Every finding on record at Green Meadows Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number: 3012557. The survey team entered the home health agency on 6/9/26 at 1012 hours. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the HHA. GLOSSARY AND DEFINITIONS: CM: Case Manager DPCS: Director of Patient Care Services DVT: Deep Vein thrombosis (a blood clot that forms in a vein deep in the body) EENT: Eyes, Ears, Nose, Throat HHA: Home Health Agency IV: intravenous (situated, performed, or occurring within or entering by way of a vein) Midline catheter: a short intravenous tube inserted into a large vein in the upper arm, used for medium-term IV therapy lasting up to four weeks. mg: milligram(s) ml: millimeter(s) NS: Normal Saline PICC line: Peripherally Inserted Central Catheter (a type of central venous catheter that provides access to the large veins near the heart through a vein in the upper arm) P&P: Policy and Procedure PCG: Primary Caregiver POC: Plan of Care PT: Physical Therapy/Therapist RN: Registered Nurse ROC: Resumption of Care SN: Skilled Nursing/Nurse SOC: Start of Care W: Week

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care for one of five sampled patients (Patient 1 ). This failure created the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 1's clinical record was initiated on 6/9/26. The clinical record showed the SOC was 5/2/26. The patient was certified for home health services during the certification period from 5/2/26 to 6/30/26. Review of the Initial Comprehensive Assessment dated 5/2/26, showed RN 1 completed vital signs, pain, safety measures, medications, functional limitations, fall risk assessment, activities permitted, prognosis, supportive assistance, environmental factors, neuro/muscular, gastrointestinal, genitourinary, nutritional, cardio/pulmonary, and integumentary assessment. However, the mental status assessment was blank. On 6/11/26 at 1445 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was completed within the last five days of every 60 days for one of five sampled patients (Patient 3). This failure had the potential for not addressing the care needs for this patient. Findings: Review of Patient 3’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 8/16/25. The patient was certified for home health services during the certification period from 8/16/25 to 10/14/25, 10/15/26 to 12/13/25, 12/14/25 to 2/11/26, 2/12/26 to 4/12/26, 4/13/26 to 6/11/26, and 6/12/26 to 8/10/26. Review of the Recertification Comprehensive Nursing Assessment dated 5/30/26, showed no documented evidence the assessments for mental, nutritional, integumentary, medications, and supportive assistance sections were completed. On 6/11/26 at 1302 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the findings.

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 interview and record review, the agency failed to attempt to reschedule, inform, and advise/educate patient/caregiver on impacts of missed visits on three of five sampled patients (Patients 1, 3, and 5). This failure had the potential of creating the risk of not providing the necessary care and services to these patients. Findings: Review of the agency's P&P titled Missed Visit effective date 10/1/24, showed the clinician assigned to the visit must make at least two distinct communication attempts to reach the patient/caregiver to ascertain why the visit was missed. If the patient is safe but refuses the visit or requests cancellation, the clinician must educate the patient regarding the direct clinical risks. This clinical education must be documented. Every effort must be made to reschedule the visit within the same calendar week to maintain compliance with the ordered weekly frequency block. The Clinical Documentation Requirements included a formal "Missed Visit Note" or designated EMR (electronic medical record) form must be completed by the end of the shift on the day the visit was missed. The record must explicitly contain the following: - The precise reason for the missed encounter. - Detailed communication of the specific clinical education provided to the patient/caregiver regarding medical dangers of missing treatment. - The date, time, and specific method of notification to the physician/practitioner, along with any reciprocal orders received. 1. Review of Patient 3’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 8/16/25. The patient was certified for home health services during the certification periods from 8/16/25 to 10/14/25, 10/15/26 to 12/13/25, 12/14/25 to 2/11/26, 2/12/26 to 4/12/26, 4/13/26 to 6/11/26, and 6/12/26 to 8/10/26. Review of the Recertification Assessment Order/Telephone Order dated 2/9/26, showed SN visits 1W9 (one time a week for nine weeks). Review of the Communication Note under Comments Section dated 3/23/26, showed the patient was not available. However, there was no further specific documentation to clarify the reason why patient was not available, if there was attempt to reschedule within the week, and if the physician was informed. There was no documentation on patient/caregiver education regarding the potential clinical impact of missed treatments or services. Additionally, the "Caller" and the "Caller Phone" information was blank. On 6/11/26 at 1305 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the communication note should have more detailed information related to the missed visit, the missed visit should have been rescheduled, and the doctor should have been informed. 2. Review of Patient 5’s closed clinical record was initiated on 6/9/26. The closed clinical record showed the SOC was 2/3/26. The patient was certified for home health services during the certification period from 2/03/26 to 4/03/26. The patient was discharged on 3/25/26. Review of the POC, for the certification period from 2/3/26 to 4/3/26, showed SN visits 3 times per week for one week and 2 times per week for eight weeks (total 19 visits); and the comprehensive evaluation and care of the left lower limb cellulitis and stasis ulcer. Review of the Communication Note dated 2/26/26, showed RN 6 as the caller and CM 1 as the staff name. Documentation showed the SN reported that the patient refused a visit. However, there was no further specific documentation to clarify the reason why patient refused the visit, if the missed visit was rescheduled within the week, and if the physician was informed. There was no documentation on patient/caregiver education regarding the potential clinical impact of missed treatments or services. Additionally, the form showed the physician's name and signature was blank. On 6/11/26 at 1413 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the communication note should have more detailed information for clarifications. 3. Review of Patient 1’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 5/2/26. The patient was certified for home health services during the certification period from 5/2/26 to 6/30/26. Review of the POC, for certification period from 5/2/26 to 6/30/26, showed skilled nursing visit was 1W9 (one time a week for nine weeks) for IV teach and train. Review of the Missed Communication Note under the Comments Section dated 5/21 and 5/22/26, showed the patient refused. There was no specific detailed documentation to clarify the reason why patient refused the visit and if the physician was informed. There was no documentation on patient/caregiver education regarding the potential clinical impact of missed treatments or services. In addition, the "Caller" and the "Caller phone" information was blank. On 6/11/26 at 1057 hours, a telephone call was conducted with RN 5. RN 5 was asked what was the process for the missed visits. RN 5 stated she reports to the Case Manager, she would inform the physician of the missed visit, and would reschedule for the missed visit. On 6/11/26 at 1155 hours, a telephone call was conducted with RN 4. RN 4 was asked what was the process for missed visits. RN 4 stated for missed visits, she would inform the Case Manager, she would inform the physician, and would arrange to reschedule a visit for the patient. On 6/11/26 at 1453 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the communication note should have been more detailed for clarifications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure to follow the physician's orders for two of five sampled patients (Patients 1 and 5). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1' s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 5/2/26. The patient was certified for home health services during the certification period from 5/2/26 to 6/30/26. Review of the POC, for the certification period from 5/2/26 to 6/30/26, showed the following: -For the patient’s surgical incisions to remain clean, dry, and intact with no signs and symptoms of bleeding or infection throughout the episode. -SN to educate on the patient/caregiver observation of dressing; education to report changes to drainage amount to dressing; reasessing integrity and the changes in pain to incision locations (right chest incision, right axillary incision, and bilateral groin incisions). -SN to educate on signs and symptoms of DVT including: increased pain, redness and/or warmth -SN to educate on signs and symptoms of mitral valve repair: decreased energy, abnormal blood pressure/ heart rate, episodes of dizziness, tingling or numbness to extremities, -SN visits for IV teach and train, PICC line dressing change, and blood draw Review of the Initial Comprehensive Assessment dated 5/2/26, showed the patient had a PICC line on the right upper arm. Review of the SN visit notes showed the following: -On 5/4, 5/18, 5/25, 6/1, 6/2, and 6/8/26, showed RN 5 gathered supplies and blood lab specimen was drawn as follows: lumen on the PICC line was flushed with 10 ml NS, aspirated 10 ml of blood and discarded, blood specimens were obtained, and line was flushed with NS. *However, there was no documented evidence of IV teaching. In addition, the patient/caregiver response section showed the section for if the patient verbalized understanding or requires more understanding was left blank. *Furthermore, there was no documented evidence educating the patient/caregiver on patient/caregiver observation of dressing and to report changes to drainage amount to dressing, dressing integrity, and the changes in pain to incision locations. -On 5/15/26, RN 4 provided skilled teaching/instructions to the patient/caregiver regarding signs and symptoms of infection for PICC line, effectiveness of treatment, and verbalized understanding. *However, there was no documented evidence of the education provided related to the signs and symptoms of DVT and mitral valve repair. On 6/11/26 at 1057 hours, a telephone call was conducted with RN 5. RN 5 was asked what the HHA's process was for following the plan of care. RN 5 stated the plan of care was about the physician's orders and should be followed and documented. On 6/11/26 at 1155 hours, a telephone call was conducted with RN 4. RN 4 was also asked what the HHA's process was for following the plan of care. RN 4 stated the plan of care included the physician's orders and should be followed and documented. On 6/11/26 at 1448 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings. 2. Review of Patient 5’s closed clinical record was initiated on 6/9/26. The closed clinical record showed the SOC was 2/3/26. The patient was certified for home health services during the certification periods from 2/03/26 to 4/03/26. The patient was discharged 3/25/26. Review of the POC for the certification period from 2/3/26 to 4/3/26, showed SN to assess the patient’s IV midline site every visit for signs and symptoms of inflammation or infection, patient/caregiver’s management of IV therapy and procedure, and signs and symptoms of IV complications. Review of the Skilled Nursing Routine Visit Notes by RN 2 showed the following: -On 2/5/26, the mid line site care was provided. -On 2/6/26, the mid line right upper arm showed no complication. *However, there was no documented evidence of the assessment of IV midline site for signs and symptoms of inflammation or infection. There was no specific information of the assessment of the patient/caregiver’s management of IV therapy and procedure. On 6/11/26 at 1422 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure communication was conducted with the physician involved in the plan of care related to PT evaluation for one of five sampled patients (Patient 1). This failure had the potential for the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 1’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 5/2/26. The patient was certified for home health services during the certification period from 5/2/26 t0 6/30/26. Review of the POC dated 5/2/26, for the certification period from 5/2/26 to 6/30/26, showed PT evaluation for improvement in mobility after the patient had been cleared for PT by the physician. Review of the Communication Notes dated after 6/2/26, showed coordination with the patient, pharmacy, Infectious Disease Clinic, and laboratory results. * However, there was no documented evidence on the communication note to clarify with the physician if the patient was already cleared or not for PT evaluation. On 6/11/26 at 1451 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was asked if there was communication with the physician to ensure the patient was cleared or not for PT evaluation. The DPCS verified and was unable to find any communication note to clarify if Patient 1 was cleared or not yet cleared for PT evaluation. The DPCS added that it should have been clarified and followed up.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the written visit schedule was provided and consistent with the patient's most current plan of care for one of five sampled patients (Patient 2). This failure had the potential of creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 2’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 6/1/26. The patient was certified for home health services during the certification from periods from 6/01/26 to 7/30/26. A joint home visit with RN 2 was conducted on 6/10/26 at 1008 hours, to Patient 2’s home. Patient 2’s Admission Packet was reviewed. Patient 2’s Medication Profile was updated and medications were found to be not expired. * However, the Staff Visit Frequency Calendar was completely blank. RN 2 was asked if it should have been filled up and completed. RN 2 verified it was missed and should have been completed. On 6/11/26 at 1550 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed of the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical notes were accurate and complete for one of five sampled patients (Patient 1). This failure had the potential for not providing the necessary care and services to this patient. Findings: Review of the agency's P&P titled Medical Record Content Policy (undated) showed HHA shall ensure that the medical record contains the following information as accurate documentation of the course and results of care, treatment and services signed and dated clinical and progress notes. Review of the agency's P&P titled PICC line Dressing Change (undated) showed documentation guidelines include to document in the clinical record: appearance of the site, patency of line and flush solutions used, date and time of the dressing change, and type of dressing applied, length of catheter visible at the exit site, any physician notification, plan for the next dressing change and any client/caregiver education and their response. Review of Patient 1’s clinical record was initiated on 6/9/26. The clinical record showed the SOC was 5/2/26. The patient was certified for home health services during the certification period from 5/2/26 t0 6/30/26. Review of the POC for the certification period from 5/2/26 to 6/30/26, showed SN visits for IV teach and train, PICC line dressing change, and blood draw. Review of the Initial Comprehensive Assessment dated 5/2/26, showed the patient had a PICC line on the right upper arm. Review of the SN Nursing Progress Notes dated 5/4, 5/18, 5/25, 6/1, 6/2, and 6/8/26, showed RN 5 completed the mental status, cardiovascular, respiratory, EENT, motor/musculo-skeletal, pain, gastrointestinal, genitourinary, endocrine, integumentary, and venous assessments. *However, there was no documented evidence the PICC line assessment included the date and time dressing change, type of dressing applied, length of catheter visible at exit site, any client/caregiver education and their response. On 6/11/26 at 1456 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and verified the findings.

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number: 2587222. The survey team entered the hospice agency on 9/5/25 at 0900 hours. The agency identified the census as 213. The survey sample size was 3. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the agency. GLOSSARY AND DEFINITIONS: CEO: Chief Executive Officer cm: centimeter(s) DPCS: Director of Patient Care Services Foley catheter: a flexible tube that is passed through the urethra into the bladder allowing urine to drain out into a collection bag. Hypothyroidism: a condition in which the thyroid gland does not produce enough thyroid hormone Malleolus: the bony prominence on each side of the human ankle mcg: microgram(s) mg: milligram(s) ml: milliliter(s) N/A: Not Applicable NS: normal saline P&P: Policy and Procedure(s) PCG: Patient Care Giver PEG tube: Percutaneous Endoscopic Gastrostomy, a thin and flexible tube inserted through the abdominal wall into the stomach PICC: Peripherally Inserted Central Catheter, a thin and flexible tube inserted into a vein in the upper arm and advanced into a larger vein near the heart POC: Plan of Care PRN: As needed SN: Skilled Nursing/Nurse SOC: Start of Care Stage 3 pressure injury: full thickness skin loss involving damage to the subcutaneous tissue that may extend to underlying connective tissue Stage 4 pressure injury: full thickness tissue loss with exposed bone, tendon, or muscle Trochanter: a large, bony prominence at the upper part of the thigh bone Unstageable pressure ulcer: full thickness tissue loss in which the base of the ulcer is covered by dead tissue making it difficult to determine how deep the ulcer is Urinalysis: a urine screening test used to detect urinary tract infections, kidney disorders, liver problems, diabetes or other metabolic conditions. W: week

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessments were completed no later than five calendar days after the SOC, consistent with the patients' immediate needs for two of three sampled patients (Patients 1 and 3). This failure had the potential risk of not identifying and addressing the care needs timely for these patients. Findings: Review of the agency’s P&P titled PICC Line Dressing Change (undated) showed the registered nurse will inspect catheter insertion site for signs of redness, swelling, inflammation, tenderness, or exudate; inspect the catheter hub for any kinked or weakened areas; note the length of catheter exposed; and document the appearance of the site, patency of line and flushed solutions used, date and time of the dressing change, and type of dressing applied, length of catheter visible at exit site, any physician notification, plan for next dressing change, and client/caregiver education and their response. 1. Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. Review of the Comprehensive Nursing Assessment dated 7/30/25, showed under the Infusion section, a check mark for “N/A” for options of peripheral line, midline catheter, and central line; but there was documentation of the insertion site as right upper arm and insertion date of 7/29/25. The summary of the care provided narrative section showed the patient had a PICC line to the right upper arm. The SN assessed the site as clean, dry, intact, and no signs of infection. However, the SN did not assess the length of the catheter extended from the site, catheter hub, patency of the line, and type of dressing applied as per the agency’s P&P. On 9/10/25 at 1121 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated the nurses should assess for the PICC line site location, how many ports of entry, arm circumference, and length of catheter from the entry site. The DPCS stated the comprehensive assessment should be completed within five days of the SOC. The DPCS was informed and acknowledged the finding. 2. Review of Patient 3’s closed clinical record was initiated on 9/9/25. The clinical record showed the SOC was 7/17/25. The patient was certified for home health services during the certification period from 7/17/25 to 9/14/25. The patient was discharged from the agency on 8/1/25. Review of the Comprehensive Nursing Assessment dated 7/17/25, showed a check mark for “Central Line” with the type/band as “PICC.” In addition, there was documentation of double lumen. The patient and caregiver education provided and response section showed PICC line care and dressing change. However, the SN did not assess the length of the catheter extended from the exit site, catheter hub, patency of the line, type of dressing applied, appearance of insertion site, and date the PICC was insert as per the agency’s P&P. On 9/10/25 at 1416 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated the PICC assessment was incomplete. The DPCS was informed and acknowledged the finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included the patient's current medications to identify any potential adverse effects and drug reactions for one of three sampled patients (Patient 1). This failure had the potential risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for this patient. Findings: Review of the agency’s P&P titled Medication Reconciliation revised February 2021 showed the agency will reconcile the patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reaction, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. The Patient Medication Profile for certification period from 7/30/25 to 9/27/25, showed the patient’s medications included tramadol (pain medication) 50 mcg tablet one tablet via PEG tube as needed for pain and hydrocodone-acetaminophen (pain medication) 5-325 mg 1/2 tablet via PEG tube every four to six hours as needed for pain. *However, the tramadol order had an incorrect dosage and no frequency of administration; and there were no specific instructions as to which pain medication to give first for mild, moderate or severe pain, tramadol vs hydrocodone-acetaminophen. On 9/10/25 at 1111 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated the tramadol dosage 50 mcg was a typo and should have been 50 mg. The DPCS was informed and acknowledged the finding.

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 interview and record review, the agency failed to ensure care and services were provided as per the POC for two of three sampled patients (Patients 1 and 2). This failure had the potential risk for not addressing and providing the appropriate care needs for these patients. Findings: Review of the agency’s P&P titled Wound Management and Skin Care dated 2/2/21, showed the registered nurse is responsible for accurately documenting the wound assessment and management plan; adhering to the patient’s individualized skin and wound care management plan; and report and consult any changes to the skin and wound condition to the DPCS, physician, and wound specialist (where required). Wound assessment should have the following descriptions: date of the wound assessment, wound location, wound size, wound shape, wound depth, tissue type in the wound, surround the wound and peri-wound area, any undermining, odor, heat, and exudate volume. 1. Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. a. The POC, for the certification period from 7/30/25 to 9/27/25, showed the patient had the following pressure injuries: unstageable pressure injury to left lateral malleolus and right trochanter, Stage 3 pressure injury to first metatarsal head, and stage 4 to coccyx. In addition, in the integumentary section, showed the SN to perform, demonstrate, instruct, and validate the PCG’s ability to perform proper wound care; and assess, perform, instruct patient/caregiver on measure to prevent skin breakdown including proper positioning techniques, frequent position changes, hygiene, skin inspection, skin care, and increase protein in diet. However, review of the Wound Care Worksheet dated 7/31, 8/1, and 8/6/25, failed to show documented evidence the SN had assessed for the four pressure injuries for wound depth, tissue type in the wound, surround the wound and peri-wound area, any undermining, odor, heat, and exudate volume as per the patient’s POC. In addition, review of the Wound Care Worksheet dated 8/6/25, failed to show documented evidence the SN’s pressure injury wound assessments included the wound measurements for the unstageable to the left lateral malleolus and right trochanter and Stage 3 pressure injury to the first metatarsal head. On 9/10/25 at 1200 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated the nurses should assess the patient’s pressure injuries, including the location, measurement, drainage, and characteristics of the wound. The DPCS was informed and acknowledged the finding. b. The POC, for the certification period from 7/30/25 to 9/27/25, showed under the genitourinary section, the disciplines were to instruct the patient/PCG on proper indwelling catheter care. However, review of the Nursing Progress Note dated 7/31/25, failed to show documented evidence the discipline instructed the patient/PCG on proper indwelling catheter care. On 9/10/25 at 1135 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/9/25. The clinical record showed the SOC was 7/10/25. The patient was certified for home health services during the certification period from 7/10/25 to 9/7/25. The POC, for the certification period from 7/10/25 to 9/7/25, cited SN visits 1w9 (one visit each week for nine weeks) and 3 PRN visits for indwelling catheter management. The Nursing Progress Note showed there was no SN visit during the weeks of 8/24/25 to 8/30/25 and 8/31/25 to 9/6/25. However, there was no documented evidence to show the attempts to reschedule the missed visits. There was no documented evidence the physician was notified of the missed visits. On 9/10/25 at 1330 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the clinicians’ visits were pre-plotted. The DPCS stated if there was a missed visit to the patient, the nurse would call the case manager. The case manager would try to attempt to reschedule another visit within the week; however, if the case manager was unable to reschedule within the week then, it would be considered as a missed visit and the physician would be notified. The DPCS was informed and acknowledged the finding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients received care and services as per the written POCs for two of three sampled patients (Patients 1 and 2). This failure had the potential risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. The POC, for the certification period from 7/30/25 to 9/27/25, showed SN to perform, demonstrate, instruct, and validate the PCG’s ability to perform the proper wound care as follows: irrigate all wound with sodium chloride 0.9 %, flush 10 ml with each dressing change, for the following wounds: - unstageable pressure injury to the left lateral malleolus, and apply bordered foam dressing change every 3 days or PRN if soiled or loose - Stage 3 pressure injury to the left first metatarsal head, and apply bordered foam dressing change every 3 days or PRN if soiled or loose - unstageable pressure injury to the right trochanter, and apply saline moist gauze or sterile gauze and bordered foam dressing, change daily - Stage 4 pressure injury to the coccyx, and apply saline moist gauze or sterile gauze and bordered foam dressing, change daily In addition, the Other Notes narrative section of the POC, showed, “SN performed wound care as instructed by the caregiver: wounds were cleansed with NS, pat dried, Santyl ((used to remove necrotic tissue of the wound) ointment applied, and covered with foam dressing.” However, the POC, for the certification period from 7/30/25 to 9/27/25, did not include an order to apply Santyl ointment as part of the wound treatment for the pressure injuries. On 9/10/25 at 1410 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/9/25. The clinical record showed the SOC was 7/10/25. The patient was certified for home health services during the certification period from 7/10/25 to 9/7/25. The POC, for the certification period from 7/10/25 to 9/7/25, showed SN to change or insert catheter using a 16 French size Foley catheter, swab area three times with cleaning swabs or betadine (topical antiseptic) and inflating 10 ml balloon using aseptic technique, secure with tape or adhesive anchor. The POC also showed catheter changes and irrigation as ordered by the physician. Review of the Nursing Progress Note showed the following: - dated 8/8/25, in the genitourinary section, the catheter size was 18 French. - dated 8/9/25, in the genitourinary section, the catheter size was 22 French. However, further review of the clinical record failed to show documented evidence of a physician’s order to change or insert a catheter size of 18 or 22 French. On 9/10/25 at 1351 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS stated the nurse should have a physician’s order for each different catheter size. The DPCS was informed and acknowledged the finding.

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 interview and record review, the agency failed to ensure the physician was notified promptly related to the changes of conditions for one of three sampled patients (Patient 2). This failure had the potential risk of not providing quality of care and services to Patient 2. Findings: Review of the agency’s P&P titled Plan of Care – CMS #485 and Physician/Practitioners Orders revised April 2023 showed in the event of a change in patient condition or needs that suggest outcomes are not being achieved and/or that the patient’s plan of care should be altered, the agency will notify both the responsible physician/ practitioner and the physician(s) associated with the relevant aspect of care. Review of Patient 2’s clinical record was initiated on 9/9/25. The clinical record showed the SOC was 7/10/25. The patient was certified for home health services during the certification period from 7/10/25 to 9/7/25. The POC, for the certification period from 7/10/25 to 9/7/25, cited SN visits 1w9 and 3 PRN visits for indwelling catheter management. In addition, the POC showed to notify physician of any significant change in the patient’s medical condition. Review of the Nursing Progress Note dated 7/24/25, showed in the Additional SN Note section, “SN received a call from the patient’s daughter reporting that she observed crystal-like particles in the catheter tubing. The patient’s daughter and facility staff were advised to follow up with the primary care physician regarding a possible urinalysis.” *However, further review of the clinical record failed to show documented evidence the physician was notified about the patient’s catheter tubing having crystal-like particles or to follow up with the primary care physician for a possible urinalysis. On 9/10/25 at 1346 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The DPCS stated the nurse or the case manager should have notified the physician. The DPCS was informed and acknowledged the finding.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient's physician for one of three sampled patients (Patient 1). This failure had the potential of not providing necessary care and services to Patient 1. Findings: Review of the agency’s P&P titled Wound Management and Skin Care dated 2/2/21, showed the registered nurse is responsible to report and consult any changes to the skin and wound condition to the DPCS, physician, and wound specialist (where required). Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. The POC, for the certification period from 7/30/25 to 9/27/25, showed the patient had the following pressure injuries: unstageable pressure injury to the left lateral malleolus and right trochanter, Stage 3 to the first metatarsal head, and Stage 4 to the coccyx. Review of the Wound Care Worksheet showed the following: - dated 8/1/25, the measurements of the Stage 4 pressure injury to the coccyx were 4.8 cm (length) x 5.7 cm (width) x 1.0 cm (depth). -dated 8/6/25, the measurements of the Stage 4 pressure injury to the coccyx were 5.0 cm x 6.0 cm x 1.5 cm. *The documentation showed the size of the patient’s Stage 4 pressure injury to the coccyx was increased. However, there was no documented evidence the SN communicated the increased in size of the patient’s Stage 4 pressure injury to the coccyx. On 9/10/25 at 1410 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS stated an increased in size of a pressure injury was considered a change of condition and the physician should be notified. The DPCS was informed and acknowledged the finding.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the services were integrated in the POCs for two of three sampled patients (Patients 1 and 2). This failure had the potential risk of not providing quality of care and services to these patients. Findings: Review of the agency’s P&P titled Coordination of Patient Care revised February 2021 showed the agency must assure communication with all physicians/practitioners involved in the plan of care. Integrated orders from all physicians/practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. Integrated services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. 1. Review of Patient 1’s closed clinical record was initiated on 9/5/25. The clinical record showed the SOC was 7/30/25. The patient was certified for home health services during the certification period from 7/30/25 to 9/27/25. The patient was discharged from the agency on 8/7/25. The POC, for the certification period from 7/30/25 to 9/27/25, showed SN to perform, demonstrate, instruct, and validate the PCG’s ability to perform the proper wound care as follows: irrigate all wound with sodium chloride 0.9 %, flush 10 ml with each dressing change and for Stage 4 pressure injury to coccyx, apply saline moist gauze or sterile gauze and bordered foam dressing, and change daily. Review of the Wound Specialist Visit Note dated 8/5/25, showed the wound treatment was provided at bedside for the Stage 3 pressure injury to the sacral region with hydrogel (used to facilitate debridement in wounds with necrotic and slough tissues) and antibacterial components. In addition, the documentation showed the patient’s previous orders shall continue with the remaining wounds. The frequency showed initially, to change daily or every two days, depending on exudate levels and peri wound skin condition. Review of the Wound Care Worksheet dated 8/6/25, showed the patient’s sacral/coccyx Stage 3 pressure injury was treated with hydrogel and covered with a foam dressing. *However, further review of the clinical record failed to show documented evidence of the physician coordinated a specific new wound treatment order for the patient’s pressure injury wound to coccyx. On 9/10/25 at 1410 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 9/9/25. The clinical record showed the SOC was 7/10/25. The patient was certified for home health services during the certification period from 7/10/25 to 9/7/25. The Medication Profile, for the certification period from 7/10/25 to 9/7/25, showed the following medications: - atenolol (antihypertensive) 25 mg one tablet daily - amlodipine (antihypertensive) 5 mg one tablet daily - omeprazole delayed release (anti-GERD) 20 mg one capsule daily - lisinopril (antihypertensive) 20 mg one tablet daily - dapagliflozin propanediol (antidiabetic) 5 mg one tablet daily - atorvastatin (antilipemic) 20 mg one tablet daily - glipizide (antidiabetic) 5 mg one tablet daily - levothyroxine (a drug used to treat hypothyroidism) 75 mcg one tablet daily Review of the Nursing Progress Note dated 7/27/25, showed in the Additional SN Notes narrative section, “the patient remains compliant with prescribed medication and is currently on antibiotics.” *However, further review of the clinical record failed to show documented evidence the patient was on an antibiotic medication. In addition, there was no documented evidence the SN had coordinated the patient was on antibiotic treatment. On 9/10/25 at 1346 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. The Administrator and DPCS were informed and acknowledged the finding.