Grace Compassion Home Health Agency

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, record review and interviews the agency failed to ensure the patient received the home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, and which was established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration for 1 (Patient 3) of 3 active patients’ records reviewed. This failure places patients at risk of not receiving necessary treatments and services, which could potentially result in the deterioration of the patients’ health conditions or death. Findings: Record review of Patient 3 revealed a Plan of Care (POC) for period 8/11/2025 to 10/09/2025 and a SOC of 8/11/2025 with an admitting diagnosis (condition) of “Encounter for change or removal of surgical wound dressing” and a condition of “Osteomyelitis (bone infection),” signed by RN A. The POC contained a skilled nurse frequency of 3 times a week for 9 weeks. Documentation on the POC stated, “Patient has wound on the left foot with VAC (Wound VAC machine that uses suction to remove excess fluid and infection to promote healing) and PICC line (a long, thin tube that is inserted into a vein in the arm and guided to a large vein near the heart) for antibiotics (medications that kill the growth of bacteria that cause infections). The POC contained orders for “dressing change on the PICC line site weekly,” and wound care to patient’s left foot “three times per week.” Patient 3’s records revealed a schedule of visits in the agency’s EMR system. The EMR system had visits scheduled for 8/11, 8/13, 8/16, 8/19, 8/27 and 8/29. The skilled nurse visit dated 8/13/2025 and completed by LVN B did not contain documentation that wound care was completed on Patient 3’s left foot. The visit dated 8/16/2025 was an “LVN Supervisory Visit” for LVN B signed by the Adm/DON/agency owner that did not contain an assessment of the patient or documentation of any treatments completed. The skilled nurse visit dated 8/19/2025 in the agency’s EMR system had a status “Saved from mobile device” with no evidence the patient was seen that day. The agency’s EMR system did not contain any coordination notes on the reason why Patient 3 was not scheduled for 3 nursing visits a week as ordered by the physician on the POC. Observation, record review, and interview was conducted with Patient 3 during a Home Visit on 8/27/2025 at 9:15am. The surveyor observed a central venous catheter present to the patient’s right upper chest with a clear transparent dressing covering the site, and a wound vac to patient’s left foot. When asked about the services and frequency of visits provided by the home health agency, Patient 3 said she was visited only twice by the agency’s nurses since coming onto home health services. Patient 3 stated, a nurse from the agency came on 8/12/2025 (Agency’s records did not contain a visit dated 8/12/2025. LVN B documented a visit on 8/13/2025). Patient 3 provided the surveyor with the first name of the nurse who conducted the initial visit, which did not match the names of the agency staff or contracted LVN B. Patient 3 stated the nurse did not change the wound vac dressing to her left foot because the nurse told her (Patient 3) she did not have an order. Patient 3 said that a different nurse came on 8/14/2025 (agency records did not contain a visit dated 8/14/2025. SOC visit was dated 8/11/2025 and signed by RN A). When asked about the name of the second nurse, Patient 3 stated she could not remember the name. Patient 3 stated, since 8/14/2025” no one has come out to see me. I’ve called 3 times with urgent needs because the wound vac was leaking and the bandage over the central line (central venous catheter) was coming off.” Patient 3 stated that the wound clinic completes the wound care on Mondays and the wound clinic visited her on 8/25/2025. Patient 3 stated, her doctor ordered the wound dressing to be changed 3 times a week on Mondays, Wednesdays and Fridays. A phone interview was conducted with contracted nurse LVN B on 9/2/2025 at 3:35pm. When asked about LVN B’s employment with the agency, LVN B stated, “I don’t work for any particular agency, I do prn work for multiple agencies and get assignments,” through a messaging application. When asked about the agency’s policies LVN B stated, she was “not familiar with the agency’s specific policies.” When asked about Patient 3, LVN B stated, “I only saw her once, I was the first one (nurse) to see her. I saw her before the admitting nurse did, which is unusual. There were no orders, I had nothing (no POC and medication profile).” The surveyor shared the findings of Patient 3 and asked about the wound care to Patient 3’s left foot. LVN B stated she documented in her visit note on 8/13/2025, the wound care was not done because she did not have a doctor’s order. An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 3:39pm. When asked about the agency’s policy on implementing the POC, the Adm/DON stated, the nurses and therapists “should follow what is on the plan of care and notify the doctor if changes are needed.” The surveyor asked, who’s responsible for making the nurse visit assignments and schedule? The Adm/DON/agency owner stated, “I am. I usually do it with (QA). But I am responsible for making sure that we’re (the agency is) communicating with the nurses on who is going,” to see the patients. At 4:11pm the Adm/DON requested to briefly pause the interview. An interview was conducted with the Adm/DON (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. The surveyor shared the findings for Patient 3 and the interview with LVN B. The Adm/DON stated, “She (LVN B) said she did (Patient 3’s wound care).” When asked why the patient was not receiving 3 visits a week by the home health agency as ordered by the physician and listed on the POC. The Adm/DON stated, “I can’t tell you about this one (Patient 3 not receiving nursing visits 3 times a week), but this patient does have a wound care clinic that goes out once per week and that consumes one of our nursing visits.” The Adm/DON stated, “The issue is insurance approval. That’s my suspicion… I just have to look into it (Patient 3 not having 3 nursing visits a week scheduled), because I don’t know what really happened.” When asked about the potential patient outcome for the care plan not being followed, the Adm/DON/agency owner stated, “these (wound care not being done, visit frequency not followed) can definitely affect the patient up front. The patient’s condition will worsen.” Review of agency’s policy, “5.8 Implementing Care and Treatment,” revision 1/29/2020 reads in part, “Agency staff providing patient care and treatment will be competent to the level of care/treatment needed and will provide care within the frequency parameters established on the care planning document(s). The Agency will designate a qualified registered nurse who oversees the following when coordinating the assignments of patient care: The principles of the care to be provided; The staff qualifications and proficiency levels; The patient population. The agency will assign appropriate disciplines needed to provide patient care/ treatment. When assigning staff, Agency will attempt to limit the number of different staff members within one discipline providing care to one patient. The assigned discipline(s) will be provided with information needed to provide patient care/ treatment including, but not limited to, the plan of care… If there is a change in the schedule of care, the patient and/or caregiver are notified prior to the scheduled time (if at all possible) by the appropriate discipline. Services may be placed on hold for up to two weeks if caregiver, with documented competency by the RN, can assume all care and services currently provided by the HHA. Other conditions or placing services on hold will be evaluated by administrator and clinical manager on a case-by-case basis. When the provision of care treatment cannot be implemented as established on the care planning document(s), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by discipline/ Patient Care Manager.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on observation, interviews and record reviews, the agency failed to provide treatments and services necessary to avoid physical harm or neglect for 1 (Patient 3) of 3 patients reviewed for patient rights. The agency failed to schedule skilled nursing visits as ordered on the plan of care for Patient 3. The agency’s nurse failed to assess and document Patient 3’s right foot wound during the start of care visit dated 8/11/2025 and omitted in the plan of care the right foot wound orders received from the hospital on 8/06/2025. The agency failed to order wound supplies for Patient 3’s right foot. These failures place patients at an increased risk for abuse, neglect, and exploitation by agency staff. Findings: Record review of Patient 3 revealed a “Home Health Care Fax Packet” from Hospital (A1) faxed to the agency on 8/6/2025 (patient discharged from the hospital on 8/11/2025). The packet contained documentation of a “right foot debridement (medical procedure to remove dead, damaged, or infected tissue) of wound, incision and drainage of abscess (localized collection of dead white blood cells, bacteria, and tissue debris)” and “left foot debridement of wound, application of skin graft (a piece of healthy skin is transplanted from one area of the body to another to repair or replace damaged or missing skin), application of wound vac (machine that uses suction to remove excess fluid and infection to promote healing)” on 7/30/2025. The packet contained documentation of a tunneled central venous catheter without a port (a thin flexible tube that is placed in a large vein of the neck or chest and is threaded under the skin to the exit site where it is accessed to deliver fluids or medications directly into the bloodstream) placed on 8/01/2025. The packet contained a physician’s order to clean and irrigate Patient 3’s left foot wound with wound cleanser (a solution with a water and salt base, containing hypochlorous acid a natural substance produced by the human body’s white blood cells to fight infection), dress wound with black foam, prepare periwound (skin surrounding wound) with no sting barrier spray (forms a protective coating to prevent irritation of skin from adhesives), cover wound with vac drape (adhesive covering, helps maintain negative pressure wound therapy), wound vac set at rate 125 mm Hg continuous pressure (pressure setting to promote wound healing). The packet contained an order to cleanse Patient 3’s right foot wound with wound cleanser (a solution with a water and salt base, containing hypochlorous acid), pack wound with hydrocolloid silver dressing (contains fibers that absorb excess fluid and form a gel that conforms to the wound bed, and silver to prevent infection), cover with 4 inch by 4 inch gauze, absorbent wound dressing pad, and secure with gauze wrap and cloth tape. The orders documented a frequency of Mondays, Wednesdays, and Fridays, for wound care to Patient 3’s right foot and left foot. Record review of Patient 3 revealed a Plan of Care (POC) for period 8/11/2025 to 10/09/2025 with a SOC date of 8/11/2025 and an admitting diagnosis (condition) of “Encounter for change or removal of surgical wound dressing” and a condition of “Osteomyelitis (bone infection),” signed by RN A. The POC contained a skilled nurse frequency of 3 times a week for 9 weeks. Documentation on the POC stated, “Patient has wound on the left foot with VAC (Wound VAC) and PICC line (a long, thin tube that is inserted into a vein in the arm and guided to a large vein near the heart) for antibiotics (medications that kill the growth of bacteria that cause infections). The POC contained orders for “dressing change on the PICC line site weekly,” and wound care to the left foot “three times per week.” The left foot wound care orders on the POC stated, skilled nurse to cleanse wound with wound cleanser (a solution with a water and salt base, containing hypochlorous acid), apply black foam, prepare periwound with no sting barrier spray, cover wound with VAC drape, wound vac set to 125 mmHg continuous pressure, and secure with an elastic compression bandage. The POC did not contain the wound orders from hospital (A1) for Patient 3’s right foot. The POC also did not contain an order with steps on how to complete the dressing changes on Patient 3’s central venous catheter site. The order received from Hospital A1 on 8/06/2025 did not contain instructions to secure the wound vac dressing with an elastic bandage as documented on the POC. Record review of Patient 3 revealed a start of care OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) visit dated 8/11/2025 and signed by RN A. The SOC visit contained documentation in the “Treatment Performed” section stating, “SN to wash hands, put gloves on, position patient’s feet correctly and remove the old dressing. SN to cleanse wound with… (wound cleanser containing a water and salt base and hypochlorous acid), apply black foam, prep peri wound with no sting barrier spray, cover wound with VAC drape, wound VAC set at 125 mm Hg pressure continuous, and secure with (elastic compression) bandage to maintain pressure and avoid falling off due to the position of the wound. SN to cleanse and perform PICC line dressing change on the right upper chest weekly. Narrative: SN performed wound care/dressing change per order and patient tolerated well.” The SOC visit lacked documentation of the right foot wound, right foot wound orders, and the steps for completing dressing changes on Patient 3’s central venous catheter site. Record review of Patient 3 revealed a skilled nurse visit dated 8/13/2025 signed by LVN B. The skilled nurse visit contained documentation in the integumentary (protective outer layer of the body to include skin) comment section which stated, “PICC” dressing changed, “wound vac to left foot,” dressing “noted to right foot, no wound orders at this time.” The skilled nurse visit did not contain evidence that LVN B completed Patient 3’s wound care, and the “Care Coordination” section was checked marked not applicable. Record review of Patient 3 revealed a progress note faxed to the agency on 08/26/2025 from wound clinic B2 during a home visit dated 8/20/2025. Documentation on the progress note stated, “The patient is new to the Wound Center in-home program for an initial visit for the evaluation and management of non-healing wound(s)…Dressing noted to right foot to be uncleaned and disheveled…No signs or symptoms of infection noted…Left foot wound has NPWT (wound vac) in place…A small amount of skin graft noted to wound.” The progress note contained documentation of the debridement of the wounds to both feet and completion of wound care on 08/20/2025. Documentation on the progress note from the wound clinic stated that wound care was to be done by the wound clinic on Mondays and home health on Wednesdays and Fridays. Record review of Patient 3 revealed a schedule of visits in the agency’s EMR system. The EMR system had visits scheduled for 8/11, 8/13, 8/16, 8/19, 8/27 and 8/29. The visit dated 8/16/2025 was an “LVN Supervisory Visit” for LVN B signed by the Adm/DON/agency owner that did not contain an assessment of the patient or documentation of any treatments completed. The skilled nurse visit dated 8/19/2025 in the agency’s EMR system had a status “Saved from mobile device” with no evidence the patient was seen that day. The agency’s EMR system did not contain any coordination notes on the reason why Patient 3 was not scheduled for 3 nursing visits a week as ordered by the physician. Patient 3’s records did not contain evidence of communication with Patient 3, wound clinic B2 or the physician regarding the missed visits. Observation, record review, and interview with Patient 3 during a Home Visit on 8/27/2025 at 9:15am revealed that there was no home health folder in patient’s home. Patient 3’s discharged papers dated 8/11/2025 from hospital A1 contained “Continuing Care. Home Medical Care” with the name, address, and phone number of the home health agency. The surveyor observed a central venous catheter present to the patient’s right upper chest with a clear transparent dressing covering the site, and a wound vac to patient’s left foot. The gauze wrap on patient’s right foot had visible dried wound drainage on the exterior surface of the dressing. When asked about the services and frequency of visits provided by the home health agency, Patient 3 stated the podiatrist (doctor who specializes in the treatment of foot and ankle conditions) who performed the skin graft surgery on her left foot, gave “strict orders” for wound care 3 times a week. Patient 3 said she was visited only twice by the agency’s nurses since coming onto home health services. Patient 3 stated, “The skin graft to my left foot is gone,” and her podiatrist “isn’t going to be happy about this (deteriorated skin graft).” Patient 3 stated she was discharged from hospital A1 on 8/11/2025, and a nurse from the agency came on 8/12/2025 (Agency’s records did not contain a visit dated 8/12/2025. LVN B documented a visit on 8/13/2025). Patient 3 provided the surveyor with the first name of the nurse who conducted the initial visit, which did not match the names of the agency staff or contracted LVN B. Patient 3 stated the nurse changed the central venous catheter dressing because the “dressing was coming off.” Patient 3 stated the nurse did not change the wound dressings because the nurse told her (Patient 3) she did not have an order. When asked if the initial agency nurse provided admission consents for Patient 3 to sign, Patient 3 stated, “No.” Patient 3 stated on 8/13/2025 she called the agency and spoke to the “scheduler,” who informed her that the agency would send a nurse to complete the admission. When asked for the name of whom she spoke to, Patient 3 stated she could not remember the name. Patient 3 said that a different nurse came on 8/14/2025 (agency records did not contain a visit dated 8/14/2025. SOC visit was dated 8/11/2025 and signed by RN A). When asked about the name of the second nurse, Patient 3 stated she could not remember the name. Patient 3 stated the nurse changed the central venous catheter dressing and completed the wound vac dressing “incorrectly” on her left foot. When asked how the wound care was done incorrectly by the nurse, Patient 3 stated that the nurse wrapped her left foot with an elastic bandage after the wound vac was applied. When asked if the elastic bandage caused any harm or injury, Patient 3 stated, “no.” Patient 3 stated, the nurse who came on 8/14/2025 did not do the wound care on her right foot, and she (Patient 3) did not sign the admission consents for home health. Patient 3 stated, “Since 8/14/2025 no one has come out to see me. I’ve called 3 times with urgent needs because the wound vac was leaking and the bandage over the central line (central venous catheter) was coming off.” Patient 3 stated that when she called the agency, they told her a nurse was “scheduled for the next day” or the nurse would return her call. Patient 3 reported that on three occasions after calling the agency, she was not visited by a nurse the following day or received a return call. When asked who she spoke to at the agency, Patient 3 stated she could not recall the names. Patient 3 stated, she (Patient 3) last changed the dressing to the central venous catheter site on 8/25/2025. Patient 3 stated that the wound clinic completes the wound care on her right and left foot on Mondays and the wound clinic visited her on 8/25/2025. Patient 3 stated she changed the wound vac dressing on her left foot on Wednesdays and Fridays when there was drainage on the bandage. Patient 3 stated that she has been unable to change the dressing to her right foot on Wednesdays and Fridays because she had not received the wound supplies that the agency was supposed to order. Patient 3 said that the hospital ordered a month’s supply of the wound vac dressings that were delivered to her home shortly after she returned home from the hospital. A phone interview was conducted with contracted nurse LVN B on 9/2/2025 at 3:35pm. When asked about LVN B’s employment with the agency, LVN B stated, “I don’t work for any particular agency, I do prn work for multiple agencies and get assignments,” through a messaging application. When asked about the agency’s policies on coordination of care and treatment orders, LVN B stated, she was “not familiar with the agency’s specific policies.” When asked about Patient 3, LVN B stated, “I only saw her once, I was the first one (nurse) to see her. I saw her before the admitting nurse did, which is unusual. There were no orders, I had nothing (no POC and medication profile).” The surveyor shared the findings of Patient 3 and asked about the wound care and central venous catheter site. LVN B stated she documented in her visit note on 8/13/2025, the wound care was not done because she did not have a doctor’s order. LVN B stated, Patient 3 “had a PICC line,” the dressing “was soaking wet and falling off. LVN B stated she changed the dressing to the “PICC line” without an order because “I didn’t want it (PICC line site) to become infected.” When asked why she did not communicate with the agency and physician regarding the missing orders. The LVN stated, she did not notify the agency or physician “because the admitting nurse was scheduled to see (admit) the patient” and write the orders from the physician. LVN B stated she declined “to sign up” to see Patient 3 after 8/13/2025 because “Things were not done correctly (LVN visit scheduled before the admission was completed, no orders, no POC, and no medication profile)” by the agency. A phone interview was conducted with RN A on 9/3/2025 at 12:18pm. When asked about the agency’s policy and process on completion of an admission once assigned, RN A was unable to state the agency’s policy and stated, the RN has “24 to 48 hours” to see the patient. RN A stated that if the assigned nurse was unable to see the patient, the nurse called the agency, which then called the patient to see if they wanted to reschedule the admission, or the agency assigned a different nurse to do the admission. When asked about the agency’s policy and process of adding orders to the plan of care, RN A stated, “when I get wound orders from the hospital those orders are included in the plan of care.” RN A stated that patients who received wound treatments in the hospital are often discharged home with wound supplies. RN A stated the nurse must “put those orders (from the hospital) in the plan of care and continue with that order until the doctor reassesses the patient and changes the order.” When asked about the start of care assessment of Patient 3 during the agency’s admission process, RN A stated, “I can’t remember. I think the patient had a skin graft…I don’t have my computer. I only see these people (patients) once every 6 weeks.” The surveyor shared RN A’s documentation on the POC, RN A stated, “I know she (Patient 3) had blood on her left foot. I think she was using a wheelchair that day. She had a skin graft to her left foot. I’m trying to remember.” The surveyor shared RN A’s documentation on Patient 3’s start of care OASIS visit dated 8/11/2025 and asked about the wound to patient’s right foot. RN A stated the day she completed Patient 3’s SOC admission (RN A could not recall the date) “I went there (to Patient 3’s home). There was blood all over the bed. It (the wound) was only on one leg. I don’t think there was a wound on her right. I think it (the wound) was on her left foot.” When asked if a physician’s order on the steps to cleanse and dress the central venous catheter site were obtained, RN A stated, “I don’t remember.” When asked about the details or steps of Patient 3’s left foot wound orders documented on the POC, RN A stated, “She (Patient 3) has a wound vac, I can’t tell you what was exactly written. Like I told you before I can’t remember all these people (patients).” The surveyor shared the documentation from hospital (A1) and the wound orders to patient’s right and left foot. When asked how the agency provides the nurse with the hospital orders and documentation before a patient’s admission, RNA stated “it is attached to her (Patient 3’s) records in the attachments” in the agencies EMR system, where the nurse can view the attachments. When asked about the potential patient outcome for wound supplies not being ordered for Patient 3’s right foot wound, and orders for patient’s right foot wound and central venous catheter site not being on the POC. RN A refused to give a direct answer and stated “to the best of my knowledge the patient was treated the way she was supposed to be, and nothing was omitted. There was nothing that was missed from the patient’s care. The patient received the order she was supposed to receive.” An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 3:39pm. When asked about the agency’s policy on the time frame to complete a start of care OASIS admission. The Adm/DON/agency owner was not able to state the details of the agency’s policy, and stated,” within the payroll time frame of 14 days to have everything completed (assessment, documentation, POC, medication profile). Our (agency’s) goal is for them (the nurses) to finish it (admission documentation) within the first week… Home health can be tough sometimes getting the nurses to chart. We (management) gave some of them (nurses) verbal warnings to ensure that they (nurses) documented, because it affects us (the agency) too.” The surveyor asked, who’s responsible for making the nurse visit assignments and schedule? The Adm/DON/agency owner stated, “I am. I usually do it with (QA). But I am responsible for making sure that we’re (the agency is) communicating with the nurses on who is going,” to see the patients. When asked about the agency’s policy and procedure on what is included on the POC, the Adm/DON/agency owner stated “the patient needs, patient education, the patient’s projected visit frequency, prn visits, medical supplies and orders. If they (patients) need medical supplies, there is an order component that carries on the order. During the admissions sometimes the nurses are not sure about the order and want to check in with the doctor first. They (the nurses) might not necessarily put it in the plan of care. They will get approval from the doctor and then create an additional order.” When asked about the agency’s policy and procedure on obtaining orders for treatment and wound orders, the Adm/DON/agency owner stated, “The nurse will make sure that there is an order. They (nurses) communicate with the doctor and then the order is created. Either they (doctor or wound care clinic) are going to send us (the agency) the order, or the nurse is going to verbally take the order from the phone and create the order.” When asked about the agency’s policy and process of coordination with the doctors and wound care clinics and documentation of the coordination, the Adm/DON/agency owner stated, “the nurses have to document the coordination, the reason the doctor was notified, and what was discussed.” The Adm/DON/agency owner stated that sometimes the nurses document their coordination with the doctor during the next patient visit instead of writing it on a communication note on the actual day the nurse spoke to the doctor. The Adm/DON/owner stated that the nurse will document the communication with the physician on a coordination note in the patient’s record if the nurse wants to “draw attention” to an issue with the patient. At 4:11pm the Adm/DON requested to briefly pause the interview. An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. When asked about the agency’s policy on abuse, neglect and exploitation, the Adm/DON stated, “we (Adm/DON or Alt Adm) take the staff involved off the schedule and investigate it (allegation of ANE) and then we (Adm/DON or Alt Adm) have to report it (allegation of ANE). I think it’s 24 hours that we have to report it (allegation of ANE) to the state if it is being reported to us (agency), and then we (Adm/DON or Alt Adm) investigate and take an action on it (ANE). We do heavy education on it (ANE) and we let go of the staff involved.” When asked about the agency’s policy and process on receiving and investigating a complaint, the Adm/DON stated, “if it’s abuse or neglect we(agency) report it (complaint) and investigate it(complaint). It depends, some other complaints are not necessary.” When asked how the agency documents and investigates a complaint regarding a nurse not calling before they arrive to the patient’s home or the patient has a complaint against the nurse, the Adm/DON/agency owner stated, “some of them (complaints) are not necessarily documented.” The Adm/DON/agency owner stated, if the agency receives a call requesting the nurse to call before they arrive, the agency makes sure “the nurse always calls.” The Adm/DON/agency owner stated, the agency addresses the complaint, evaluates the process and follows up with the patient. The Adm/DON/agency owner stated “If they (patients) are not happy with the nurse, we (agency management) place them (patients) with a different nurse. If needs are not resolved, then we (agency management) document it (complaint)in our complaint book” with the implementation the agency took and then follow up with the patient. The surveyor shared the findings for Patient 3 and the interviews with RN A and LVN B. When asked why Patient 3 did not receive 3 nursing visits a week by the home health agency as ordered by the physician on the POC, the Adm/DON stated, “I can’t tell you about this one (Patient 3 not receiving 3 visits a week), but this patient does have a wound care clinic that goes out once per week and that consumes one of our nursing visits.” The Adm/DON stated, “The issue is insurance approval. That’s my suspicion… I just have to look into it (Patient 3 not having 3 nursing visits a week scheduled), because I don’t know what really happened.” The Adm/DON/agency owner did not provide additional information or comments when asked about LVN B’s statement regarding being assigned a skilled nursing visit to Patient 3 before RN A completed the patient’s admission. The surveyor shared the allegation made by Patient 3 that the agency did not respond to her request for a nurse visit when she called 3 times. Adm/DON stated she was not aware of the complaint. When asked about the potential patient outcome for orders not being on the plan of care, the Adm/DON/ agency owner stated, “if it’s (the order) not there (in the POC) it’s going to definitely affect the treatments and actions. The outcome is not going to be good because treatments like wound care and the PICC line will be missed. The patient’s condition will get worse…Our goal is to ensure the plan of care reflects what’s going on with the patient and everything (orders, treatments, wound care, supplies, medications) is in there (in POC), and if something (treatments, services) is missed we (nurses) have to make sure we call the doctor and get an order for it.” When asked about the potential patient outcome for treatments performed without a physician’s order, the Adm/DON stated, “We (nurses and therapists) need to make sure we have the proper order when treating the patient. The outcome is it (wound, PICC or central venous catheter site) will get worse… Even if it doesn’t get worse it’s (treatment without an order is) still not right, you need the doctor’s orders to treat whatever you are treating.” When asked about the potential patient outcome for lack of coordination with the doctors, wound clinics and contract nurses. The Adm/DON/agency owner stated, “Something (orders, treatments, supplies, or services) can be missed. We (agency) definitely need to make sure there is coordination even if it’s not documented. We (agency) still have to show the documentation that there is coordination so it will make sense why the nurse is going to see the patient.” When asked about the potential patient outcome for patient neglect, to include the frequency of nursing visits not being followed and wound care not being done. The Adm/DON stated, “The patient’s condition will worsen. If there is a change, we (the nurses) have to document that. We have to call the doctor.” 9/26/2025 10:42am Phoned wound clinic B2 and spoke with the receptionist. Requested to speak to the nurse practitioner (NP) caring for Patient 3. The receptionist stated she would send an email to the NP with the surveyors contact information and request for a call back regarding Patient 3. 9/26/2025 10:58am Phoned the podiatrist’s office and requested to speak with the podiatrist for Patient 3. The receptionist stated she would send a message to the podiatrist with the surveyor’s contact information and request for a call back regarding Patient 3. An interview was conducted with the new Alt Adm/DON, Director of Patient Care, and the Adm/agency owner (via phone) on 9/26/2025 at 3:05pm. When asked about the agency’s investigation of the missed visits for Patient 3, the Adm/agency owner stated, “there was an insurance authorization issue and a nurse issue as well.” The Adm/agency owner stated the nurse that was scheduled for 8/15 “doesn’t want to be involved with the wounds” and did not notify the “intake person (scheduler)” of the need to reschedule the visit to another nurse. The Adm/agency owner stated the following week the agency scheduled a different nurse for 8/18, and the nurse tried to reach Patient 3 by phone “multiple times” and received no response from Patient 3. The Adm/agency owner stated the agency implemented a new process of conducting wellness checks on patients not returning the nurses’ calls that went into effect on 9/5/2025. The Adm/agency owner stated the Director of Patient Care is sent to the patient’s home to conduct the wellness check. When asked about the steps the agency takes when there is an insurance authorization issue with a patient, the Adm/agency owner stated, “the doctor is the key you (the agency) can’t just discharge the patient you (agency) have to talk to the doctor and let them know we (the agency) are having authorization issues and the patient is aware too. A lot of times these patients advocate more effectively when they call the insurance and get approval. Sometimes it doesn’t work so we (the agency) get the doctor involved… We (the agency) might have to find another home health or the doctor’s office will handle the questions regarding the patient’s needs for home health.” When asked about the negative outcomes for not seeing patients at the ordered frequency and failure to provide care as ordered by the physician, the Adm/agency owner stated, “it increases the client’s (patient’s) risk of getting an infection which can lead to further complications. Anything could come out of this (missed visits and orders) bleeding, infection, anything.” When asked if missed nursing visits and wound care not completed as ordered by the physician was neglect by the agency, the Adm/agency owner stated, “it’s neglect in my opinion because we (the agency) should have found different measures to handle this (visits not being scheduled/wound care not done). Care of this patient (Patient 3) was our liability. We (the agency) didn’t have enough documentation. My goal is to ensure we (the agency) don’t do anything that puts liability on us. I’m not going to sugar coat it because the patient (Patient 3) needed the frequency of visits, and it wasn’t done. So, our (agency) goal is to ensure that this isn’t done to every patient now. That we’re (agency staff are) consistent with our frequency. We’re (agency) going to definitely do everything we can to avoid any type of neglect in the future.” 9/29/2025 9:57am Phoned podiatrist’s office a second time and spoke with the receptionist. The surveyor requested to speak with the podiatrist that provided care to Patient 3. The receptionist stated the podiatrist was seeing patients and she would send a second message to the podiatrist with the surveyor’s contact information and a request for a call back regarding Patient 3. An interview was conducted with wound clinic B2’s nurse practitioner (NP) on 9/29/2025 at 11:48am. When asked about the HHA’s coordination with wound clinic B2 regarding Patient 3, the NP stated, communication from the HHA initially was “not great.” The NP stated during his initial visit on 8/20/25 Patient 3 reported no visits were made by the HHA nurses the previous week and Patient 3 needed wound supplies for her right foot wound. The NP stated the wound clinic sent a fax (fax received on 8/26 per agency records) to the agency which contained his progress note from 8/20, and orders with the list of wound supplies that needed to be ordered by the HHA. The NP stated he ordered wound supplies the following week (on 8/25) when Patient 3 reported she had not received the wound supplies from the HHA. The NP stated he called the HHA on 8/22/25 after he received a call from Patient 3 reporting that the wound vac was not working. The NP stated the HHA assured him that a nurse would be sent to trouble shoot the wound vac and change the wound dressings. When asked who he spoke to, the NP could not recall the name. The NP stated when he returned to see Patient 3 on 8/25 the patient reported that the nurse from the HHA did not visit her after the NP’s call. The NP stated Patient 3’s visit notes, communication and orders from the wound clinic are faxed to the agency after each visit. When asked about the skin graft to Patient 3’s left foot. The NP stated Patient 3 had a partial skin graft during the NP’s initial visit on 8/20/2025 and “The skin graft never covered the entire section of the wound or wound bed.” The NP stated after 8/25/2025 the skin graft to Patient 3’s left foot continued to deteriorate despite the wound care provided 3 times a week by the wound clinic and HHA. The NP stated, “I can’t tell if there ever was a skin graft now.” When asked if the missed nursing visits from 8/14 to 8/26 by the HHA could have led to the deterioration of the skin graft, the NP stated, “The wound vac was malfunctioning, so it was not beneficial in healing the wound.” The NP stated Patient 3 reported she removed the wound vac when there was leakage from the wound vac. The NP stated it’s “a strong possibility” the skin graft failed due to the HHA nurse not coming out to troubleshoot the wound vac when requested by Patient 3 (during period 8/14-8/26). The NP stated he wrote an order to have the wound vac discontinued during his visit with Patient 3 on 9/3 (faxed to the HHA on 9/7) because it was not beneficial in healing Patient 3’s left foot wound. Asked if Patient 3 was seen by the podiatrist that performed the skin graft, The NP stated Patient 3 reported she no longer sees the podiatrist and was told to follow up with her primary care physician. Asked if coordination from the HHA has improved from 9/3/2025 onward. The NP stated coordination occurred when the nurse from the HHA verified the new wound care orders faxed to the HHA on 9/7/2025. The NP stated Patient 3 has not voiced any missed visit from the HHA after 8/25 and the wound care appears to be completed by the HHA nurses as ordered. Asked about the status of Patient 3’s wounds to her right and left foot. The NP stated the wounds have improved including measurements since the wound vac has been discontinued. Asked if the NP had any additional information to add, the NP stated, “No.” An interview was conducted with the agency’s Quality Assurance (QA) on 9/29/2025 at 2:30pm. When asked about QA’s job junctions, QA stated, he answers the phones, ensures documentation is completed by the agency staff and assists the Adm/agency owner, Alt Adm/DON and Director of Patient Care (DPC). When asked about the agency’s process of handling complaint calls, QA stated he directs the calls to the DPC, Adm/agency owner, or Alt Adm/DON who are responsible for documenting the complaint in the complaint log. When asked about the agency’s process of handling patients’ calls requesting a nurse visit, QA stated the agency will call the nurses (agency nurses and contract nurses) to confirm availability and will schedule a nurse visit to one of the available nurses. When asked about the agency’s process if there are no available nurses, QA stated, “We have not really had that issue.” QA stated the Adm/Agency owner has completed nursing visits when needed. When asked if he had received any calls from Patient 3 in the last 2 months requesting a nurse visit, QA stated, “I can’t recall. I would have put it (the call) in a communication note.” When asked where the communication notes would be located, QA stated in the patient’s records in the agency’s EMR system. When asked if he had received a call on 8/22 from the nurse practitioner from wound clinic B2 requesting a nurse visit on Patient 3 for a malfunctioning wound vac. QA stated he could not recall a phone call from the nurse practitioner and stated he would have entered the communication from the doctor’s office or wound clinic on a coordination note. An interview was conducted with the new Alt Adm/DON and the DPC on 9/29/2025 at 3:45pm. The surveyor shared the interviews with the NP and QA. The DPC stated she was not aware of a call from the NP on 8/22/2025. The new Alt Adm/DON was not an employee for the agency on 8/22 and was unable to provide additional information. Review of agency’s policy “5.3 Abuse/Neglect/Exploitation” revision 1/29/2020 reads in part, “The Agency employees/contractors will be aware of signs and symptoms indicating possible abuse, neglect, and/or exploitation and upon hire will sign an acknowledgement affirming compliance with Agency Policy. All Agency employees and contractors are required, and have the legal obligation, to report suspected abuse, neglect or exploitation to the Texas Department of Family and Protective Services (TDFPS), and the Texas Department of Aging and Disabilities (DADS) and Agency management. If there is cause to believe abuse, neglect, or exploitation of the patient has occurred by an Agency employee, representative, volunteer or contractor, the incident(s) will be reported to TDFPS and DADS immediately, meaning 24 hours, upon witnessing the act or upon receipt of the allegation…Reportable conduct includes: Abuse or neglect that causes or may cause death or harm to an individual receiving agency services.” Review of agency’s “3.1 Patient Bill of Rights and Responsibilities (Elderly Bill of Rights),” revision 1/29/2021, reads in part, “The patient and representative, if any, have the right to be informed of the patient’s rights in a language and manner the individual can understand. The Agency must protect and promote the exercise of these rights…To be free from neglect…Any HHA staff whether employed directly or under arrangement in the normal course of providing services to patients, who identifies, notices or recognizes incidences or these circumstances must report this to the HHA and the Agency must investigate complaints made by the patient/the patient’s representative/and the patient’s caregiver/ and family regarding these: treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately or regarding the mistreatment, neglect…by anyone furnishing services on behalf of the Agency and must document the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations while the complaint is being investigated.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interviews and record review, the agency failed to ensure in advance of and during treatment, that patients were informed and consented to the care furnished by the agency to include; completion of all assessments; establishing and revising the plan of care; the disciplines that will furnish the care; the frequency of visits; expected outcomes of care; patient-identified goals; anticipated risks and benefits; factors that could impact treatment effectiveness; and any changes in the care to be furnished for 1 (Patient 3) of 3 active patients’ records reviewed. This failure places patients at risk of not being informed and involved in the care provided by the agency, resulting in patients’ inability to give informed consent for treatment and services. This can lead to patients’ dissatisfaction and mistrust of the agency. Findings: Observation, record review, and interview with Patient 3 during a Home Visit on 8/27/2025 at 9:15am revealed that there was no home health folder in patient’s home. Patient 3’s discharged papers dated 8/11/2025 from hospital A1 contained “Continuing Care. Home Medical Care” with the name, address, and phone number of the home health agency. When asked about the services and frequency of visits provided by the home health agency, Patient 3 stated she was discharged from hospital A1 on 8/11/2025, and a nurse from the agency came on 8/12/2025 (Agency’s records did not contain a visit dated 8/12/2025. LVN B documented a visit on 8/13/2025). Patient 3 provided the surveyor with the first name of the nurse who conducted the initial visit, which did not match the names of the agency staff or contracted LVN B. Patient 3 stated the nurse changed the central venous catheter dressing because the “dressing was coming off.” Patient 3 stated the nurse did not change the wound dressings because the nurse told her (Patient 3) she did not have an order. When asked if the initial agency nurse provided admission consents for Patient 3 to sign, Patient 3 stated, “No.” Patient 3 stated on 8/13/2025 she called the agency and spoke to the “scheduler,” who informed her that the agency would send a nurse to complete the admission. When asked for the name of whom she spoke to, Patient 3 stated she could not remember the name. Patient 3 said that a different nurse came on 8/14/2025 (agency records did not contain a visit dated 8/14/2025. SOC visit was dated 8/11/2025 and signed by RN A). When asked about the name of the second nurse, Patient 3 stated she could not remember the name. Patient 3 stated the nurse changed the central venous catheter dressing and completed the wound vac dressing “incorrectly” on her left foot. Patient 3 stated she did not sign the admission consents for home health during the nurse’s visit on 8/14/2025. A phone interview was conducted with contracted nurse LVN B on 9/2/2025 at 3:35pm. When asked about LVN B’s employment with the agency, LVN B stated, “I don’t work for any particular agency, I do prn work for multiple agencies and get assignments,” through a messaging application. When asked about Patient 3, LVN B stated, “I only saw her once, I was the first one (nurse) to see her. I saw her before the admitting nurse did, which is unusual. There were no orders, I had nothing (no POC and medication profile).” LVN B stated she documented in her visit note on 8/13/2025, that Patient 3’s wound care was not done because she did not have a doctor’s order. LVN B stated, Patient 3 “had a PICC line,” the dressing “was soaking wet and falling off. LVN B stated she changed the dressing to the “PICC line” without an order because “I didn’t want it (PICC line site) to become infected.” LVN B stated she declined “to sign up” to see Patient 3 after 8/13/2025 because “Things were not done correctly (LVN visit scheduled before the admission was completed, no orders, no POC, and no medication profile)” by the agency. Record review of Patient 3 revealed an “Admission Consent and Contract for Services” dated 8/11/2025 with RN A’s signature above the “Witness Signature (Agency Representative)” line. Above the “Patient signature” line, Patient 3’s last name was written first, followed by the first name. 9/3/2025 10:41am Patient 3 returned call after surveyor had left a message to return call. The surveyor requested Patient 3’s email address to email the admission consents so Patient 3 could verify the signature. Patient 3 stated, she had not signed anything for the agency with the except of the nurse’s tablet during a visit on 8/29/25 to confirm the nurse was present at her home. Patient 3 provided her email address and stated she would review the consent documents once she received them and would send a written statement regarding the signature. 9/3/2025 11:06am Patient 3 called surveyor and stated, “the signature is forged and not mine.” A phone interview was conducted with RN A on 9/3/2025. When asked about the date RN A completed the admission for home health on Patient 3, RN A stated, she could not recall the date she did the admission visit, “I think I submitted it (the consents and admission documentation) to the office. I don’t have all the information in my head. I don’t see them (the patients) every week I see them once in six weeks. It’s hard for me to remember everything about each of them (patients).” The surveyor asked, who signed the admission consents for Patient 3? RN A stated, she called Patient 3 on the scheduled day for the start of care admission, and Patient 3 had requested that a nurse come as soon as possible because the “wound vac panel (canister that holds wound drainage)” had come off overnight. RN A stated “I told her (Patient 3) that I did not have the consent papers with me. She (Patient 3) said I should just leave that one (the consents) and just come because her foot I think got awful or something.” RN A stated “When I got there, the bed had blood everywhere and the dressing came off. When I finished seeing the patient and everything (cleaned patient and completed left foot wound dressing) I thought I’m going to finish this paperwork and submit it.” RN A stated, Patient 3 gave RN A verbal permission to print Patient 3’s name on the admission consents. RN A stated, “I wrote her (Patient 3’s) name there (in the consents). I didn’t sign it. I wrote her name on it.” RN A stated, “I went there to clean up the mess (wound drainage/blood) …what I did was write her (Patient 3’s) name there myself and wrote the date that she was supposed to sign it.” When asked why RN A did not have an admission packet with her, RN A stated, “I always come to the office for admission booklets. I was out of the booklets. I went there (Patient 3’s home) and did what I needed to do just listen to this situation (wound vac issues and need for wound care) at the moment, and then when I got the booklet, I printed her (Patient 3’s) name everywhere she’s (Patient 3 is) supposed to sign her name.” When asked about the agency’s policy on admission consent’s and obtaining the patient’s, family or legal guardian’s signature, RN A was unable to state the agency’s policy. RN A stated, “as soon as the patient gives you (the RN) the power (authorization) I print their name” and “document whether or not they have the ability to sign their name.” When asked about the agency’s patient rights policy regarding patients that could sign consents independently, RN A was unable to state the policy and stated, “I’m not sure.” When asked about the potential patient outcome for not obtaining the patient or legal representative’s signature on the consents. RN A refused to give a direct answer and stated, “in the case of an emergency the patient signing the consents is not the number one priority, because in this case the patient (Patient 3) was requesting to be treated first before the paper (consents), and that was the only reason it was done (RN A printing Patient 3’s name on the patient signature block on the consents).” An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. The surveyor shared the findings of Patient 3 and the interview with RN A. The Adm/DON stated, “I didn’t know this (RN A printing Patient 3’s name on the patient signature block of the consents), thank you for letting me know.” When asked about the agency’s policy on consents for home health, treatment and care the Adm/DON/agency owner stated, “that’s (admission consents is) the first thing you (the nurse) do.” The Adm/DON/agency owner stated the agency’s policy is that consents are provided and explained to the patients before any treatment or services are administered by the agency. When asked about the potential patient outcome for patients being treated without written consent. The Adm/DON did not give a direct answer and stated, “You (the RN) need to make sure the patient is aware of what they’re signing up for… to let them (the patients) know about treatments, the plan of care, therapy and that patients can refuse care. Coordination of care with everybody (nurses, therapy, physicians, wound care clinics) should be included.” Review of agency’s “3.1 Patient Bill of Rights and Responsibilities (Elderly Bill of Rights),” revision 1/29/2021, reads in part, “The patient and representative, if any, have the right to be informed of the patient’s rights in a language and manner the individual can understand. The Agency must protect and promote the exercise of these rights…The Agency must provide the patient and the patient’s representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: Obtain the patient’s or representatives signature confirming that he or she has received a copy of the notice of rights and responsibilities…The agency must ensure that written informed consent that specifies the type of care and services that may be provided by the agency has been obtained for every client/patient, either from the client/patient or guardian. The client/patient or guardian must sign or mark the consent form in advance of furnishing care or during the initial evaluation visit before initiation of treatment.””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observations, record reviews and interviews the agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for 3 (Patients 1, 2 and 3) of 3 active patients’ records reviewed. This failure places patients at risk of not receiving interventions and treatments ordered by a physician, which could lead to poor patients’ health outcomes. Findings: Record review of Patient 1 revealed a plan of care for period 8/1/2025 to 9/29/2025 with an admitting diagnosis (condition) of “Type 2 diabetes mellitus (chronic condition where the body does not use insulin properly leading to high blood sugar levels) with foot ulcer (open wound)” signed by RN D. The POC contained a nurse visit frequency of 3 times a week. Records contained a start of care OASIS visit dated 08/01/2025 signed by RN D with documentation stating, “non-pressure chronic ulcer of the left heel/midfoot with necrosis (death of cells or tissue due to disease, injury, or failure of the blood supply) of muscle tissue, currently managed with a wound vac (machine that uses suction to remove excess fluid and infection to promote healing), and presence of a PICC line (a long, thin tube that is inserted into a vein in the arm and guided to a large vein near the heart) for medication administration or therapy.” Patient 1’s records contained physician orders dated 07/15/2025 from Hospital (C3) with wound orders to cleanse wound to left middle foot with wound cleanser (a solution with a water and salt base, containing hypochlorous acid a natural substance produced by the human body’s white blood cells to fight infection), apply collagen (a structural protein that supports and promotes natural wound healing) and silver alginate (a highly absorbent wound dressing made from seaweed fibers and embedded with silver, that kills bacteria and promotes wound healing), and cover with foam dressing. Patient 1’s records contained a Fax dated 8/14/2025 from Clinic (D4) with an order dated 8/12/2025 for a Wound Vac set at 125 mmHg (pressure setting to promote wound healing) “to left ankle. Change 3 times a week. Also please evaluate PICC line to see if it needs to be cleaned.” The POC signed by RN D on 8/1/2025 did not contain orders for PICC line site care/dressing changes or orders for the wound care to patient’s left middle foot. Record review of Patient 2 revealed a recertification Plan of Care (POC) for period 8/05/2025 to 10/03/2025 with an admitting diagnosis (condition) of “Pressure ulcer of other site stage 3 (deep pressure wound/bedsore, that goes past the skin layers into the fatty tissue),” signed by RN A. The POC contained a nurse frequency of twice a week for 9 weeks, and physical therapy and occupational therapy to evaluate and treat. The recertification POC did not contain any wound orders. The recertification OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) dated 6/02/2025 and signed by RN A had the “Yes” box checked marked under the question “Does this patient have at least one unhealed pressure ulcer/injury at stage 2 (an open shallow pressure wound that has gone through the top layer of skin) or higher or designated as unstageable?” with documentation in the narrative section stating, patient has a history of a pressure ulcer on the “left side of the bottom.” The recertification visit did not contain wound orders or evidence that wound care was completed during the visit. Patient 2’s records revealed skilled nursing visits dated 8/8, 8/11 and 8/18 completed by LVN C. The skilled nurse visits contained documentation of a Pressure Ulcer stage 3 to “left buttock”, measurements of the wound, and treatments performed. LVN C documented, cleansed wound to left buttocks with normal saline (solution of salt and water), blue antibacterial foam dressing moistened and packed in wound, and wound covered with foam dressing. Record review of Patient 3 revealed a Plan of Care (POC) for period 8/11/2025 to 10/09/2025 with an admitting diagnosis (condition) of “Encounter for change or removal of surgical wound dressing” and a condition of “Osteomyelitis (bone infection),” signed by RN A. The POC contained a skilled nurse frequency of 3 times a week for 9 weeks. Documentation on the POC stated, “dressing change on the PICC line site weekly.” Patient 3’s records revealed a “Home Health Care Fax Packet” from Hospital (A1) with a faxed date of 8/6/2025 which contained documentation of a “right foot debridement (medical procedure to remove dead, damaged, or infected tissue) of wound, incision and drainage of abscess (localized collection of dead white blood cells, bacteria, and tissue debris)” on 7/30/2025. The Home Health Care Fax Packet also contained documentation of a tunneled central venous catheter without a port (a thin flexible tube that is placed in a large vein of the neck or chest and is threaded under the skin to the exit site where it is accessed to deliver fluids or medications directly into the bloodstream) with an insertion date of 8/01/2025. The Home Health Care Fax Packet contained an order to cleanse the right foot wound with wound cleanser (a solution with a water and salt base, containing hypochlorous acid a natural substance produced by the human body’s white blood cells to fight infection), pack wound with hydrocolloid silver dressing (contains fibers that absorb excess fluid and form a gel that conforms to the wound bed, and silver to prevent infection), cover with 4 inch by 4 inch gauze, absorbent wound dressing pad and secure with gauze wrap and cloth tape. The orders contained a frequency of Mondays, Wednesdays, and Fridays for wound care to the right foot. Patient 3’s home health agency start of care OASIS visit dated 8/11/2025 and signed by RN A revealed documentation of a “PICC line,” and did not contain documentation of a central venous catheter or wound to patient’s right foot. The POC dated 8/11/2025 and signed by RN A did not contain orders for the central venous catheter or wound orders for patient’s right foot wound. Observation and interview were conducted with Patient 3 during a Home Visit on 8/27/2025 at 9:15am. The surveyor observed a central venous catheter present to patient’s right upper chest, and gauze wrap to patient’s right foot. Patient 3 stated, dressing changes to her right foot are scheduled to be changed 3 times a week and the wound clinic comes once a week on Mondays. Patient 3 stated, the home health nurses changed the central venous catheter dressing on 8/12 and 8/14 (Agency records did not contain visits dated 8/12 and 8/14. Visits were dated 8/11 and 8/13). 9/2/2025 2:39pm Phoned contracted LVN C and left voicemail with name and contact number to return call. A phone interview was conducted with contracted RN D on 9/2/2025 at 2:47pm. When asked about the agency’s policy on care planning and what should be included in the plan of care, RN D was unable to state the agency’s policy and said, “the agency has not shared that (information) with me before.” When asked about Patient 1, RN D stated she only saw the patient once and received a message from the agency on the communication software application, asking the contracted RN to complete the admission on Patient 1 on 8/01/2025. RN D stated the “doctors notes” were attached to the message. The surveyor shared the findings for Patient 1 and asked why the PICC line orders and wound care for patient’s left foot were not on the POC. RN D stated she did not receive the wound care orders or PICC line dressing change orders from the hospital or agency. When asked about communication/coordination with the doctor, RN D stated, “I don’t have the name off the top of my head. It should be the orthopedic doctor (a doctor that specializes in the correction of deformities of bones or muscles).” RN D stated, she did not document the communication with the doctor. RN D stated during the SOC admission, Patient 1 had a dressing to her left ankle and a wound vac machine, but did not have “the foam” for the wound vac dressing changes. RN D stated, Patient 1 told her during the SOC visit that she (Patient 1) was seen by the wound care clinic twice a week and Patient 1 saw her primary care doctor once a week. RN D stated Patient 1 told her she had an appointment at the wound clinic the next day on 8/2/2025. RN D stated, she asked Patient 1 to confirm the wound orders during her appointment at the wound clinic. RN D stated on 8/1/2025 she received a call from the doctor’s office asking if the HHA could draw labs. RN D stated she notified the Adm/DON/agency owner through the messaging application regarding drawing labs and was told the agency could draw the requested labs. RN D stated Patient 1 had supplies to change the PICC line dressing for “several weeks” but did not have the supplies for the wound care to Patient 1’s left foot. RN D stated she notified the Adm/DON/agency owner on the messaging application that Patient 1 did not have orders for wound care and PICC dressing changes. RN D stated in her message she informed the ADM/DON/agency owner that Patient 1 needed wound care supplies to be ordered, and Patient 1’s PICC line dressing needed to be changed in 1 week. RN D stated she received a message through the messaging application that an agency nurse would deliver supplies the next day (on 8/2/2025). A phone interview was conducted with RN A on 9/3/2025 at 12:18pm. When asked about the agency’s policy and process of adding orders to the plan of care, RN A stated, “when I get wound orders from the hospital those orders are included in the plan of care.” RN A stated that patients who received wound treatments in the hospital are often discharged home with wound supplies. RN A stated the nurse must “put those orders (from the hospital) in the plan of care and continue with that order until the doctor reassesses the patient and changes the order.” RN A stated the orders are added to the SOC or recertification OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) and then transfers to the POC. The surveyor shared the findings for Patient 2 and asked why the wound orders for patient’s “left buttocks” was not on the recertification OASIS visit and POC. RN A stated, “I don’t know. There should be one (wound order). Maybe I omitted it (the wound). It was a tiny wound. If I did not include it (wound orders) in the OASIS, then it (wound orders) will not be included in the plan of care.” When asked about the potential patient outcome for wound orders not being on the POC, RN A did not give a direct answer and stated, “I’m not sure what it could be. The nurses always do the wound care. I always do what I am supposed to do.” When asked about the start of care assessment of Patient 3 during the agency’s admission process, RN A stated, “I can’t remember. I think the patient had a skin graft…I don’t have my computer. I only see these people (patients) once every 6 weeks.” The surveyor shared RN A’s documentation on the POC, RN A stated, “I know she (Patient 3) had blood on her left foot. I think she was using a wheelchair that day. She had a skin graft to her left foot. I’m trying to remember.” The surveyor shared RN A’s documentation on Patient 3’s start of care OASIS visit dated 8/11/2025 and asked about the wound to patient’s right foot. RN A stated the day she completed Patient 3’s SOC admission (RN A could not recall the date) “I went there (to Patient 3’s home). There was blood all over the bed. It (the wound) was only on one leg. I don’t think there was a wound on her right. I think it (the wound) was on her left foot.” The surveyor shared the documentation from hospital (A1) and the wound orders to patient’s right foot. When asked how the agency provides the nurse with the hospital orders and documentation before a patient’s admission, RN A stated “it is attached to her (Patient 3’s) records in the attachments” in the agencies EMR system, where the nurse can view the attachments. When asked about the potential patient outcome for omitted orders on the POC for patient’s right foot wound and central venous catheter site, RN A did not give a direct answer and stated “to the best of my knowledge the patient (Patient 3) was treated the way she was supposed to be, and nothing was omitted. There was nothing that was missed from the patient’s care. The patient received the order she was supposed to receive.” An interview was conducted with the Adm/DON (via phone conference) and the interim Alt Adm on 9/3/2025 at 3:39pm. When asked about the agency’s policy and procedure on what is included on the POC, the Adm/DON stated, “the patient needs, patient education, the patient’s projected visit frequency, prn visits, medical supplies and orders. If they (patients) need medical supplies, there is an order component that carries on the order. During the admissions sometimes the nurses are not sure about the order and want to check in with the doctor first. They (the nurses) might not necessarily put it in the plan of care. They will get approval from the doctor and then create an additional order.” When asked if the additional order transfers to the POC, the Adm/DON stated, if “the doctor wants something (a treatment, wound order, therapy) to be discontinued then it (agency’s EMR system) doesn’t let us (nurses) do a new plan of care. The plan of care is created from OASIS. When asked about the agency’s policy and process of updating the recertification POC to include the orders written after the start of care OASIS. The Adm/DON stated, “The recert generates a new plan of care. If there is an update (additional physician orders) the nurse needs to make sure that the update (additional physician orders) is there (in the recertification POC) because the nurse sees the patient.” At 4:11pm the Adm/DON requested to briefly pause the interview. An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. The survey shared the findings on Patients 1, 2 and 3 and the interviews with RN A and RN D. When asked about the potential patients’ outcomes for orders not included in the POC, the Adm/DON stated, “The outcome is not going to be good because treatments like wound care and the PICC line will be missed. The patient’s condition will get worse.” Review of agency’s policy “5.7 Care Planning Process” revision 1/29/2020, reads in part, “the 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… The appropriate licensed professional staff member, with physician and/or non-physician participation, is responsible for developing the plan of care within 3- 5 days of the initial assessment. A registered nurse initiates the plan of care for skilled nursing care and for personal hygiene/activities of daily living care… An RN is responsible for coordinating the plan of care when multi-disciplines are involved, or when more than one agency is involved, to decrease the possibility of duplication/ conflict and to identify responsibilities. Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the POC. The POC, 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: All pertinent clients diagnoses/problems… types of services, supplies and equipment required, frequency and duration of visits to be made, goals/outcomes to be achieved…all medications and treatments, specific procedures/treatments to be performed. Review of agency’s policy “5.6 Orders for Care,” revision 1/29/2020, reads in part “The agency will obtain orders and provide care in accordance with physicians, physician’s nurse practitioner (NP) and physician’s assistant (PA) orders which are established prior to initiating patient care and reviewed revised by the physician, physicians nurse practitioner or physician’s assistant every 60 days and as needed. All orders are kept current and renewed or updated as appropriate to: Changes in patients condition occurs; The ordered care is ineffective; Changes in diagnosis, treatment (including procedures and medications), and equipment; Desired goals are not being achieved; Applicable law and regulation. The data/information/orders will be documented upon initial certification and subsequent recertification as defined by the plan of care (POC) form.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, record reviews and interviews the agency failed to ensure services and treatments are administered only as ordered by a physician or allowed practitioner for 1 (Patients 3) of 3 active patients’ records reviewed. This failure could potentially place patients at risk for poor health outcomes and decreased patient satisfaction and trust. Findings: Record review of Patient 3 revealed a Plan of Care (POC) for period 8/11/2025 to 10/09/2025 with an admitting diagnosis (condition) of “Encounter for change or removal of surgical wound dressing” and a condition of “Osteomyelitis (bone infection),” signed by RN A. The POC contained a skilled nurse frequency of 3 times a week for 9 weeks. The POC contained documentation for “dressing change on the PICC line (a long, thin tube that is inserted into a vein in the arm and guided to a large vein near the heart that is used to administer fluids or medications directly into the blood stream) site weekly.” The POC did not contain a physician’s order on how to cleanse the PICC line site and/or the dressing to be used to cover the site.” Patient 3’s records contained a start of care OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) visit dated 8/11/2025 and signed by RN A with documentation of “SN to cleanse and perform PICC line dressing change on the right upper chest weekly.” Patient 3’s records revealed a skilled nurse visit dated 8/13/2025 signed by LVN B which contained documentation in the integumentary (protective outer layer of the body to include skin) comment section which stated, “PICC dressing changed.” Observation and interview were conducted with Patient 3 during a Home Visit on 8/27/2025 at 9:15am. The surveyor observed a central venous catheter (a thin flexible tube that is placed in a large vein of the neck or chest and is threaded under the skin to the exit site where it is accessed to deliver fluids or medications directly into the bloodstream) present to patient’s right upper chest. When asked about the care provided to the central venous catheter site, Patient 3 stated a nurse from the agency came on 8/12/2025 and changed the central venous catheter dressing because the “dressing was coming off.” Patient 3 stated a different nurse came on 8/14/2025 and changed the central venous catheter dressing. A phone interview was conducted with LVN B on 9/2/2025 at 3:35pm. When asked about the agency’s policy on treatments without an order, LVN B stated she was a contracted nurse, and “not familiar with the agency’s specific policies.” When asked about Patient 3, LVN B stated, “I only saw her once, I was the first one (nurse) to see her. I saw her before the admitting nurse did, which is unusual. There were no orders, I had nothing (no POC and medication profile).” The surveyor shared the findings of Patient 3 and asked about the central venous catheter site. LVN B stated Patient 3 “had a PICC line,” to her right upper chest and the dressing “was soaking wet and falling off.” LVN B stated she changed the dressing to the “PICC line” because “I didn’t want it (PICC line site) to become infected.” When asked about doctor notification for an order, LVN B stated, “the admitting nurse was scheduled to see the patient.” A phone interview was conducted with RN A on 9/3/2025 at 12:18pm. The surveyor shared the findings for Patient 3. RN A stated, she could not remember the date she admitted Patient 3 and did not have her computer to look up the information. When asked if a physician order was obtained regarding cleansing and dressing the central venous catheter site, RN A stated, “I don’t remember.” When asked about the potential patient outcome for not obtaining physician orders and including them in the POC, RN A refuses to give a direct answer and stated, “to the best of my knowledge the patient was treated the way she was supposed to be, and nothing was omitted. There was nothing that was missed from the patient’s care. The patient received the order she was supposed to receive.” An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 3:39pm. When asked about the agency’s policy on obtaining orders for treatment, The Adm/DON stated, “The nurse will make sure that there is an order. They (the nurses) communicate with the doctor and then the order is created. Either they (doctor or wound care clinic) are going to send us (the agency) the order or the nurse is going to verbally take the order from the phone and create the order.” At 4:11pm the Adm/DON requested to briefly pause the interview. An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. The surveyor shared the finds on Patient 3 and the interviews with RN A and LVN B. When asked about the potential patient outcome for treatments performed without a physician’s order, the Adm/DON stated, “We (nurses and therapists) need to make sure we have the proper order when treating the patient. The outcome is it (wound, PICC or central venous catheter site) will get worse… Even if it doesn’t get worse it’s (treatment without an order is) still not right, you need the doctor’s orders to treat whatever you are treating.” Review of agency’s policy “5.6 Orders for Care,” revision 1/29/2020, reads in part “The agency will obtain orders and provide care in accordance with physicians, physician’s nurse practitioner (NP) and physician’s assistant (PA) orders which are established prior to initiating patient care and reviewed revised by the physician, physicians nurse practitioner or physician’s assistant every 60 days and as needed. All orders are kept current and renewed or updated as appropriate to: Changes in patients condition occurs; The ordered care is ineffective; Changes in diagnosis, treatment (including procedures and medications), and equipment; Desired goals are not being achieved; Applicable law and regulation. The data/information/orders will be documented upon initial certification and subsequent recertification as defined by the plan of care (POC) form… Drugs, services, and treatments are administered only as ordered by a physician, physician’s nurse practitioner or physician’s assistant. Review of agency’s policy “IVT.6 Peripherally Inserted Central Catheters (PICC) and extended peripheral catheters” revision 01/29/2020, reads in part, “patient shall meet the criteria for admission as defined in the administrative policy and procedure manual and: Physician order obtained for home infusion therapy…Procedure: RN will assess the PICC line insertion site upon patient admission with PICC order from MD… SN (skilled nurse) will perform dressing change and port flushes at MD ordered frequency. RN will use sterile technique and sterile supplies documenting dressing change: all steps in sterile dressing change including: removing old dressing and disposing per OSHA guidelines, washing hands and changing to sterile gloves, establishing A sterile field, cleansing the site moving from insertion site out, noting the length of the PICC line, covering the site per MD orders, patient tolerance of the dressing change. SN will perform flushes per MD ordered frequency documenting flushes: All steps and clean technique flashes including: cleansing the port, flushing with 5 to 10 cc’s normal saline, flushing with 3 to 5 cc’s heparin.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, record reviews and interviews the Home Health Agency failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for 2 (Patients 1 and 3) of 3 active patients’ records reviewed. This failure placed patients at risk for not receiving adequate care, treatments and interventions, which could potentially affect the agency’s ability to meet the patients’ needs. Findings: Record review of Patient 1 revealed a plan of care for period 8/1/2025 to 9/29/2025 with an admitting diagnosis (condition) of “Type 2 diabetes mellitus (chronic condition where the body does not use insulin properly leading to high blood sugar levels) with foot ulcer (open wound)” signed by RN D. The POC contained a nurse visit frequency of 3 times a week and documentation to “Notify Physician of vital sign out of range: Heart rate greater than 100 (beats per minute). Diastolic Blood Pressure (pressure in the arteries when the heart relaxes between beats) greater than 90.” Patient 1’s records contained a start of care OASIS (a tool used by CMS to collect and report patient information for quality improvement and monitoring) visit dated 08/01/2025 and signed by RN D with a documented heart/pulse rate of 108 and a diastolic blood pressure of 94. The “Care Coordination” section of the Start of care OASIS was blank with no evidence the physician was notified of the “out of range” heart/pulse rate and diastolic blood pressure. Patient 3’s records contained a skilled nurse visit dated 08/14/2025 signed by LVN E with a documented diastolic blood pressure of 97 and heart/pulse rate of 109. The “Care Coordination” section of the skilled nurse visit was blank with no evidence the physician was notified of the “out of range” heart/pulse rate and diastolic blood pressure. Record review of Patient 3 revealed a plan of care for period 8/11/2025 to 10/09/2025 with an admitting diagnosis (condition) of “Encounter for change or removal of surgical wound dressing” and a condition of “Osteomyelitis (bone infection),” signed by RN A. The POC contained a skilled nurse frequency of 3 times a week for 9 weeks. The POC contained documentation for “dressing change on the PICC line (a long, thin tube that is inserted into a vein in the arm and guided to a large vein near the heart that is used to administer fluids or medications directly into the blood stream) site weekly.” The POC did not contain a physician’s order on how to cleanse the PICC line site and/or the dressing to be used to cover the site. Patient 3’s records contained a start of care OASIS visit dated 8/11/2025 and signed by RN A with documentation of “SN to cleanse and perform PICC line dressing change on the right upper chest weekly.” Patient 3’s records revealed a skilled nurse visit dated 8/13/2025 signed by LVN B which contained documentation in the integumentary (protective outer layer of the body to include skin) comment section which stated, “PICC dressing changed.” The “Care Coordination” section of the skilled nurse visit contained a check mark in the box labeled “N/A” with no evidence the doctor was notified for an order. Observation and interview were conducted with Patient 3 during a Home Visit on 8/27/2025 at 9:15am. The surveyor observed a central venous catheter (a thin flexible tube that is placed in a large vein of the neck or chest and is threaded under the skin to the exit site where it is accessed to deliver fluids or medications directly into the bloodstream) present to patient’s right upper chest covered with a clear transparent dressing. When asked about the care provided to the central venous catheter site, Patient 3 stated a nurse from the agency came on 8/12/2025 (Agency records did not contain a visit dated 8/12. LVN B’s visit was dated 8/13) and changed the central venous catheter dressing because the “dressing was coming off.” Patient 3 stated a different nurse came on 8/14/2025 (Agency records did not contain a visit dated 8/14. RN A’s visit was dated 8/11) and changed the central venous catheter dressing. A phone interview was conducted with RN D on 9/2/2025 at 2:47pm. The surveyor shared the findings on Patient 1. When asked about the blank coordination section of the start of care OASIS dated 8/1/2025 and if the physician was notified of patient’s heart/pulse rate of 108 and diastolic blood pressure greater than 90. RN D did not give a direct answer or confirmation the doctor was notified, and stated, “I’m not sure why it (coordination section) is blank…I don’t have the name off the top of my head. It should be the orthopedic doctor.” When asked if the communication with the doctor was documented, RN stated, “I did not document the doctor was notified.” A phone interview was conducted with contracted nurse LVN B on 9/2/2025 at 3:35pm. When asked about LVN B’s employment with the agency, LVN B stated, “I don’t work for any particular agency, I do prn work for multiple agencies and get assignments,” through a messaging application. When asked about the agency’s policies on coordination of care and treatment orders, LVN B stated, she was “not familiar with the agency’s specific policies.” When asked about Patient 3, LVN B stated, “I only saw her once, I was the first one (nurse) to see her. I saw her before the admitting nurse did, which is unusual. There were no orders, I had nothing (no POC and medication profile).” The surveyor shared the findings of Patient 3 and asked about the wound care and central venous catheter site. LVN B stated she documented in her visit note on 8/13/2025, the wound care was not done because she did not have a doctor’s order. LVN B stated, Patient 3 “had a PICC line,” the dressing “was soaking wet and falling off. LVN B stated she changed the dressing to the “PICC line” without an order because “I didn’t want it (PICC line site) to become infected.” When asked why she did not communicate with the agency and physician regarding the missing orders. LVN B stated, she did not notify the agency or physician “because the admitting nurse was scheduled to see (admit) the patient” and write the orders from the physician. LVN B stated she declined “to sign up” to see Patient 3 after 8/13 because “Things were not done correctly (LVN visit scheduled before the admission was completed, no orders, no POC, and no medication profile)” by the agency. A phone interview was conducted with LVN E on 9/03/2025 at 2:25pm. When asked about the agency’s policy on coordination and notification of the physician for a change in patient condition. LVN E stated, “I will notify the case manager and doctor” when there is a change in condition. The surveyor shared the findings on Patient 1. When asked about the notification of the doctor for Patient’s “out of range” heart rate/pulse and diastolic blood pressure, LVN E stated, Patient 1 “was noncompliant” with treatments and had several missed visits due to not returning the nurses’ calls. LVN E stated, “I only saw her once. I didn’t notify the doctor because of her activities (noncompliance with care) and refusal (of care). The patient didn’t want me to manage anything (patient care, medications and wound care). I would have notified the doctor if I saw a pattern (of continued elevated pulse/heart rate, and diastolic blood pressure).” An interview was conducted with the Adm/DON (via phone conference) and the interim Alt Adm on 9/3/2025 at 3:39pm. When asked about the agency’s policy and process of notification of the physician for a change in patient condition, out of range vital signs or if an order is needed, the Adm/DON stated, “The nurses will notify the doctor and get an order and document the reason the doctor was notified, what was discussed, and write the order.” The Adm/DON/agency owner stated that sometimes the nurses document their coordination with the doctor during the next patient visit instead of writing it on a communication note on the actual day the nurse spoke to the doctor. The Adm/DON/owner stated that the nurse will document the communication with the physician on a coordination note in the patient’s record if the nurse wants to “draw attention” to an issue with the patient. At 4:11pm the Adm/DON requested to briefly pause the interview. An interview was conducted with the Adm/DON/agency owner (via phone conference) and the interim Alt Adm on 9/3/2025 at 4:49pm. The surveyor shared the findings of Patients 1 and 3 and the interviews with LVN B, RN D and LVN E.” When asked about the potential patient outcome for lack of coordination with the doctors, wound clinics and contract nurses. The Adm/DON/agency owner stated, “Something (orders, treatments, supplies, or services) can be missed. We (agency) definitely need to make sure there is coordination even if it’s not documented. We (agency) still have to show the documentation that there is coordination so it will make sense why the nurse is going to see the patient.” Review of agency’s policy, “5.9 Monitoring Patient Care/Coordination of Care” revision 1/29/2025, reads in part, “the HHA must: Assure communication with all physicians involved in the plan of care. Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on record review, observation and interviews, the agency failed to provide written notice of the agency’s transfer and discharge policy for 2 (Patients #1 and 2) of 2 patients who received home visits from the surveyor. This failure did not conform to the patients right to be provided information regarding the criteria used to determine if the patient could be discharged or transferred from agency services. The failure potentially placed the patients at risk of inadequate plans of continued healthcare and services after discharge from the agency. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 02/16/2024-04/15/2024 with a SOC 02/16/2024. During a home visit and interviews on 05/28/2024 at 10:05 AM, the surveyor reviewed the home folder provided by the agency and asked ALF staff, Identifier D if anything was missing from the folder or removed. Identifier D stated, “no.” Review of the patient’s home folder contained no evidence a written notice of the agency’s transfer and discharge policy had been provided. Patient #2: Record review revealed a POC dated 03/05/2024-05/03/2024 with a SOC dated 07/24/2020. During a home visit and interviews on 05/24/2024 at 9:05 AM, the surveyor reviewed the home folder provided by the agency and asked ALF staff, Identifier C, if anything was missing from the folder or removed. Identifier C stated, “everything is there.” Review of the patient’s home folder contained no evidence a written notice of the agency’s transfer and discharge policy had been provided. During an interview with the Administrator/DON on 05/29/2024 at 3:40 PM, the surveyor reviewed the findings and asked why the agency did not provide written notice of the agency’s transfer and discharge policy. The Administrator/DON brought a blue folder into the conference room and asked if the surveyor had seen the new tri-fold sample home folder provided by the agency consultant. The surveyor stated the Patients (#1 and #2) home folders reviewed during the home visits were not tri-fold and appeared older and mildly worn. The folders did not contain the agency’s transfer and discharge policy. The Administrator/DON stated, “I’m aware they (policies) are supposed to be in there, I’m surprised it’s not there.” Agency policy, revised date 01/29/2020, quoted in part: “4.5 PATIENT TRANSFER / AGENCY DISSOLUTION, … The Agency will initiate patient transfer or transfer and discharge only when: The transfer or discharge is necessary for the patient’s welfare …” Agency policy, revised date 01/29/2020, quoted in part: “4.6 PATIENT DISCHARGE, The Agency will discharge patient when the patient meets discharge criteria… The Agency will provide appropriate discharge planning and notification, per regulations….””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record reviews, observation and interviews, the agency failed to ensure the patient plans of care were complete and included all required elements. In 1 (Patient #1) of 1 patient whose record included care received from a dialysis facility, the POC did not include instructions for the SN to assess Patient #1’s CV access site (a long plastic, flexible tube inserted into the vein located in the upper chest). This failure potentially placed the patient at risk of infection and complications with performance of the CV access when the SN did not have instructions for a CV access site assessment. In 2 (Patient’s #3 and 4) of 2 patients who received wound care from a SN, the POC did not include instructions for the SN to perform specific wound care. This failure potentially placed the patients at risk of infection and a decline in health status when the SN did not have instructions for specific wound care. In 1 (Patient #7) of 1 patient record reviewed whose primary diagnosis was CHF, the POC did not include instructions for the SN to assess the patient’s weight or report to the physician a change or increase in weight. This failure potentially placed the patient at risk of fluid overload and health complications when the SN did not have instructions to weigh and report changes to the physician. FINDINGS: REFERENCES: Assessment of a vascular access: “... Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores or swelling... assess the vascular access for any bleeding or hemorrhage….” (Lippincott Journal of nursing management, 2010). Assessment of CHF includes: “… weight increase, shortness of breath, pitting edema (swelling due to excessive fluid accumulation in body tissues), jugular vein distension and ascites (distended or tense abdomen).” (Healio Cardiology: https://www.healio.com/news/cardiology/20210526/congestive-heart-failure-volume-fluid-status). Patient #1: Record review revealed a POC dated 02/16/2024-04/15/2024 with a SOC 02/16/2024. The POC listed the following diagnoses: Sepsis (a serious condition in which the body responds improperly to an infection), High blood pressure and Diabetes, Type 2. The POC did not include written instructions for the SN to assess the CV (Central Venous catheter- a long plastic, flexible tube inserted into the vein located in the upper chest. Two flexible tubes at the end remain outside the body and are used to allow for the transfer of blood to and from the body during dialysis) access site. Dialysis- a machine that cleans the blood from excess waste and water. A comprehensive SOC assessment signed by the RN E, dated 02/16/2024 included on page 8, “… ELIMINATINON STATUS, (check marked) Dialysis: Type: Hemodialysis, Dialysis Treatment Schedule M-W-F (Monday, Wednesday, Friday).…” On page 20, “… Patient goes for dialysis three times a week due to kidney disease. Shunts [sic] intact on the left upper chest….” During a home visit interview with Patient #1 on 05/28/2024 at 10:05 AM, the surveyor asked about the dialysis treatment and care/services received by the agency nurse. Patient #1 stated she had the CV access on her chest more than a year, “for a while.” The surveyor asked if the nurse assessed the CV access during the SN visits. Patient #1 stated the nurse did not check the CV access. In an interview with the Administrator/DON on 05/29/2024 at 1:30 PM, the surveyor reviewed the findings and the POC. The surveyor asked if the RN E was available to join us for preliminary findings reviews. The Administrator/DON stated she had tried to reach RN E but was unable to reach her at that time. The surveyor asked who was responsible for nursing services oversight. The Administrator/DON stated, “I try to read the (SN) notes the best I can.” The surveyor asked why the POC did not include instructions for the SN to assess the patient’s CV access site. The Administrator reviewed the POC in the agency EHR system and stated, “It’s not there, I thought it was there, I don’t know.” Patient #3: Record review revealed a POC dated 03/31/2024-05/29/2024 with a SOC 01/31/2024. The POC listed the following diagnoses: Metabolic encephalopathy; mild protein-calorie malnutrition and muscle weakness. Review of the entire record did not reveal any verbal physician orders for wound care. The POC did not include instructions for the SN to perform wound care. The comprehensive reassessment signed by the RN E, dated 03/29/2024 included: On page 2, “Potential Risk for Infection Assessment, “… Assess for Predictors: … Wounds (checked marked): On page 5, “… INTEGUMENTARY STATUS… Wound, Pressure injury (ulcer), on page 6, “… Comments: Patient with small sacral wound that is almost healed, this wound requires dressing changed.” On page 13, “… Wound Care Flowsheet… Location: sacral area, Wound Type: Pressure Ulcer, Measurement Length: 1.0 cm, Measurement Depth: 0.5 cm, Surrounding Tissue: Pink, Drainage: Serosanguineous, Drainage Amount: Minimal and Odor: none, Treatment performed: Performed dressing change per order and patient tolerated well.” SN visit notes signed by the LVN F, dated 04/03/2024; 04/10/2024; 04/15/2024; 04/22/2024, 05/01/2024 and 05/08/2024, included on page 1, “Integumentary … Comment: sacral and right index toe wounds, …” Page 4 included, “… Wound Care Flowsheet, Wound 1: Location: sacral … Wound 2: Location: rt. … Treatment Performed: Cleanse wound with dakin solution (a potent antibacterial solution effective in the treatment of wounds), pat dry, cover with w/d (wet to dry) dsg (dressing) and cover with border gauze for sacral. Rt. Index toe cleanse with dakin solution cover with wet gauze.” During an interview with the Administrator/DON on 05/29/2024 at 2:00 PM, the Administrator/DON included the RN E on a conference phone call. The surveyor reviewed the findings and the POC and asked why the POC did not include instructions for the SN to perform wound care. RN E stated the ALF aide applied ointment and a small bandage to the patient’s backside only after incontinent care since the area was tiny and healed up now. RN E stated she wasn’t sure why everything was not on the POC. The Administrator/DON stated she was aware ointments or anything used on the patient to be included on the POC. Patient #4: Record review revealed a POC dated 03/25/2024-05/23/2024 with a SOC 03/25/2024. The POC listed the following diagnoses: Diabetes Type 2 and High blood pressure. The POC included, “… SN indicated for wound care management based on physician orders due to the inherent complexity of the wound or no able/willing caregiver to perform wound care. SN to instruct patient/caregiver on wound care performance and assess wound progression or decline….” Review of the entire record did not reveal any verbal physician orders for wound care. The POC did not include instructions for the SN to perform wound care. A comprehensive SOC assessment dated 03/25/2024 was completed by the RN E. Page 20 included, “… Patient has wound on the scrotum that needs to be dresses [sic]/cleaned three times per week. SN cleaned and dressed the wound during home health admission, though patient had very limited supplies….” During an interview with the Administrator/DON on 05/29/2024 at 2:30 PM, the Administrator/DON included the RN E on a conference phone call. The surveyor reviewed the findings and the POC and asked why the POC did not include instructions for the SN to perform wound care. RN E stated, “I always dress the wound if found on admission, it’s on the OASIS.” The surveyor stated the POC did not include the instructions for wound care such as the type of cleansing to be done, application of any treatments, frequency, or duration of wound care. The Administrator/DON stated, “the POC is generated from the OASIS, it doesn’t have everything on it. I don’t know why it’s not there (on the POC).” Patient #7: Record review revealed a POC dated 11/18/2023-01/16/2023 with a SOC 05/22/2023. The POC listed the primary diagnosis as CHF (Congestive heart failure is a condition in which the heart can’t pump enough blood to the body’s other organs) and additional diagnoses of chest pain and weakness. The POC did not include instructions for the SN to assess the patient’s weight or report to the physician a change or increase in weight. A comprehensive reassessment dated 11/15/2023 was completed by the RN E. Page 5 included, “… Activity: Walks with help….” Pages 11-12 included, “… Interventions: SN to assess cardiovascular status for heart sounds, edema, peripheral circulation, angina. Skilled Nurse to observe and assess all body systems…. Instruct pt/cg to weigh patient and report weight gain or loss of 5lbs in 7 days….” During an interview with the Administrator/DON on 05/29/2024 at 3:00 PM, the Administrator/DON included the RN E on a conference phone call. The surveyor reviewed the findings and the POC and asked why the POC did not include instructions for the SN to weigh the patient and report weight changes. The Administrator/DON stated the POC is supposed to have weight checks, “it should be on the POC, it’s a standard practice for CHF, I don’t know why it’s not there.” Agency policy, dated 01/29/2020, quoted in part, “5.7 CARE PLANNING PROCESS, The 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…. Each patient/client must receive an individualized POC, including any revisions or additions. The individualized POC must specify the care and services necessary to meet the patient/client needs as identified in the comprehensive assessment … The POC, which includes the following plan of care elements, … will serve as the initial plan of care: … All medications and treatments, specific procedures/treatments to be performed, … other appropriate items such as precautions and contraindications, …””