Every finding on record at Epic Health Services, Inc

A Recertification survey was conducted at Aveanna Healthcare, located at 67 Millbrook Street, Suite 405, Worcester, MA., 01606, on February 11, 2026, February 12, 2026 and February 13, 2026, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Aveanna Healthcare, located at 67 Millbrook Street, Suite 405, Worcester, MA., 01606, on February 11, 2026, February 12, 2026 and February 13, 2026, for compliance with CFR Part 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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 record review, policy review and interview, the agency failed to ensure the patient participated in, was informed about, and consented or refused care in advance of and during treatment, where appropriate, including the care to be furnished, based on the comprehensive assessment, for 2 patients (#2 and #18), out of a total sample of 18 patients. Findings include: 2. Patient #18 was admitted to the agency in September 2023 with a diagnosis of depression. Review of the clinical record indicated the initial start of care was completed by the nurse on 9/5/23. Further review of the clinical record contained a consent signed by Patient #18 on 9/15/23, ten days after admission to the agency. During an interview on 2/13/26 at 12:30 P.M., the Administrator said the consent was signed late and not upon admission, as required. Review of the agency's policy entitled, Patient Service Agreement, date reviewed 12/31/25, indicated the following: *During the admission visit and/or prior to the delivery of care, the Patient Service Agreement is reviewed, explained and signed by each patient (or responsible person) receiving services. *This agreement includes authorization/consent for treatment, assignment of benefits, release of information, financial responsibility, billing procedures, advanced directives, grievance reporting, acknowledgement of receipt of rights and responsibilities, etc. The Patient Service Agreement becomes part of the clinical record. 1. Patient #2 was admitted to the agency in August 2025 with a diagnosis of hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal cord damage) with hemiparesis (weakness on one side of the body, often caused by stroke, brain injury, tumors, or conditions like cerebral palsy [lifelong disorder affecting movement, muscle tone, and posture due to abnormal brain development or damage before, during, or shortly after birth]). Review of the clinical record indicated the initial start of care visit was completed by the nurse on 8/30/25. Further review of the clinical record did not include evidence of signed consents. During an interview on 2/13/26 at 12:45 P.M., the Administrator said the consents provided during the first visit were not signed by Patient #2, as required.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure the initial assessment visit was held either within 48 hours of the referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner ordered start of care date, for 2 patients (#4 and #18), out of a total sample of 18 patients. Findings include: 2. Patient #18 was admitted to the agency in September 2023 with s diagnosis of depression. Review of the clinical record indicated the patient was referred to the agency on 9/1/23. Further review of the clinical record indicated the patient was discharged from a nursing facility on 9/2/23 and the admission visit was completed by the nurse on 9/5/23, and not within 48 hours of the referral. During an interview on 2/13/26 at 12:30 P.M., the Administrator said the start of care was not within the 48 hours of the agency receiving the referral, as required. Review of the agency's policy entitled, Comprehensive Assessment, 7/24/25, indicated the following: *Standard Initial Assessment Visit-The initial assessment must be held within 48 hours of referral or within 48 hours of the patient's return home, or on the physician ordered start of care. 1. Patient #4 was admitted to the agency in November 2025 with a diagnosis of paroxysmal atrial fibrillation (AFib-a form of heart arrhythmia where the upper chambers beat irregularly, starting and stopping abruptly on their own within 7 days). Review of the clinical record indicated the patient was referred to the home care agency on 11/7/25. Further review of the clinical record indicated the admission visit was completed by a nurse on 11/10/25, not within 48 hours of the referral, as required. During an interview on 2/13/26 at 3:10 P.M., the Clinical Manager said the agency received the referral and discharge documents on 11/7/25, however the information was not uploaded in the electronic medical record until 11/10/25. She said the initial visit was not completed within 48 hours of the referral, as required.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to ensure the tablet computer (a portable, touchscreen device) used to document patient visits was sanitized after use, medical equipment was cleansed after use, and infection control guidelines were maintained during home visit observations for 2 patients (#11 and #16), out of a total sample of 5 patient home visits. Findings include: Review of the 2007 Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated September 2024, included the following: *Environmental Measures: Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions (Primary, evidence-based infection control practices applied to all patients at all times that include hand hygiene, environmental cleaning, ...). The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated. Review of the agency policy entitled, Infection Control Plan/Program, revised 2/4/2025, included the following: *All professional and paraprofessional staff will comply with the CDC recommendations regarding Standard Precautions. 1. Patient #11 was admitted to the agency in December 2025 with a diagnosis of 2 part non-displaced fracture of the neck of the left humerus (long bone of the upper arm). During a home visit on 2/11/26 at 3:45 P.M., the surveyor observed Nurse #1 use a thermometer, blood pressure cuff, stethoscope, and a pulse oximeter (a non-invasive device placed on a finger that measures the percentage of oxygen in the blood and pulse rate) to monitor the patient's temperature, blood pressure, oxygen level and pulse. She then cleansed the thermometer and pulse oximeter with cleansing wipes and put them in her bag. She placed the blood pressure cuff and stethoscope into her bag without cleansing them. Upon completion of the visit, Nurse #1 handed the patient the tablet and the patient signed the tablet with his/her finger. Nurse #1 did not cleanse the tablet and exited the home. During an interview on 2/12/26 at 4:15 P.M., Nurse #1 said she should have cleansed the blood pressure cuff, oxygen oximeter and tablet after use in the patient's home, as required, but she did not. 2. Patient #16 was admitted to the agency in January 20025 with a diagnosis of Parkinson's Disease (a progressive movement disorder of the nervous system). During a home visit on 2/12/26 at 2:20 P.M., the surveyor observed the Occupational Therapist (OT) complete her visit and handed the patient the tablet and a stylus to sign to sign the tablet. Patient #16 signed the tablet with the stylus and handed the tablet and stylus back to the OT. The OT did not cleanse the tablet nor the stylus and exited the home. During an interview on 2/13/26 at 3:00 P.M., the OT said she did not cleanse the tablet or the stylus after the patient signed it, as required. During an interview on 2/13/26 at 4:00 P.M, the Administrator said Nurse #1 and the OT did not follow infection control guidelines by not cleansing the medical equipment, the tablets, and the stylus during the home visits for Patient #11 and Patient #16, as required.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care, for 7 patients (#5, #10, #11, #18, #7, #9 and #15), out of a total sample of 18 patients. Findings include: 5. Patient #7 was admitted to the agency in January 2026 with a diagnosis of Influenza A (viral respiratory infection). Review of the physician ordered Home Health Certification and POC, dated 1/3/26 through 3/3/36, indicated the following: -Effective 1/7/26, Physical Therapy (PT) visit: 2 times a week for 9 weeks. Review of the clinical record indicated that for the week of 2/1/26 through 2/7/26, only 1 PT visit was provided, not 2, as ordered. During an interview on 2/13/26 at 3:45 P.M., the Administrator said the POC was not followed for the week of 2/1/26 and there was no documentation to indicated why a PT visit was missed. 6. Patient #9 was admitted to the agency in December 2025 with a diagnosis of dilated cardiomyopathy (a serious heart muscle disease where the left ventricle enlarges (dilates), becomes thin, and cannot pump blood efficiently, often leading to heart failure). Review of the physician ordered Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -Effective 1/11/26, Home Health Aide (HHA) visit: 2 times a week for 7 weeks, and once a week for 7 weeks. Review of the clinical record indicated that for the weeks of 1/11/26 through 1/17/26, 1/18/26 through 1/24/26, 1/25/26 through 1/31/25, 2/1/26 through 2/7/26, and 2/8/26 through 2/15/26, only 2 HHA visits were provided weekly, not 3, as ordered. During an interview on 2/13/25 at 4:10 P.M., the Clinical Manager (CM) said that the order for HHA visits was for the patient to have 2 A.M. visits a week, and 1 P.M. visit a week. After reviewing the clinical record, the CM said the patient was only receiving 2 visits a week, not 3 as ordered, and the POC was not followed. 7. Patient #15 was admitted to the agency in December 2025 with a diagnosis of encounter for orthopedic aftercare following surgery. Review of the physician ordered Home Health Certification and POC, dated 12/11/1/25 through 2/8/26, indicated the following: -Effective 12/15/25, PT visits: 2 times a week for 9 weeks. Review of the clinical record indicated that for the week of 12/28/25 through 1/3/26, only 1 PT visit was provided, not 2, as ordered. During an interview on 2/13/26 at 4:45 P.M., the CM said the POC was not followed for the week of 12/28/25 and there was no documentation to indicate why 2 PT visits were not provided, as ordered. Review of the agency policy entitled, Physician/Allowed Practitioner Orders/Plan of Care, revised 2/13/2025, included the following: -Plan of Treatment/Plan of Care: *A complete, individualized Plan of Care/Treatment will be developed for all patients receiving ongoing clinical services according to applicable law and state regulations. The initial Plan of Care/Treatment is developed in conjunction with the physician/prescriber, patient/patient representative, and the Company's health care professional as part of the admission process. Plan of Care/Treatment is developed before services are furnished. *The Plan of Care/Treatment must include the following as applicable....... -A description of any treatments, procedures, and services and/or specific therapy to be performed. -Frequency, duration of each treatment, service, shifts and/or visits..... 1. Patient #5 was admitted to the agency in September 2025 with a diagnosis of unspecified fracture of the upper end of the left humerus (upper arm bone). Review of a physician signed Interim Order, dated 10/8/25, indicated the following: -Physical Therapy (PT) visits: 2 times a week for 9 weeks. Review of the clinical record indicated the following: *Week of 11/2/25-11/8/25, 1 PT visit was provided and not 2 PT visits, as ordered. 2. Patient #10 was admitted to the agency in January 2026 with a diagnosis of malignant neoplasm (growth) of the vagina. Review of the Home Health Certification and POC, dated 1/7/26 through 3/7/26, indicated the following: -Skilled Nurse (SN) visits: 1 time for 1 day, 1 time for 1 week and 3 times a week for 8 weeks. Review of the clinical record indicated the following: *Week of 1/11/26 -1/17/26, 2 SN visits were provided and not 3 SN visits, as ordered. *Week of 1/18/26 -1/24/26, 2 SN visits were attempted and refused by the patient. There was no documentation if a third SN visit was attempted or provided. 3. Patient #11 was admitted to the agency in December 2025 with a diagnosis of nondisplaced fracture (the bone is broken but remains in proper alignment) of the left humerus. Review of the Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -PT visits: 1 time a week for 1 week. Review of the clinical record indicated the following: *Week of 12/20/25-1/3/26, no PT visit was provided, as ordered. 4. Patient #18 was admitted to the agency in September 2023 with a diagnosis of depression. Review of the Home Health Certification and POC, dated 12/23/25 through 2/20/26, indicated the following: -PT visits: one time a week for one week, and 2 times a week for 8 weeks. Review of the clinical record indicated the following: *Week of 12/21/25-12/27/25, no PT visits were provided, as ordered. *Week of 12/28/25-1/3/26, 1 PT visit was provided, not 2 visits, as ordered. *Week of 1/11/26-1/17/26, 1 PT visit was provided, not 2 visits, as ordered. *Week of 1/18/26-1/24/26, 1 PT visit was provided, not 2 visits, as ordered. During an interview on 2/13/26 at 12:30 P.M., after reviewing the clinical records for Patients #5, #10, #11 and #18, the Administrator said the physician ordered visits were not provided, as required.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that staff communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care, for 11 patients (#3, #4, #6, #7, #9, #15, #17, #5, #10, #11, and #18), out of a total sample of 18 patients. Findings include: 8. Patient #5 was admitted to the agency in September 2025 with a diagnosis of unspecified fracture of upper end of left humerus (upper arm bone). Review of a physician signed Interim Order, dated 10/8/25, indicated the following: -PT visits: 2 times a week for 9 weeks. Review of the clinical record indicated for the week of 11/2/25-11/8/25, 1 PT visit was provided and not 2 PT visits, as ordered. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed PT visit for the week of 11/2/25. 9. Patient #10 was admitted to the agency in January 2026 with a diagnosis of malignant neoplasm (growth) of the vagina. Review of the Home Health Certification and POC, dated 1/7/26 through 3/7/26, indicated the following: -SN visits: 1 time for 1 day, 1 time for 1 week and 3 times a week for 8 weeks. Review of the clinical record indicated for the week of 1/11/26, 2 SN visits were provided and not 3 SN visits, as ordered. For the week of 1/18/26, 2 SN visits were attempted and refused by the patient. There was no documentation if a third SN visit was attempted or provided. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed SN visits for the weeks of 1/11/26 and 1/18/26. 10. Patient #11 was admitted to the agency in December 2025 with a diagnosis of nondisplaced fracture (the bone is broken but remains in proper alignment) of the left humerus. Review of the Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -PT visits: 1 time a week for 1 week. Review of the clinical record indicated for the week of 12/20/25, no PT visit was provided, as ordered. Further review of the clinical record did not contain any documentation the physician had been notified of the missed PT visit for the week of 12/20/25. 11. Patient #18 was admitted to the agency in September 2023 with a diagnosis of depression. Review of the Home Health Certification and POC, dated 12/23/25 through 2/20/26, indicated the following: -PT visits: one time a week for one week, and 2 times a week for 8 weeks. Review of the clinical record indicated for the week of 12/21/25, no PT visits were provided, for the weeks of 12/28/215, 1/11/26, and 1/18/26, only 1 PT visit was provided each week, not 2 visits, as ordered. Further review of the clinical record did not contain any documentation that the physician had been notified of any of the missed PT visits. Review of the agency's policy entitled, Missed Services, date reviewed 9/28/23, indicated the following: *When scheduled services, visits, or shifts are not provided for any reason, the medical doctor (MD) must be notified, and documentation of the notification must be in the patient's record to reflect the alteration in the plan of care. 1. Patient #3 was admitted was admitted to the agency in December 2025 with a diagnosis of essential hypertension (high blood pressure). Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 12/18/25 through 2/15/26, indicated the following: -Occupational Therapy (OT) visit: 1 time a day for 1 day, once a week for 1 week, and 2 times a week for 6 weeks. Review of the clinical record indicated the following OT Quick Notes written to indicate missed visits; however, the notes did not indicate the physician had been notified of the missed visits: -1/9/26 ,1/17/26, 1/9/26, 1/28/26, and 1/31/26. During an interview on 2/13/26 at 3:15 P.M., the Clinical Manager (CM) said that the Occupational Therapist had not notified the physician, as required, when visits were missed. 2. Patient #4 was admitted to the agency in November 2025 with a diagnosis of paroxysmal atrial fibrillation (AFib-is a type of heart arrhythmia that can cause a fast heart rate and other symptoms, like chest discomfort, heart palpitations, shortness of breath and dizziness). Review of the physician ordered Home Health Certification and POC, dated 11/8/25 through 1/8/26, indicated the following: -Effective 11/12/25, OT visit: 1 time a day for 1 day, once a week for 1 week, and 2 times a week for 2 weeks. -Effective 11/13/25, PT visit: once a week times 1 week, and 2 times a week times 7 weeks. Review of the clinical record indicated the following OT and PT Quick Notes written to indicate missed visits; however, the notes did not indicate the physician had been notified of the missed visits: -11/24/25 OT and 12/15/25 PT. During an interview on 2/13/26 at 3:00 P.M., the Administrator said the Occupational Therapist, nor the Physical Therapist had not notified the physician, as required, when services were not provided as ordered, and were missed. 3. Patient #6 was admitted to the agency in December 2025 with a diagnosis of alcoholic gastritis (inflammation of the stomach lining) with bleeding. Review of the physician ordered Home Health Certification and POC, dated 12/24/25 through 2/21/26, indicated the following: -Effective 12/28/25, PT visit: once a week for 1 week, 2 times a week for 7 weeks. Review of the clinical record indicated the following PT Quick Note written to indicate a missed visit; however, the notes did not indicate the physician had been notified timely of the missed visits: -1/29/26 PT, the physician was not notified until 2/11/26. During an interview on 2/13/26 at 12:15 P.M., the Administrator said the Physician Therapist did not notify the physician at the time of the missed visit, and that the POC was not implemented as ordered. 4. Patient #7 was admitted to the agency in January 2026 with a diagnosis of Influenza A (viral respiratory infection). Review of the physician ordered Home Health Certification and POC, dated 1/3/26 through 3/3/36, indicated the following: -Effective 1/7/26, Physical Therapy (PT) visit: 2 times a week for 9 weeks. Review of the clinical record indicated that for the week of 2/1/26 only 1 PT visit was provided, not 2 as ordered, and there was no documented missed visit. During an interview on 2/13/26 at 3:45 P.M., the Administrator said staff had not documented a missed visit for the week of 2/1/26, and had not notified the physician, as required, when the POC was not followed. 5. Patient #9 was admitted to the agency in December 2025 with a diagnosis of dilated cardiomyopathy (a serious heart muscle disease where the left ventricle enlarges (dilates), becomes thin, and cannot pump blood efficiently, often leading to heart failure. Review of the physician ordered Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -Skilled Nurse visit: once a day times 1 day, 2 times a week for 1 week, 3 times a week for 8 weeks, and 1 as needed (PRN) visit. -Effective 1/11/26, Home Health Aide (HHA) visit: 2 times a week for 7 weeks, and once a week for 7 weeks. Review of the clinical record indicated the following HHA and SN Quick Notes written to indicate missed visits; however the notes did not indicate the physician had been notified of the missed visits: -12/31/25 SN, 1/23/26 HHA, 1/28/26 HHA, 1/30/26 SN, 2/6/26 HHA, and 2/6/26 SN. Additionally, review of the clinical record indicated 3 HHA visits were not provided weekly, as ordered, and there was no documentation that the physician had been notified of services not provided, as ordered. During an interview on 2/13/25 at 4:10 P.M., the CM said that physician had not been notified of the missed HHA and SN visits, and not notified that HHA services were not being provided 3 times a week, as ordered. 6. Patient #15 was admitted to the agency in December 2025 with a diagnosis of encounter for orthopedic aftercare following surgery. Review of the physician ordered Home Health Certification and POC, dated 12/11/1/25 through 2/8/26, indicated the following: -Effective 12/15/25, PT visits: 2 times a week for 9 weeks. Review of the clinical record indicated that for the week of 12/28/25, only 1 PT visit was provided, not 2, as ordered. Additionally, there was no Quick Note indicating a missed visit. During an interview on 2/13/25 at 4:30 P.M., the CM said the staff did not document the reason for the missed visit, and had not notified the physician, as required. 7. Patient #17 was admitted to the agency in January 2026 with a diagnosis of major depressive disorder with psychotic features. Review of the physician ordered Home Health Certification and POC, dated 1/30/26 through 3/30/26, indicated the following: -SN visit: once a day times 1 day, and 3 times a week for 9 weeks. Review of the clinical record indicated that for the week of 2/1/26, only 2 SN visits were provided, not 3 as ordered, and there was not a Quick Note to indicate a missed visit, or physician notification. During an interview on 2/13/26 at 3:45 P.M., the Administrator said the SN had not written a Quick Note to indicate a missed visit for the week of 2/1/26, and the physician was not notified of services not provided, as ordered.

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: Based on record review, policy review, and interview the facility failed to ensure staff entries were legible, clear, complete, appropriately authenticated, dated, and timed relative to a.) staff visit notes for 13 patients (#2, #3, #4, #6, #7, #9, #14, #17, #1, #5, #11, #12 and #16, and b.) physician ordered Home Health Certifications and Plans of Care (POC) for 4 patients (#2, #1, #11, and #13), out of a total sample of 18 patients. Findings included: 9. Patient #1 was admitted to the agency in October 2025 with a diagnosis of Diabetes Mellitus (DM-a chronic metabolic disease marked by high blood sugar levels, occurring when the body either doesn't produce enough insulin or cannot effectively use the insulin it makes) with hyperglycemia (high blood sugar). a. Review of the Home Health Certification and POC, dated 10/10/25 through 12/8/25, indicated the following: -SN visits: 1 time times 1 day, 1 time a week for 1 week, and 6 times a week for 1 week. Review of the clinical record indicated the following: *10/13/25 SN visit, note was signed on 10/16/25. *10/16/25 SN visit, note was signed on 10/20/25. b. Review of the clinical record indicated the Home Health Certification and POC, dated 10//10/25 through 12/8/25, was signed by the physician on 11/13/25, and not within the required 30 day timeframe. 10. Patient #5 was admitted to the agency in September 2025 with a diagnosis of unspecified fracture of the upper end of the left humerus (upper arm bone). a. Review of the Home Health Certification and POC, dated 9/30/35 through 11/28/25, indicated the following: -SN visits: 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. Review of a Verbal Order, dated 10/1/25, indicated for PT visits: 2 times a week for 9 weeks. Review of the clinical record indicated the following: *10/1/25 SN visit, note was signed on 10/12/25. *10/1/25 PT visit, note was signed on 10/5/25. *10/3/25 SN visit, note was signed on 10/12/25. *10/6/25 SN visit, note was signed on 10/12/25. *10/8/25 SN visit, note was signed on 10/12/25. *10/10/25 SN visit, note was signed on 10/13/25. *10/13/25 SN visit, note was signed on 10/20/25. *10/17/25 SN visit, note was signed on 10/20/25. *10/24/25 SN visit, note was signed on 10/30/35. *10/29/25 SN visit, note was signed on 11/3/25. *11/7/25 PT visit, note was signed on 11/10/25. 11. Patient #11 was admitted to the agency in January 2026 with a diagnosis of malignant neoplasm (growth) of the vagina. a. Review of the Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -SN visits:1 time a day times 1, and 1 time a week for 9 weeks. -PT visits: 1 time a week times 1 week, and 1 time a day times 1. Review of the clinical record indicated the following: *12/30/25 SN visit, note was signed on 1/2/26. *1/5/26 PT visit, note was signed on 1/8/26. b. Review of the clinical record indicated the Home Health Certification and POC, dated 12/30/25 through 2/2726, was signed by the physician on 2/4/26, and not with the 30 day required timeframe. 12. Patient #12 was admitted to the agency in October 2025 with a diagnosis of chronic pain syndrome. a. Review of the Home Health Certification and POC, dated 12/24/25 through 2/21/26, indicated the following: -SN visits: 4 times a week for 1 week, and 7 days a week for 8 weeks. Review pf the clinical record indicated the following: *1/18/26 SN visit, note was signed on 1/21/26. *2/9/26 SN visit, note was signed on 2/12/26. 13. Patient #13 was admitted to the agency in October 2025 with a diagnosis of open wound to the low back and pelvis. b. Review of the clinical record indicated the Home Health Certification and POC, dated 10/24/25 through 12/22/25, was signed by the physician on 12/3025, and not within the 30 day required timeframe. 14. Patient #16 was admitted to the agency in January 20025 with a diagnosis of Parkinson's Disease (a progressive movement disorder of the nervous system). a. Review of the Home Health Certification and POC, dated 1/13/26 through 3/13/26, indicated the following: -Occupational Therapist (OT) visits: 1 time a day times 1 day, 1 time a week for 1 week, and 2 times a week for 8 weeks. Review of the clinical record indicated the following: *2/5/26 OT visit, note was signed on 2/12/26. *2/6/26 OT visit, note was signed on 2/12/26. *2/10/26 OT visit, note was signed on 2/13/26. During an interview on 2/13/26 at 2:00 P.M., after reviewing all the clinical records noted above, the Administrator said all the clinical notes were signed late and not within the required timeframe of 24 hours. She further said the Home Health Certification and POCs for Patients #2, #1, #11 and #13 were signed by the physician beyond the required 30 day timeframe. Review of the agency's policy entitled, Documentation Standards, date reviewed 2/20/25, indicated the following: *All documentation will be completed in a timely manner and with regard to the standards decribed to them. *All electronic documentation is captured and submitted at the point of care. Review of the agency's policy entitled, Physician/Allowed Practitioner Orders/POC, reviewd 2/13/25, indicated the following: *Signed/dated returned orders will be incoporated into the medical record within 30 days of the initiation of care or dated of interim order, unless otherwise specified and allowed by applicable state law and regulation. 1. Patient #2 was admitted to the agency in August 2025 with a diagnosis of hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal cord damage) with hemiparesis (weakness on one side of the body, often caused by stroke, brain injury, tumors, or conditions like cerebral palsy [lifelong disorder affecting movement, muscle tone, and posture due to abnormal brain development or damage before, during, or shortly after birth]). a.) Review of the physician ordered Home Health Certification and POC, dated 8/30/25 through 10/28/25, indicated the following: -Skilled Nurse (SN) visit: 1 time a day for 1 day (8/30/25), and 1 time a day for 58 days. -Occupational Therapy (OT) visit: 1 time a day for 1 day (9/4/25) and 2 times a week for 8 weeks. Review of the clinical record indicated the following: *8/31/25 SN visit, note was signed on 9/2/25. *9/4/25 OT visit, note was signed on 9/8/25. *9/8/25 SN visit, note was signed on 9/12/25. b.) The Home Health Certification and POC, dated 8/30/25 through 10/28/25, was not signed by the physician until 11/12/25. 2. Patient #3 was admitted was admitted to the agency in December 2025 with a diagnosis of essential hypertension (high blood pressure). a.) Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 12/18/25 through 2/15/26, indicated the following: -Physical Therapy (PT) visit: 1 time a day for 1 day, once a week times 1 week, and 2 times a week for 5 weeks. -Occupational Therapy (OT) visit: 1 time a day for 1 day, once a week for 1 week, and 2 times a week for 6 weeks. Review of the clinical record indicated the following: *12/18/25 PT visit, note was signed on 12/21/25. *1/5/26 OT visit, note was signed on 1/7/26. *1/7/26 OT visit, note was signed on 1/12/26. *1/13/26 OT visit, note signed on 1/19/26. *1/21/26 and 1/23/26 OT visits, notes signed on 2/6/26. 3. Patient #4 was admitted to the agency in November 2025 with a diagnosis of paroxysmal atrial fibrillation (AFib-is a type of heart arrhythmia that can cause a fast heart rate and other symptoms, like chest discomfort, heart palpitations, shortness of breath and dizziness). a.) Review of the physician ordered Home Health Certification and POC, dated 11/8/25 through 1/8/26, indicated the following: -Effectivce 11/10/25 SN visit: 1 time a day for 1 day, once a week for 1 week, and effective 11/23/25, 2 times a week for 7 weeks. -Effective 11/12/25 OT visit: 1 time a day for 1 day, once a week for 1 week, and 2 times a week for 2 weeks. -Effective 11/13/25, PT visit: once a week times 1 week, and 2 times a week times 7 weeks. Review of the clinical record indicated the following: *11/10/25 SN visit, note was signed on 11/12/25. *11/12/25 OT visit, note was signed on 1/14/25. *11/13/25 PT visit, note signed on 11/17/25. *11/14/25 OT visit, note signed on 11/16/25. *11/26/25 OT visit, note signed on 11/28/26. 4. Patient #6 was admitted to the agency in December 2025 with a diagnosis of alcoholic gastritis (inflammation of the stomach lining) with bleeding. a.) Review of the physician ordered Home Health Certification and POC, dated 12/24/25 through 2/21/26, indicated the following: -SN visit: 1 time a day for 1 day, 2 times a week for 1 week, and 5 times a week for 8 weeks. Review of the clinical record indicated the following: *12/25/25 and 12/26/25 SN visits, note signed on 12/28/25. *12/29/25 and 12/30/25 SN visits, notes signed on 1/4/26. *1/1/26 SN visit, note signed on 1/3/26. *1/2/26 SN visit, note signed on 1/4/26. *1/5/26, 1/6/26, and 1/7/26 SN visits, notes signed on 1/9/26. *1/8/26 and 19/26 SN visits, notes signed on 1/11/26. *1/12/26 SN visit, note signed on 1/16/26. *1/13/26, 1/14/26, 1/16/26 SN visits, notes signed on 1/18/26. *1/15/26 SN visit, note signed on 1/19/26. *1/19/26 SN visit, note signed on 1/21/26. *1/22/26, and 1/23/26 SN visits, notes signed on 1/25/26. *1/27/26, 1/28/27, 1/29/26 and 1/30/26 SN visits, notes signed on 2/1/26. *2/2/26 SN visit, note signed on 2/4/26. *2/5/26 and 2/6/26 SN visits, notes signed on 2/8/26. 5. Patient #7 was admitted to the agency in January 2026 with a diagnosis of Influenza A (viral respiratory infection). a.) Review of the physician ordered Home Health Certification and POC, dated 1/3/26 through 3/3/36, indicated the following: -SN visit: 1 time a day for 1 day, and 2 times a week for 9 weeks. -Effective 1/7/26, PT visit: 2 times a week for 9 weeks. -Effective 1/23/26 OT visit: 1 time a day for 1 day, and 2 times a week for 4 weeks. Review of the clinical record indicated the following: *1/6/26 SN visit, note signed on 1/9/26. *1/7/26 PT visit, note signed on 1/10/26. *1/8/26 SN visit, note signed on 1/14/26. *1/13/26 SN visit, note signed on 1/17/26. *1/15/26 SN visit, note signed on 1/23/26. *1/20/26 SN visit, note signed on 1/25/26. *1/22/26 SN visit, note signed on 1/31/26. *1/23/26 OT visit, note signed on 1/27/26. *1/28/26 and 1/29/26 visits, notes signed on 2/3/26. *2/2/26 OT visit, note signed on 2/9/26. *2/3/26 SN visit, note signed on 2/8/26. *2/5/26 SN visit, note signed on 2/9/26. 6. Patient #9 was admitted to the agency in December 2025 with a diagnosis of dilated cardiomyopathy (a serious heart muscle disease where the left ventricle enlarges (dilates), becomes thin, and cannot pump blood efficiently, often leading to heart failure. a.) Review of the physician ordered Home Health Certification and POC, dated 12/30/25 through 2/27/26, indicated the following: -Effective 1/2/26, PT visit: 1 time a day times 1 day, and 1 time a week times 8 weeks. -Effective 1/2/26, OT visit: 1 time a day times 1 day, and 1 time a week times 8 weeks. Review of the clinical record indicated the following: *1/2/26 PT visit, note signed on 1/4/26. *1/2/26 OT visit, note signed on 1/5/26. *1/6/26 PT visit, note signed on 1/9/26. *1/13/26 PT visit, note signed on 1/15/26. 7. Patient #14 was admitted to the agency in February 2025 with a diagnosis of diabetes (condition causing elevated blood sugar levels). a.) Review of the physician ordered Home Health Certification and POC, dated 12/11/25 through 2/8/26, indicated the following: -SN visit: 1 time a week for 9 weeks. Review of the clinical record indicated the following: *12/18/25 SN visit, note signed on 12/20/25. *1/8/26 SN visit, note signed on 1/10/26. *1/15/26 SN visit, note signed on 1/17/26. *1/22/26 SN visit, note signed on 1/24/26. *1/29/26 SN visit, note signed on 2/1/26. *2/5/26 SN visit, note signed on 2/7/26. 8. Patient #17 was admitted to the agency in January 2026 with a diagnosis of major depressive disorder with psychotic features. a.) Review of the physician ordered Home Health Certification and POC, dated 1/30/26 through 3/30/26, indicated the following: -SN visit: once a day times 1 day, and 3 times a week for 9 weeks. Review of the clinical record indicated the following: *1/30/26 SN visit, note signed on 1/2/26.

Complaint Reference Number: 109723 A Complaint Survey was conducted at Aveanna Healthcare on 09/16/24 to determine compliance with the following Conditions of Participation related to Home Health Agencies: - -CFR 484.50: Patient rights. - -CFR 484.60: Care planning, coordination of services, and quality of care. The Agency was found to be at Standard Level non-compliance, and a statement of deficiencies was generated as a result of the investigation of this complaint.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on records reviewed and interviews, for two of three sampled Patients (Patient #1 and Patient #3), the Agency failed to ensure nursing staff implemented and followed their plans of care related to wound care, when nursing staff did not measure wounds as ordered. Findings include: The Agency’s Policy, titled Physician Orders, dated 12/07/23, indicated a complete, individualized plan of care would be developed for all Patients receiving ongoing clinical services, and care would follow a written plan of care established and reviewed by the physician. 1) Patient #1 was admitted to the Agency in March 2024, diagnoses included non-pressure chronic ulcers of the left ankle, chronic venous insufficiency, peripheral vascular disease, diabetes, and ablation of the left leg. Review of Patient #1’s Wounds Plan of Care, dated 03/29/24, indicated nursing would measure his/her wounds once weekly on Wednesdays. Review of Patient #1’s Admission Standard Visit Summary, dated 03/29/24, indicated he/she had four wounds on his/her left leg, measurements included: -Wound #1 (Anterior Left Calf): Length: 6 Centimeters (CM), Width: 2 cm, Depth: 0.2 cm. -Wound #2 (Anterior Left Medial Calf): Length: 5 cm, Width: 2 cm, Depth: 0.2 cm. -Wound #3 (Anterior Left Pretibial): Length: 1 cm, Width: 1 cm, Depth: 0.3 cm. -Wound #4 (Posterior Left Upper Calf): Length: 0.9 cm, Width: 0.1 cm, Depth: 0.1 cm. Further review of Patient #1’s Medical Record indicated there was no documentation to support that wound measurements were conducted on 04/03/24 or 04/10/24, or any other time while Patient #1 was receiving nursing care and services from the Agency. During a telephone interview on 09/16/24 at 01:21 P.M., Nurse #1 said it was the Agency’s practice to measure wounds weekly, said she could not recall measuring Patient #1’s wounds, and said if she did measure Patient #1’s wounds she would have documented them in Patient #1’s Medical Record. During an interview on 09/16/24 at 01:51 P.M., the Nurse Clinical Director said wound measurements should have been obtained weekly and documented in Patient #1’s Medical Record as outlined in the plan of care, but were not. 2) Patient #3 was admitted to the Agency in June 2024, diagnoses included lymphedema, and stasis ulcer wound on his/her right leg. Review of Patient #3’s Plan of Care, dated for Certification Period 08/25/24 through 10/23/24, indicated nursing would measure his/her right leg wound once weekly on Tuesday or Wednesday, depending on which day the visit fell on for the week. Review of Patient #3’s Skin Status Note, dated 08/14/24, indicated nursing measured the wound on his/her right leg and the measurements were: Length: 15.25 cm and Width: 25.4 cm. Further review of Patient #3’s Medical Record indicated there was no documentation to support there were any other measurements obtained by nursing of his/her right leg wound. During an interview on 09/16/24 at 01:51 P.M., the Nurse Clinical Director said Patient #3’s wound measurements should have been obtained and documented weekly by nursing as outlined in the plan of care, but were not.

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 records reviewed and interviews, for one of three sampled Patients (Patient #1), the Agency failed to ensure nursing promptly notified the physician that Patient #1's leg wounds were worsening, as required. Findings include: The Agency’s Policy, titled Physician’s Orders, dated 12/07/23, indicated the physician would be promptly alerted to any changes in the patient’s condition or needs that suggest that outcomes were not being achieved and/or the plan of care should be altered. Patient #1 was admitted to the Agency in March 2024, diagnoses included non pressure chronic ulcers of the left ankle, chronic venous insufficiency, peripheral vascular disease, diabetes, and ablation of the left leg. Review of Patient #1’s Admission Standard Visit Summary, dated 03/29/24, indicated he/she had four wounds on his/her left leg, measurements included: -Wound #1 (Anterior Left Calf): Length: 6 Centimeters (CM), Width: 2 cm, Depth: 0.2 cm. -Wound #2 (Anterior Left Medial Calf): Length: 5 cm, Width: 2 cm, Depth: 0.2 cm. -Wound #3 (Anterior Left Pretibial): Length: 1 cm, Width: 1 cm, Depth: 0.3 cm. -Wound #4 (Posterior Left Upper Calf): Length: 0.9 cm, Width: 0.1 cm, Depth: 0.1 cm. Further review of Patient #1’s Medical Record indicated there was no documentation to support that wound measurements were conducted on 04/03/24 or 04/10/24, or any other time while Patient #1 was receiving nursing care and services from the Agency. Review of Patient #1’s Patient Care Note, dated 04/10/24 indicated the wounds on his/her left leg were getting worse, and he/she had an appointment with the wound clinic. Further review of the Patient Care Note indicated there was no documentation to support what date Patient #1 had an appointment with the wound clinic for, or that his/her physician was notified of the condition of his/her wounds. Review of Patient #1’s Emergency Room to Hospital Admission Summary, dated 04/13/24, indicated he/she was diagnosed with a pseudomonas infection and sepsis, and required admission to the Intensive Care Unit. During a telephone interview on 09/16/24 at 01:21 P.M., Nurse #1 said she could not recall how she knew that Patient #1 had an appointment at the wound clinic, and said she should have called his/her physician to notify them of the worsening wounds. During an interview on 09/16/24 at 01:51 P.M., the Nurse Clinical Director said Nurse #1 should have notified Patient #1’s physician that his/her wounds were worsening, but had not.

A Recertification survey was conducted at Aveanna Healthcare on 3/1/23 through 3/3/23, and 3/6/23 through 3/7/23, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies and the Covid 19 Health Care Staff Vaccination requirements. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on documentation review and interview, the Agency failed to ensure it staff received annual Emergency Preparedness (EP) program training, as required. Findings included: Review of the Agency's EP Plan, dated 1/10/2023, indicated, but not limited to, the following: -The location must provide EP training at least annually. -The location must maintain documentation of the training. -The location must demonstrate staff knowledge of the EP. During an interview on 3/7/22 at 1:45 P.M., the Administrator said annual EP program training had not been provided to employees at any of the Agency's three branches, as required.

A Recertification survey was conducted at Aveanna Healthcare on 3/1/23 - 3/3/23, and 3/6/23 - 3/7/23, to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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 record review and interview, the Agency failed to ensure its staff provided services in conformance with the Physician's order for four Patients (#7, #9, #16, #17), out of a total sample of 17 Patients. Specifically, the Agency's staff did not provide the following visits as ordered: 1. Physical Therapy (PT) for Patient #7, 2. Skilled Nurse Visit (SNV) for Patient #9, 3. SNV for Patient #16, and 4. PT, SNV and Occupational Therapy (OT) for Patient #17. Findings include: Review of the facility's Missed Services policy, dated 7/29/22, indicated, but was not limited to, the following: -Patients/caregivers should be consulted in advance regarding scheduling of services so the patient receives the ordered services. Because the frequency of services are ordered by the physician, a missed service affects the plan of care, which may need to be updated or changed. 1. Patient #7 was admitted to the Agency in March 2022 with diagnoses including Diabetes Mellitus (a disease that results in too much sugar in the blood) with skin ulcers. Review of the Physician's order for certification period 12/29/22 through 2/26/23, indicated the following: -PT visit (PTV) once a week for one week. -PTV twice a week for six weeks. -PTV once a week for one week. Review of the clinical record indicated Patient #7 did not receive a PT visit week one as ordered, and received only one PT visit on 1/5/23, not two as ordered, during week two. During an interview on 3/7/23 at 12:30 P.M., after reviewing the clinical record, the Director of Nurses (DON) said that Patient #7's Plan of Care relative to PT visits was not followed as ordered for week one and week two. 2. Patient #9 was admitted to the Agency in March 2022 with a diagnosis of chronic venous Hypertension (high blood pressure in the veins over a long time) and a non-pressure chronic ulcer (an open wound resulting from an inadequate blood supply) to the right lower leg. a. Review of the Physician's order for certification period 10/28/22 through 12/26/22 indicated: -SNV once a week for one week. -SNVs three times a week for nine weeks. Review of the clinical record indicated one missed SNV per week occurred from 10/30/22 through 11/19/22 and from 11/27/22 through 12/24/22. b. Review of the Physician's order for certification period 12/27/22 through 2/24/23 indicated: -SNVs, twice a week for one week. -SNVs three times a week for eight weeks. Review of the clinical record indicated the following: -One missed SNV occurred 12/27/22 through 12/31/22. -One missed SNV per week occurred from 1/1/23 through 1/21/23. -Three missed SNVs occurred 1/22/23 through 1/28/23. -One missed SNV occurred 1/29/23 through 2/4/23. -Two missed SNVs occurred 2/5/23 through 2/18/23, and -One missed SNV occurred 2/19/23 throgh 2/24/23. c. Review of the Physician's order for certification period 2/25/23 through 4/25/23 indicated: -SNV three visits per week for 10 weeks. Review of the clinical record indicated one missed SNV occurred 2/26/23 through 3/4/23. During an interview on 3/7/23 at 2:00 P.M., after reviewing the clinical record, the Administrator said the missed SNVs were due either to Patient #9 refusing a visit or due to a wound clinic visit occuring on the same day as scheduled SNV. She further said the Plan of Care should have been updated to reflect the wound clinic schedule. 3. Patient #16 was admitted to the Agency in December 2022 with a diagnosis of open wound to the right lower leg. Review of the Physician's order for certification period 9/17/22 through 11/15/22 indicated: -SNV once a week for one week. -SNV seven times a week for nine weeks. Review of the clinical record indicated missed SNV on 12/18/22, 12/24/22 and 12/26/22. During an interview on 3/7/23 at 2:15 P.M., after reviewing the clinical record, the Administrator said the Physician order was not followed relative to SNVs, as ordered, resulting in the three missed visits. 4. Patient #17 was admitted to the Agency in September 2022 with a diagnosis of non-pressure chronic ulcer of the right foot. Review of the Physician's orders for certification period 9/17/22 through 11/15/22 indicated: -SNV once a week for one week. -SNV once a week for three weeks. -PTV once a week for two weeks. -PTV two times a week for six weeks. -OT Visit (OTV) once a week for one week, -OTV, effective 9/20/22, two times a week for eight weeks, and -OTV, effective 10/17/22, two times a week for four weeks. Review of the clinical record indicated a missed SNV on 9/29/22, a missed PTV on 10/20/22 and missed OTVs on 9/23/22, 9/29/22, 10/28/22 and 11/3/22. During an interview on 3/7/23 at 2:30 P.M, after reviewing the clinical record, the Adminstrator said the Physician orders were not followed relative to a missed SNV on 9/29/22, a missed PTV on 10/20/22 and missed OTVs on 9/23/22, 9/29/22, 10/28/22 and 11/3/22..

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff communicated with the Physician when there was a change to the plan of care for five Patients (#7, #13, #9, #16, #17), out a total sample of 17 Patients. Specifically, 1. the Physician was not notified when PTVs were not provided as ordered for Patient #7, 2. the Physician was not notified when SNVs were not provided as ordered for Patient #13, 3. the Physician was not notified when Skilled Nursing Visits (SNVs) were not provided as ordered for Patient #9, 4. the Physician was not notified when SNVs were not provided as ordered for Patient #16, and 5. the Physician was not notified when a SNV, a Physical Therapy Visit (PTV) and Occupational Therapy Visits (OTVs) were not provided as ordered for Patient #17. Findings include: Review of the Agency policy, titled Missed Services, reviewed 7/29/22, included but not limited to: -When scheduled services, visits or shifts are not provided for any reason, the appropriate notification should be completed and sent to the physician or other appropriate ordering provider/entity in a timely manner. A copy of the notification is placed in the patient's record to reflect the alteration of the plan of care. 3. Patient #9 was admitted to the Agency in March 2022 with a diagnosis of chronic venous Hypertension (high blood pressure in the veins over a long time) and a non-pressure chronic ulcer (an open wound resulting from an inadequate blood supply) to the right lower leg. a. Review of the Physician's order for certification period 10/28/22 through 12/26/22 indicated: -SNV once for one week. -SNV three a week for nine weeks. Review of the clinical record indicated one missed SNV per week occurred from 10/30/22 through 11/19/22 and from 11/27/22 through 12/24/22. b. Review of the Physician's order for certification period 12/27/22 through 2/24/23 indicated: -SNVs twice a week for one week. -SNVs three times a week for eight weeks. Review of the clinical record indicated the following: -One missed SNV occurred 12/27/22 through 12/31/22. -One missed SNV per week occurred from 1/1/23 through 1/21/23. -Three missed SNVs occurred 1/22/23 through 1/28/23. -One missed SNV occurred 1/29/23 through 2/4/23. -Two missed SNVs per week occurred 2/5/23 through 2/18/23, and -One missed SNV occurred 2/19/23 throgh 2/24/23. c. Review of the Physician's order for certification period 2/25/23 through 4/25/23 indicated: -SNVs three times a week for 10 weeks. Review of the clinical record indicated one missed SNV occurred 2/26/23 through 3/4/23. Review of the clinical record did not contain any documentation that the Physcian had been notified of any the missed SNVs. During an interview on 3/7/23 at 2:00 P.M., after reviewing the clinical record, the Administrator said the Plan of Care was not followed relative to the missed SNVs and the Physician was not notified, as required. 4. Patient #16 was admitted to the Agency in December 2022 with a diagnosis of open wound to the right lower leg. Review of the Physician's order for certification period 9/17/22 through 11/15/22 indicated: -SNV once a week for one week. -SNVs seven times a week for nine weeks. Review of the clinical record indicated missed SNVs on 12/18/22, 12/24/22 and 12/26/22. Review of the clinical record did not contain any documentation that the Physician had been notified of any the missed SNVs.. During an interview on 3/7/23 at 2:15 P.M., after reviewing the clinical record, the Administrator said the Plan of Care was not followed relative to SNVs as ordered and the Physician was not notified of the missed visits, as required. 5. Patient #17 was admitted to the Agency in September 2022 with a diagnosis of non-pressure chronic ulcer of the right foot. Review of the Physician's orders for certification period 9/17/22 through 11/15/22 indicated: -SNV once a week for one week. -SNV once a week for three weeks. -PTV once a week for two weeks. -PTV two times a week for six weeks. -OTV once a week for one week. -OTV, effective 9/20/22, two times a week for eight weeks, and -OTV, effective 10/17/22, two times a week for four weeks. a. Review of the clinical record indicated a missed SNV on 9/29/22. b. Review of the clinical record indicated a missed PTV on 10/20/22. c. Review of the clinical record indicated missed OTVs on 9/23/22, 9/29/22, 10/28/22 and 11/3/22. Review of the clinical record did not contain any documentation that the Physician had been notified of the missed SNV, PTV, and OTVs. During an interview on 3/7/23 at 2:30 P.M., after reviewing the clinical record, the Administrator said the Plan of Care was not followed relative to missed SN, PT and OT visits, as ordered, and the Physician was not notified of the missed visits, as required. 4. Patient #7 was admitted to the agency in March 2022. Review of the Physician's order for certification period 12/29/22 through 2/26/23, indicated the following: -PT Visit (PTV) once a week for one week. -PTV twice a week for six weeks. -PTV once a week for one week. Review of the clinical record indicated Patient #7 did not receive a PTV week one as ordered, and received only one PTV, not two as ordered, during week two, on 1/5/23. During an interview on 3/7/23 at 12:30 P.M., after reviewing the clinical record, the Director of Nurses (DON) said that the Physician was not notified of the missed PTVs for week one and week two. She said staff should have updated the Physician that the Plan of Care relative to PTVs had not been followed as ordered, during the first two weeks of the certification period. 5. Patient # 13 was admitted to the Agency in October 2022. Review of Resumption of Care (ROC) Physician's order, dated 11/14/22, indicated the following: -Effective week of 11/13/22, SNV twice a week for one week. -SNV once a week for three weeks. -Two, as needed (PRN), SNVs. Review of a nursing note, dated 11/25/22, indicated a missed SNV on 11/18/22 and an attempt to reschedule the visit was refused by Patient #13. The documentation did not indicate the Physician was notified of the missed SNV. Review of the Physician's order for certification period 12/13/22 through 2/10/23, indicated the following: -SNV once a week for four weeks. -Effective for the week of 1/15/23, SNV once every two weeks for four weeks. -One PRN SNV. Review of a nursing note, dated 12/17/22, indicated a missed SNV on 12/15/22 and Patient #13 requested to wait until the following week for a SNV. The note did not indicate the Physician was notified of the missed SNV. During an interview on 3/7/23 at 11:15 A.M., after reviewing the clinical record, the DON said that there was not any documented evidence that the Physician had been notified of the two missed SNVs and that the Plans of Care were not followed, as ordered.