Every finding on record at Honest Elite Caregivers, Inc.

Based on the findings of an onsite unannounced complaint investigation survey conducted on September 24, 2025, September 25, 2025, September 26, 2025 and concluded offsite on September 29, 2025 and September 30, 2025, Honest Elite Caregivers, Inc., was found not to be in compliance with the following requirement(s) of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of the survey, (2) Conditions and (4) Standard level deficiencies were cited. One condition resulted in an Immediate Jeopardy. The immediate jeopardy was abated on 9/26/25 at 3:55PM with the acceptance and implementation of the agency’s removal plan.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on review of clinical records, personnel files, agency policies and job descriptions, and based on interview with director of nursing and agency owner, the agency failed to provide a complete individualized plan of care that must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment for one (1) of four (4) clinical records reviewed. CR#1. The agency failed to ensure that the individualized plan of care included all settings and treatment related to patient's tracheostomy and ventilator (G574) and the agency failed to ensure complete medication and treatment orders were included on initial "Home Health Certification and Plan of Care" (G576) This CONDITION is not met as evidenced under the following standards: Cross Reference Tags: 484.60(a)(2) The individualized plan of care must include the following (G574) 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care (G576)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of agency policies, clinical records (CR), and an interview with the director of nursing, the agency failed to ensure that the individualized plan of care included all settings and treatment related to patient's tracheostomy and ventilator for one (1) of four (4) CRs reviewed: CR# 1 Findings include: Review of agency policy occurred on 9/26/25 and 9/29/25 approximately 2:00 PM and revealed the following: Policy titled, "2.8 Care Plan" stated, "To ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of services by the RN, based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment...Home Health services from members of the agency staff as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan...The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment...steps to be taken in developing the care plan include:...type of services,...equipment required...all patient care orders, including verbal orders, must be recorded in the plan of care..." Policy titled, "2.21 Physician/Allowed Practitioner's Plan of Treatment" stated, "A physician/allowed practitioner or allowed practitioner prepares a plan of treatment and it is made available to the agency...Physician/allowed practitioner's orders are established and documented for the health care services the agency provides...verbal orders may be accepted by Registered Nurses or other professionally licensed person (PT, OT, ST)...The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment...must include: all diagnoses relevant to the agency's plan of care, the type of services and equipment needed, frequency of visits needed, prognosis, medications and treatments, special diets and nutritional requirements, activities permitted, functional limitations, instructions for timely discharge and referral, IV therapy services, rehabilitation potential, safety measures to protect against injury, instructions for timely discharge or referral, other appropriate items, a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors...Any changes in the physician/allowed practitioner's plan of treatment shall be made in writing and signed and dated by the physician/allowed practitioner...." Review of Clinical Records occurred on 9/24/25 at approximately 2:00 PM, 9/25/25 and 9/26/25 at approximately 9:45AM, 9/29/25 and 9/30/25 at approximately 2:00PM and revealed the following: CR #1: Start of Care (SOC): 6/26/25. Home Health Certification and Plan of Care revealed current certification period of 8/25/25-10/23/25. Plan of care further revealed skilled nurse frequency of 24 hours per day for seven (7) days per week for nine (9) weeks. Plan of care did not list specific tracheostomy or ventilator orders. The previous plan of care for the first certification period 6/26/25-8/24/25 also did not list specific tracheostomy or ventilator orders. “Admission Narrative” on the 8/25/25-10/23/25 care plan stated, “She is currently on the ventilator, setting verified and functioning properly. No s/s (signs and symptoms) of distress noted. Tracheostomy site assess. Clean and dry at this time. Education provided to support positioning of neck ties to CG (caregiver)….CG present and education provided on smoking safety, ventilator checks, suction technique and medication administration.” Hospitalization dates during current period include: 9/7/25-9/8/25, 9/14/25-9/16/25 and 9/17/25-9/19/25. Surveyor requested tracheostomy and ventilator orders on 9/25/25 at approximately 11:00 AM and was given only the following from the agency. Director of Nursing and Owner of agency stated during this time that the nurses use hospital discharge orders and Medication/Treatment Administration Record in addition to the care plan to determine the care needs of the patient. Durable Medical Equipment (DME) company (“Adapt Health”) order revealed updated tracheostomy orders from 9/16/25 which stated, “Tracheostomy Tube, 4, cuffed…Tracheostomy ties, Disposable inner cannula (2x daily change) standard length, 4, reusable inner cannula, Saline bullets…, tracheostomy care kit…that is signed by a medical practitioner on 9/16/25. DME Company “Adapt Health” orders from 7/10/25 concerning the ventilator stated, “V+Pro Invasive Ventilator…SIMV-Vol Breath rate 16, Tidal Volume 400, Peep +5, Pressure Support 10, Oxygen 2-7 LPM (liters per minute)…RT (respiratory therapist) to titrate any parameters not specified including Rise Time, Inspiratory Time, Trigger, Flow Pattern and comfort settings, RT to titrate ALL parameters to ranges specified…Vent 8-24 hours/day…Assessments: Download and clinical assessments including oximetry, HR (heart rate), breath sounds, oxygen titration, and alarm adjustment may be performed as needed, patient/caregiver to understand disease condition, outcomes and need for mechanical ventilator operation, troubleshooting, supplies and infection control, patient/caregiver to understand and be able to handle unexpected situations and the importance of reducing future admissions for exacerbation of disease process. Comments: SIMV mode at night (oxygen 2-7 LPM): Trach Collar 0-7 LPM oxygen during the day.” Order signed by a medical practitioner on 7/18/25. DME Company “Adapt Health” order from 9/19/25 concerning the ventilator stated adjustments to the settings “Bi-Level: Breath rate 0, EPAP 12, and IPAP 8….Ventilator continuous…” order signed by a medical practitioner on 9/19/25. There was no documentation in the care plan of the incorporation of the specific orders for the tracheostomy or ventilator as noted by the DME company above as it pertains to the patient or the nursing care regarding CR#1. The tracheostomy and ventilator orders were signed by a physician but were not incorporated into the patient's plan of care with the home health agency. On 9/26/25 at approximately 10:00 AM Director of Nursing stated while in the patient's residence the skilled nurses use hospital discharge paperwork and the "Medication/Treatment Administration Record" to complete their nursing responsibilities/tasks. Review of September 2025 "Medication/Treatment Administration Record" that was kept in the patient's home revealed the following tracheostomy/ventilator tasks/responsibilities: "Keep trach (tracheostomy) collar no more than 2 fingers width...Trach 4.0 cuffed. SP02 (oxygen level) goal 88-92.5...Trach size 4. Tube type: cuffless, Shiley, Nightly pressure support 12/8, Fi02 40%...PEEP 20/PEEP +7.5/35 % Wean back daily trach (tracheostomy) collar and nightly AVAPS (average volume-assured pressure support) when medically appropriate...Change inner (inner cannula) 9AM and 9PM daily...V+ Pro Invasive Ventilator or V Home Bi-Level rate 0, EPAP 12, IPAP 8, Vent (ventilator) continuous, tracheostomy tube, adult, standard length 4, cuffed, non-fenestrated... trach ties...reusable inner cannula 4, saline bullets sterile saline or water up to 5 cc daily, the pt (patient) is a respiratory suction pump and requires saline/sterile water to clean catheter daily...Vent settings: Set tidal volume: 350 ml, Set respiratory rate 16, clinical Fi02 35%, Titrate Fi02 to goal Sp02 of 88-92%, clinical PEEP 7.5...When Sp02 is stable and within goal range, titrate down Fi02 by 10-20% q (every) 15-30 min (minutes) to lowest Fi02 that maintains Sp02 within goal range." Most recent hospital discharge orders from 9/16/25 stated, "trach (tracheostomy) suctioning PRN (as needed), replace inner cannula PRN (as needed), humidified oxygen through trach (tracheostomy) collar to replace function of nasal cavity" signed by physician on 9/16/25. OASIS (Outcome and Assessment Information Set) Start of Care completed on 6/26/25. Assessment lists use of 6 Shiley XL trach. Narrative stated, "Patient with tracheostomy 6XL Shiley trach tube received in rehab lying in bed, connected to a portable ventilator. Patient presents with trach dependency on mechanical ventilation for 12 hours overnight and transitioned to trach collar with humidification during the day..." Per Director of Nursing on 9/25/25 at approximately 12:30 PM patient was assessed while still in hospital to ensure a smoother transition to care while at home. During interview with the director of nursing and owner on 9/26/25 at approximately 12:00 PM confirmed the findings noted above.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and interview with the director of nursing, the agency failed to record orders in patient's plan of care for one (1) of four (4) clinical records reviewed (CR#1) Findings include: Review of agency policy occurred on 9/26/25 and 9/29/25 approximately 2:00 PM and revealed the following: Policy titled, "2.8 Care Plan" stated, "To ensure that a patient's needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of services by the RN, based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment...Home Health services from members of the agency staff as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan...The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment...steps to be taken in developing the care plan include:...type of services,...equipment required...all patient care orders, including verbal orders, must be recorded in the plan of care..." Policy titled, "2.21 Physician/Allowed Practitioner's Plan of Treatment" stated, "A physician/allowed practitioner or allowed practitioner prepares a plan of treatment and it is made available to the agency...Physician/allowed practitioner's orders are established and documented for the health care services the agency provides...verbal orders may be accepted by Registered Nurses or other professionally licensed person (PT, OT, ST)...The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment...must include: all diagnoses relevant to the agency's plan of care, the type of services and equipment needed, frequency of visits needed, prognosis, medications and treatments, special diets and nutritional requirements, activities permitted, functional limitations, instructions for timely discharge and referral, IV therapy services, rehabilitation potential, safety measures to protect against injury, instructions for timely discharge or referral, other appropriate items, a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors...Any changes in the physician/allowed practitioner's plan of treatment shall be made in writing and signed and dated by the physician/allowed practitioner...." Review of Clinical Records occurred on 9/24/25 at approximately 2:00 PM, 9/25/25 and 9/26/25 at approximately 9:45AM, 9/29/25 and 9/30/25 at approximately 2:00PM and revealed the following: CR #1: Start of Care (SOC): 6/26/25. Home Health Certification and Plan of Care revealed current certification period of 8/25/25-10/23/25. Plan of care further revealed skilled nurse frequency of 24 hours per day for seven (7) days per week for nine (9) weeks. Plan of care did not list specific tracheostomy or ventilator orders. The previous plan of care for the first certification period 6/26/25-8/24/25 also did not list specific tracheostomy or ventilator orders. “Admission Narrative” on the 8/25/25-10/23/25 care plan stated, “She is currently on the ventilator, setting verified and functioning properly. No s/s (signs and symptoms) of distress noted. Tracheostomy site assess. Clean and dry at this time. Education provided to support positioning of neck ties to CG (caregiver)….CG present and education provided on smoking safety, ventilator checks, suction technique and medication administration.” Hospitalization dates during current period include: 9/7/25-9/8/25, 9/14/25-9/16/25 and 9/17/25-9/19/25. Surveyor requested tracheostomy and ventilator orders on 9/25/25 at approximately 11:00 AM and was given only the following from the agency. Director of Nursing and Owner of agency stated during this time that the nurses use hospital discharge orders and Medication/Treatment Administration Record in addition to the care plan to determine the care needs of the patient. Durable Medical Equipment (DME) company (“Adapt Health”) order revealed updated tracheostomy orders from 9/16/25 which stated, “Tracheostomy Tube, 4, cuffed…Tracheostomy ties, Disposable inner cannula (2x daily change) standard length, 4, reusable inner cannula, Saline bullets…, tracheostomy care kit…that is signed by a medical practitioner on 9/16/25. DME Company “Adapt Health” orders from 7/10/25 concerning the ventilator stated, “V+Pro Invasive Ventilator…SIMV-Vol Breath rate 16, Tidal Volume 400, Peep +5, Pressure Support 10, Oxygen 2-7 LPM (liters per minute)…RT (respiratory therapist) to titrate any parameters not specified including Rise Time, Inspiratory Time, Trigger, Flow Pattern and comfort settings, RT to titrate ALL parameters to ranges specified…Vent 8-24 hours/day…Assessments: Download and clinical assessments including oximetry, HR (heart rate), breath sounds, oxygen titration, and alarm adjustment may be performed as needed, patient/caregiver to understand disease condition, outcomes and need for mechanical ventilator operation, troubleshooting, supplies and infection control, patient/caregiver to understand and be able to handle unexpected situations and the importance of reducing future admissions for exacerbation of disease process. Comments: SIMV mode at night (oxygen 2-7 LPM): Trach Collar 0-7 LPM oxygen during the day.” Order signed by a medical practitioner on 7/18/25. DME Company “Adapt Health” order from 9/19/25 concerning the ventilator stated adjustments to the settings “Bi-Level: Breath rate 0, EPAP 12, and IPAP 8….Ventilator continuous…” order signed by a medical practitioner on 9/19/25. There was no documentation in the care plan of the incorporation of the specific orders for the tracheostomy or ventilator as noted by the DME company above as it pertains to the patient or the nursing care regarding CR#1. The tracheostomy and ventilator orders were signed by a physician but were not incorporated into the patient's plan of care with the home health agency. On 9/26/25 at approximately 10:00 AM Director of Nursing stated while in the patient's residence the skilled nurses use hospital discharge paperwork and the "Medication/Treatment Administration Record" to complete their nursing responsibilities/tasks. Review of September 2025 "Medication/Treatment Administration Record" that was kept in the patient's home revealed the following tracheostomy/ventilator tasks/responsibilities: "Keep trach (tracheostomy) collar no more than 2 fingers width...Trach 4.0 cuffed. SP02 (oxygen level) goal 88-92.5...Trach size 4. Tube type: cuffless, Shiley, Nightly pressure support 12/8, Fi02 40%...PEEP 20/PEEP +7.5/35 % Wean back daily trach (tracheostomy) collar and nightly AVAPS (average volume-assured pressure support) when medically appropriate...Change inner (inner cannula) 9AM and 9PM daily...V+ Pro Invasive Ventilator or V Home Bi-Level rate 0, EPAP 12, IPAP 8, Vent (ventilator) continuous, tracheostomy tube, adult, standard length 4, cuffed, non-fenestrated... trach ties...reusable inner cannula 4, saline bullets sterile saline or water up to 5 cc daily, the pt (patient) is a respiratory suction pump and requires saline/sterile water to clean catheter daily...Vent settings: Set tidal volume: 350 ml, Set respiratory rate 16, clinical Fi02 35%, Titrate Fi02 to goal Sp02 of 88-92%, clinical PEEP 7.5...When Sp02 is stable and within goal range, titrate down Fi02 by 10-20% q (every) 15-30 min (minutes) to lowest Fi02 that maintains Sp02 within goal range." Most recent hospital discharge orders from 9/16/25 stated, "trach (tracheostomy) suctioning PRN (as needed), replace inner cannula PRN (as needed), humidified oxygen through trach (tracheostomy) collar to replace function of nasal cavity" signed by physician on 9/16/25. OASIS (Outcome and Assessment Information Set) Start of Care completed on 6/26/25. Assessment lists use of 6 Shiley XL trach. Narrative stated, "Patient with tracheostomy 6XL Shiley trach tube received in rehab lying in bed, connected to a portable ventilator. Patient presents with trach dependency on mechanical ventilation for 12 hours overnight and transitioned to trach collar with humidification during the day..." Per Director of Nursing on 9/25/25 at approximately 12:30 PM patient was assessed while still in hospital to ensure a smoother transition to care while at home. During interview with the director of nursing and owner on 9/26/25 at approximately 12:00 PM confirmed the findings noted above.

Personnel qualifications CFR(s): 484.115 Condition of participation: Personnel qualifications. HHA staff are required to meet the following standards: This CONDITION is not met as evidenced by: Based on review of agency policies/procedures, clinical records (CR), personnel files (PF) and staff/administrative interview, the facility failed to ensure that all registered nurses have current license to practice in the state of Pennsylvania for one (1) of sixteen (16) skilled nurses with the agency (PF#15). This condition was not met based on non-compliance with above standards, and the nature and potential severity of the deficient practices. The cumulative effects of these deficient practices resulted in the agency's inability to ensure the health and safety of patients and resulted in Immediate Jeopardy. As a result of the systemic deficient practice that led to significant patient safety risk, an immediate jeopardy situation was identified on 9/26/25 at 12:00 PM. A first Removal Plan received from agency on 9/26/25 at 2:20PM and was rejected on 9/26/25 at 2:40PM. A second Removal Plan received from agency on 9/26/25 at 3:06PM and was rejected on 9/26/25 at 3:22PM. A third removal plan received from agency on 9/26/25 at 3:33 PM and was rejected on 9/26/25 at 3:37 PM. A fourth removal plan received from agency on 9/26/25 at 3:40 PM with approval of Forth Removal Plan on 9/26/25 at 3:45 PM. On-site verification completed September 26, 2025, at approximately 4:00PM verified that the agency completed implementation of the removal plan approved on September 26, 2025, removing the immediate jeopardy (IJ) through review of agency documentation and immediate removal of involved subject. Cross Reference: 484.115(k) Standard: Registered nurse. ·

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on a review of policies/procedures, clinical records, personnel files (PF), and interview with Agency staff the agency failed to ensure Registered Nurse was a graduate of an approved school of professional nursing who is license in the state of Pennsylvania for one (1) of sixteen (16) skilled nurses reviewed (PF# 15). A review of the following agency policies conducted on 9/26/25 starting at approximately 10:00 AM and revealed the following: Document titled, "Personnel File contents" stated, "Section 2: license copy with verification for professional staff...Section 3...Job description..." Document titled, "Title of Position: Administrator" stated, "Responsibilities...Recruits, employs and retains qualified personnel to maintain appropriate staffing levels...assures the development and qualifications of professional services and the assignment of personnel..." Document titled, "Title of Position: Registered Nurse" stated, "Qualifications...Must be a graduate from an accredited School of Nursing, Must be licensed in Pennsylvania as a Registered Nurse..." Review of personnel records occurred on 9/24/25 at approximately 2:00 PM, 9/25/25 and 9/26/25 at approximately 9:45AM, 9/29/25 and 9/30/25 at approximately 2:00PM and revealed the following: PF #15 Date of Hire: 6/5/25. File revealed no current Registered Nurse or Licensed practical Nurse licenses to practice in Pennsylvania. File review revealed New York State license for Registered Nurse that expires on 8/31/26 and Licensed Practical Nurse that expires on 2/28/26. Nursys.com report showed that PF#15 can practice in New York State and Connecticut only. Report also listed an expired Pennsylvania Licensed Practical Nurse license that expired on 6/30/20. There was no evidence of a signed job description stating Registered Nurse. Documentation of clinical visit notes completed (Clinical record #4) on 7/16/25 and 8/6/25 showed PF#15 signed as a Registered Nurse. An interview with the Director of Nursing and owner conducted on 9/26/25 at approximately 12:00 PM confirmed the above findings.

Based on the findings of an initial Medicare certification and state licensure survey conducted on October 24, 2023 and October 25, 2023, Honest Elite Caregivers, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an initial Medicare certification and state licensure survey conducted on October 24, 2023 and October 25, 2023, Honest Elite Caregivers, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included physician orders for PRN (as needed) skilled nursing (SN), for four (4) of ten (10) clinical records (CR) reviewed. (CR2, CR4, CR7, and CR10) Findings include: Reviewed agency policy number 2.3 titled “Service Policies Nursing Service” on 10/25/2023 at approximately 1:30PM. Policy states, “…3. Professional Nursing (Registered Nurse) Functions:…h. Informing the physician/allowed practitioner and other staff of changes in the patient’s condition/needs…” Policy number 2.8 titled “Care Plan” states, “…Evaluation of the Care Plan…1. A determination of whether the previously determined goals should be changed: a. When applicable, regularly contact the attending physician/allowed practitioner to discuss patient’s status, care plan and to obtain medical orders and/or recommendations…” Policy number 2.21 titled “Physician/Allowed Practitioner’s Plan of Treatment” states, “…12. Any changes in the physician/allowed practitioner’s plan of treatment shall be made in writing and signed and dated by the physician/allowed practitioner, or by the registered nurse on the staff of the agency pursuant to the verbal orders of the physician/allowed practitioner…” Policy number 2.43 titled “Clinical Record Contents” states, “…4. Change of Physician/Allowed Practitioner’s Orders: a. Changes in orders that occur before the orders are renewed are to be documented in the clinical record and a written request is to be sent to obtain the orders in writing…” Review of clinical records (CR), was conducted on 10/24/2023 from approximately 10:50AM until approximately 1:15PM revealed: CR2 - (Start of Care): 9/18/2023 – Certification Period: 9/18/2023 through 11/16/2023 (Primary Diagnosis – Left Ventricular Failure) – Contained orders for Skilled Nursing (SN): Two (2) visits per week for nine (9) weeks. During the week of 10/1/2023 – 10/7/2023, the SN visit schedule showed four (4) SN visits were conducted instead of two (2) SN visits as ordered. The administrator stated that the patient (CR2) is Diabetic and requires insulin injections. Physician's order states, "SN to prepare/teach patient/caregiver to administer insulin (dosage and frequency) using aseptic technique". The administrator stated that CR2 does not self-administer her insulin injections, and that her caregiver (son) administers her insulin. According to the administrator, CR2’s caregiver was on vacation on 10/1/2023 and 10/2/2023. Therefore, the agency made the decision to provide additional SN services on 10/1/2023 and 10/2/2023 to administer the insulin injections for CR2. Clinical record did not contain documentation that the agency needed to provide two (2) additional SN visits due to the patient's (CR2) caregiver being on vacation on 10/1/2023 and 10/2/2023. There also was no physician order for the two (2) additional SN visits, or an order for PRN (as needed) SN services. CR4 - (Start of Care): 9/29/2023 – Certification Period: 9/29/2023 through 11/27/2023 (Primary Diagnosis – Generalized Osteoarthritis) – Contained orders for Skilled Nursing (SN): Three (3) visits per week for nine (9) weeks. During the week of 10/15/2023 – 10/22/2023, the SN visit schedule showed four (4) SN visits were conducted instead of two (2) SN visits as ordered. The administrator stated that the patient (CR4) had a scheduled medical appointment on 10/16/2023 and was accompanied by an agency SN. Clinical record did not contain documentation that the agency needed to provide one (1) additional SN visit due to SN accompanying patient (CR4) to a medical appointment on 10/16/2023. Clinical record did not contain documentation that the patient (CR4) had a medical appointment scheduled for 10/16/2023 and that the SN would accompany CR4 to medical appointment. There also was no physician order for the two (2) additional SN visits, or an order for PRN (as needed) SN services. CR7 - (Start of Care): 8/16/2023 – Certification Period: 8/16/2023 through 10/14/2023 and discharged on 10/13/2023 (Primary Diagnosis – Rheumatoid Arthritis Right Hip) – Contained orders for Skilled Nursing (SN): Two (2) visits per week for nine (9) weeks. During the week of 9/10/2023 – 9/16/2023, the SN visit schedule showed three (3) SN visits were conducted instead of two (2) SN visits as ordered. The administrator stated that the SN visit on 9/16/2023 was a make-up visit for the missed visit on 8/21/2023. Clinical record did not contain documentation for the additional SN visit on 9/16/2023, and there was no physician order for the additional SN visit, or an order for PRN (as needed) SN services. CR10 - (Start of Care): 8/15/2023 – Certification Period: 8/15/2023 through 10/13/2023 and discharged on 10/13/2023 (Primary Diagnosis – Inflammatory Polyarthropathy) – Contained orders for Skilled Nursing (SN): two (2) visits per week for nine (9) weeks. During the week of 8/27/2023 – 9/2/2023, the SN visit schedule showed three (3) SN visits were conducted instead of two (2) SN visits as ordered. The administrator stated that the SN visit on 9/30/2023 was a make-up visit for when the patient (CR10) was on vacation from 8/16/2023 – 8/20/2023. Clinical record did not contain documentation for the additional SN visit on 9/30/2023, and there was no physician order for the additional SN visit, or an order for PRN (as needed) SN services. Interview with the administrator on 10/25/2023 at approximately 2:25PM confirmed the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records (CR), agency policies, and interview with the administrator, it was determined that the agency failed to ensure skilled nursing (SN) services were provided per physician’s orders, for five (5) of ten (10) clinical records (CR) reviewed. (CR4, CR6, CR7, CR8, and CR10) Findings include: Reviewed agency policy number 2.3 titled “Services Provided” on 10/25/2023 at approximately 1:20PM. Policy states, “…Registered Nurses/Licensed Practical Nurses: 1. Registered Nurses (RNs) provide quality nursing care by the visit or the shift. The highly training professionals follow the physician/allowed practitioner’s orders, monitor and instruct the patient regarding their care…” Policy number 2.30 titled “Refusal Of Care” states, “…Procedure: 1. When a patient declines care or treatment, the determination is made after an attempt has been made to explain the risks and benefits of such a decision and the consequences of it. 2. An explanation of the risks, benefits, and consequences of a refusal of care is provided to the patient and documented in the clinical record…” Review of clinical records (CR), was conducted on 10/24/2023 from approximately 10:50AM until approximately 1:15PM revealed: CR4 - (Start of Care): 9/29/2023 – Certification Period: 9/29/2023 through 11/27/2023 (Primary Diagnosis – Generalized Osteoarthritis) – Contained orders for Skilled Nursing (SN): Three (3) visits per week for nine (9) weeks. During the week of 9/29/2023 – 9/30/2023, only one (1) SN visit was conducted. The administrator stated that the patient (CR4) refused the scheduled visit for 9/30/2023. Clinical record did not contain documentation for the missed visit or that the physician was notified of the missed visit. CR6 - (Start of Care): 8/16/2023 – Certification Period: 8/16/2023 through 10/14/2023 and discharged on 10/13/2023 (Primary Diagnosis – Epilepsy) – Contained orders for Skilled Nursing (SN): Three (3) visits per week for nine (9) weeks. During the week of 8/16/2023 – 8/19/2023, only two (2) SN visits were conducted. The administrator stated that the patient (CR6) refused the third visit. Clinical record did not contain documentation for the missed visit or that the physician was notified of the missed visit. CR7 - (Start of Care): 8/16/2023 – Certification Period: 8/16/2023 through 10/14/2023 and discharged on 10/13/2023 (Primary Diagnosis – Rheumatoid Arthritis Right Hip) – Contained orders for Skilled Nursing (SN): Two (2) visits per week for nine (9) weeks. During the weeks of 8/16/2023 – 8/19/2023 and 8/20/2023 – 8/26/2023, only one (1) SN visit was conducted each week. The administrator stated that the patient (CR7) refused the scheduled visit for 8/18/2023, and the visit for 8/21/2023 was cancelled due to CR7’s medical appointment. Clinical record contained missed visit documentation for 8/21/2023, however, there was no documentation for the missed visit on 8/18/2023, or that the physician was notified of the missed visit. CR8 - (Start of Care): 9/29/2023 – Certification Period: 9/29/2023 through 11/27/2023 (Primary Diagnosis – Diabetes Mellitus Type 2, with Diabetic Chronic Kidney Disease) – Contained orders for Skilled Nursing (SN): Two (2) visits per week for nine (9) weeks. During the week of 9/29/2023 – 9/30/2023, only one (1) SN visit was conducted. The administrator stated that the patient (CR8) refused the scheduled visit for 9/30/2023. Clinical record did not contain documentation for the missed visit or that the physician was notified of the missed visit. CR10 - (Start of Care): 8/15/2023 – Certification Period: 8/15/2023 through 10/13/2023 and discharged on 10/13/2023 (Primary Diagnosis – Inflammatory Polyarthropathy) – Contained orders for Skilled Nursing (SN): two (2) visits per week for nine (9) weeks. During the week of 8/15/2023 – 8/19/2023, only one (1) SN visit was conducted. The administrator stated that the patient (CR10) was on vacation from 8/16/2023 – 8/20/2023. Clinical record did not contain documentation for the missed visit, that the physician was notified of the missed visit, or that the patient (CR10) was on vacation. Interview with the administrator on 10/25/2023 at approximately 2:25PM confirmed the above findings.