Every finding on record at Modern Home Health,Inc.

Emergency Preparedness Survey

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to provide and maintain documentation of Emergency Preparedness (EP) training to staff and contract staff at least every two (2) years for 6 (S4PTA, S7PT, S8COTA, S9HHA, S11HHA, and S13HHA) of 10 personnel files reviewed for EP training. Findings: Review of S4PTA’s personnel record revealed a hire date of 04/25/2018. Further review revealed there was no documented evidence EP training was completed after 05/18/2023. Review of S7PT’s personnel record revealed a hire date of 03/23/2015. Further review revealed there was no documented evidence EP training was completed after 05/18/2023. Review of S8COTA’s personnel record revealed S8COTA was contract staff with a hire date of 02/11/2021. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S9HHA’s personnel record revealed a hire date of 08/07/2018. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S11HHA’s personnel record revealed a hire date of 03/08/2011. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. Review of S13HHA’s personnel record revealed a hire date of 07/27/2017. Further review revealed there was no documented evidence EP training was completed in 2023, 2024, or 2025. An interview was conducted with S1ADM on 05/15/2026 at 3:15 p.m. S1ADM confirmed the above staff and contract personnel files reviewed had no documented evidence EP training was completed every 2 years as required, and should have.

Recertification Survey Abbreviations: CMS- Centers for Medicare and Medicaid Services DSW- Direct Service Worker mg- milligram ml- milliliter OASIS- Outcome and Assessment Information Set OIG- Office of Inspector General POC- Plan of Care QAPI- Quality Assurance and Performance Improvement RN- Registered Nurse SC-Subcutaneous SN- Skilled Nurse SOC- Start of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 318 patients according to the agency’s active census. Findings: Review of the agency’s undated policy titled “Encoding and Reporting OASIS Data” revealed, in part: Policy The agency will electronically report all OASIS data collected in accordance with federal regulations. Special Instructions 1. Agency will encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the client. Review of the agency’s OASIS Final Validation Report dated 04/01/2026 revealed 47 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/03/2026 revealed 21 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/10/2026 revealed 44 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/15/2026 revealed 74 total records were submitted with 3 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Error Detail Report dated 04/01/2026 to 05/07/2026 revealed on 04/17/2026 there were 2 records submitted greater than 30 days of the completion date. The agency’s OASIS Final Validation report dated 04/17/2026 was requested and unavailable for review. Review of the agency’s OASIS Final Validation Report dated 04/22/2026 revealed 55 total records were submitted with 4 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/27/2026 revealed 28 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/29/2026 revealed 77 total records were submitted with 4 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/06/2026 revealed 37 total records were submitted with 3 records submitted greater than 30 days of the completion date. An interview was conducted with S1ADM on 05/18/2026 at 12:35 p.m. S1ADM stated all OASIS assessments should be submitted within 30 days of the completion date. The above OASIS Final Validation Reports and the agency’s OASIS Error Detail Report were reviewed. S1ADM confirmed the above OASIS assessments were submitted greater than 30 days of the completion date. S1ADM confirmed the agency had no OASIS Final Validation report dated 04/17/2026 available for review. S1ADM further confirmed the above mentioned 2 records submitted on 04/17/2026 were submitted greater than 30 days of the completion date.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to provide the patient and/or legal representative with the Administrator’s name in order to file complaints for 4 (#1, #2, #6, and #7) of 7 patients with home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S4PTA on 05/12/2026 at 2:22 p.m. S4PTA reviewed Patient #1’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S7PT on 05/12/2026 at 2:00 p.m. S7PT reviewed Patient #2’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S10LPN on 05/13/2026 at 10:32 a.m. S10LPN reviewed Patient #6’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/2/2026. A home visit was conducted with Patient #7 on 05/13/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of the name of the Administrator to be used when filing a complaint. An interview was conducted with S15LPN on 05/13/2026 at 12:46 p.m. S15LPN reviewed Patient #7’s Home Health folder and confirmed there was no documentation of the name of the agency’s Administrator to be used when filing a complaint and there should have been. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated office staff were responsible for placing a label with the Administrator’s name and contact information in the patient’s Home Health folder. He stated if the information was not there on admit, the clinician admitting the patient was responsible for writing the Administrator’s name and contact information in the patient’s Home Health folder. S1ADM was made aware of the above mentioned findings for Patient #1, #2, #6, and #7 and confirmed the name of the Administrator should have been documented on the patient’s Home Health folders. Findings:

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 observations, interviews and record reviews, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 3 (#1, #2 and #5) of 7 patients reviewed with home visits. Findings: Review of the agency’s undated policy titled, “Medication Reconciliation Policy & Procedure” revealed the following, in part: Policy: It is the policy of this agency to perform medication reconciliation for all patients receiving home health services to ensure accurate and complete medication information is communicated consistently throughout the course of care. Medication reconciliation will be completed upon admission … and whenever medication changed occur. Procedure: 1. Medication Reconciliation Requirements Medication reconciliation shall be completed: At Start of Care When medications are discontinued or changed 2. Responsibilities of the Clinician The admitting or assigned clinician is responsible for: 1. Obtaining a complete and accurate medication list including: Prescription medication Over-the-counter medications… 2. Comparing: Physician orders Hospital discharge instructions Medication bottles/packages in the home 3. Identifying discrepancies including: Omitted medications Incorrect dosages… 5. Updating the medication profile in the clinical record. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/24/2026 and had a current Certification Period of 04/24/2026 through 06/22/2026. Further review revealed Patient #1 had diagnoses, which included Type 2 Diabetes Mellitus with Hyperglycemia, Anxiety Disorder and Long Term Current Use of Insulin. Review of Patient #1’s current orders revealed Patient #1 was to receive Skilled Nursing Visits once weekly for one week, three times weekly for one week, twice weekly for two weeks then once weekly for five weeks. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. with S4PTA present in the home. Patient #1’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Humulin N Kwikpen Subcutaneous (SC) 100 units/ml 8 units SC daily was on the medication profile and the patient was taking 30 units SC every morning; and Xanax 0.5 mg take one tablet by mouth twice daily was on the medication profile and the patient was a 1 mg tablet by mouth twice daily. An interview was conducted with Patient #1 during the home visit on 05/12/2026 at 2:00 p.m. Patient #1 stated she had taken 30 units of Humulin N insulin daily for years. Patient #1 stated she took Xanax 1 mg tablets every morning and night. An interview was conducted with S4PTA on 05/12/2026 at 2:22 p.m. S4PTA confirmed the medications Patient #1 was taking and the medication profile should match and did not. An interview was conducted with S5LPN on 05/13/2026 at 2:41 p.m. S5LPN stated the nurses were responsible for reconciling patient medications each visit. S5LPN was made aware of the above mentioned medication discrepancies for Patient #1. S5LPN confirmed the medications Patient #1 was taking and the agency’s medication profile should match and did not. Patient #2 Review of Patient #2’s Clinical Record revealed she began receiving services from the Home Health Agency on 02/12/2026 and had a current Certification Period of 02/12/2026 through 06/11/2026. Further review revealed Patient #2 had diagnoses, which included Essential Hypertension and Depression, Unspecified. Review of Patient #2’s current orders revealed Patient #2 was ordered to receive Skilled Nursing Visits once weekly for nine weeks. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. with S7PT and her family member present. Patient #2’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Rexulti 0.5mg 1 tablet by mouth daily was not on the medication profile and the patient was taking a 0.5mg tablet by mouth daily. An interview was conducted with Patient #2’s family member during the home visit on 05/12/2026 at 2:00 p.m. She stated Patient #2 had taken Rexulti 0.5mg daily since 02/12/2026. An interview was conducted with S7PT on 05/12/2026 at 2:20 p.m. S7PT confirmed the medications Patient #2 was taking and the medication profile should match and did not. An interview was conducted with S6RN on 05/13/2026 at 2:55 p.m. S6RN stated the nurses should reconcile patient medications each visit. S6RN was made aware of the above mentioned medication discrepancies for Patient #2. S6RN confirmed the medications Patient #2 was taking and the agency’s medication profile should match and did not. Patient #5 Review of Patient #5’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/23/2026 and had a current Certification Period of 03/23/2026 through 05/21/2026. Patient #5 had diagnoses, which included Age-Related Osteoporosis with Current Pathological Fracture, Left Pelvis, Age-Related Osteoporosis with Current Pathological Fracture, Vertebrae, Unspecified Fall, and Subsequent Encounter, and Bilateral Primary Osteoarthritis of Hip. Review of Patient #5’s current orders revealed Patient #5 was to receive Skilled Nursing Visits twice weekly for two weeks, then once weekly for seven weeks as of 03/24/2026. A home visit was conducted with Patient #5 on 05/12/2026 at 8:35 a.m. with S9HHA present. Patient #5’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Stool Softener 1 tablet by mouth daily was not on the medication profile and the patient was taking 1 tablet daily. Probiotic 1 soft gel every evening was not on the medication profile and the patient was taking 1 soft gel every evening. An interview was conducted with Patient #5 during the home visit on 05/12/2026 at 9:00 a.m. She stated she has taken the Stool Softener daily and Probiotic soft gel every evening since 04/23/2026. An interview was conducted with S3RN on 05/13/2026 at 3:45 p.m. S3RN stated nurses were responsible for reconciling patient’s medications each visit. S3RN was made aware of the above mentioned medication discrepancies for Patient #5. S3RN confirmed the medications Patient #5 was taking and the agency’s medication profile should match and did not. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated patient medications should be reconciled during each home visit by the agency’s nurses. He was made aware of Patient #1, #2 and #5’s medication discrepancies identified during their home visits. S1ADM confirmed the medications each patient were currently taking should have matched the patient’s current medication profile.

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 reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 2 (#15 and #17) of 17 sampled patients reviewed. Findings: Review of the agency’s undated policy titled, “MD (Medical Doctor) Order Policy and Procedures” revealed in part: Policy The agency shall ensure that all patient care is provided according to a physician/provider approved Plan of Care (POC) and authorized physician/provider orders. Services shall be coordinated, documented, and periodically reviewed to ensure patient needs are met safely and effectively. Procedure 4. Plan of Care Review and Updates 1. The POC shall be reviewed: at least every 60 days. Patient #17 Review of Patient #17's clinical record revealed a SOC date of 07/11/2025. Review of Patient #17’s POC for certification period 07/11/2025 through 09/08/2025 revealed Patient #17’s physician reviewed and signed the POC on 10/02/2025, which was not within the 60 day timeframe. Review of Patient #17’s POC for certification period 11/08/2025 through 01/06/2026 revealed Patient #17’s physician reviewed and signed the POC on 02/25/2026, which was not within the 60 day timeframe. An interview was conducted with S1ADM on 05/14/2026 at 3:07 p.m. The above mentioned POCs for Patients #15 and #17 were reviewed. S1ADM confirmed Patients #15 and #17’s POC orders were not reviewed and signed by the physician within the 60 day timeframe, and should have been. Findings: Patient #15 Review of Patient #15’s clinical record revealed a Start of Care (SOC) date or 01/05/2022. Review of Patient #15’s POC for certification period 04/29/2025 through 06/17/2025 revealed Patient #15’s physician reviewed and signed the POC on 07/17/2025, which was not within the 60 day timeframe. Review of Patient #15’s POC for certification period 06/18/2025 through 08/16/2025 revealed Patient #15’s physician reviewed and signed the POC on 09/15/2025, which was not within the 60 day timeframe.

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 reviews, the agency failed to provide the patient and/or caregiver with a copy of written instructions of the Home Health outlining the visit schedule, including frequencies of visits consistent with the current plan of care for 7 (#1, #2, #3, #4, #5, #6, and #7) of 7 patient home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions outlining Patient #1’s Home Health visit schedule, including the frequency of visits. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions outlining Patient #2’s Home Health visit schedule, including the frequency of visits. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions outlining Patient #3’s Home Health visit schedule, including the frequency of visits. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/29/2026, and had a current Certification Period of 04/24/2026 through 06/22/2026. A home visit was conducted with Patient #4 on 05/13/2026 at 11:30 p.m. Review of Patient #4’s Home Health folder revealed no documentation of written instructions outlining Patient #4’s Home Health visit schedule, including the frequency of visits. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions outlining Patient #5’s Home Health visit schedule, including the frequency of visits. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of written instructions outlining Patient #6’s Home Health visit schedule, including the frequency of visits. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/29/2026. A home visit was conducted with Patient #7 on 05/13/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of written instructions outlining Patient #7’s Home Health visit schedule, including the frequency of visits. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. He stated the admitting clinicians gave the patient and/or caregiver a verbal visit schedule. He was made aware of the above mentioned findings during the home visits for Patient’s #1, #2, #3, #4, #5, #6 and #7. S1ADM confirmed he was unaware of the requirement a written visit schedule including the frequency of visits was required to be provided to the patients and/or caregivers. Findings: Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions outlining Patient #2’s Home Health visit schedule, including the frequency of visits. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions outlining Patient #3’s Home Health visit schedule, including the frequency of visits. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions outlining Patient #5’s Home Health visit schedule, including the frequency of visits.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to provide the patient and/or caregiver with a copy of written instructions of the patient’s medication regimen for 7 (#1, #2, #3, #4, #5, #6, and #7) of 7 patient home visits conducted. Patient #1 Review of Patient #1’s Clinical Record revealed she was admitted to the agency on 04/24/2026, and had a current Certification Period of 04/26/2026 through 06/22/2026. A home visit was conducted with Patient #1 on 05/12/2026 at 1:40 p.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions for Patient #1’s medication regimen. Patient #2 Review of Patient #2’s Clinical Record revealed she was admitted to the agency on 02/12/2026, and had a current Certification Period of 04/13/2026 through 06/11/2026. A home visit was conducted with Patient #2 on 05/12/2026 at 1:30 p.m. Review of Patient #2’s Home Health folder revealed no documentation of written instructions for Patient #2’s medication regimen. Patient #3 Review of Patient #3’s Clinical Record revealed he was admitted to the agency on 05/08/2026, and had a current Certification Period of 05/08/2026 through 07/06/2026. A home visit was conducted with Patient #3 on 05/12/2026 at 3:00 p.m. Review of Patient #3’s Home Health folder revealed no documentation of written instructions for Patient #3’s medication regimen. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 04/29/2025, and had a current Certification Period of 04/24/2026 through 06/22/2026. A home visit was conducted with Patient #4 on 05/13/2026 at 11:30 a.m. Review of Patient #1’s Home Health folder revealed no documentation of written instructions for Patient #4’s medication regimen. Patient #5 Review of Patient #5’s Clinical Record revealed she was admitted to the agency on 03/23/2026, and had a current Certification Period of 03/23/2026 through 05/21/2026. A home visit was conducted with Patient #5 on 05/13/2026 at 8:35 a.m. Review of Patient #5’s Home Health folder revealed no documentation of written instructions for Patient #5’s medication regimen. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 03/26/2026, and had a current Certification Period of 03/26/2026 through 05/24/2026. A home visit was conducted with Patient #6 on 05/13/2026 at 10:15 a.m. Review of Patient #6’s Home Health folder revealed no documentation of written instructions for Patient #6’s medication regimen. Patient #7 Review of Patient #7’s Clinical Record revealed she was admitted to the agency on 03/31/2026, and had a current Certification Period of 03/31/2026 through 05/29/2026. A home visit was conducted with Patient #7 on 05/12/2026 at 12:30 p.m. Review of Patient #7’s Home Health folder revealed no documentation of written instructions for Patient #7’s medication regimen. An interview was conducted with S1ADM on 05/14/2026 at 10:25 a.m. S1ADM was made aware of the above mentioned findings during the home visits for Patient’s #1, #2, #3, #4, #5, #6 and #7. S1ADM confirmed each patient should have been provided written instructions of the medication regimen. Findings:

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the Registered Nurse (RN) provided home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 2 (#15 and #16) of 6 patients reviewed for Pressure Ulcers. The agency failed to ensure the RN assessed Patient #15 and #16’s Pressure Ulcers, including size and stage, on a weekly basis. Findings: Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the Registered Nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the Pressure Ulcers initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Review of the agency’s undated policy titled “Wound Care Policy & Procedure”, revealed the following, in part: The agency shall provide wound and pressure ulcer care according to physician/provider orders, current clinical standards, and applicable federal/state guidelines. Responsibilities Registered Nurse (RN) Performs comprehensive wound assessment Provides wound treatment Supervises LPN… Procedure: Upon admission and as needed thereafter, the clinician shall: To assess all pressure ulcer injuries on a weekly basis. Patient #15 Review of Patient #15’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/05/2022, had a certification period of 06/18/2025 to 08/16/2025, and was discharged from the agency on 07/11/2025. Patient #15 had diagnoses, which included Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Buttock, Stage 4 Pressure Ulcer of Right Heel, Stage 4 Pressure Ulcer of Left Ankle, and Stage 3 Pressure Ulcer of Other Site. Review of Patient #15’s Plan of Care for Certification Period 06/18/2025 to 08/16/2025 revealed the following, in part: Skilled Nursing Visits once weekly for nine weeks effective 06/18/2025. Skilled Nurse (SN) to perform wound care to Right Heel Pressure Ulcer, Left Foot Pressure Ulcer, Left Ischial Pressure Ulcer, Right Hip Pressure Ulcer, and Right Anterior Foot Pressure Ulcer once a week and as needed. Review of Patient #15’s Skilled Nursing Visit notes conducted for Certification Period 06/18/2025 to 08/16/2025 revealed Patient #15’s Stage 4 Pressure Ulcer of Right Hip, Stage 4 Pressure Ulcer of Left Buttock, Stage 4 Pressure Ulcer of Right Heel, Stage 4 Pressure Ulcer of Left Ankle, and Stage 3 Pressure Ulcer of Other Site was not assessed by a RN, to include measurements the weeks of 06/20/2025, 06/27/2025, 07/01/2025 and 07/11/2025. An interview was conducted with S1ADM on 05/14/2026 at 11:00 a.m. He reviewed Patient #15’s Clinical Record and confirmed Patient #15 had Pressure Ulcers on admission until discharge. He confirmed Patient #15’s Pressure Ulcers were not assessed by a RN on the above mentioned weeks. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 05/31/2025, had a certification period of 05/31/2025 to 07/29/2025, and was discharged from the agency on 07/18/2025. Patient #16 had diagnoses, which included Stage 2 Pressure Ulcer of Left Buttock and Stage 1 Pressure Ulcer of Sacral Region. Review of Patient #16’s Plan of Care for Certification Period 05/31/2025 to 07/29/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week, twice weekly for two weeks then once weekly for six weeks; and Skilled Nurse (SN) to perform/instruct caregiver on wound care to Left Buttock Pressure Ulcer and Sacral Pressure Ulcer three times a week and as needed. Review of Patient #16’s Physician Order dated 06/04/2025 revealed the following, in part: Increase Skilled Nursing Visits to three times weekly; and Skilled Nurse (SN) to perform wound care to Left Buttock Pressure Ulcer and Sacral Pressure Ulcer three times a week and as needed. Review of Patient #16’s Skilled Nursing Visit notes conducted for Certification Period 05/31/2025 to 07/29/2025 revealed Patient #16’s Stage 2 Left Buttock Pressure Ulcer and Stage 1 Sacral Pressure Ulcer was not assessed by a RN, to include measurements the weeks of 06/01/2025, 06/08/2025, 06/15/2025, 06/22/2025, and 07/06/2025. An interview was conducted with S1ADM on 05/14/2026 at 10:35 a.m. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had Pressure Ulcers on admission until discharge. He confirmed Patient #16’s Pressure Ulcers were not assessed by a RN on the above mentioned weeks. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to have completed clinical documentation of skilled nursing services provided according to the Plan of Care (POC) for 1 (#9) of 17 patient records reviewed. Findings: Review of the agency’s undated policy titled “Policy and Procedures for Clinical Documentation” revealed, in part: Procedures Completion TimelineRoutine visit notes: Completed and submitted with 48 hours of the visit. Review of Patient #9’s Clinical Record revealed she was admitted to the agency on 01/05/2026 with a current Certification Period of 05/05/2026 through 07/03/2026. The patient's diagnoses included, in part: Pressure Ulcer of Right Buttock, Stage 2, Pressure Ulcer of Other Site, Stage 2, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Acquired Absence of Right Leg, Below Knee. Review of the Plan of Care (POC) orders for Patient #9 for Certification Period 05/05/2026 through 07/03/2026 revealed, in part: Skilled Nurse visits one time a week for one week, then two times a week for 8 weeks. Skilled Nurse to perform wound care to Right Buttock twice a week and as needed. Skilled Nurse to perform wound care to Sacral wound twice a week and as needed. Skilled Nurse to perform wound care to Right Lower Extremity, Below Knee Amputation weekly. Review of Patient #9’s Visit Calendar revealed Patient #9 was seen by S3RN on 05/07/2026 for labs and 05/11/2026 for wound care. Further review revealed clinical note documentation for the above dates were not available for review as of 05/15/2026 at 10:51 a.m. An interview was conducted with S3RN on 05/15/2026 at 11:26 a.m. S3RN confirmed Patient #9 was seen for skilled nursing services on 05/07/2026 and 05/11/2026. S3RN confirmed all visit notes should be completed timely per agency policy. S3RN confirmed Patient #9’s skilled nurse visit documentation for 05/07/2026 and 05/11/2026 should have been completed per agency policy, and were not. An interview was conducted with S1ADM on 05/15/2026 at 11:38 a.m. S1ADM stated the agency’s policy for clinical documentation required all clinical staff to turn in visit documentation within 48 hours of their visit. Patient #9’s skilled nursing visit calendar was reviewed. S1ADM confirmed Patient #9’s skilled nurse visits on 05/07/2026 and 05/11/2026 should have been documented and available for review within 48 hours of the visit completion date, and were not.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the Registered Nurse or other appropriate skilled professional prepared written instructions for the Home Health Aide for 1 (#8) of 5 patients reviewed receiving home health aide services. Findings: Review of the agency’s undated policy titled, “Home Health Aide Policy” revealed the following, in part: Policy All home health aide services shall be provided according to a written patient-specific care plan developed and supervised by a registered nurse or qualified therapist. Home Health aides may only perform tasks assigned... Review of Patient #8’s Clinical Record revealed he was admitted to the agency on 05/02/2026, and had a current Certification Period of 05/02/2026 through 06/30/2026. Review of Patient #8's Physician Orders dated 05/08/2026 revealed Home Health Aide services were ordered for two (2) home health aide visits per week for 2 weeks, and one (1) home health aide visit per week for 4 weeks. Review of Patient #8's Visit Calendar revealed he had received home health aide visits on 05/12/2026 and 05/14/2026. Further review revealed a written plan of care with instructions for the home health aide had not been completed. An interview was conducted with S2RN on 05/15/2026 at 10:26 a.m. S2RN stated she had not completed a Care Plan with written instructions for the home health aide to care for Patient #8. An interview was conducted with S1ADM on 05/15/2026 at 10:35 a.m. S1ADM reviewed Patient #8’s clinical record and confirmed the above Physician’s order dated 05/08/2026 for Patient #8 to receive home health aide services. S1ADM confirmed there was no documented evidence of a home health aide care plan completed prior to a home health aide visit completed, and should have been.

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 reviews and interviews, the agency failed to ensure a completed discharge summary was sent to the patients’ primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge within 5 business days of the patients’ discharge from the agency for 6 (#4, #13, #14, #15, #16 and #17) of 6 patients reviewed for discharge. Review of the agency’s undated policy titled, “Discharge Planning Policy & Procedure” revealed the following, in part: Policy: It is the policy of this agency to ensure all patients receiving home health services are discharged in a safe, timely, and coordinated manner based on achievements of goals, physician orders, patient choice, transfer to a higher or alternate level of care, inability to safely continue services, or when home health eligibility criteria are no longer met. Procedure: 7. Quality Assurance The agency will monitor discharge planning processes through periodic chart audits, OASIS review, and QAPI activities to ensure: Appropriate coordination of care… Compliance with state and federal regulations. Patient #4 Review of Patient #4’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/21/2025, had a certification period of 2/21/2025 to 04/21/2025, and was discharged from the agency on 04/21/2025. Review of Patient #4’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #4’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 10:45 a.m. He reviewed Patient #4’s Clinical Record and verified the patient was discharged from the agency on 04/21/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #13 Review of Patient #13’s Clinical Record revealed he began receiving services from the Home Health Agency on 12/12/2025, had a certification period of 12/12/2025 to 02/09/2026, and was discharged from the agency on 01/02/2026. Review of Patient #13’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #13’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 11:45 a.m. He reviewed Patient #13’s Clinical Record and verified the patient was discharged from the agency on 01/02/2026. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #14 Review of Patient #14’s Clinical Record revealed he began receiving services from the Home Health Agency on 09/16/2025, had a certification period of 11/15/2025 to 01/13/2026, and was discharged from the agency on 12/11/2025. Review of Patient #14’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #14’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/12/2026 at 3:40 p.m. He reviewed Patient #14’s Clinical Record and verified the patient was discharged from the agency on 12/11/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #15 Review of Patient #15’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/05/2022, had a certification period of 06/18/2025 to 08/16/2025, and was discharged from the agency on 07/11/2025. Review of Patient #15’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #15’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 11:00 a.m. He reviewed Patient #15’s clinical record and verified the patient was discharged from the agency on 07/11/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 05/31/2025, had a certification period of 05/31/2025 to 07/29/2025, and was discharged from the agency on 07/18/2025. Review of Patient #16’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #16’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 10:35 a.m. He reviewed Patient #16’s clinical record and verified the patient was discharged from the agency on 07/18/2025. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Patient #17 Review of Patient #17’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/11/2025, had a certification period of 01/07/2026 to 03/07/2026, and was discharged from the agency on 01/31/2026. Review of Patient #17’s Clinical Record revealed no documented evidence a completed discharge summary was sent to the health care provider who would be assuming responsibility for Patient #17’s care and services upon their discharge from the agency. An interview was conducted with S1ADM on 05/14/2026 at 3:07 p.m. He reviewed Patient #17’s clinical record and verified the patient was discharged from the agency on 01/31/2026. S1ADM confirmed there was no documented evidence the discharge summary was sent to the patient’s primary care physicians or home health ordering providers within 5 business days of the patient’s discharge. Findings:

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: ABD - Abdominal BID- twice daily BP – blood pressure CMS- Centers for Medicare and Medicaid Services COTA – Certified Occupational Therapist Assistant DON- Director of Nursing HHA- Home Health Aide IU – International Units LPN- Licensed Practical Nurse meq - milliequivalent mg - milligram OASIS- Outcome and Assessment Information Set OSHA – Occupational Safety and Health Administration OT – Occupational Therapist PRN- as needed PT – Physical Therapist PTA- Physical Therapist Assistant RN- Registered Nurse SLP – Speech Language Pathologist SN – Skilled Nurse SOC – Start of Care TID- three times daily

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) as evidenced by failing to ensure the agency successfully completed and transmitted OASIS data within 30 days of completion. Review of the agency’s policy titled “Encoding and Reporting Oasis Data” revealed, in part: Policy: The agency will electronically report all OASIS data collected in accordance with federal regulations. Special Instructions: 1. Agency will encode and electronically transmit each completed OASIS assessment to the CMS (Center for Medicare and Medicaid Services) system within 30 days of completing the assessment of the client. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/03/2023 revealed 32 records were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/14/2023 revealed 38 records were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 08/17/2023 revealed 36 records were submitted more than 30 days after the date of completion on the record, which was late. On 08/31/2023 at 10:41 a.m., a phone interview was conducted with S10BM at [corporate company]. She confirmed she was responsible for all OASIS submissions for this agency. She stated she was required to submit completed OASIS weekly. She stated she emailed the OASIS validation reports to S2DON for review. She stated she was not aware of any OASIS submissions deemed late, because she doesn’t review those reports. She confirmed she was supposed to submit all completed OASIS weekly but stated she had not always been able to submit them weekly. On 08/31/2023 at 11:00 a.m., an interview was conducted with S2DON. He confirmed S10BM was responsible for the submission of all Oasis data for this agency. S2DON further confirmed he was responsible for reviewing the validation reports for accuracy, including if any submissions were late, or > 30 days of the M0090 completion date. The aforementioned validation reports were reviewed for the submission dates of 08/03/2023, 08/14/2023 and 08/17/2023. S2DON confirmed the OASIS assessments aforementioned on these dates were submitted after the 30 days of the M0090 completion date and were late.

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 observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using, and/or did not reflect medications the patients were no longer using, for 4 (#1, #3, #4, and #5) of 7 (Patients #1, #2, #3, #4, #5, #6, and #7) sampled patients reviewed who received home visits. On 08/28/2023 at 9:37 a.m., an entrance conference interview was conducted with S1ADM. She was asked to explain the agency's policy or expectation regarding the frequency of patients' drug regimen reviews. S1ADM stated she expected the medication review to be performed by the nurse or therapist every visit. Review of the Agency’s policy entitled Medication Profile revealed the following, in part: Policy: The Agency provides a mechanism for documentation of patient prescriptions, nonprescription (over the counter) medications and home remedies, including vitamins and herbs. Purpose: To identify and document medication, dose, strength, frequency and route. Procedure: 4. The nurse or therapist will add all new/changed medication(s) to the medication profile. Discontinued (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur. Patient #1 Review of the clinical record revealed a start of care date of 03/26/2023. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 07/24/2023 to 09/21/2023 revealed a primary diagnosis of Pressure Ulcer of Left Heel, Stage 4. Further review of the 485 revealed orders which included SN 2w8, 1w1. The patient’s current medication profile list was provided by S2DON on 08/28/2023. On 08/28/2023 at 3:00 p.m., a home visit was conducted in the home of Patient #1 with S4LPN. The patient provided his medications for review. Patient #1 verified the medications provided for review were the medications he was currently taking. Review of the medications listed on the patient’s current medication profile list provided by S2DON revealed the following discrepancies when compared with medications in the home: 1. Percocet Oral 5-325 mg 1 tablet by mouth 2 times per day PRN pain was listed as a current medication. A bottle of the medication with a prescription fill date of 08/11/2023 was observed in the home. Instructions on the bottle stated 10/325 mg 1 tablet 2 times a day PRN pain. Patient #1 verified this was his current dose which he had been taking for at least 2 months. 2. An over-the-counter bottle of Magnesium 250 mg was observed in the home. This medication was not listed as a current medication on the medication profile list provided by the Agency. Patient #1 verified he has been taking 2 tablets (500 mg) daily for at least a year. S4LPN verified the patient was seen by a nurse twice a week. She further verified the medication list was not up to date. A review of the SN visit documentation revealed SN visits were conducted with Patient #1 on the following dates during the current Certification Period of 07/24/2023 to the present date of 08/28/2023: 07/24/2023, 07/28/2023, 07/31/2023, 08/02/2023, 08/04/2023, 08/07/2023, and 08/09/2023. Patient #3 Review of the clinical record revealed a start of care date of 01/29/2019. The patient's primary diagnosis was Nonalcoholic Steatohepatitis (NASH). A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 08/22/2023 to 10/20/2023 revealed orders which included SN 1w4. The patient's current medication profile list was provided by S2DON on 08/28/2023. On 08/29/2023 at 9:45 a.m., a home visit was conducted in the home of Patient #3 with S9HHA present. Patient #3’s spouse provided Patient #3’s medications for review. Patient #3’s spouse verified the medications provided for review were the medications Patient #3 was currently taking. Review of the medications listed on the patient’s current medication profile list provided by S2DON revealed the following discrepancies when compared with medications in the home: 1. Fluorouracil External 5% was not observed in the home. This medication was listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had no longer been taking this medication for quite some time. 2. Fluconazole 200mg was not observed in the home. This medication was listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had no longer been taking this medication for quite some time. 3. Hyzaar 100-12.5mg was not observed in the home. This medication was listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had no longer been taking this medication for quite some time. 4. A bottle of Acetaminophen-Codeine #3 300mg-30mg was observed in the home. This medication was not listed on the medication profile list provided by the Agency. The prescription fill date was 01/06/2023. Patient #3’s spouse verified Patient #3 had been taking this medication three times daily PRN pain for at least 2 weeks. 5. A bottle of Trazadone 50mg was observed in the home. This medication was not listed on the medication profile list provided by the Agency. The prescription fill date was 08/29/2022. Instructions on the bottle stated 50mg tablet by mouth at bedtime. Patient #3’s spouse verified Patient #3 had been taking one half tablet= 25mg by mouth at bedtime since three months ago. 6. Amlodipine 10mg by mouth daily was listed on the medication profile list provided by the Agency. The prescription fill date was 04/06/2023. Instructions on the bottle stated 10 mg daily. Patient #3’s spouse verified he had been giving Patient #3 one half tablet= 5mg daily for at least 2 months. 7. A bottle of Klor Kon 10meq was observed in the home. This medication was not listed on the medication profile provided by the Agency. The prescription fill date was 07/24/2023. Patient #3’s spouse verified Patient #3 had been taking this medication for about a month. 8. A sample packet of Xifaxan 550mg was observed in the home. This medication was not listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had been taking this medication twice daily for at least 3 weeks. 9. An over-the-counter bottle of Magnesium 400mg was observed in the home. This medication was not listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had been taking this medication for at least 2 months. 10. An over-the-counter bottle of Vitamin D3 2000 international units was observed in the home. This medication was not listed on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had been taking this medication daily at least 2 months. 11. An over-the-counter bottle of Cinnamon 500mg was observed in the home. This medication was listed as a current medication on the medication profile list provided by the Agency. Patient #3’s spouse verified Patient #3 had been taking 1000mg (2 capsules) daily at least 2 months. A review of SN visit documentation revealed SN visits were conducted with Patient #3 on the following dates during the cert period 06/23/2023 to 08/21/2023 in part: 08/17/2023; and current Certification Period of 08/22/2023 to 10/20/2023 in part: 08/24/2023, 08/28/2023, and 08/30/2023. Patient #4 Review of the clinical record revealed a start of care date of 06/29/2023. The patient's primary diagnosis was Alzheimer’s Dementia. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/29/2023 to 08/27/2023 revealed orders which included SN 1w1, 2w1, 1w7. Certification Period 08/28/2023 to 10/26/2023 revealed orders which included SN 1w3. The patient's current medication profile list was provided by S2DON on 08/28/2023. On 08/29/2023 at 10:35 a.m., a home visit was conducted in the home of Patient #4 with S8PTA present. Patient #4’s spouse provided his medications for review. Patient #4’s spouse verified the medications provided for review were the medications Patient #4 was currently taking. Review of the medications listed on the patient’s current medication profile list provided by S2DON revealed the following discrepancies when compared with medications in the home: 1. A bottle of Glimeride 1mg by mouth daily before supper was observed in the home. This medication was not listed on the current medication profile list provided by the Agency. The prescription fill date was 04/17/2023. Patient #4’s spouse verified Patient #4 had been taking this medication since April 2023. 2. Amiodarone 200mg tablet by mouth daily was listed on the medication profile list provided by the Agency. The prescription fill date was 11/08/2022 with “½ tablet” written on the bottle top with permanent marker. Instruction on the bottle stated 200mg daily. Patient #4’s spouse verified Patient #4 had been taking 100mg= one half tablet daily since three months ago. A review of SN visit documentation revealed SN visits were conducted with Patient #4 on the following dates during the cert period 06/29/2023 to 08/27/2023, in part: 08/15/2023, and 08/24/2023; and current Certification Period of 08/28/2023 to 10/26/2023, in part: 08/28/2023 and 08/30/2023. On 08/30/2023 at 11:00 a.m., an interview was conducted with S5LPN. He confirmed he was not aware Patient#3’s spouse had been giving Patient #3 the Acetaminophen w/ Codeine #3, the Klor Con 10meq tablet, the Magnesium 400mg tablet, the Vitamin D3 2000 IU tablet, and the Trazadone 50mg, one-half tablet. He stated he was aware of the Xifaxan, but confirmed he hadn’t updated the medication list for any of these medications reviewed. He further confirmed he should have documented medication reconciliation at every nurse visit, including the start dates when they were changed or added, or discontinued. On 08/30/2023 at 12:32 p.m. an interview was conducted with S3RN. She stated she had seen Patient #3 today. She stated every patient’s Patient Medication Record list should be reviewed and updated at every visit. She confirmed Patient #3’s Patient Medication Record dated 08/22/2023-10/20/2023 was incorrect and should have reflected what Patient #3 was currently taking and it did not. On 08/30/2023 at 11:45 a.m., a phone interview was conducted with S6LPN. She stated a medication record review should be performed at every nurse visit. She confirmed she had not updated Patient #4’s Amiodarone ½ tablet (100mg) dose, or the Glimeride 1mg tablet dose on his current Patient Medication Record list. She stated the Patient Medication Record reviews should be documented at the time of each visit when medication changes were noted. On 08/31/2023 at 11:40 a.m., an interview was conducted with S2DON. He confirmed the aforementioned Patient Medication Records for Patient #3 dated 08/17/2023 and 08/28/2023 were not correct and had not been updated at each nursing visit. He confirmed the aforementioned medications for Patient #3 with start dates for 08/23/2023 and 08/24/2023 were not updated. S2DON further confirmed the aforementioned Patient Medication Records for Patient #4, dated 08/15/2023 and 08/28/2023, were not correct, and had not been updated. He confirmed that all nurses should perform medication reconciliation at every skilled nurse visit. He confirmed the Patient Medication Record for Resident #4 dated 08/28/2023 had not been updated. He confirmed Patient #4’s medications reviewed (Amiodarone and Glimeride) should have been updated when Patient #4’s Amiodarone dose changed and Patient #4’s Glimeride dose started. Patient #5 Review of the clinical record revealed a start of care date of 05/04/2023. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 07/03/2023 to 08/31/2023 revealed a primary diagnosis of Dysarthria Following Unspecified Cerebrovascular Disease. Further review of the 485 revealed orders which included SN 1w9. The patient’s current medication profile list was provided by S2DON on 08/28/2023. On 08/29/2023 at 8:45 a.m., a home visit was conducted in the home of Patient #5 with S3RN. The patient provided her medications for review. Her grandson was also present in the home and verified he was familiar with the patient’s medications. Patient #5 and her grandson verified the medications provided for review were the medications she was currently taking. Review of the medications listed on the patient’s current medication profile list provided by S2DON revealed the following discrepancies when compared with medications in the home: 1. Norco Oral 5-325 mg 1 tablet by mouth every 6 hours PRN was listed as a current medication. A bottle of the medication with a prescription fill date of 05/30/2023 was observed in the home. Instructions on the bottle stated 7.5/325 mg 1 tablet every 8 hours PRN pain. Patient #5 and her grandson verified this was her current dose which she had been taking when needed for at least 2 months. 2. Coreg Oral 6.35 mg 1 tablet twice daily was listed as a current medication. A bottle of the medication with a prescription fill date of 06/19/2023 was observed in the home. Instructions on the bottle stated 25 mg twice daily. Patient #5 and her grandson verified this was her current dose which she had been taking for at least 2 months. 3. Hydrochlorothiazide Oral 25 mg ½ tablet daily was listed as a current medication. Patient #5’s grandson stated the patient had not taken this medication in at least 2 months. 4. Glimepiride Oral 1 mg 1 tablet twice daily until blood sugars are below 120 and then decrease and continue one tablet daily was listed as a current medication. Patient #5’s grandson stated the patient started taking this medication PRN about 2 months ago due to her blood sugar dropping too low when she took it daily. 5. Olmesartan Medoxomil Oral 40 mg 1 tablet daily was listed as a current medication. Patient #5’s grandson stated the patient had not taken this medication in at least 2 months. 6. Gemtesa Oral 75 mg 1 tablet daily was listed as a current medication. Patient #5’s grandson stated the patient only took this medication short-term and had not taken it in over 2 months at least. 7. A bottle of Atorvastatin 40 mg by mouth every evening was observed in the home. This medication was not listed on the current medication profile list provided by the Agency. The prescription fill date was 05/22/2023. Patient #5’s grandson verified the patient had been taking this medication for at least 2 months. 8. A bottle of Mag-Oxide 400 mg by mouth twice daily was observed in the home. This medication was not listed on the current medication profile list provided by the Agency. The prescription fill date was 08/21/2023. Patient #5’s grandson verified the patient had been taking this medication for at least 2 months. 9. A bottle of Esomeprazole Magnesium 40 mg 1 tablet by mouth every morning before breakfast was observed in the home. This medication was not listed on the current medication profile list provided by the Agency. The prescription fill date was 07/18/2023. Patient #5’s grandson verified the patient had been taking this medication for about 2 months. 10. A bottle of Felodipine 5 mg 1 tablet by mouth daily PRN if blood pressure high was observed in the home. This medication was not listed on the current medication profile list provided by the Agency. The prescription fill date was 04/21/2023. Patient #5’s grandson stated this medication had been in the home for several months to use as needed if the patient’s blood pressure was elevated. S3RN verified the patient was seen by a nurse one time a week. She further verified the medication list was not up to date. A review of the SN visit documentation revealed SN visits were conducted with Patient #5 on the following dates during the current Certification Period of 07/03/2023 to 08/31/2023: 07/05/2023, 07/12/2023, 07/20/2023, 07/25/2023, 08/01/2023, 08/08/2023, 08/15/2023, and 08/23/2023. On 08/31/2023 at 11:20 a.m., an interview was conducted with S2DON. He was notified of the medication discrepancies found during the home visits for Patients #1 and #5. He verified the medication profiles were not up to date. S2DON verified nurses should reconcile all medications during each SN visit and update the medication profiles accordingly.

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 observations, interviews and record reviews, the Agency failed to ensure staff followed accepted standards of infection control practices for 3 (#1, #3, #6) of 7 (#1, #2, #3, #4, #5, #6, #7) patients observed during home visits. The agency staff failed to: 1. Ensure staff (S4LPN) practiced proper hand hygiene while providing wound care during a home visit with Patient #1; and 2. Ensure staff (S7PT and S9HHA) used proper infection control techniques regarding disinfection of reusable equipment and use of a barrier during 2 home visits with Patients #3 and #6. Review of the Agency's policy entitled Exposure Control Plan: OSHA Regulations included the following, in part: POLICY: The Agency will develop, implement and maintain infection control policies and procedures for patients diagnosed with infections and/or contagious diseases and for the protection of employees caring for such patients. Policies and procedures will reflect OSHA regulations and accepted standards of care. PURPOSE: To prevent and control the exposure of home care staff and patient/caregivers to infections and hazardous products. PROCEDURE: Nurse, Home Health Aide and other Staff Bags: 1. ….The outside of the bag, because it is exposed to all environments, is considered “soiled”. A barrier may be used under the bag as needed. Methods of Disinfection: 6. Stethoscopes and Blood Pressure cuffs will be cleaned with Agency approved disinfectant after each use by the employee who has possession of the equipment. Nursing Bag Technique: 2. Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area if indicated. Review of the Agency's policy entitled Hand Hygiene Policy and Compliance Program included the following, in part: POLICY: Hand Hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms. PURPOSE: To prevent transfer of germs and transmission of infections to patients and caregivers and to implement a hand hygiene compliance program. PROCEDURE: 7. The agency will follow the Centers for Disease Control and prevention (CDC) guidelines for hand hygiene: CDC Hand Hygiene Guidelines Recommendations: IV. Use of gloves: D. Change or remove gloves if moving from contaminated to clean patient site or the environment. CDC Guidelines: (II) Recommend. Guideline Categories. Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale. Patient #1 Review of the clinical record revealed a SOC date of 03/26/2023. The patient's current diagnoses included Pressure Ulcer Left Heel Stage 4, Pressure Ulcer Sacral Region Stage 4, Pressure Ulcer Right Hip Stage 4, Pressure Ulcer Right Buttock Stage 4, Pressure Ulcer Left Buttock Stage 4, and Pressure Left Hip Stage 4. A review of the Home Health Certification and Plan of Care/485 for the certification period of 07/24/2023 to 09/21/2023 revealed Orders and Treatments which included the following: SN 2w8, 1w1. Right Hip: Cleanse wound bed with wound cleanser/normal saline, apply skin prep to peri wound, apply Santyl and antibiotic cream to wound bed, cover with Hydrofera Blue and cover with foam dressing 3 times weekly; Left Hip: Cleanse wound bed with wound cleanser/normal saline, apply skin prep to peri wound, apply Santyl and antibiotic cream to wound bed, cover with Hydrofera Blue and cover with foam dressing 3 times weekly; Right Ischium: Cleanse wound bed with wound cleanser/normal saline, apply skin prep to peri wound, apply Santyl and antibiotic cream to wound bed, cover with Hydrofera Blue and cover with foam dressing 3 times weekly; Left Ischium: Cleanse wound bed with wound cleanser/normal saline, apply skin prep to peri wound, apply Santyl and antibiotic cream to wound bed, cover with Hydrofera Blue and cover with foam dressing 3 times weekly; Sacrum: Cleanse wound bed with wound cleanser/normal saline, apply skin prep to peri wound, apply Santyl and antibiotic cream to wound bed, cover with Hydrofera Blue and cover with foam dressing 3 times weekly; and Left Heel: Cleanse with saline, apply Silver Alginate, cover with ABD pad, wrap with football wrap (2 foams, 2 cast padding, flexinet and blue bootie) 3 times a week. On 08/28/2023 at 3:00 p.m., a visit was conducted in the home of Patient #1 with S4LPN present to provide wound care. A dressing was observed to be in place on the patient's left heel. S4LPN proceeded to remove the old dressing from the patient's left heel and throw it in an open trash can observed on the floor next to the patient's bed. S4LPN did not change her gloves and proceeded to measure the wound, perform wound care and apply a new dressing to the patient's left heel while wearing the same pair of gloves. Wounds to the patient’s left hip, left ischium, right hip, right ischium, and sacral area were observed to be uncovered. S4LPN changed gloves and then proceeded to clean wounds, measure wounds, perform wound care, and apply new dressings to all 5 wounds wearing the same pair of gloves, while moving from a clean to a contaminated site. During the home visit on 08/28/2023, an interview was conducted with S4LPN at 4:00 p.m. when she completed the visit. She verified she wore the same pair of gloves while going from dirty to clean during wound care to the left heel. She further verified wearing the same pair of gloves while going from dirty to clean during the consecutive wound care provided to the patient’s left hip, left ischium, right hip, right ischium, and sacral area wounds. Patient #3 Review of the clinical record revealed a SOC date of 01/29/2019 with a current primary diagnosis of Nonalcoholic Steatohepatitis(NASH). A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 08/22/2023 to 10/20/2023 revealed orders which included the following: HHA 1w4. An observation was made during the home visit conducted for Patient #3 on 08/29/2023 at 9:55 a.m. with S9HHA present. S9HHA was observed performing the blood pressure (BP) on Resident #3. S9HHA removed a BP cuff and stethoscope from her bag at the bedside, which was observed on the resident’s dresser with no barrier beneath it. S9HHA then obtained Resident #3’s BP in her right arm and returned the BP cuff and stethoscope to her bag without properly cleaning or disinfecting them. An interview was conducted on 08/29/2023 at 10:13 a.m. with S9HHA. She confirmed she had taken Resident #3’s BP and returned the BP cuff and stethoscope to her bag without properly cleaning/disinfecting the used equipment first. She stated she should have cleaned them, but she did not. She stated she normally cleans them with an alcohol wipe before returning them to her bag. Patient #6 Review of the clinical record revealed a SOC date of 07/17/2023 with a current primary diagnosis of Type 2 Diabetes Mellitus. A review of the Home Health Certification and Plan of Care/485 for the certification period of 07/18/2023 to 09/15/2023 revealed original Orders and Treatments which included the following: SN 2w1, 1w8. A Resumption of Care Order dated 08/29/2023 revealed an order for a PT evaluation. On 08/29/2023 at 1:00 p.m., a visit was conducted in the home of Patient #6 with S7PT present. S7PT was observed performing her visit outside of the patient’s home. She placed her equipment bag and I-pad on the surface of a fabric-covered pad which was sitting on top of a large plastic container near the patient on the outside of the home. S7PT did not use a barrier between the surface and her equipment. The fabric-covered pad was unclean in appearance, which included a layer of dust particles. The equipment bag was leaned against an old, dusty duffle bag placed on top of the fabric-covered pad. During an interview with S7PT, she verified she had not been instructed to use a barrier between her equipment and surfaces that were potentially contaminated. On 08/31/2023 at 11:20 a.m., an interview was conducted with S2DON. He was notified of the observations of staff during the home visits with Patients #1, #3, and #6. S2DON verified the nurse should have changed her gloves when going from clean to dirty aspects of each wound and should not have worn the same pair of gloves to perform wound care to multiple wounds for Patient #1. He further verified all staff should use a barrier between surfaces and their bags/equipment during home visits and should properly disinfect any reusable patient equipment before returning it to their bags.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure skilled professionals assumed responsibility, according to Agency policy, for preparing and incorporating clinical notes in the clinical records of 3 (#1, #3, #12) of 17 (#1-#17) sampled patient records reviewed. Review of an Agency policy entitled Timely Submission of Patient Documentation revealed the following, in part: POLICY: The Agency will ensure the timely and proper submission of patient documentation. PURPOSE: To comply with state/federal laws and regulations related to timely submission of all patient documentation. PROCEDURE: 2. Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc. Patient #1 Review of the clinical record revealed the patient had a SOC date of 03/26/2023. A review of the Home Health Certification and Plan of Care/485 for the certification period of 07/24/2023 to 09/21/2023 revealed Orders and Treatments which included the following: SN 2w8, 1w1. Review of the nurses’ notes in the clinical record conducted on 08/28/2023 revealed no documentation of SN visits after 08/09/2023. Further review of the nurses’ notes in the clinical record on 08/31/2023 at 9:00 a.m. revealed nurses’ notes were entered for visits that occurred after 08/09/2023 through 08/21/2023, but there was no documentation of SN visits documented after 08/21/2023. On 08/31/2023 at 11:20 a.m., an interview was conducted with S2DON. After reviewing the patient’s clinical record, he verified S4LPN was the primary nurse assigned to perform SN visits for Patient #1. He further verified he was aware S4LPN was behind on completing documentation of her SN visits for this patient. Patient #3 Review of the clinical record revealed the patient had a SOC date of 01/29/2019. A review of the Home Health Certification and Plan of Care/485 for the certification period of 08/22/2023 to 10/20/2023 revealed Orders and Treatments which included the following: SN 1w4. Review of the nurses’ notes in the clinical record conducted on 08/28/2023 revealed a SN visit scheduled on 08/24/2023 for S5LPN. Further review revealed no notes or documentation had been completed for this visit. On 08/30/2023 at 11:00 a.m., an interview was conducted with S5LPN. He confirmed that his nurses’ note dated 08/24/2023 was late and incomplete, and should have been turned in within 72 hours of his visit. On 08/31/2023 at 11:40 a.m., an interview was conducted with S2DON. He confirmed S5LPN’s visit note dated 08/24/2023 had not been available for surveyor review until 08/30/2023, and was late. Patient #12 Review of the clinical record revealed the patient had a SOC date of 07/18/2023. A review of the Home Health Certification and Plan of Care/485 for the certification period of 07/18/2023 to 09/15/2023 revealed Orders and Treatments which included the following: PT 1w1, 2w4 effective 07/21/2023; OT 1w1, 2w3 effective 7/20/2023. Review of the Occupational Therapy notes in the clinical record revealed no OT/COTA visits were conducted after 08/10/2023. An OT Discharge visit was scheduled for 08/10/2023 in the electronic record, but had not been initiated/completed. Review of the Physical Therapy notes in the clinical record revealed no PT/PTA visits were conducted after 08/14/2023. A PT Discharge visit was scheduled for 08/16/2023 in the electronic record, but had not been initiated/completed. On 08/30/2023 at 10:20 a.m., an interview was conducted with S2DON. After reviewing the patient’s clinical record, he stated he was unsure if OT and PT had been discharged from the home. He stated if OT and PT were discharged, the OT and PT Discharge Summaries were late and had not been completed according to the Agency’s policy. He stated he would expect the Discharge Summaries to be completed within 24-48 hours, but no later than 72 hours. On 08/31/2023 at 11:35 a.m., an interview was conducted with S2DON. He verified the Agency’s policy stated documentation needed to be completed within 72 hours following a visit and he expected staff to enter all documentation of their visits within that same timeframe of 72 hours.