Every finding on record at Angel's Care Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/19/26. Standard level deficiencies cited.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, the Agency failed to ensure the communication plan included a current staff list and their contact information. Findings include: 1. The Agency’s Emergency Preparedness plan was reviewed on 02/19/26 and included a staff list which lacked the names of the current employees (E #1, E#2, E #3, E #5, E #6, E #7, E# 8, E#9 , E#10 and E #11) and contained the names of multiple staff that had left/separated from the Agency. 2. During a staff interview with the Administrator, Director of Nursing, Account Manager and Office Manager on 02/19/26 from 10:00 AM to 11:30 AM, the Administrator confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/19/26. The Plan included tabletop exercises for the year 2023, 2024 and 2025. The Plan lacked documentation that the Agency activated its Emergency Preparedness plan for an actual emergency or conducted/participated in full-scale or facility based exercises, as required. 2. During a staff interview with the Administrator, Director of Nursing, Account Manager and Office Manager on 02/19/26 from 10:00 AM to 11:30 AM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 02/19/26. Standard level deficiencies cited. Abbreviations: Pt./Pts. = patient/patients # = number % = percent AM = morning PM = afternoon SN = Skilled Nurse RN = Registered Nurse SOC = Start of Care POC = Plan of Care PsOC = Plans of Care cc = cubic centimeter ml = milliliter OASIS = Outcome and Assessment Information Set mg /dl = Milligrams per Deciliter PRN = as needed > = more than G - tube = Gastrostomy tube

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, for 92 of 379 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed, resulting in a warning. Findings include: 1. The Error Summary report for 01/01/25 to 01/27/26, was reviewed on 02/17/26 at 12:30 PM. The report documented 92 of 379 late submissions, 24.27% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Director of Nursing on 02/18/26 at 11:30 AM, it was confirmed that the error occurred.

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 observations and interviews during a home visit, clinical records reviews and staff interviews, for 3 of 7 (Pts. #2, 6 and 7) clinical records, the Agency failed to ensure that the orders in the POC were followed. Findings include: 1. Pt. #2 was admitted for home health services on 07/21/24 with the diagnoses of but not limited to Hypertensive Heart Disease and Gastrostomy status. During a home visit conducted with the Home Health Aide on 02/17/26 at 3:30 PM, it was observed that there was a box containing 8 oz. “TwoCal HN” nutrition packs. The caregiver at the time of the visit was interviewed and stated that 1 pack is administered twice a day. The clinical record was reviewed on 02/18/26. The record included a physician order dated 02/09/26, “Addendum to 485…Nutritional Supplement: May give Jevity 1.2 bolus feeding 300 ml once a day per g-tube with 30 cc of water flush before and after tube feeding administration...” The physician order in the POC was not followed. 2. Pt. #6 was admitted to home health services on 05/27/25 with diagnosis of but not limited to Type 2 Diabetes Mellitus and Presence of Urogenital Implants. The clinical record was reviewed on 02/18/26. The clinical record included the initial POC effective 05/27/25, that required: “….SN to perform fingerstick for fasting blood sugar / random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…. Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The clinical record included the following Nursing Progress notes dated 07/08/25, 07/19/25 and 08/02/25, that lacked blood sugar assessments as ordered. 3. Pt. #7 was admitted to home health services on 08/22/25 with diagnosis of but not limited to Essential (Primary) Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/18/26 and 02/19/26. The clinical record included a POC effective 08/22/25. that required: “….SN to perform fingerstick for fasting blood sugar / random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…. Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The clinical record included the following Nursing Progress notes dated 09/27/25, 10/04/25, 10/11/25 and 10/18/25, that lacked blood sugar assessments as ordered. 4. During staff interviews with the Administrator, Director of Nursing, Account Manager and Office Manager on 02/18/26 from 2:30 PM to 3:30 PM and on 02/19/26 from 10:00 AM to 11:30 AM, the Director of Nursing confirmed the above findings.

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 observation and interviews during home visits, clinical record review and staff interviews, for 6 of 7 Pts (Pts. #2, 5, 3, 4, 6 and 7), the Agency failed to ensure that the PsOC included all the requirements. Findings include: 1. Pt. #2 was admitted for home health services on 07/21/24 with the diagnoses of but not limited to Hypertensive Heart Disease and Gastrostomy status. During a home visit conducted with the Home Health Aide on 02/17/26, it was observed that Pt. #2 had a gastrostomy tube (G-tube) and the G-tube insertion site was covered with a gauze and secured by tape. During the same home visit, the patient’s caregiver was interviewed, it was stated that the caregiver was not aware on how and how often the dressing was changed. The clinical record was reviewed on 02/18/26 and included a POC effective 01/12/26. The POC lacked documentation of the procedure and frequency of G-tube dressing changes and equipment and supplies used for the care of the G-tube. 2. Pt. #5 was admitted for home health services on 01/20/26 with the diagnoses of but not limited to Essential Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/18/26 and included a POC effective 01/20/26. The POC lacked documentation of documentation of blood glucose monitoring parameters. 3.Pt. #3 was admitted for home health services on 01/14/26 with the diagnoses of but not limited to Essential (Primary) Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/18/26 and included a POC effective 01/14/26, that required: “….SN to perform fingerstick for fasting blood sugar / random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia… Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The POC lacked documentation of Pt. specific parameters for random blood sugar. 4. Pt. # 4 was admitted to home health services on 10/24/25 with diagnosis of but not limited to Chronic Atrial Fibrillation and Cystostomy Status. The clinical record was reviewed on 02/18/16. The clinical record included a recertification POC effective 12/23/25, with orders for : “SN frequency:….1 wk 9 and 2 PRN visits for suprapubic catheter troubleshooting….SN to continue to assess / instruct pt/cg on infection prevention related to Cystostomy….” , but lacked catheter size, inflation, and specific interventions related to suprapubic catheter care. 5. Pt. #6 was admitted to home health services on 05/27/25 with diagnosis of but not limited to Type 2 Diabetes Mellitus and Presence of Urogenital Implants. The clinical record was reviewed on 02/18/26. The clinical record included the initial POC effective 05/27/25, that required: “….SN to perform fingerstick for fasting blood sugar / random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…. Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The clinical record included a recertification POC effective 07/26/25, that required: “….Skilled Nurse for skilled assessment/observation of vital signs as well as status of …..Endocrine….SN to educate on recognizing, treating and preventing acute complications such as hypoglycemia and hyperglycemia…. Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The PsOC lacked documentation of Pt. specific parameters for random blood sugar. The same clinical record also included in the POC effective 05/27/25 and POC effective 07/26/25, that required: “….Skilled Nurse for skilled assessment/observation of vital signs as well as status of ….Genitourinary system….” , but lacked type of catheter, size, inflation, and specific interventions related to catheter care. 6. Pt. #7 was admitted to home health services on 08/22/25 with diagnosis of but not limited to Essential (Primary) Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/18/26 and 02/19/26. The clinical record included a POC effective 08/22/25. that required: “….SN to perform fingerstick for fasting blood sugar / random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia…. Parameters Fasting Blood Sugar (FBS) 200.00 mg/dl.....” The POC lacked documentation of Pt. specific parameters for random blood sugar. 7. During staff interviews with the Administrator, Director of Nursing, Account Manager and Office Manager on 02/18/26 from 2:30 PM to 3:30 PM and on 02/19/26 from 10:00 AM to 11:30 AM, the Director of Nursing confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical records reviewed and staff interview, for 2 of 2 (Pts. # 6 and 7), the Agency failed to ensure a discharge summary included all the required elements and was sent to the Physician within the required timeframe. Findings include: 1. Pt. #6 was admitted to home health services on 05/27/25 with diagnosis of but not limited to Type 2 Diabetes Mellitus and Presence of Urogenital Implants. The clinical record was reviewed on 02/18/26. The clinical record included a discharge summary dated 08/29/25, that lacked medications Pt. was on at discharge, as required. The discharge summary/episode summary report was sent to the Physician on 09/11/25 (more than the required 5-day timeframe). 2. Pt. #7 was admitted to home health services on 08/22/25 with diagnosis of but not limited to Essential (Primary) Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/18/26 and 02/19/26. The clinical record included a discharge summary dated 10/20/25, that lacked medications Pt. was on at discharge, as required. The discharge summary/episode summary report was sent to the Physician on 11/20/25 (more than the required 5-day timeframe). 3. During a staff interview with the Administrator, Director of Nursing, Account Manager and Office Manager on 02/19/26 from 10:00 AM to 11:30 AM, the Administrative staff confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Emergency Plan and staff interview, it was determined the Agency failed to develop and maintain an emergency communication Plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Plan was reviewed on 12/13/22 at 1:40 PM. The plan’s communication plan lacked names and contact information for all entities providing service under arrangement, Pt. Physicians, and volunteers. 2. During an interview with the Administrator and Agency Supervisor on 12/14/22 at 12:00 PM, it was confirmed the Agency did not have a complete communication plan, which included the required names and contact information.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: wk = week # = number AM = morning R = right % = percent SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care MD = Medical Doctor RN = Registered Nurse SN = Skilled Nurse E = Employee PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist HHA = Home Health Aide

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline. This was found in 4 of 7 (Pts. #1, 2, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 12/12/22 1:10 PM to 12/13/22 at 3:00 PM: Pt. #1. SOC: 09/08/22. Pt. received SN, PT and OT services. Pt. #2. SOC: 09/12/22. Pt. received SN and HHA services. Pt. #6. SOC: 09/08/22. Pt. received SN services. Pt. #7. SOC: 01/13/22. Pt. received SN and PT services. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Administrator and Agency Supervisor on 12/14/22 at 11:00 AM, it was confirmed the Agency failed to ensure Pts. were informed, and/or participated determining the frequency of visits provided by each discipline.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. were made aware of and consented to their financial responsibility for the cost of Agency services, if any, at the SOC. This was found in 2 of 7 (Pt. #3 and 5) Pts. reviewed for consent to financial responsibility. Findings include: 1. Pt. #3. SOC 1/24/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/13/22 at 1:00 PM. The record lacked documentation the Pt. was informed of the cost of their financial responsibility for services, if any, at the SOC. 2. . #5. SOC 11/17/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/13/22 at 9:40 AM. The record lacked documentation the Pt. was informed of the cost of their financial responsibility for services, if any, at the SOC. 3. During an interview with the Administrator and Agency Supervisor on 12/14/22 at 12:00 PM, it was confirmed there was no documentation the above Pts. were made aware of their costs, if any, for Agency services at the SOC.

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: A. Based on clinical record review, observations and Caregiver interview during a home visit, Agency policy review, and staff interview, it was determined the Agency failed to ensure it provided services as ordered by the Physician in the POC. This was found in 2 of 7 (Pt. #1 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/8/22. Diagnoses include: Essential (Primary) Hypertension, and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/12/22 at 1:10 PM. The record contained the POC effective 9/8/22 to 1/6/22 and the POC effective 11/7/22. Both of these PsOC included the Physician’s order: “…SN to perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done...” The record lacked documentation the Patient’s blood sugar level was assessed on 10/28/22, 11/9/22, 11/17/22, 11/26/22, 12/2/22, and 12/10/22. 2. Pt. #2. SOC 9/12/22. Primary Diagnosis: Hypertensive Heart Disease. The clinical record was reviewed on 12/12/22 at 2:15 PM. The record included the initial comprehensive assessment, completed by the RN on 9/12/22. This assessment contained documentation the Pt. had a “R toe” wound. This assessment lacked the wound type, measurements, appearance, color, drainage, odor, presence of undermining, or condition of the surrounding skin. The record also contained the POC effective 9/12/22 to 11/10/22 and the POC effective 11/11/22. Both of these PsOC contain the Physician’s orders: “SN Frequency: 1wk9,” and “SN to assess wound every visit and document wound measurements weekly. SN to instruct and demonstrate wound care per MD order: Cleanse wound with normal saline. Betadine to affected right foot wound daily, cover with dry gauze and secure in place with Kerlix wrap daily. SN to report to MD any signs of delayed wound healing or wound infection for proper treatment and management.” The record lacked any assessments/measurements of the Patient’s right foot wound upon the SN’s weekly visits for the weeks beginning 10/16/22 through 12/3/22, as well as documentation the SN provided Pt./Caregiver with instruction/teaching regarding wound care. 3. A home visit was conducted on 12/13/22 at 1:15 PM, along with E #1. During this home visit, The Patient’s Caregiver stated she performs the Patient’s wound care, and that the SN only helped change the Patient’s dressing one time recently, when the Caregiver requested assistance; otherwise, the SN doesn’t unwrap the Patient’s foot to assess it, cleanse it, or re-dress it. The Caregiver then attempted to remove the Patient’s right foot dressing, which was stuck to the Patient’s foot. The Caregiver then poured a copious amount of betadine from a bottle on top of the Patient’s right foot dressing, to attempt to loosen it. The Caregiver stated this is what she always does. When asked if the Caregiver had any normal saline to apply to the dressing in order to loosen it or to wash the Patient’s foot, she stated “no, but that would be a good idea.” Once unwrapped, the Patient’s right great toe appeared approximately to be covered approximately 40 – 50% with black, necrotic tissue, although difficult to visualize, as the entire top of the Patient’s foot was covered in a thick, sticky substance that the Caregiver identified as old betadine from previous dressing changes. The Patient’s 2nd and 3rd right toes appeared to be stuck together, and lacked toenails. The Patient’s Caregiver stated the Patient’s foot dressing is always covered with a plastic bag during showers, and the Pt. never gets his foot wet/receives a washing or soaking, just the addition of more betadine and a new dressing. The Patient’s Caregiver also stated the Pt. has had the right wound “since 2016, and it never got any better.” 4. The Agency policy titled “Wound Care Policy” was reviewed on12/14/22 at 1:15 PM. The policy required: “…The admitting clinician will document each wound status, including location and etiology, measurement of length, width, width, and depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing, and peri wound skin condition…The clinician will provide wound care and self-management education to the Patient/Caregiver at each visit…The Nurse will provide wound care per Physician orders…At each visit, the Patient’s skin will be assessed. At each dressing change, the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing, and peri wound skin condition…At least every week, the wound assessment and documentation will include measurement of length, width, depth, and undermining and tunneling, if present…” 5. During an interview with the Administrator and Agency Supervisor on 12/14/22 at 12:00 PM, the above findings were confirmed. The Agency Supervisor stated that if a Patient is a known diabetic, SN visits notes should include documentation of the Patient’s current blood sugar levels. The Agency Supervisor also stated all wounds should be assessed on each SN visit, and measured for length, width, depth, drainage, and condition of the wound and surrounding skin at least weekly, and this assessment should then be documented in the Patient’s clinical record.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 6 of 7 (Pts. #3, 4, 7, 1, 2 and 5) clinical record reviewed. 4. Pt. #1. SOC 9/8/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/12/22 at 1:10 PM. The record contained a document titled “Authorization and Agreements for Home Health Services,” which was signed by the Pt. on 9/8/22. The section of this document titled “Advance Directives” was left blank. 5. Pt. 2. SOC 9/12/22. Primary Diagnosis: Hypertensive Heart Disease. The clinical record was reviewed on 12/12/22 at 2:15 PM. The record contained a document titled “Authorization and Agreements for Home Health Services,” which was signed by the Pt. on 9/12/22. The section of this document titled “Advance Directives” was left blank. 6. Pt. #5. SOC 9/23/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/13/22 at 9:40 AM. The record contained a document titled “Authorization and Agreements for Home Health Services,” which was signed by the Pt. on 9/12/22. The section of this document titled “Advance Directives” was left blank. The record also included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the sections of the form including the items/services Medicare doesn’t pay for, the reason Medicare doesn’t pay for the items/services, the estimated cost of these items/services, which items/services the Pt. still wants, and the date were all left blank. 7. The Agency policy titled "Health Record Documentation Policy" was reviewed on 12/14/22 at 1:35 PM. The policy required: "...The medical record should be complete and legible..." 8. During an interview with the Administrator and Agency Supervisor on 12/14/22 at 12:00 PM, the above findings were confirmed. The Agency Supervisor stated all documents should be completely filled out. Findings include: 1. Pt. #3. SOC 1/24/22. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/13/22 at 1:00 PM. The record contained a form, "Authorization/agreement For Services.” The form was signed and dated by Pt. at the SOC, but the section titled “Advance Directives” was left blank. 2. Pt. #4. SOC 4/15/22. Principal Diagnosis: Atherosclerotic Heart Disease. The clinical record was reviewed on 12/13/22 at 3:00 PM. The record contained a form, "Authorization and Agreement for Home Health Services.” The form was signed and dated by the Pt. at the SOC, but the section titled “Advance Directives” was left blank. 3. Pt. #7. SOC 1/13/22. Principal Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/13/22 at 2:00 PM. The record contained a form, "Authorization and Agreement for Home Health Services.” The form was signed and dated by the Pt. at the SOC, but the section titled “Advance Directives” was left blank.