pain issues. Side effects of the pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness...” The pain medication was not included on the plan of care. The record included eight nurse visit notes completed and electronically signed by the Adm/LVN between 03/10/2025 – 04/21/2025 that included the patient had right knee pain rated 3-5 on a 0-10 scale and was currently taking the prescription pain medication: Hydrocodone/Acetaminophen and Acetaminophen (pain medication). The Hydrocodone/Acetaminophen and Acetaminophen were not included on the plan of care. The plan of care did not include the psychosocial and cognitive status; the pain medication; 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; and pain parameters to report to the physician. During an interview with the Adm/LVN and ADON on 09/11/2025 at 1:30 PM, the surveyor asked why Hydrocodone/Acetaminophen and Acetaminophen were not included on the plan of care. The Adm/LVN stated the patient hardly ever took the pain medications but she had them available if she needed them. The ADON stated she did not know. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 11/18/2024 to 01/16/2025 signed by the Alt Adm/DON on 11/18/2024 with a start of care date of 09/19/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/18/2024. The plan of care included a diagnosis of arthritis, pain, back pain and high blood pressure. The plan of care read in part, “… Reason Homebound… increase pain to lower back… increase pain to joints when sitting for more than 30 mins… hx of RIGHT HIP PAIN that causes generalize weakness… painful ambulation…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses. The Psychosocial/Cognitive section was blank and incomplete. The record included a consent form signed by an agency representative with an illegible signature and dated 09/19/2024 and signed, but not dated, by the patient. The consent form included the patient had a medical power of attorney. The plan of care did not include the psychosocial and cognitive status; pain parameters to report to the physician; and information related to a medical power of attorney. During an interview with the Adm/LVN and ADON on 09/11/2025 at 1:43 PM, the surveyor asked why the medical power of attorney information that was included on the consent form was not included on the plan of care. The Adm/LVN stated the patient did have a medical power of attorney and the information should be on the plan of care. The Adm/LVN stated the agency’s consultant was supposed to catch the omissions for the agency. The ADON did not answer. Patient 3: Record review of the electronic and paper medical record included a plan of care dated 10/02/2022 to 11/30/2022 signed by the Alt Adm/DON on 08/03/2022 (sic) with a start of care date of 08/03/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/29/2022 (sic). The plan of care included a diagnosis of diabetes, high blood pressure and muscular dystrophy (causes muscles to weaken and lose mass). The plan of care read in part, “… Reason Homebound… have increased pain to lower back… c/o increase pain to joints… SN to prepare/administer insulin orders prescribed by physician using aseptic technique… … assess/instruct pt/cg on interventions in pain management…” During an interview with the Adm/LVN and ADON on 09/11/2025 at 2:00 PM, the surveyor asked if Patient 3 took insulin for diabetes. The Adm/LVN stated the patient was on insulin and administered his own insulin, and the nurse prepared and administered it as needed. The ADON stated insulin should have been included on the plan of care and medication list. The plan of care did not include Insulin; 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; and pain parameters to report to the physician. Patient 4: Record review of the electronic and paper medical record included a plan of care dated 06/28/2023 to 08/26/2023 signed by the Alt Adm/DON on 07/27/2023 with a start of care date of 03/05/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/28/2023 (sic). The plan of care included a diagnosis of lung disease, muscle wasting and kidney failure. The plan of care read in part, “… Pt has right ankle pain that is 6-7/10 (6-7 out of 10) and she has been limping… Pt have increase pain to lower back… Pt c/o increase pain to joints… hx of right hip pain… SN to assess/instruct pt/cg on interventions in pain management…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses. The Psychosocial/Cognitive section was blank and incomplete. The record included eight nurse visit notes completed and electronically signed by the Adm/LVN between 06/28/2023 – 08/26/2023 that included the patient had knee pain rated 3-5 on a 0-10 scale and was currently taking the prescription pain medication: Hydrocodone. The plan of care did not include the psychosocial and cognitive status; Hydrocodone; 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; and pain parameters to report to the physician. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 2:06 PM, the surveyor asked why Hydrocodone was not included on the POC. The Adm/LVN stated it was an oversight. The ADON stated she did not know. Patient 5: Record review of the electronic and paper medical record included a plan of care dated 01/21/2025 to 03/21/2025 signed by the Alt Adm/DON on 01/21/2025 with a start of care date of 01/21/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 01/28/2025. The plan of care included a diagnosis of high blood pressure, diabetes and heart disease. The plan of care read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… right hip pain… current use of… pain medications to address pain issues… Side effects of the… pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness… safety measures… SN to assess/instruct pt/cg on interventions in pain management…” The record included four nurse visit notes completed and electronically signed by the Adm/LVN between 01/28/2025 – 02/13/2025 that included the patient had a caregiver that was willing and able to administer insulin. The four nurse notes included the patient’s current pain medication was Hydrocodone/Acetaminophen for pain rated 3-5 on a 0-10 pain scale. The plan of care did not include insulin and a pain medication; 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; pain parameters to report to the ordering clinician; and for the nurse to monitor blood sugar levels. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 11:17 AM, the surveyor asked if Patient 5 was on insulin and a pain medication. The Adm/LVN stated yes but she did not know why she or the Alt Adm/DON did not add the medications to the plan of care and medication list. The Adm/LVN stated the patient was on insulin when admitted to the agency on 01/21/2025. The surveyor asked why the plan of care did not have orders for the nurse to monitor blood sugar levels. The Adm/LVN stated she did not know. The ADON stated she did not know why the items were not included on the plan of care. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/07/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The record included three nurse visit notes completed and electronically signed by LVN between 11/10/2022 – 11/24/2022 that included neck pain rated 3-5 on a 0-10 pain scale. The plan of care did not include 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; and pain parameters to report to the physician. Patient 7: Record review of the electronic and paper medical record included a plan of care dated 06/05/2023 to 08/03/2023 signed by the Alt Adm/DON on 04/06/2023 (sic) with a start of care date of 04/06/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 06/04/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The plan of care also included the pain medication, Tramadol 50 mg by mouth as needed. The record included a consent form signed and dated by the Alt Adm/DON on 04/06/2023 and signed by a family member of Patient 7. The consent form included the patient had a medical power of attorney. The plan of care did not include the frequency of administration or the as needed reason to take Tramadol; 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; orders for the nurse to monitor blood sugar levels; and information related to advanced directives. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 2:43 PM, the surveyor asked why the frequency of administration or the as needed reason to take Tramadol was not included on the plan of care. The Adm/LVN stated she did not know. The ADON stated it should have been included. The surveyor asked why the plan of care did not include orders for the nurse to monitor blood sugar levels. The Adm/LVN stated she did not know why the Alt Adm/DON left the information off the plan of care but she did check the blood sugar levels during her visits, even though she did not have an order. The surveyor asked if the patient had a medical power of attorney and if so, why the information was not included on the plan of care. The Adm/LVN stated yes, but it was an oversight that it wasn’t included on the plan of care. The ADON stated all of the information should have been included and she wished the Alt Adm/DON was present so they could ask her why they weren’t included. Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/19/2024. The plan of care included a diagnosis of diabetes, high blood pressure, heart disease, heart failure and kidney failure. The plan of care also included Hydrocodone/acetaminophen every 6 hours and insulin to be administered via injection at bedtime for diabetes. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 07/18/2024. The assessment included Patient 8 had continuous left leg pain rated 5 resulting in sweating, moaning/crying, irritability and anger. The assessment read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… Pt have a hx of right hip pain… painful ambulation… current use of… pain medications to address pain issues…” The record included three nurse visit notes completed and electronically signed by the Adm/LVN between 07/20/2024 – 07/22/2024 that included Hydrocodone/acetaminophen was the current pain medication. The notes included the patient and cg were able to self-administer insulin, but did not include blood sugar levels. The plan of care did not include 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; orders for the nurse to monitor blood sugar levels; and pain parameters to report to the physician. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 3:00 PM, the surveyor asked why plan of care did not have orders for the nurse to monitor the blood sugar levels. The Adm/LVN stated a family member monitored the blood sugars. Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 04/30/2023. The plan of care included a diagnosis of knee pain and high blood pressure. The plan of care did not include any medications. The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses…” The Psychosocial/Cognitive section was blank and incomplete. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 04/29/2024. The assessment included Patient 9 took the pain medication, Tylenol, for knee pain. The assessment read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… hx of right hip pain… current use of… pain medications to address pain issues…” The record included three nurse visit notes completed and electronically signed by the Adm/LVN between 05/05/2023 – 05/18/2023 that included knee pain rated 3-5 on a 0-10 pain scale. The plan of care did not include Tylenol; psychosocial and cognitive status; 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. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 3:25 PM, the surveyor asked why Tylenol was not included on the plan of care. The Adm/LVN stated she did not know. The ADON stated the medication should have been included. During an interview with the CFO on 09/04/2025 at 11:20 AM and with the Adm/LVN at 11:45 AM, the CFO and Adm/LVN stated the DON and the ADON were out of the country and were not available in person or by telephone. During an interview with the CFO on 09/09/2025 at 11:15 AM, the CFO stated the agency hired a new ADON. In an interview on 09/12/2025 at 2:55 PM, the CFO stated the hire date for the new ADON was 09/08/2025. During an interview with the ADON on 09/09/2025 at 11:15 AM, the ADON stated she probably would not know the answers to clinical questions if asked since she was a new employee and did not make any of the prior nursing visits under review. During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the surveyor asked who was responsible for ensuring the plan of cares included all required elements. The Adm/LVN stated the Adm/LVN and the DON. During an interview with the Adm/LVN, ADON and CFO on 09/11/2025 at 1:20 PM, the surveyor asked why the plan of cares for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9 did not include 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. The ADON stated the nurse that completed the assessments probably did not complete that section on the assessments. The ADON stated she did not know why the information was not included on the plan of cares. The Adm/LVN stated she did not know why. The surveyor asked why pain parameters to report to the physician were not included on the plan of cares for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 8. The Adm/LVN stated she was surprised the information was not on the plan of cares because it was supposed to be included. The ADON stated she did not know why. The surveyor asked why the cognitive/psychosocial section was not completed on the plan of cares for Patient 2, Patient 2, Patient 4 and Patient 9. The Adm/LVN stated it was an oversight. The ADON stated it should have been included. The surveyor asked why the plan of cares were not reviewed and the issues identified. The Adm/LVN stated she could not answer for the DON. The ADON stated she did not know why. The surveyor asked how the patient’s could be affected by the failures and why agency policies were not followed. The Adm/LVN stated it wasn’t good for the agency and patient’s because patient issues could be missed. The CFO stated they needed additional training because when the agency was purchased, the prior agency owner did not provide sufficient training. The ADON stated more training was needed. Agency policy titled, “Plan of Care TX.6” with a revision date of 04/17/2006 read in part, “… Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems… Policy Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs… Procedure I. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care… 3. The 485, which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client’s care and will serve as the initial plan of care: client’s primary and secondary diagnoses/problems… medications and treatment… specific procedures/treatments to be performed, including amount, frequency and duration…””

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: This is a repeated violation cited at G948 on 09/07/2022. Based on record review and interview, the Adm/LVN and Alt Adm/DON failed to organize and direct the day-to-day operation of the agency in that: #1. The Adm/LVN and Alt Adm/DON failed to ensure the plan of cares included all pertinent diagnoses; psychosocial and cognitive status; all medications; 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; patient-specific interventions; and information related to advanced directives (medical power of attorney) in nine of nine records reviewed (Patient 1, 2, 3, 4, 5, 6, 7, 8 and 9) in that: a. In one of nine records reviewed (Patient 1), the plan of care did not include the psychosocial and cognitive status; Hydrocodone/Acetaminophen (strong prescription pain medication) and Acetaminophen (pain medication); 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; and pain parameters to report to the physician. b. In one of nine records reviewed (Patient 2), the plan of care did not include the psychosocial and cognitive status; pain parameters to report to the physician; and information related to a medical power of attorney. c. In one of nine records reviewed (Patient 3), the plan of care did not include Insulin (an injectable medicine used to lower blood sugar levels); 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; and pain parameters to report to the physician. d. In one of nine records reviewed (Patient 4), the plan of care did not include the psychosocial and cognitive status; Hydrocodone; 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; and pain parameters to report to the physician. e. In one of nine records reviewed (Patient 5), the plan of care did not include insulin and a strong prescription pain medication; 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; pain parameters to report to the ordering clinician; and orders for the nurse to monitor blood sugar levels. f. In one of nine records reviewed (Patient 6), the plan of care did not include 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; and pain parameters to report to the physician. g. In one of nine records reviewed (Patient 7), the plan of care did not include the frequency of administration or the as needed reason to take Tramadol (strong prescription pain medication); 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; orders for the nurse to monitor blood sugar levels; and information related to advanced directives. h. In one of nine records reviewed (Patient 8), the plan of care did not include 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; orders for the nurse to monitor blood sugar levels; and pain parameters to report to the physician. i. In one of nine records reviewed (Patient 9), the plan of care did not include Tylenol (pain medication); psychosocial and cognitive status; 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. #2. The Adm/LVN and Alt Adm/DON failed to electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patient) for 56.25% (9 of 16) of assessments transmitted during 09/03/2024-09/03/2025. #3. The Adm/LVN and Alt Adm/DON failed to provide the completed written Notice of Medicare Non-Coverage notice at least two days in advance of terminating on-going care in three of three patients (Patients 6, 8 and 9) discharged records reviewed. #4. The Adm/LVN and Alt Adm/DON failed to ensure the comprehensive assessment accurately reflected the patients’ health status for seven of nine Patients (Patient 1, 2, 5, 6, 7, 8 and 9) whose records were reviewed in that Patient 1, 2, 5, 6, 7, 8 and 9’s comprehensive assessment included an inaccurate diagnosis of hemiplegia (paralysis) affecting the right dominant side. #5. The Adm/LVN and Alt Adm/DON failed to conduct and document performance improvement projects for two of two calendar years (2023 and 2024) that were reviewed and failed to have at least one performance improvement project in development or ongoing for calendar year 2025 that reflected the scope, complexity and past performance of the agency’s services and operations and the measurable progress achieved on the projects. These failures showed lack of overall administrative leadership and agency oversight and could place the agency’s clients at risk of not receiving interventions as needed; injury; declining health status; and at risk of inadequate care, services and poor outcomes. #1. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 03/03/2025 to 05/01/2025 signed by the Alt Adm/DON on 03/03/2025 with a start of care date of 03/03/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 03/03/2025. The plan of care included a diagnosis of diabetes (high blood sugar levels), heart disease, high blood pressure, and arthritis in the right knee (joint pain and swelling). The plan of care read in part, “… Reason Homebound… Pt have increase pain to lower back… Pt c/o increase pain to joints when sitting for more than 30 mins… Pt have a hx of right hip pain… Patient is homebound due to unsteady, painful ambulation with extremely poor balance and current use of pain medications to address pain issues. Side effects of the pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses…” The Psychosocial/Cognitive section was blank and incomplete. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 03/03/2025 and a recertification nurse assessment electronically signed by the Alt Adm/DON on 04/28/2025. The two assessments read in part, “… Patient is homebound due to unsteady, painful ambulation with extremely poor balance and current use of pain medications to address pain issues. Side effects of the pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness...” The pain medication was not included on the plan of care. The record included eight nurse visit notes completed and electronically signed by the Adm/LVN between 03/10/2025 – 04/21/2025 that included the patient had right knee pain rated 3-5 on a 0-10 scale and was currently taking the prescription pain medication: Hydrocodone/Acetaminophen and Acetaminophen (pain medication). The Hydrocodone/Acetaminophen and Acetaminophen were not included on the plan of care. The plan of care did not include the psychosocial and cognitive status; the pain medication; 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; and pain parameters to report to the physician. During an interview with the Adm/LVN and ADON on 09/11/2025 at 1:30 PM, the surveyor asked why Hydrocodone/Acetaminophen and Acetaminophen were not included on the plan of care. The Adm/LVN stated the patient hardly ever took the pain medications but she had them available if she needed them. The ADON stated she did not know. Patient 2: Record review of the electronic and paper medical record included a plan of care dated 11/18/2024 to 01/16/2025 signed by the Alt Adm/DON on 11/18/2024 with a start of care date of 09/19/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/18/2024. The plan of care included a diagnosis of arthritis, pain, back pain and high blood pressure. The plan of care read in part, “… Reason Homebound… increase pain to lower back… increase pain to joints when sitting for more than 30 mins… hx of RIGHT HIP PAIN that causes generalize weakness… painful ambulation…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses. The Psychosocial/Cognitive section was blank and incomplete. The record included a consent form signed by an agency representative with an illegible signature and dated 09/19/2024 and signed, but not dated, by the patient. The consent form included the patient had a medical power of attorney. The plan of care did not include the psychosocial and cognitive status; pain parameters to report to the physician; and information related to a medical power of attorney. During an interview with the Adm/LVN and ADON on 09/11/2025 at 1:43 PM, the surveyor asked why the medical power of attorney information that was included on the consent form was not included on the plan of care. The Adm/LVN stated the patient did have a medical power of attorney and the information should be on the plan of care. The Adm/LVN stated the agency’s consultant was supposed to catch the omissions for the agency. The ADON did not answer. Patient 3: Record review of the electronic and paper medical record included a plan of care dated 10/02/2022 to 11/30/2022 signed by the Alt Adm/DON on 08/03/2022 (sic) with a start of care date of 08/03/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/29/2022 (sic). The plan of care included a diagnosis of diabetes, high blood pressure and muscular dystrophy (causes muscles to weaken and lose mass). The plan of care read in part, “… Reason Homebound… have increased pain to lower back… c/o increase pain to joints… SN to prepare/administer insulin orders prescribed by physician using aseptic technique… … assess/instruct pt/cg on interventions in pain management…” During an interview with the Adm/LVN and ADON on 09/11/2025 at 2:00 PM, the surveyor asked if Patient 3 took insulin for diabetes. The Adm/LVN stated the patient was on insulin and administered his own insulin, and the nurse prepared and administered it as needed. The ADON stated insulin should have been included on the plan of care and medication list. The plan of care did not include Insulin; 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; and pain parameters to report to the physician. Patient 4: Record review of the electronic and paper medical record included a plan of care dated 06/28/2023 to 08/26/2023 signed by the Alt Adm/DON on 07/27/2023 with a start of care date of 03/05/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/28/2023 (sic). The plan of care included a diagnosis of lung disease, muscle wasting and kidney failure. The plan of care read in part, “… Pt has right ankle pain that is 6-7/10 (6-7 out of 10) and she has been limping… Pt have increase pain to lower back… Pt c/o increase pain to joints… hx of right hip pain… SN to assess/instruct pt/cg on interventions in pain management…” The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses. The Psychosocial/Cognitive section was blank and incomplete. The record included eight nurse visit notes completed and electronically signed by the Adm/LVN between 06/28/2023 – 08/26/2023 that included the patient had knee pain rated 3-5 on a 0-10 scale and was currently taking the prescription pain medication: Hydrocodone. The plan of care did not include the psychosocial and cognitive status; Hydrocodone; 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; and pain parameters to report to the physician. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 2:06 PM, the surveyor asked why Hydrocodone was not included on the POC. The Adm/LVN stated it was an oversight. The ADON stated she did not know. Patient 5: Record review of the electronic and paper medical record included a plan of care dated 01/21/2025 to 03/21/2025 signed by the Alt Adm/DON on 01/21/2025 with a start of care date of 01/21/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 01/28/2025. The plan of care included a diagnosis of high blood pressure, diabetes and heart disease. The plan of care read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… right hip pain… current use of… pain medications to address pain issues… Side effects of the… pain medications being exhibited by the patient are disorientation, drowsiness, and dizziness… safety measures… SN to assess/instruct pt/cg on interventions in pain management…” The record included four nurse visit notes completed and electronically signed by the Adm/LVN between 01/28/2025 – 02/13/2025 that included the patient had a caregiver that was willing and able to administer insulin. The four nurse notes included the patient’s current pain medication was Hydrocodone/Acetaminophen for pain rated 3-5 on a 0-10 pain scale. The plan of care did not include insulin and a pain medication; 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; pain parameters to report to the ordering clinician; and for the nurse to monitor blood sugar levels. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 11:17 AM, the surveyor asked if Patient 5 was on insulin and a pain medication. The Adm/LVN stated yes but she did not know why she or the Alt Adm/DON did not add the medications to the plan of care and medication list. The Adm/LVN stated the patient was on insulin when admitted to the agency on 01/21/2025. The surveyor asked why the plan of care did not have orders for the nurse to monitor blood sugar levels. The Adm/LVN stated she did not know. The ADON stated she did not know why the items were not included on the plan of care. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/07/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The record included three nurse visit notes completed and electronically signed by LVN between 11/10/2022 – 11/24/2022 that included neck pain rated 3-5 on a 0-10 pain scale. The plan of care did not include 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; and pain parameters to report to the physician. Patient 7: Record review of the electronic and paper medical record included a plan of care dated 06/05/2023 to 08/03/2023 signed by the Alt Adm/DON on 04/06/2023 (sic) with a start of care date of 04/06/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 06/04/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The plan of care also included the pain medication, Tramadol 50 mg by mouth as needed. The record included a consent form signed and dated by the Alt Adm/DON on 04/06/2023 and signed by a family member of Patient 7. The consent form included the patient had a medical power of attorney. The plan of care did not include the frequency of administration or the as needed reason to take Tramadol; 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; orders for the nurse to monitor blood sugar levels; and information related to advanced directives. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 2:43 PM, the surveyor asked why the frequency of administration or the as needed reason to take Tramadol was not included on the plan of care. The Adm/LVN stated she did not know. The ADON stated it should have been included. The surveyor asked why the plan of care did not include orders for the nurse to monitor blood sugar levels. The Adm/LVN stated she did not know why the Alt Adm/DON left the information off the plan of care but she did check the blood sugar levels during her visits, even though she did not have an order. The surveyor asked if the patient had a medical power of attorney and if so, why the information was not included on the plan of care. The Adm/LVN stated yes, but it was an oversight that it wasn’t included on the plan of care. The ADON stated all of the information should have been included and she wished the Alt Adm/DON was present so they could ask her why they weren’t included. Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/19/2024. The plan of care included a diagnosis of diabetes, high blood pressure, heart disease, heart failure and kidney failure. The plan of care also included Hydrocodone/acetaminophen every 6 hours and insulin to be administered via injection at bedtime for diabetes. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 07/18/2024. The assessment included Patient 8 had continuous left leg pain rated 5 resulting in sweating, moaning/crying, irritability and anger. The assessment read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… Pt have a hx of right hip pain… painful ambulation… current use of… pain medications to address pain issues…” The record included three nurse visit notes completed and electronically signed by the Adm/LVN between 07/20/2024 – 07/22/2024 that included Hydrocodone/acetaminophen was the current pain medication. The notes included the patient and cg were able to self-administer insulin, but did not include blood sugar levels. The plan of care did not include 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; orders for the nurse to monitor blood sugar levels; and pain parameters to report to the physician. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 3:00 PM, the surveyor asked why plan of care did not have orders for the nurse to monitor the blood sugar levels. The Adm/LVN stated a family member monitored the blood sugars. Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 04/30/2023. The plan of care included a diagnosis of knee pain and high blood pressure. The plan of care did not include any medications. The plan of care included a section titled, “Psychosocial/Cognitive” that included grief, spiritual needs, ability to access transportation for medical appointments, cultural issues, the current cognitive functioning (level of alertness, orientation, comprehension, concentration, and immediate memory of simple commands), if the patient was able/ready/willing to learn to read, and strengths and weaknesses…” The Psychosocial/Cognitive section was blank and incomplete. The record included a start of care nurse assessment electronically signed by the Alt Adm/DON on 04/29/2024. The assessment included Patient 9 took the pain medication, Tylenol, for knee pain. The assessment read in part, “… Pt have increase pain to lower back… Pt c/o increase pain to joints… hx of right hip pain… current use of… pain medications to address pain issues…” The record included three nurse visit notes completed and electronically signed by the Adm/LVN between 05/05/2023 – 05/18/2023 that included knee pain rated 3-5 on a 0-10 pain scale. The plan of care did not include Tylenol; psychosocial and cognitive status; 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. During an interview with the Adm/LVN and the ADON on 09/11/2025 at 3:25 PM, the surveyor asked why Tylenol was not included on the plan of care. The Adm/LVN stated she did not know. The ADON stated the medication should have been included. During an interview with the CFO on 09/04/2025 at 11:20 AM and with the Adm/LVN at 11:45 AM, the CFO and Adm/LVN stated the DON and the ADON were out of the country and were not available in person or by telephone. During an interview with the CFO on 09/09/2025 at 11:15 AM, the CFO stated the agency hired a new ADON. In an interview on 09/12/2025 at 2:55 PM, the CFO stated the hire date for the new ADON was 09/08/2025. During an interview with the ADON on 09/09/2025 at 11:15 AM, the ADON stated she probably would not know the answers to clinical questions if asked since she was a new employee and did not make any of the prior nursing visits under review. During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the surveyor asked who was responsible for ensuring the plan of cares included all required elements. The Adm/LVN stated the Adm/LVN and the DON. During an interview with the Adm/LVN, ADON and CFO on 09/11/2025 at 1:20 PM, the surveyor asked why the plan of cares for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8 and Patient 9 did not include 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. The ADON stated the nurse that completed the assessments probably did not complete that section on the assessments. The ADON stated she did not know why the information was not included on the plan of cares. The Adm/LVN stated she did not know why. The surveyor asked why pain parameters to report to the physician were not included on the plan of cares for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 8. The Adm/LVN stated she was surprised the information was not on the plan of cares because it was supposed to be included. The ADON stated she did not know why. The surveyor asked why the cognitive/psychosocial section was not completed on the plan of cares for Patient 2, Patient 2, Patient 4 and Patient 9. The Adm/LVN stated it was an oversight. The ADON stated it should have been included. The surveyor asked why the plan of cares were not reviewed and the issues identified. The Adm/LVN stated she could not answer for the DON. The ADON stated she did not know why. The surveyor asked how the patient’s could be affected by the failures and why agency policies were not followed. The Adm/LVN stated it wasn’t good for the agency and patient’s because patient issues could be missed. The CFO stated they needed additional training because when the agency was purchased, the prior agency owner did not provide sufficient training. The ADON stated more training was needed. #2. During pre-survey activity on 09/03/2025: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 09/03/2024-09/03/2025. The HHA Error Summary by Agency report included 9 of 16 OASIS assessments (56.25%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/LVN on 09/10/2025 at 2:30 PM. The Alt Adm/LVN stated the CFO was responsible for submitting OASIS assessments to the CMS system. During an interview with the CFO on 09/12/2025 at 3:00 PM, the surveyor asked who was responsible for submitting OASIS assessments to CMS and why agency policy was not followed. The CFO stated the agency’s electronic health vendor, Identifier A, submitted the OASIS assessments for the agency, but the CFO was responsible for overseeing it. The CFO stated the agency had issues with [Identifier A], and when they called [Identifier A] about the issues, [Identifier A] gave them reasons about technical issues when submitting the assessments. The CFO stated the failure affected the agency because they were not getting paid on time by CMS and the payments were lowered by percentages if assessments were submitted late. During an interview with the Adm/LVN on 09/12/2025 at 10:45 AM, the surveyor asked why OASIS assessments were submitted past 30 days of completion date and why agency policy was not followed. The Adm/LVN stated they were having issues with [Identifier A] who submitted the assessments for them. #3. A discharge roster was provided to the surveyor by the CFO on 09/09/2025 at 3:10 PM that included the reason for discharge. During an interview with the CFO on 09/04/2025 at 11:20 AM and with the Adm/LVN at 11:45 AM, the CFO and Adm/LVN stated the DON and the ADON were out of the country and were not available in person or by telephone. During an interview with the CFO on 09/09/2025 at 11:15 AM, the CFO stated the agency hired a new ADON. In an interview on 09/12/2025 at 2:55 PM, the CFO stated the hire date for the new ADON was 09/08/2025. During an interview with the ADON on 09/09/2025 at 11:15 AM, the ADON stated she probably would not know the answers to clinical questions since she was a new employee and did not make any of the prior nursing visits that were under review. During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the Adm/LVN stated the DON was responsible for giving patients discharge notices. Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The record included a discharge OASIS assessment dated 12/05/2022 signed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The record included a discharge summary signed and dated by the Alt Adm/DON on 12/05/2022. The discharge summary included the patient was discharged due to no authorization. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 12/05/2022 The reason for this discharge is: Pt ran out of authorization… Notified: 11/30/2022 By: [Adm/LVN]… Phone call date 11/30/2022 Patient/SO acknowledges awareness of discharge…” The discharge roster included the patient was discharged on 12/05/2022 with a discharge reason of goals met and discharged to home or self-care (routine discharge). During an interview with the Adm/LVN and ADON on 09/11/2025 at 2:30 PM, the surveyor asked why the discharge list included goals were met but the 5-day discharge notice included the patient ran out of authorization. The Adm/LVN stated the discharge reason was the patient no longer had insurance authorization for visits. The Adm/LVN stated the discharge list was wrong. The record did not include the form Notice of Medicare Non-Coverage. Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The record included a discharge OASIS assessment dated 07/25/2024 signed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The discharge OASIS included the patient remained in the community with formal assistive services at discharge. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 07/25/2024 The reason for this discharge is: Pt has different insurance… Notified: 07/20/2024 By: [Adm/LVN]… Phone call date 07/20/2024 Patient/SO acknowledges awareness of discharge…” The 5-day discharge notice was not signed by the patient. The record included a discharge summary initialed and dated by the Alt Adm/DON on 07/25/2024. The discharge summary read in part, “… Reason for discharge… non-compliance… Circumstances of Discharge… when the patient or payer could no longer pay for the services provided by the HHA…” The record included discharge order signed and dated by the Alt Adm/DON on 07/25/2024 that listed the discharge reason as the patient signed up with a new provider. The discharge roster included Patient 8 was discharged on 07/25/2024 with a discharge reason of discharged/transferred to a short-term general hospital for inpatient care/transfer to hospital. During an interview with the Adm/LVN and ADON on 09/11/2025 at 3:00 PM, the surveyor asked why the patient was discharged from the agency. The Adm/LVN stated the patient was discharged from the agency because the agency could not bill Medicaid for home health services. The Adm/LVN stated the discharge roster was wrong due to a mistake on the agency’s part. The record did not include the form Notice of Medicare Non-Coverage. Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The record included a discharge OASIS assessment dated 05/28¬/2023 and initialed by the Alt Adm/DON. The discharge OASIS did not include the discharge reason. The discharge OASIS included the patient remained in the community with formal assistive services at discharge. The record included a 5-day discharge notice that read in part, “…You will be discharged from home health services on: 05/28/2023 The reason for this discharge is: The patient switched to another agency… Notified: 05/23/2023 By: [Adm/LVN]… Phone call date 05/23/2023 Patient/SO acknowledges awareness of discharge…” The record included a discharge summary initialed and dated by the Alt Adm/DON on 05/23/2023 and a second discharge summary initialed and dated by the Alt Adm/DON on 05/28/2023. The discharge summaries read in part, “… Reason for discharge… recovered (goals achieved)…” The discharge roster included the patient was discharged on 05/28/2023 with a discharge reason of discharged to home or self-care (routine discharge). During an interview with the Adm/LVN and ADON on 09/11/2025 at 3:25 PM, the surveyor asked why the patient was discharged from the agency. The Adm/LVN stated goals were met. During an interview with the Adm/LVN, ADON and CFO on 09/11/2025 at 11:17 AM, the surveyor asked why the Notice of Medicare Non-Coverage was not given to Patients 6, 8 and 9 at least 2 days in advance of agency discharge. The Adm/LVN stated she was not aware of the Notice of Medicare Non-Coverage form and it was an oversight none of the discharged patients received the notice. The CFO stated it was because their electronic health record vendor [Identifier A], did not give the agency the notice. The ADON stated she could not answer for the agency since she was a new employee. #4. During an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the surveyor asked who was responsible for ensuring the plan of cares included all required elements. The Adm/LVN stated the Adm/LVN and the DON. Patient 1: Record review of the electronic and paper medical record included a plan of care dated 03/03/2025 to 05/01/2025 signed by the Alt Adm/DON on 03/03/2025 with a start of care date of 03/03/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 03/03/2025. The plan of care included a diagnosis of diabetes (high blood sugar levels), heart disease, high blood pressure, and arthritis in the right knee (joint pain and swelling). The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 03/03/2025 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 2: Record review of the electronic and paper medical record included a plan of care dated 11/18/2024 to 01/16/2025 signed by the Alt Adm/DON on 11/18/2024 with a start of care date of 09/19/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/18/2024. The plan of care included a diagnosis of arthritis, pain, back pain and high blood pressure. The record included a comprehensive assessment (used to generate the plan of care dated 11/18/2024 to 01/16/2025) signed and dated by the Alt Adm/DON on 11/17/2024 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 5: Record review of the electronic and paper medical record included a plan of care dated 01/21/2025 to 03/21/2025 signed by the Alt Adm/DON on 01/21/2025 with a start of care date of 01/21/2025. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 01/28/2025. The plan of care included a diagnosis of high blood pressure, diabetes and heart disease. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 01/21/2025 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 6: Record review of the electronic and paper medical record included a plan of care dated 11/07/2022 to 01/05/2023 signed by the Alt Adm/DON on 11/07/2022 with a start of care date of 11/07/2022. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 11/07/2022. The plan of care included a diagnosis of high blood pressure, chronic pain syndrome, neck pain, spinal pain and other chronic pain. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 11/07/2022 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 7: Record review of the electronic and paper medical record included a plan of care dated 06/05/2023 to 08/03/2023 signed by the Alt Adm/DON on 04/06/2023 (sic) with a start of care date of 04/06/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 06/04/2022. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 06/03/2023 (used to generate the plan of care dated 06/05/2023 to 08/03/2023) that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 8: Record review of the electronic and paper medical record included a plan of care dated 07/18/2024 to 09/15/2024 signed by the Alt Adm/DON on 07/18/2024 with a start of care date of 07/18/2024. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 07/19/2024. The plan of care included a diagnosis of diabetes, high blood pressure, heart disease, heart failure and kidney failure. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 07/18/2024 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” Patient 9: Record review of the electronic and paper medical record included a plan of care dated 04/29/2023 to 06/27/2023 signed by the Alt Adm/DON on 04/30/2023 with a start of care date of 04/29/2023. The physician ordered the nurse to visit the patient once a week for nine weeks beginning the week of 04/30/2023. The plan of care included a diagnosis of knee pain and high blood pressure. The record included a comprehensive assessment signed and dated by the Alt Adm/DON on 04/29/2023 that read in part, “… Pt have a hx of RIGHT HIP PAIN that causes generalize weakness with hemiplegia affecting right dominant side...” During an interview with the Adm/LVN on 09/12/2025 at 2:35 PM, the surveyor asked if Patients 1, 2, 5, 6, 7, 8 or 9 had hemiplegia affecting the right side. The Adm/LVN stated none of the patients had that diagnosis. The surveyor asked why the information was included on the comprehensive assessments. The Adm/LVN stated she did not know because the Alt Adm/DON checked the plan of cares, but the Alt Adm/DON and the person that was the ADON during the time period the assessments were completed (Prior ADON), were both out of the country and not available. The surveyor asked how the inaccurate information could affect the patients and why agency policy was not followed. The Adm/LVN stated patients could be greatly affected because the agency nurses might treat the patient for the wrong cause. #5. In an interview with the Adm/LVN on 09/10/2025 at 2:30 PM, the Adm/LVN stated the CFO was responsible for the agency’s overall quality assessment performance improvement activities and performance improvement projects. Record review at of the agency’s quality assessment performance improvement binder, available for review upon surveyor arrival to the agency on 09/12/2025, did not include any reports, reviews or documentation that indicated the agency conducted performance improvement projects for calendar year 2023 and 2024 or had a performance improvement project in development or ongoing for calendar year 2025. In an interview with the CFO on 09/12/2025 at 11:40 AM, the surveyor asked why performance improvement projects had not been done for calendar year 2023 and 2024 and in development or ongoing for calendar year 2025. The CFO stated they had been done and he would locate them. On 09/12/2025 at 12:20 PM, the CFO gave a report titled, “Final Validation Report” to the surveyor and asked if the report was what the surveyor was looking for. The surveyor reviewed the report and stated, “No.” The CFO stated the agency paid their consultant to prepare the performance improvement projects, but the consultant had not yet given them to the agency. The surveyor again requested the projects for 2023 and 2024 and in development or ongoing for calendar year 2025 and the CFO stated he was trying to get them from the consultant. In an interview with the Adm/LVN and the CFO on 09/12/2025 at 12:27 PM, the surveyor asked the Adm/LVN what the agency’s performance improvement projects were for calendar year 2023 and 2024 and in development or ongoing for calendar year 2025. The Adm/LVN stated she knew what they were but was unable to recall them. The Adm/LVN stated she would go look for them, but they were not aware they were missing and therefore, did not know what the reports would have included. The Adm/LVN and CFO both stated they did not know the projects were not included in the binder until the surveyor asked for them. The surveyor asked how the agency could follow the reports if they didn’t have them or know what was included in the reports. The CFO stated he did not know. In an interview with the CFO on 09/12/2025 at 12:35 PM, the CFO stated the agency paid their consultant lots of money to prepare all of their reports, but the consultant either did not complete the performance improvement projects or the consultant couldn’t find them. In an interview with the Adm/LVN and the CFO on 09/12/2025 at 12:45 PM, the surveyor asked how this failure could affect the patients and why the agency did not follow its policy. The CFO stated the patients could be affected by the agency not following through or giving them proper care. The CFO further stated that agency policy was not followed because they were not aware they did not have the performance improvement projects. The Adm/LVN nodded her head up and down in agreement. Agency policy titled, “Responsibilities of the Administrator LD.6” with a revision date of 07/01/2012 read in part, “…PURPOSE To define the responsibilities of the Administrator to ensure Agency compliance with applicable federal, state and local laws and regulations as appropriate. POLICY Agency Administrator will assume overall responsibility and authority for administrative and leadership functions… The Administrator will be responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to agency patients on a day-to-day basis… PROCEDURE A. Administrator of a Licensed and Certified Agency 1. Agency defines the responsibilities of the Licensed/Certified Administrator to include… 1.1 Manage the daily operations of the agency… 1.2 Organize and direct the Agency’s ongoing functions. 1.3 Administratively supervise the provision of quality care to agency patients/clients. 1.4 Supervise to ensure implementation of agency policy and procedures… 1.5 Plan, organize, direct and evaluate operations to ensure the provision of adequate and appropriate care and services… 1.12 Direct and monitor organizational Performance Improvement activities… 1.21 Ensure completion, maintenance and submission of required reports… 1.22 Ensure documentation of services is accurate and timely…” Agency policy titled, “Plan of Care TX.6” with a revision date of 04/17/2006 read in part, “… Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems… Policy Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goals, actions or interventions that will resolve or alleviate the patient’s problems and/or needs… Procedure I. The appropriate licensed professional staff member, with physician participation, is responsible for developing the plan of care… 3. The 485, which includes the following plan of care elements, is developed in consultation with staff, client, physician and other providers involved in the client’s care and will serve as the initial plan of care: client’s primary and secondary diagnoses/problems… medications and treatment… specific procedures/treatments to be performed, including amount, frequency and duration…” Agency policy titled, “MEDICAL RECORD INFORMATION TIMELINES IM.10” with a revision date of 05/01/2011 read in part, “… PURPOSE To establish timely parameters for all medical record information… PROCEDURE… 1.11 Completed and encoded OASIS data will be transmitted to the state within 30 days of the M0090 [completion] date…” Agency policy titled, “Patient Discharge PE.6” with a revision date of 04/01/2011 read in part, “PURPOSE To assess each patient’s discharge planning and/or continuing care needs prior to discharge from Agency. To provide for continuity of care as well as appropriate and timely post-discharge care and documentation… POLICY Agency will provide appropriate discharge planning and notification, per regulations… PROCEDURE… B. Termination Notice… 1. Agency staff will provide valid delivery notice (involves both delivery and completion) of the generic notice to the beneficiary when the end of all covered care is foreseen, even if the beneficiary agrees with the discharge… No later than two (2) days before the proposed end of covered services. Agency representative will provide generic notice to patient (or authorized representative)… If Agency fails to give valid notice, patient coverage continues for at least 2 days after notice is received… 1.3 Agency representative will assure the patient (or authorized representative) understands that the purpose and contents of the notice is to notify the patient that: End of covered care is imminent, and Patient (or authorized representative) may appeal the termination decision… 1.4 Agency will have patient (or authorized representative) complete and sign generic notice. Patient or authorized representative should sign and date two copies, keep one, and return a copy to Agency…” Agency policy titled, “Medical Record Content IM.8” with a revision date of 10/01/2011 read in part, “…Policy Agency will initiate and maintain an individual and accurate medical record for each patient receiving care…””