Every finding on record at Misbah Home Health Care LLC

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA followed the aide care plan for 1 of 1 patient receiving HHA services (Patient #3). Findings include: 1. Review of the Home Health Aide Services policy, dated 9/03/25, indicated “… A specific care plan is developed documenting the Aide services to be provided… The aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising nurse…” 2. Review of Patient #3’s clinical record included and Aide Care Plan which indicated the task of Bed Linen Change was to be completed weekly. Aide Visit Notes for 3/19/26, 3/20/26, 3/23/26, 3/24/26, and 3/25/26, all with the task of Bed Linen Change marked as completed. The clinical record failed to indicate HHA 1 was performing the task of Bed Linen Change only weekly. 3. During an interview on 3/26/26 at 5:09 PM, HHA 1 relayed she usually changed Patient #3’s bed linens two to three times per week. HHA 1 relayed she had changed Patient #3’s bed linens two times the previous week. 4. During an interview on 3/27/26 at 11:25 AM, the Administrator relayed the aide could change bed linens more frequently than the aide care plan indicated if the patient requested it, but if it was not a one-time thing, such as for a spill, the aide should notify the nurse to determine if the frequency needed to be increased.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: February 12, 13, 16, 17 and 18, 2026 Active Census: 9 At this Emergency Preparedness survey, Misbah Home Health Care LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

This visit was for an Initial State and Medicaid Licensure Survey of a Home Health provider. Survey Dates: February 12, 13, 16, 17 and 18, 2026 12-month Unduplicated Skilled Admissions: 12 Abbreviations Used: CM-Clinical Manager EMR-Electronic Medical Record HHA-Home Health Aide RN-Registered Nurse POC-Plan of Care SN-Skilled Nurse SOC-Start of Care

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, record review, and interview, the home health agency failed to ensure the comprehensive assessment included an accurate review of all patient medications for 5 of 9 active patient records reviewed (Patient #1, 3, 4, 6, 7) and 1 of 3 discharged patient records reviewed (Patient #12) and failed to ensure the drug interactions were reviewed by the physician for 2 of 9 active records reviewed (Patient #4 and 6). X. A home visit observation of HHA 1 providing care for Patient #3 was conducted on 2/13/26 at 4:57 PM. During the visit, observed glucose tablets with four carbohydrates per tablet (a supplement used to treat low blood sugar), Biofreeze roll-on and gel (a topically applied pain reliever), Clear Eyes Redness Relief eye drops (an over the counter eye drop to relieve eye redness due to irritation and mild dry eyes), and aspirin 81 milligram tablets (an over-the-counter medication used to prevent heart attacks and strokes). HHA 1 who was also a relative and caregiver of Patient #3, relayed Patient # 3 had been taking the glucose tablets as needed for low blood sugar for more than a year, had been using the Biofreeze as needed for pain for about two months, had been using the eye drops as needed for dry eyes for more than six months, and had been taking the aspirin daily at the doctor’s direction for over one year. Review of Patient #3’s clinical record included a medication list. The medication list failed to include glucose tablets, Biofreeze roll-on and/or gel, eye drops, or aspirin. During an interview on 2/17/26 at 1:57 PM, the Administrator, who conducted the recertification assessment for Patient #3 for the certification period 1/21/26 to 3/21/26, indicated she was not aware of the glucose tablets, Biofreeze roll-on and/or gel, eye drops, or aspirin in the Patient’s home. Findings include: 1. The 9/03/25 agency policy “Medication Profile” indicated at the admission professional will check all medications a client may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication; the clinician shall promptly report any identified problems to the physician and the medication profile should include route and frequency of administration. 2. The 9/03/25 agency policy “Medication Reconciliation” indicated the agency will reconcile all medication taken by the client prior to admission to home care with those ordered at the time of admission…at 60-day reassessment visits and at the time of discharge. 3. Patient #1’s clinical record evidenced a SOC on 9/26/25. The record included a recertification comprehensive assessment completed by the Administrator on 1/20/26 and a POC for the certification period 1/24/26 to 3/24/26. The recertification comprehensive assessment evidenced drug regimen review had been completed. During a home visit observation conducted with Patient #1 and the CM on 2/13/26 at 10:00 AM, Surveyor comparison of the home health agency’s POC medication list against the medications found in the home evidenced the following discrepancies: a) Losartan (used to treat high blood pressure) 50 milligrams (mg) 2 tablets by mouth daily was found in the home. This medication was listed on the home health agency’s medication profile as 100 mg, 1 tablet daily. The home health agency’s records failed to evidence the correct prescribed dose for Losartan. b) Docusate Sodium (used as a stool softener) 100 mg capsule was found in the home. The home health agency’s medication profile failed to evidence an order for Docusate Sodium. Per Patient #1, they use this medication daily as needed. c) Fluticasone Propionate-Salmeterol (used to treat COPD) 250-50 micrograms (mcg)/ACT, 1 puff in lungs two times a day was listed on the home health agency’s medication profile. This medication was not found in the home. Per Patient #1, they have not used this medication due to the high cost for several months. d) Fluticasone Propionate Nasal Suspension (used to treat allergies) 50 mcg/dose, 1 spray into both nare every day was listed on the home health agency’s medication profile. Per Patient #1, they only use this mediation as needed for allergies. During an interview on 2/16/26 at 2:15 PM, the Administrator relayed medications should have been reviewed during every visit. 5. Patient #4's clinical record evidenced a SOC on 10/08/25 and a recertification comprehensive assessment completed on 2/03/26 by the Administrator. The record failed to evidence the medication interactions had been performed and sent to the physician for review. During an interview on 2/17/26 at 2:15 PM, the Administrator relayed the clinical record for Patient #4 did not include documentation of the drug interactions completed. During an interview on 2/18/26 at 1:55 PM, the Administrator verified the agency did not have record of the drug interactions sent to the physician. 6. Patient #6's clinical record evidenced a SOC on 10/03/25 and a recertification comprehensive assessment completed on 1/29/26 by the CM. The record failed to evidence the medication interactions had been performed and sent to the physician for review. During an interview on 2/18/26 at 1:55 PM, the Administrator verified the agency did not have record of the drug interactions sent to the physician. 7. Patient #7’s clinical record included a POC for the certification period 12/21/25 to 2/18/26. The POC medication list evidenced the following discrepancy: a) Nurtec (used to migraines) 75 mg, one tablet by mouth as needed was listed on the home health agency POC medication profile. This medication failed to include the dosage frequency on the POC. During an interview on 2/17/26 at 3:11 PM, the CM relayed the Nurtec medication should have included a dosage frequency. 8. Patient #12’s discharged clinical record included a POC for the certification period 10/07/25 to 12/05/25. The POC medication list evidenced the following discrepancy: a) Ibuprofen (used to pain/fever) 600 mg, one tablet by mouth as needed was listed on the home health agency POC medication profile. This medication failed to include the dosage frequency and indication for use on the POC. During an interview on 2/17/26 at 2:42 PM, the CM relayed the as needed medications should include dosage frequency and indication for use.

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 record review and interview, the home health agency failed to establish a POC at the time of SOC with the patient’s physician for 1 of 6 active records reviewed with SOC in the past four months (Patient #6). Findings include: 1. The 9/03/25 agency policy “Plan of Care” indicated home care services are furnished under the supervision and direction of the client’s physician. 2. Patient #6’s clinical record evidenced a SOC completed on 10/03/25 by RN 1 and included a POC for the certification period 10/03/25 to 12/01/25. The clinical record failed to evidence collaboration with the physician for home health SOC and POC orders on 10/03/25 . During an interview on 2/17/26 at 2:42 PM, the CM verified the clinical record for Patient #6 did not evidence collaboration with the physician for POC orders.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the POC included accurate information regarding safety precautions, medical equipment, and SN intervention frequencies for 3 of 9 active records reviewed (Patient #2, 3, and 6). Findings include: 1. The Plan of Care policy, dated 9/03/25, indicated “… The Plan of Care shall be completed in full to include… Medications, treatments, and procedures… Medical supplies and equipment required… Any safety measures to protect against injury…” 2. Review of Patient #2’s clinical record included a POC for certification period 12/22/25 to 2/19/26. The POC included aspirin tablets (an antiplatelet medication used to prevent heart attacks and strokes) and Plavix (an antiplatelet medication used to prevent blood clots). The POC failed to include antiplatelet or bleeding precautions. During an interview on 2/17/26 at 3:26 PM, the CM relayed Patient #2’s POC should have included bleeding precautions, but it didn’t. 3. A home visit observation of HHA 1 providing care for Patient #3 was conducted on 2/13/26 at 4:57 PM. During the visit, observed there were no grab bars in Patient #3’s bedroom or bathroom. When asked where the grab bars were, HHA 1 relayed there were no grab bars in the home. Review of Patient #3’s POC for certification period 1/21/26 to 3/21/26 included grab bars in the durable medical equipment and supplies section. The POC failed to include only equipment the Patient had in the home. The POC included SN frequency of SN visits every other week for medication set up, assessment and education. The POC also included SN interventions to monitor the patient's condition weekly and assess for signs and symptoms of uncontrolled diabetes, to monitor blood pressure weekly, and to assess gait and balance weekly. The POC failed to align the frequency of SN visits with the frequency of interventions. During an interview on 2/17/26 at 1:57 PM, the Administrator relayed someone had been in the bathroom when she did the recertification assessment for certification period 1/21/26 to 3/21/26 so she had not observed whether there were grab bars. The Administrator also relayed she should have put every other week for the nursing interventions in the POC. 4. Patient #6’s clinical record included a POC for the certification period 1/31/26 to 3/31/26 with orders for SN visits every other week. The POC included SN interventions to monitor the patient's condition weekly, assess for signs and symptoms of uncontrolled diabetes, provide culturally appropriate education on diabetes management, medication adherence, diet and lifestyle modifications with interpreter assistance. The POC failed to align the frequency of SN visits with the frequency of interventions. During an interview on 2/17/26 at 3:02 PM, the CM relayed the SN interventions should have been changed on the POC to match the SN visit frequencies.

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 record review and interview, the agency failed to provide services as ordered by a physician for 2 of 7 active records reviewed with SN services only (Patient #6 and 9). X. Review of Patient #9’s clinical record included a POC for certification period 10/09/25 to 12/07/25 which was returned signed by the provider on 10/30/25. The record included a faxed order for SN frequency and medication set up labeled as a verbal order which was returned signed by the provider on 10/21/25. The record included a Patient Communication Log entry which indicated RN 1 had spoken with an RN at Patient #9’s provider’s office on 10/09/25 at 4:15 PM. The entry indicated a verbal order for SOC was requested, and indicated the provider was unavailable. A document from the provider’s office was provided by the CM on 2/18/26 at 2:01 PM. The document indicated the provider’s RN had relayed the assessment findings and plan for SN frequency and med set up to the provider on 10/09/25 at 4:21 PM. The document indicated the provider’s response was “Noted, thanks!” and the provider’s initials on 10/09/25 at 4:55 PM. The record included a SN visit note dated 10/16/25 in which the nurse filled Patient #9’s medication box. The agency failed to obtain provider orders for SN services prior to this SN visit. During an interview on 2/17/26 at 4:32 PM, the CM indicated she would look for the provider order for the SN visit on 10/16/25. During an interview on 2/18/25 at 2:01 PM, the CM relayed the document provided at that time was the only documentation she had received from the provider’s office related to the order from 10/09/25. Findings include: 1. The 9/03/25 agency policy “Physician/Allowed Non-Physician Practitioner Orders” indicated when the nurse or therapist receives a verbal order...he/she shall write the order as given and then read the order back to the physician verifying that the person receiving the order heard it correctly and interpreted the order correctly. The order must include the date, specific order, be signed...and sent to the physician/allowed non-physician practitioner for signature and date. 2. Patient #6’s clinical record evidenced a SOC on 10/03/25 and included a POC for the certification period 10/03/25 to 12/01/25. The clinical record failed to evidence collaboration with the physician for home health SOC and POC orders on 10/03/25 . The record evidenced SN visits were completed on 10/09/25, 10/16/25, 10/23/25 and 10/30/25. The clinical record failed to evidence a verbal or signed order for services that were provided on 10/09/25, 10/16/25, 10/23/25 and 10/30/25. During an interview on 2/17/26 at 2:42 PM, the CM verified the clinical record for Patient #6 did not evidence collaboration with the physician for POC orders.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the recertification POC was reviewed with the physician or attending practitioner no less frequently than once every 60 days, for 1 of 2 active records reviewed with SOC in the past four months (Patient #7). Findings include: 1. Patient #7’s clinical record evidenced a SOC on 10/22/25 and included a POC for the certification period 10/22/25 to 12/20/25 signed by Physician A on 11/06/25 and a recertification POC for the certification period 12/21/25 to 2/18/26 signed by Physician A on 2/16/26, 102 days later. The record failed to evidence the recertification POC and 60 Day Summary were sent to the attending physician at least every 60 days. During an interview on 2/18/26 at 10:41 AM, the Administrator verified the record did not include any documentation of the 60-day summary being sent to the physician until 2/16/26.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to collaborate with the Patient regarding discharge for 1 of 1 discharge record reviewed without documented reason for discharge (Patient #10). Findings include: 1. The 9/03/25 agency policy “Client Discharge Process” indicated the client will be given a fifteen (15) day notice of discharge and this will be documented in the chart. 2. Patient #10’s clinical record evidenced a discharge completed on 12/03/25. The record failed to evidence documentation that Patient #10 was given a 15-day notice of discharge. During an interview on 2/17/26 at 2:50 PM, the CM relayed the physician ordered the discharge on 12/03/25 and she verified the clinical record did not evidence documentation of the physician ordered discharge.

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 record review and interview, the home health agency failed to provide the frequency of visits to be furnished for 2 of 2 home visit observations with the CM (Patients #1 and 3). X. A home visit observation of HHA 1 providing care for Patient #3 was conducted on 2/13/26 at 4:57 PM. During the visit, reviewed the contents of Patient #3’s agency folder. The folder failed to include a schedule of home visits for February 2026. During an interview on 2/13/26 at 5:29 PM, HHA 1 relayed Patient #3 had not yet received a copy of the February visit schedule. Findings include: 1. Patient #1’s clinical record evidenced a SOC date of 9/26/25 and included a POC for the certification period 1/24/26 to 3/24/26. The record evidenced Patient #1 received 2 SN visits from 1/24/26 to 2/13/26. During a home visit observation on 2/13/26 at 10:00 AM, review of Patient #1’s home binder failed to include a copy of the current schedule of visits. 3. During an interview on 2/17/26 at 2:15 PM, the Administrator relayed the patient should have been given a copy of the visit schedule at the end of the month for the next month. 4. During an interview on 2/17/26 at 3:11 PM, the CM relayed the agency tries to get the schedule out monthly, as soon as possible.

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, record review, and interview, the home health agency failed to ensure staff followed infection control policies, procedures, and standards of care related to hand hygiene and equipment disinfection for 3 of 3 RN home visit observations (CM and RN 2). Findings include: 1. The Handwashing/ Hand Hygiene policy, dated 9/03/25, indicated “… Indications for handwashing and hand antisepsis… After removing gloves… After touching objects that are potentially contaminated… 2. The Visit Bag Technique policy, dated 9/03/25, indicated “… After use… Equipment must be placed on the dirty side of the barrier… Hand hygiene must be performed… Equipment must be cleaned and disinfected using an approved sanitizing agent…” 3. The Centers for Disease Control document Clinical Safety: Hand Hygiene for Healthcare Workers, found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, indicated “… If your task requires gloves, perform hand hygiene before donning gloves… Always clean your hands after removing gloves…” 4. A home visit observation of the CM providing care for Patient #2 was conducted on 2/13/26 at 11:22 AM. Observed the CM fill the medication box. The CM touched her pen with gloved hands and then touched Patient #2’s pills with the same gloves. The CM alternated touching the pen and the medication without glove change for each medication placed in the medication box. The CM failed to disinfect the pen which was touched multiple times during medication set up. After filling the medication box, the CM doffed her gloves and used an alcohol-based hand sanitizer. The CM then placed clean equipment in the nurse visit bag. The CM then donned gloves without again performing hand hygiene. During an interview on 2/17/26 at 3:31 PM, the CM indicated she had not been disinfecting the pen used during home visits but relayed the pen should have been disinfected. 5. During a home visit observation conducted with Patient #1 and the CM on 2/13/26 at 10:00 AM, the CM gathered the clipboard and papers from the nurse bag. She zipped the nurse bag closed and donned gloves. The CM failed to perform hand hygiene before donning gloves. During the observation, the CM filled the medication boxes. The CM touched her pen with gloved hands and then touched Patient #1’s pills with the same gloves. The CM alternated touching the pen and the medications without glove change for each medication placed in the medication box. The CM failed to disinfect the pen which was touched multiple times during medication set up. During an interview on 2/17/26 at 3:11 PM, the CM relayed the ink pen is clean when removed from the nurse bag and should have been considered dirty after use. She also relayed gloves should have been changed after touching the ink pen.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the skilled nurse failed to conduct a complete physical assessment for 2 of 2 home visit observations conducted with the CM (Patient #1 and 2). X. A home visit observation of the CM providing care for Patient #2 was conducted on 2/13/26 at 11:22 AM. Observed the CM auscultate Patient #2’s heart tones for 15 seconds. The CM failed to auscultate the Patient’s heart tones for at least one minute. During an interview on 2/17/26 at 3:32 PM, the CM she had not listened to Patient #2’s heart tones for one minute because she did not have a provider order for an apical pulse. Findings include: 1. Review of chapter 9 of Nursing Skills edited by K. Ernstmeyer and E. Christman, published in 2021, and found on the National Institutes of Health website at https://www.ncbi.nlm.nih.gov/books/NBK593199/ indicated when auscultating for heart sounds, “The apical pulse should be counted over a 60-second period… it is important to identify the S1 [‘lub’] and S2 [‘dub’] sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.” 2. During a home visit observation with Patient #1 on 2/13/26 at 10:00 AM, the CM assessed Patient #1’s heart sounds anteriorly in six areas. The CM failed to assess the apical pulse for at least 60 seconds. During an interview on 2/17/26 at 2:15 PM, the Administrator relayed heart tones should be assessed apically for at least a minute. During an interview on 2/17/26 at 3:11 PM, the CM relayed lung sounds should be assessed on the landmarks of the heart and she verified she did not assess Patient #1’s apical pulse.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review and interview, the home health agency failed to ensure the HHA performed the required competency skills evaluation tasks with a patient or pseudo patient (person acting as a patient) for 1 of 1 HHA file reviewed (HHA 1). Findings include: 1. HHA 1's personnel file evidenced a hire date of 9/15/25. The file included a Home Health Aide Competency Checklist completed by the CM on 9/15/25. The checklist failed to evidence how the skills were performed and what client/patient the skills were performed with. During an interview on 2/17/26 at 2:30 PM, the CM verified the Competency Checklist for HHA did not evidence the competency skills checkoffs were completed with a patient or pseudo-patient.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on personnel file review and interview, the home health agency failed to maintain the required HHA competency skills evaluation documentation for 1 of 1 HHA file reviewed (HHA 1). Findings include: 1. HHA 1's personnel file evidenced a hire date of 9/15/25. The file included a Home Health Aide Competency Checklist completed by the CM on 9/15/25. HHA 1’s personnel file failed to evidence the location and how the skills competencies were performed. During an interview on 2/17/26 at 2:30 PM, the CM verified HHA 1’s personnel file did not include where the check-offs were completed and who they were completed with.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure HHA visit documentation was accurate for 1 of 1 HHA (HHA 1). Findings include: 1. Review of the Home Health Aide Services policy, dated 9/03/25, indicated “… Home health aides must document each visit at the time care is provided…” 2. A home visit observation of HHA 1 providing care for Patient #3 was conducted on 2/13/26 at 4:57 PM. During the visit, HHA 1, who was also a relative and caregiver of Patient #3, relayed she had already assisted Patient #3 with bathing prior to the start of the visit. Review of Patient #3’s clinical record included an HHA visit note dated 2/13/26 with a start time of 5:00 PM and an end time of 8:00 PM. The HHA visit noted indicated the Personal Care, Cultural preference bucket with cup, task was completed. The HHA visit note failed to accurately reflect tasks completed during the HHA visit. During an interview on 2/17/26 at 4:32 PM, the CM indicated HHAs should not document tasks as completed that were not completed at the time of the HHA visit.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the clinical record included all orders and assessments for 2 of 9 active patient records reviewed (Patient #3 and 5). Findings include: 1. Review of the Clinical Documentation policy, dated 9/03/25, indicated “… A separate note shall be completed for each visit/shift and signed and dated by the appropriate professional. Actual time and length of the client visit will be included in each note…” 2. Review of the Physician/ Allowed Non-Physician Practitioner (NPP) Orders policy, dated 9/03/25, indicated “… All signed physician/non-physician practitioner (NPP) orders shall be maintained in the clinical record…” 3. Review of Patient #3’s clinical record failed to include the written recertification order signed by RN 1 on 11/18/25 at 10:53 AM. A copy of a written recertification order dated 11/18/25 and signed by the provider on 11/18/25 was provided by the Administrator on 2/18/26 at 10:49 AM. During an interview on 2/18/26 at 10:49 AM, the Administrator relayed she wasn’t sure why the order wasn’t showing up in the EMR, and the agency was reaching out to the EMR company. The Administrator further relayed the paper copy of the order was found in a folder of items that needed to be filed into the patient’s charts that were in the locked chart room. 4. Review of Patient #5’s clinical record included a Patient Communication Log entry by RN 1, a former agency employee, dated 10/03/25. The log entry indicated an initial evaluation was conducted on 10/03/25. The clinical record failed to include documentation of the content of the initial evaluation. During an interview on 2/18/26 at 12:17 PM, the CM indicated RN 1 couldn’t contact the provider on 10/03/25 so she went back out on 10/06/25 to complete the comprehensive assessment. The CM relayed there was no separate note for the initial assessment on 10/03/25 and relayed the information obtained on 10/03/25 was incorporated into the narrative of the comprehensive assessment dated 10/06/25.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 2 of 3 discharged records reviewed (Patient #10 and 12). Findings include: 1. The 9/03/25 agency policy “Client Discharge Process” indicated a completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the client after discharge withing 5 business days of the client’s discharge. 2. Patient #10’s clinical record evidenced a discharge date on 12/05/25 and included a copy of the discharge summary sent to the physician on 12/18/25. The record failed to evidence a discharge summary had been submitted to the physician within 5 days of discharge. During an interview on 2/18/26 at 10:44 AM, the Administrator verified the discharge summary was sent to the physician on 12/18/25, nine business days after discharge. 3. Patient #12’s clinical record evidenced a discharge date on 11/17/25 and included a copy of the discharge summary sent to the physician on 12/01/25. The record failed to evidence a discharge summary had been submitted to the physician within 5 days of discharge. During an interview on 2/18/26 at 10:45 AM, the CM verified the discharge summary was sent to the physician on 12/01/25, ten business days after discharge. 4. During an interview on 2/17/26 at 2:15 PM, the Administrator relayed the discharge summary is reviewed with the patient at the time of discharge and should be sent to the physician within two days. 5. During an interview on 2/17/26 at 2:42 PM, the CM relayed the discharge summary is sent to the physician within five days of discharge.