Every finding on record at Albert Gallatin Home Care and Hospice Services Company, LLC

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on February 9, 2026, Amedisys Home Health of PA, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on February 9, 2026, Amedisys Home Health of PA, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of Clinical Records (CR), home visit observations (HV), and interview with agency staff, the agency failed to ensure the Plan of Care (POC) included all medications the patient is currently using for seven (7) of seventeen (17) CR reviewed (CR# 6, 8, 12-13, 15, &17), supplies and equipment required for five (5) of seventeen (17) CR reviewed (CR# 6, 11, 12, 14, & 15), and patient-specific interventions for three (3) of seventeen (17) CR reviewed (CR# 9, 12, & 17). Findings included: Review of CR#6 on 2/4/26 at approximately 12:00pm revealed start of care (SOC) date 1/2/26, dates reviewed 1/2/26-2/4/26. Plan of Care (POC) included diagnosis of Type II Diabetes Mellitus with other skin ulcer and interventions for diabetic teaching and monitoring. Medication list included Novolog Flexpen U-100 insulin Aspart 100 unit/ml (3ml) subcutaneous 3 times a day per sliding scale (methos of managing blood sugar where the dose of fast acting insulin is determined by current blood glucose level). POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. Review of CR#8 on 2/4/26 at approximately 1:00pm revealed SOC date 10/21/25, dates reviewed 12/20/25-2/4/26. POC and med list included Ipratropium 0.5mg Albuterol 3mg (2.5mg base)/3ml Nebulization solution inhalation every 4 hours pro re nata (PRN) as needed). POC and medication list failed to include indications/symptoms for as needed use. Review of CR#9 on 2/4/26 at approximately 1:30pm revealed SOC date 1/12/26, dates reviewed 1/12/26-2/4/26. POC included orders to draw labs every Monday. Labs ceased being drawn when PICC line (peripherally inserted central catheter-flexible tube inserted into an upper arm vein and threaded to a large vein near the heart for long term IV therapy) was removed. No order from doctor to discontinue lab draws. Review of CR#11 2/4/26 at approximately 2:30pm revealed SOC date 12/26/25, dates reviewed 12/26/25-2/4/26. POC included liquid oxygen base unit, liquid oxygen portable unit, and oxygen concentrator on equipment/supply list. POC and medication list failed to include oxygen. POC and medication list included ipratropium 0.5mg-albuterol 3mg (2.5mg base)/3ml nebulization solution inhalation 2 times a day PRN. POC and medication list failed to include indications/symptoms for as needed use. POC failed to include nebulizer on equipment list. Review of CR#12 on 2/9/26 at approximately 10:00am revealed SOC date 1/2/26, dates reviewed 1/2/26-2/9/26. HV conducted 2/5/26 at approximately 9:00am revealed patient has a bedside commode in the home and a bi-pap (bilevel positive airway pressure) machine (a non-invasive ventilator that helps people breathe by delivering pressurized air through a mask, with higher pressure during inhalation and lower pressure during exhalation). POC equipment list failed to include bedside commode. POC failed to include order for bi-pap use and settings to be programmed. POC and medication list included Narcan 4 mg/actuation nasal spray as directed. POC and medication list fail to include directions for use. Review of CR#13 on 2/9/26 at approximately 10:30am revealed SOC date 1/29/26, dates reviewed 1/29/26-2/9/26. HV conducted 2/5/26 at approximately 10:30am revealed through interview with patient wife that patient receives chemotherapy. POC and medication list failed to include chemotherapy. Review of CR#14 on 2/9/26 at approximately 11:00am revealed SOC date 1/6/26, dates reviewed 1/6/26-2/9/26. HV conducted 2/6/26 at approximately 9:30am revealed patient has a home INR (international normalized ratio-standardized laboratory measurement used to determine how quickly blood clots) machine. POC includes order to obtain INR via fingerstick machine. POC equipment list failed to include home INR monitoring machine. Review of CR#15 on 2/9/26 at approximately 11:30am revealed SOC date 1/23/26, dates reviewed 1/23/26-2/9/26. HV conducted 2/6/26 at approximately 10:45am revealed patient uses home blood glucose monitoring by continuous monitoring device and also blood glucose machine via fingerstick and meter. POC included order for blood glucose testing before meals and at bedtime. POC and medication list included insulin lispro (u-100) 100 unit/ml subcutaneous pen 3 times a day per sliding scale. POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. POC and medication list failed to include the sliding scale. POC failed to include diabetic supplies. Review of CR#17 on 2/9/26 at approximately 12:30pm revealed SOC date 12/18/25, dates reviewed 12/18/25-2/9/26. POC included diagnosis of type II diabetes mellitus with diabetic polyneuropathy and intervention for "...blood glucose testing as ordered and report abnormal findings to physician..." POC failed to include clear orders for frequency of blood glucose testing and normal parameters for results. POC and medication list included Novolog flexpen u-100 insulin aspart 100 unit/ml (3ml) subcutaneous 3 times per day per sliding scale. POC and medication list failed to include the sliding scale. Interview with agency Administrator and 2 branch Directors of Operations on February 9, 2026, at approximately 3:00pm confirmed findings.

Based on the findings of an onsite unannounced complaint investigation survey completed November 1, 2023, Amedisys Home Health of PA was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and employee (EMP) interview, the agency failed to ensure the frequency of visits was appropriate to meet the patients' needs for one (1) of four (4) clinical records reviewed (CR #2). Findings included: Review of Clinical records (CR) 11/1/23 at approximately 11:30am revealed: CR#2. Start of Care: 9/15/23. Certification period reviewed: 9/15/23-11/13/23. CR#2. Start of Care: 9/15/23. Certification period reviewed: 9/15/23-11/13/23. Diagnosis of aftercare post genitourinary system surgery, skilled nursing ordered 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 6 weeks. Initial assessment notes that patient lives with spouse and sibling. Wound care ordered to be completed 3 times daily, caregiver to perform in the absence of the nurse. On 9/29/23 the clinical note documented that the caregiver had fallen and broken their arm and was no longer able to perform wound care, and that the patient was unable due to location of the wounds. On this date an order was also written to increase nursing frequency starting week of 10/1/23 to perform wound care due to no caregiver availability. Frequency increased to 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 1 week. On 10/2/23 skilled nurse documented in the clinical note that the skin graft was green and mushy, leaking urine, burning, urgency, and pain. The frequency ordered due to the caregiver inability to perform the wound care did not satisfy the frequency of the dressing change as ordered at 3 times a day. No documentation of education or return demonstration to alternate caregiver to perform in nurse absence. An interview with the agency's director of operations and assistant vice president of operations on 11/11/23 at approximately 3:30pm confirmed the above findings.

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 review of agency policy, clinical records (CR), and employee (EMP) interview, the agency failed to ensure services or treatments are only administered per order of physician for one (1) of four (4) clinical records reviewed (CR #2). Findings included: Review of agency policy on 11/2/23 at approximately 1:00pm and revealed: "...Physician Orders and Medical Supervision of the Plan of Care...PROCEDURE: ...Medical Supervision: ...2. Dugs, services and treatments are administered only as ordered by a physician or allowed practitioner that establishes and periodically reviews the plan of care... Review of Clinical records (CR) 11/1/23 at approximately 11:30am revealed: CR#2. Start of Care: 9/15/23. Certification period reviewed: 9/15/23-11/13/23. In clinical note dated 9/27/23, it was documented that the nurse instructed the patient to "wrap ice pack in towel and apply to area (surgical area0 3-4 times daily for 20 minutes." In clinical note dated 9/29/23, it was documented that the nurse "instructed to apply barrier cream 2 times daily..." The Pla of care failed to include orders for interventions documented by the clinician. An interview with the agency's director of operations and assistant vice president of operations on 11/11/23 at approximately 3:30pm confirmed the above findings. Repeat deficiency, previously cited: 11/18/22.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on review of agency policy, clinical records (CR), and employee (EMP) interview, the agency failed to ensure communication with physician for change in patient condition for one (1) of four (4) clinical records reviewed (CR #2). Findings included: Review of agency policy on 11/2/23 at approximately 1:00pm and revealed: "...Coordination of Care...PROCEDURE: ...The Clinical Manager/designee is assigned to supervise and coordinate care for a patient: a. Has the primary responsibility to notify the attending physician and other agency staff of any significant changes in the patients status; b. Assures the communication with all physicians involved in the Plan of Care; ...5. Relevant physicians are notified promptly of any changes in the patient's condition or needs..." Review of Clinical records (CR) 11/1/23 at approximately 11:30am revealed: CR#2. Start of Care: 9/15/23. Certification period reviewed: 9/15/23-11/13/23. In clinical note dated 9/27/23, it was documented that the nurse left a message for the surgeon regarding pain, swelling, difficulty passing urine. No follow-up documentation regarding response from surgeon or additional attempts to reach surgeon. An interview with the agency's director of operations and assistant vice president of operations on 11/11/23 at approximately 3:30pm confirmed the above findings.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), and employee (EMP) interview, the agency failed to ensure an able and willing caregiver was trained to perform wound care in nurses' absence for one (1) of four (4) clinical records reviewed (CR #2). Findings included: Review of Clinical records (CR) 11/1/23 at approximately 11:30am revealed: CR#2. Start of Care: 9/15/23. Certification period reviewed: 9/15/23-11/13/23. Diagnosis of aftercare post genitourinary system surgery, skilled nursing ordered 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 6 weeks. Initial assessment notes that patient lives with spouse and sibling. Wound care ordered to be completed 3 times daily, caregiver to perform in the absence of the nurse. On 9/29/23 the clinical note documented that the caregiver had fallen and broken their arm and was no longer able to perform wound care, and that the patient was unable due to location of the wounds. On this date an order was also written to increase nursing frequency starting week of 10/1/23 to perform wound care due to no caregiver availability. Frequency increased to 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 1 week. On 10/2/23 skilled nurse documented in the clinical note that the skin graft was green and mushy, leaking urine, burning, urgency, and pain. The frequency ordered due to the caregiver inability to perform the wound care did not satisfy the frequency of the dressing change as ordered at 3 times a day. No documentation of education or return demonstration to alternate caregiver to perform in nurse absence. An interview with the agency's director of operations and assistant vice president of operations on 11/11/23 at approximately 3:30pm confirmed the above findings.

Based on the findings of an unannounced on-site Medicare Recertification and State Re-Licensure survey completed on January 31, 2023, Amedisys Home Health of PA, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site Medicare Recertification and State Re-Licensure survey completed on January 31, 2023, Amedisys Home Health of PA, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of agency policy and procedure, clinical records (CR), Home visit Observation (OBS), and staff (EMP) interview, the agency failed to ensure the Plan of Care (POC) included supplies and equipment required for four (4) of seventeen (17) CRs reviewed (CR 6, 7, 11, & 13.) Findings included: “…Plan of Care (POC)/Care Planning Process…PROCEDURE: …6. The individualized plan of [care] must include the following: …d. all types of services, supplies, and equipment required…” Review of CR 6 on January 27, 2023, at 2:05pm revealed: Start of Service (SOS) 7/13/2022, dates reviewed 1/9/23-1/27/23. Medication list and plan of care included diagnosis and interventions for Diabetes Mellitus and wound care. POC failed to include diabetic supplies and wound care supplies. Review of CR 7 on January 27, 2023, at 2:15pm revealed: Start of Service (SOS) 12/8/2022, dates reviewed 12/8/22-1/27/23. Start of care narrative note revealed patient discharged from hospital with cervical collar to be worn at all times. POC failed to include cervical collar in supplies. Home visit observation (HV 1) conducted on 1/25/23 at 9:00am revealed patient report of nightly use and surveyor observation of C-pap machine at bedside. Review of CR 11 on January 30, 2023, at 12:15pm revealed: Start of Service (SOS) 1/19/23, dates reviewed 1/19/23-1/30/23. POC failed to include C-pap in supplies. Home visit observation (HV 5) conducted on 1/26/23 at 10:00am revealed patient report of nightly use of Bi-pap machine. Review of CR 13 on January 30, 2023, at 12:45pm revealed: Start of Service (SOS) 1/20/2023, dates reviewed 1/20/23-1/30/23. POC failed to include for Bi pap in supplies. Exit interview on January 31, 202 at 12:00pm with Area Vice President, and Directors of Operations for parent and branch locations confirmed findings.

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 review of agency policy and procedure, clinical records (CR), Home visit Observation (OBS), and staff (EMP) interview, the agency failed to include orders/interventions in plan of care for four (4) of seventeen (17) records reviewed (CR 7, 11, 13, & 17.) Findings included: Review of agency policy on January 31, 2023, at 10:30am revealed “…Plan of Care (POC)/Care Planning Process…PROCEDURE: …6. The individualized plan of [care] must include the following: …o. Patient-specific interventions and education…” Review of CR 7 on January 27, 2023, at 2:15pm revealed: Start of Service (SOS) 12/8/2022, dates reviewed 12/8/22-1/27/23. Start of care narrative note revealed patient discharged from hospital with cervical collar to be worn at all times. POC failed to include order for cervical collar. Home visit observation (HV 1) conducted on 1/25/23 at 9:00am revealed patient report of nightly use and surveyor observation of C-pap machine at bedside. Review of CR 11 on January 30, 2023, at 12:15pm revealed: Start of Service (SOS) 1/19/23, dates reviewed 1/19/23-1/30/23. POC failed to include orders for C-pap. Home visit observation (HV 5) conducted on 1/26/23 at 10:00am revealed patient report of nightly use of Bi-pap machine. Review of CR 13 on January 30, 2023, at 12:45pm revealed: Start of Service (SOS) 1/20/2023, dates reviewed 1/20/23-1/30/23. POC failed to include orders for Bi pap. Review of CR 17 on January 30, 2023, at 1:40am revealed: Start of Service (SOS) 12/11/2022, dates reviewed 12/11/22-1/30/23. POC included Bi-pap in equipment/supplies. POC failed to include orders for Bi pap. Exit interview on January 31, 202 at 12:00pm with Area Vice President, and Directors of Operations for parent and branch locations confirmed findings.

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 review of agency policy and procedure, clinical records (CR), Home visit Observation (OBS), and staff (EMP) interview, the agency failed to promptly notify the physician 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 three (3) of three (3) Home Visit conducted in which findings outside of physician ordered parameters were identified (CR 11-13) and failed to contact physician regarding requested Speech therapy evaluation for one (1) of one (1) start of care in which the patient/caregiver requested a discipline evaluation not ordered upon referral or identified by clinician (CR13.) Findings included: Review of agency policy on January 31, 2023, at 10:30am revealed: “…Coordination of Care…REGULATORY GUIDANCE: … (1) …The HHA must promptly alert the relevant physician(s) to any changes in the patient’s condition or need that suggest that outcomes are not being achieved and/or that the plan of care should be altered…” Review of CR 1 on January 27, 2023, at 11:00am revealed: Start of Service (SOS) 6/10/2022, dates reviewed 6/10/22-8/13/22. Coordination note upon start of care conducted by physical therapist revealed patient/family member request for speech therapy services. Therapist stated in note that doctor would be contacted to request Speech therapy evaluation. No evidence of communication with doctor for addition of discipline. Home visit observation (HV 1) conducted on 1/25/23 at 9:00am revealed patient report to nurse of failure to move bowels for 3 days. Nurse stated to patient, “better think about taking a laxative.” Review of CR 11 on January 30, 2023, at 12:15pm revealed: SOS 1/19/23, dates reviewed 1/19/23-1/30/23. Patient medication list failed to include a laxative. Documentation review of visit confirmed no documented communication to physician regarding patient report of failure to move bowels or ordered obtained for laxative. Home visit observation (HV 3) conducted on 1/25/23 at 12:00pm revealed patient report to speech therapist failure to move bowels for 3 days. Review of CR 11 on January 30, 2023, at 12:30pm revealed: SOS 12/31/22, dates reviewed 12/31/22-1/30/23. Documentation review of visit confirmed no documented communication to physician regarding patient report of failure to move bowels. Home visit observation (HV 5) conducted on 1/26/23 at 10:00am revealed patient documentation and report to registered nurse of weight gain of 5.4 pounds from 1/20/23-1/2/23. Review of CR 13 on January 30, 2023, at 12:45pm revealed: SOS 1/20/23, dates reviewed 1/20/23-1/30/23. Plan of care documented intervention to “report increased edema or weight gain of >2 lbs in 1 day or >5 lbs in 1 week…” No evidence documented that weight gain reported to doctor. Exit interview on January 31, 202 at 12:00pm with Area Vice President, and Directors of Operations for parent and branch locations confirmed findings.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure the patient medication schedule/instructions included indications for PRN medications ordered by physician for three (3) of seventeen (17) CRs reviewed. (CR 4, 5, & 13) Findings included: Review of agency policy on January 31, 2023, at 10:30am revealed: “…Physician Orders and Medical Supervision of the Plan of Care…Medications…: *NOTE: All medication orders must include the following: … In addition: PRN orders must include: … Specific observations or indications for use…” Review of CR 5 on January 27, 2023, at 1:00pm revealed: Start of Service (SOS) 8/30/2022, dates reviewed 8/30/23-9/24/22. Medication list and plan of care included “Dulera 200mcg-5mcg/Actuation HFA Aerosol Inhaler 2 puffs inhalation PRN reason: COPD instructions 1 puff” and “Fluticasone Propionate 50mcg/activation nasal spray suspension 2 spray daily/PRN reason: COPD instruction: 1puff.” Medication schedule failed to include indications for PRN use of medication. Review of CR 6 on January 27, 2023, at 2:05pm revealed: Start of Service (SOS) 7/13/2022, dates reviewed 1/9/23-1/27/23. Medication list and plan of care included “Magnesium 250mg tablet PO (by mouth) daily/PRN (as needed) instructions: PRN supplement. Medication schedule failed to include indications for PRN use of medication. Review of CR 13 on January 30, 2023, at 12:45pm revealed: Start of Service (SOS) 1/20/2023, dates reviewed 1/20/23-1/30/23. Medication list and plan of care included “Loratadine 10mg tablet oral daily/PRN 1 tablet reason: allergies.” Medication schedule failed to include indications for PRN use of medication. Exit interview on January 31, 202 at 12:00pm with Area Vice President, and Directors of Operations for parent and branch locations confirmed findings. Repeat deficiency, previously cited: 9/9/22, 11/18/22

Based on the findings of an unannounced onsite complaint investigation survey completed on September 12, 2022, Amedisys Home Health of PA, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical records (CR), personnel files (PF), agency complaint investigation documentation, and staff (EMP) interview, the agency failed to ensure documentation of corrective action was maintained for one (1) of six (6) employees referenced in complaints reviewed. (PF 3) Findings included: Review of agency policy on September 12, 2022, at approximately 10:00am revealed: "...Patient/Caregiver Grievance/Complaint...PROCEDURE...4) The Director of Operations/designee must document all components of the investigation including actions taken to prevent further potential violations... Review of PF 3, date of hire 5/14/2018, on September 12, 2022, at approximately 11:00am failed to include evidence of follow-up coaching related to complaint received by agency on 7/12/2022. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure the physician orders were followed for one (1) of four (4) CRs reviewed. (CR 4) Findings included: Review of CR 4, start of services 7/17/2022, on September 12, 2022, at approximately 2:10pm revealed physician order dated 7/22/2022 for nurse to obtain lab work 7/23/2022. No documentation of visit conducted 7/23/2022. Complaint documentation revealed caregiver called agency on 7/26/2022 to file a complaint due to no visit conducted 7/23/2022 or labs obtained. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.

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 review of Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure treatments were administered only as ordered by a physician for one (1) of four (4) CRs reviewed. (CR 1) Findings included: Review of CR 1, start of services 7/2/2022, on September 12, 2022, at approximately 12:30pm revealed visit narrative note written by Registered Nurse (RN) dated July 8, 2022. Note included documentation that "...[caregiver] has Zinc ointment. RN educated [caregiver] to apply 3-4 times/day..." CR failed to include evidence of doctor order for treatment documented. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on review of Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure communication with physician for one (1) of four (4) CRs reviewed. (CR 1) Findings included: Review of CR 1, start of services 7/2/2022, on September 12, 2022, at approximately 12:30pm revealed Plan of Care (POC) included order for nurse to obtain a urine specimen and bloodwork via venipuncture the week of 7/4/2022. Visit note dated 7/6/2022 documented inability to obtain the urine specimen and the bloodwork. Visit note dated 7/8/2022 documented patient refusal for nurse to attempt venipuncture per order. CR contained order dated 7/8/2022 to obtain bloodwork via venipuncture the week of 7/10/2022. Visit note date 7/12/2022 documnted failed attempt to obtain labwork per order. No documentation evidence in CR that the ordering physician was notified of the inaibility to obtain ordered labwork. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure the patient medication schedule/instructions, included medication name, dosage and frequency of all medications ordered by physician for one (1) of four (4) CRs reviewed. (CR 1) Findings included: Review of CR 1, start of services 7/2/2022, on September 12, 2022, at approximately 12:30pm revealed physician verbal order dated 7/8/2022 for new wound care to bilteral buttock/coccyx area. order read "cleanse with mild soap and water or wound cleanser, apply Mupirocin Ointment..." Medication list failed to include Mupirocin Ointment. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of Clinical Records (CR) and staff (EMP) interview, the agency failed to ensure the clinician prepared a clinical note for visit/interventions conducted for one (1) of four (4) CRs reviewed. (CR 4) Findings included: Review of CR 4, start of services 7/17/2022, on September 12, 2022, at approximately 2:10pm revealed lab work obtained at visit on 7/25/2022. On call records reveal the lab called on 7/25/2022 informing on call clinician that labs were not labeled with correct patient information. documentation of call to doctors’ office revealed refusal to accept as patient's bloodwork. doctor's office requested re-draw of bloodwork. On call documentation revealed results for re-draw of patient's bloodwork. No documentation in CR of visit or procedure to obtain bloodwork. Exit interview conducted September 12, 2022, at approximately 3:00pm with Shared Services Area Vice President-Clinical and Directors of Operations from 3 of 5 locations. Findings reviewed.