Every finding on record at Pinnacle Care Holdings, LLC

Complaint Survey #3047268.

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 interviews, the agency failed to ensure skilled professionals accurately prepared clinical notes. The agency failed to ensure the skilled nurse documented changes in Patient #1’s wound assessment for 1 (#1) of 3 patients reviewed with wounds. Findings: Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/28/2026, had a certification period of 03/29/2026 to 05/27/2026, and was discharged from the agency on 04/20/2026. Patient #1 had diagnoses, which included Unspecified Open Wound Left Ankle and Stage 2 Pressure Ulcer of Left Heel. Review of Patient #1’s Plan of Care for Certification Period 03/29/2026 to 05/27/2026 revealed the following, in part: Skilled Nursing Visits twice weekly for four weeks effective 03/29/2026. Skilled Nurse to perform wound care to Left Heel Pressure Ulcer and Left Dorsal Ankle twice a week and as needed. Review of Patient #1’s Skilled Nursing Visit note dated 04/13/2026 by S3LPN revealed the following, in part: Site Location: Left Dorsal Ankle Type: Trauma Healing: Healing by secondary intent Wound Measurement: 5.0 cm x 2.5 cm x 0.3 cm Wound Tissue Observed: Slough 10% Surrounding Tissue: Intact Drainage: Serosanguineous Drainage Amount: Small Review of Patient #1’s Clinical Notes for Certification Period 03/29/2026 to 05/27/2026 revealed the following, in part: 04/13/2026- Skilled Nurse reports the patient’s wife will be sending him to the Emergency Room for evaluation of lower extremity wound. Further review revealed no documented evidence of Patient #1’s change in wound condition on 04/13/2026. An interview was conducted with S3LPN on 07/07/2026 at 9:20 a.m. She stated Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound. She stated on 04/13/2026, she unwrapped Patient #1’s left lower leg dressing to provide wound care. She stated the Left Dorsal Ankle wound was open, looked like bone or cartilage was exposed, and there was a lot of serosanguinous drainage with clear pus. She confirmed this was a significant change in Patient #1’s Left Dorsal Ankle wound. She confirmed she did not document the change in Patient #1’s Left Dorsal Ankle wound assessment, including the cartilage or tendons being exposed, change in size and change in drainage and should have. An interview was conducted with S2DON on 07/07/2026 at 12:03 p.m. He reviewed Patient #1’s clinical record and verified Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound. He stated there was a change in Patient #1’s Left Dorsal Ankle wound on the 04/13/2026 skilled nurse visit made by S3LPN. He stated S3LPN should have documented the worsening of the wound on the wound assessment or in a clinical note. He confirmed the Left Dorsal Ankle wound assessment by S3LPN on 04/13/2026 was not accurately documented and should have been. An interview was conducted with S1ADM on 07/08/2026 at 2:30 p.m. He stated he expected the nurses to document changes in a patient’s wound in the wound assessment section of the visit note. He stated he expected the nurses to document significant wound changes in the wound assessment and in a clinical note. He reviewed Patient #1’s clinical record and confirmed Patient #1 had a Left Heel Pressure Ulcer and Left Dorsal Ankle wound until discharge. He confirmed on 04/13/2026, Patient #1’s Left Dorsal Ankle wound had a change in condition. He confirmed there was no clinical note documented by S3LPN for the significant change in Patient #1’s Left Dorsal Ankle wound. He confirmed the Left Dorsal Ankle wound assessment by S3LPN on 04/13/2026 was not accurately documented and should have been.

The entity is in compliance with federal emergency preparedness requirements.

Recertification Survey Abbreviations: mg- milligram OASIS- Outcome and Assessment Information Set

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure a patient’s OASIS assessments accurately reflected the patient’s wound status at the time of the assessments for 1 (#16) of 12 patients reviewed with wounds. Findings: Review of Patient #16’s Clinical Record revealed he began receiving services from the home health agency on 11/13/2024 and continued to receive services through his discharge certification period of 05/12/2025 to 07/10/2025. Patient #16 had a diagnosis of a Stage 3 Pressure Ulcer of Sacral Region. Further review revealed Patient #16 had no additional Pressure Ulcers. Review of Patient #16’s OASIS Assessments dated 01/08/2025, 03/12/2025, and 05/09/2025 revealed assessment of Patient #16’s Sacral Wound type was listed as “Other: nursing addressing.” Further review revealed the Sacral Wound was not listed as a Pressure Ulcer. Review of Patient #16’s Discharge OASIS Assessment dated 07/10/2025 revealed the following: Current number of unhealed Pressure Ulcers/Injuries at each stage/Stage 2: 10. An interview was conducted with S1ADM on 04/30/2026 at 2:30 p.m. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had a Sacral Pressure Ulcer on admission until discharge. He explained that when a wound was documented as one type, it populated to the next assessment as that type. He stated, on 12/27/2024, a Certified Occupational Therapy Assistant documented Patient #16’s Sacral wound as: “Other: Nursing addressing.” He stated none of the nurses following her updated the wound type on the OASIS assessments. S1ADM confirmed Patient #16’s OASIS assessments dated 01/08/2025, 03/12/2025, and 05/09/2025 did not accurately reflect Patient #16’s Sacral Pressure Ulcer and should have. He further confirmed Patient #16 had one Stage 3 Pressure Ulcer and not 10 Stage 2 Pressure Ulcers, which was inaccurate on his discharge OASIS dated 07/10/2026.

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 2 (#3 and #5) of 7 patients reviewed with home visits. Findings: Review of the agency’s policy titled, “Medication Reconciliation” with a last review date of 04/21/2026, revealed the following, in part: Purpose: Medication Reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient is taking. Policy: The agency utilizes this medication reconciliation process and approach to ensure shared responsibility of health care providers in collaboration with patients and families. Procedure: 2. The clinician is to determine what medications the patient is actually taking. 6. The clinician is to review medications at each visit. 7. If there is a new medication, the medication should be documented … in the Electronic Medical Record. 8. If the medication has changed… In the Electronic Medical Record, discontinue the “old” dosage, and add the new dosage as if it were a new medication. 9. If a medication has been completed or discontinued by the Medical Doctor … discontinue in the Electronic Medical Record. Patient #3 Review of Patient #3’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/20/2026 and had a current Certification Period of 03/21/2026 through 05/19/2026. Patient #3 had diagnoses, which included Parkinsonism, Corticobasal Degeneration, and Weakness. Patient #3 was ordered to receive Speech Therapy Visits twice weekly for six weeks. A home visit was conducted with Patient #3 on 04/27/2026 at 2:00 p.m. with S6ST present in the home. Patient #3’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: Carbidopa-Levodopa 25-100 mg take two tablets by mouth twice a day was on the medication profile and the patient was taking two tablets three times a day; Nabumetone 750 mg take one tablet by mouth at bedtime was on the medication profile and the medication was prescribed as needed for pain; and Tylenol Arthritis 8 hour 650 mg take two caplets every night as needed for pain was present in the home and not on the medication profile. An interview was conducted with Patient #3’s spouse during the home visit. She stated she managed Patient #3’s medications and filled his pill planner weekly. She stated Patient #3 was prescribed and had taken Nabumetone as needed every night for pain since 03/30/2026. She stated Patient #3 had taken Tylenol Arthritis two caplets every night for pain since December 2025. She stated Patient #3 had been taking Carbidopa-Levodopa two tablets three times a day for months. An interview was conducted with S6ST on 04/27/2026 at 3:45 p.m. S6ST confirmed the above medication discrepancies during the home visit. S6ST stated medications should be reconciled during every home visit. Patient #5 Review of Patient #5’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/25/2026 and had a current Certification Period of 02/25/2026 through 04/25/2026. Patient #5 had diagnoses, which included Essential Hypertension and Unspecified Atrial Flutter. Patient #5 was ordered to receive the following discipline visit frequency: Skilled Nursing Visits- 02/25/2026 once weekly for four weeks; 03/15/2026 three times a week for one week then twice weekly for three weeks; and 03/26/2026 twice weekly for one week then three times weekly for four weeks. Physical Therapy Visits- 02/25/2026 twice weekly for three weeks; and 03/26/2026 once weekly for one week then twice weekly for three weeks. Occupational Therapy Visits - 02/25/2026 once weekly for one week then twice weekly for three weeks; and 04/15/2026 twice weekly for one week then twice weekly for three weeks. A home visit was conducted with Patient #5 on 04/28/2026 at 3:50 p.m. with S7OT present in the home. 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: Isosorbide Mononitrate Extended Release 30 mg take one tablet by mouth every other day was on the medication profile and the patient was no longer taking; Digoxin 0.125 mg take half a tablet by mouth in the morning was present in the home and not on the medication profile; Atorvastatin Calcium 80 mg take one tablet by mouth daily was on the medication profile and the patient was no longer taking; and Doxycycline Hyclate 100 mg take one tablet twice a day for 10 days was on the medication profile and the patient was no longer taking. An interview was conducted with Patient #5’s sister on 04/28/2026 at 4:20 p.m. She stated she managed Patient #5’s medications and filled his pill planner weekly. She stated Patient #5’s Atorvastatin Calcium was discontinued sometime in March 2026. She stated Patient #5’s Isosorbide Mononitrate was discontinued and the Digoxin was started on 04/15/2026. She stated Patient #5 completed the Doxycycline sometime in March 2026. An interview was conducted with S7OT on 04/28/2026 at 4:25 p.m. S7OT stated patient’s medications should be reconciled each visit. S7OT confirmed the medications Patient #5 was taking and the medication profile should match and did not. An interview was conducted with S1ADM on 04/29/2026 at 8:10 a.m. He stated medications should be reconciled during each home visit by the clinicians. He stated medication reconciliation should have been completed by comparing the medications in the home to the patient’s current medication profile. He was made aware of Patient #3 and #5’s medication discrepancies identified during their home visits. He confirmed the medications each patient were currently taking should have matched the patient’s current medication profile.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to assure communication with all physicians involved in the Plan of Care. The agency failed to ensure the physician was notified Physical Therapy services were not provided as ordered for 1 (#6) of 11 patients reviewed with orders for Home Health Therapy services. Findings: Review of Patient #6’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/10/2026 and had a current Certification Period of 04/10/2026 through 06/08/2026. Further review revealed a physician’s order dated 04/08/2026 for admission to home health, which included Physical Therapy to evaluate and treat. Review of Patient #6’s Coordination Note signed by S8PT dated 04/13/2026 revealed the following, in part: Physical Therapy missed visit. Refused Physical Therapy eval. Review of Patient #6’s Physician Orders and Coordination Notes for Certification Period 04/10/2026 through 06/08/2026 revealed no documented evidence the provider was notified Physical Therapy services were not provided as ordered. An interview was conducted with S8PT on 04/30/2026 at 9:40 a.m. He stated Patient #6 was ordered to receive Physical Therapy services. He stated Patient #6 refused Physical Therapy services on 04/13/2026. He stated when therapy services were refused he would document a note in the patient’s records per the agency’s policy. He stated agency staff would send the notification to the patient’s physician, but he was unsure which staff were responsible for the notifications. He confirmed he did not notify Patient #6’s physician the physical therapy services were not provided as ordered. An interview was conducted with S1ADM on 04/30/2026 at 11:30 a.m. He stated if a patient refused an ordered therapy service, he or the therapy coordinator contacted the physician’s office. He stated then a note was entered into the patient’s clinical record documenting the physician was made aware the ordered services were not provided. He confirmed there was no documented evidence the physician was notified Physical Therapy services were not provided as ordered for Patient #6.

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 (#14 and #16) of 12 patients reviewed for Pressure Ulcers. The agency failed to ensure the RN assessed Patient #14 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 policy titled “Wound Care Policy & Procedure”, with a revision date of 03/2023, revealed the following, in part: Policy: The objective of establishing wound care guidelines is to be able to administer appropriate/effective wound care in the home. Personnel: The Registered Nurse is responsible for dressing change, assessment and measurement of all complex/complicated wound at least weekly. Patient #14 Review of Patient #14’s Clinical Record revealed he began receiving services from the Home Health Agency on 10/10/2025, had a Certification Period of 10/10/2025 to 12/08/2025 and 12/09/2025 to 02/06/2026, and was discharged from the agency on 12/15/2025. Patient #14 had diagnoses, which included Stage 3 Pressure Ulcer of Right Heel. Review of Patient #14’s Plan of Care for Certification Period of 10/10/2025 to 12/08/2025 revealed the following, in part: Skilled Nursing Visits once weekly for one week then three times weekly for eight weeks; and Skilled Nurse to perform wound care to Right Heel Pressure Ulcer three times a week and as needed. Review of Patient #14’s Plan of Care for Certification Period of 12/09/2025 to 02/06/2026 revealed the following, in part: Skilled Nursing Visits twice weekly times for four weeks; and Skilled Nurse to perform wound care to Right Heel Pressure Ulcer on skilled nursing visits and as needed. Review of Patient #14’s Skilled Nursing Visit notes conducted for Certification Periods of 10/10/2025 to 12/08/2025 and 12/09/2025 to 02/06/2026 revealed Patient #14’s Stage 3 Right Heel Pressure Ulcer was not assessed by a RN, to include measurements, the weeks of 10/26/2025, 11/09/2025, 11/23/2025, and 12/07/2025. An interview was conducted on 04/30/2026 at 11:30 a.m. with S1ADM. He reviewed Patient #14’s Clinical Record and confirmed a Registered Nurse had not assessed or measured Patient #14’s Pressure Ulcer on the weeks of 10/26/2025, 11/09/2025, 11/23/2025, and 12/07/2025. Patient #16 Review of Patient #16’s Clinical Record revealed he began receiving services from the Home Health Agency on 11/13/2024, had a discharge Certification Period of 05/12/2025 to 07/10/2025, and had diagnoses, which included Stage 3 Pressure Ulcer of Sacral Region. Review of Patient #16’s Plan of Care for Certification Period of 05/12/2025 to 07/10/2025 revealed the following, in part: Skilled Nursing Visits once weekly for four weeks then twice weekly for four weeks; Measure wound first Registered Nurse visit of week; and Skilled Nurse to perform wound care to Sacrum on skilled nursing visits. Review of Patient #16’s Skilled Nursing Visit notes conducted for Certification Period 05/12/2025 to 07/10/2025 revealed Patient #16’s Stage 3 Sacral Pressure Ulcer was not assessed by a RN, to include measurements, the weeks of 06/15/2025, 06/22/2025, and 06/29/2025. An interview was conducted on 04/30/2026 at 2:30 p.m. with S1ADM. He reviewed Patient #16’s Clinical Record and confirmed Patient #16 had a Sacral Pressure Ulcer on admission until discharge. He confirmed Patient #16’s Sacral Pressure Ulcer was not assessed by a RN on the weeks of 06/15/2026, 06/22/2026, and/or 06/29/2026. S1ADM confirmed Pressure Ulcers should have been assessed, including measurements, weekly by a Registered Nurse.

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 observation during a home visit, interviews, and record reviews, the agency failed to ensure patients received home health aide services included in the plan of care for 2 (#7 and #13) of 3 patients reviewed with home health aide services. Findings: Patient #7 Review of Patient #7’s Clinical Record revealed he began receiving services from the agency on 03/26/2026, had a current certification period of 03/26/2026 through 05/24/2026, and had a diagnosis of Parkinson’s Disease with Dyskinesia. Further review of the Clinical Record revealed Patient #7 was ordered to receive home health aide services twice weekly for three weeks then twice weekly for four weeks. Review of Patient #7’s Home Health Aide Care Plan for the certification period of 03/26/2026 through 05/24/2026 revealed interventions, which included change bed linens and make bed. Review of Patient #7’s Home Health Aide Visit Notes by S4CNA dated 03/31/2026, 04/02/2026, 04/09/2026, 04/14/2026, 04/16/2026, 04/21/2026, and 04/23/2026 revealed documentation of not applicable for the interventions of change bed linens and make bed. Further review of the Home Health Aide Visit Notes revealed no additional documentation to indicate why the bed linen changes and making of the bed was not applicable. An interview was conducted with S4CNA on 04/29/2026 at 8:40 a.m. She confirmed she provided home health aide services for Patient #7. She stated she had not made Patient #7’s bed or changed his linens during any of her visits. A home visit was conducted with Patient #7 on 04/28/2026 at 2:00 p.m. with S3CNA present. S3CNA did not provide linen changes or make the bed during the visit. Patient #7’s wife was present in the home, and an interview was conducted with Patient #7’s wife during the home visit. Patient #7’s wife stated the home health aides had never offered to change bed linens or make Patient #7’s bed. She stated she did not know changing bed linens or making the bed were services offered by the agency. She stated if the aides had offered to change the linens or make the bed, she would have allowed them. An interview was conducted with S3CNA on 04/28/2026 at 3:13 p.m. She stated home health aide services should have been provided for the patients for each visit based on the aide care plan. She confirmed bed making and linen changes were interventions on Patient #7’s aide care plan. She confirmed she did not provide a linen change or make Patient #7’s during the visit on 04/28/2026. Patient #13 Review of Patient #13’s Clinical Record revealed he began receiving services from the agency on 12/04/2025, had a discharge certification period of 12/04/2025 through 02/01/2026, and had diagnoses of Osteoarthritis of Left Knee and Paraplegia. Further review of the Clinical Record revealed Patient #13 was ordered to receive home health aide services twice weekly for three weeks. Review of Patient #13’s Home Health Aide Care Plan for the certification period of 12/04/2025 through 02/01/2026 revealed interventions, which included temperature, blood pressure, pulse, and respirations every visit. Review of Patient #13’s Home Health Aide Visit Notes by S5CNA dated 12/16/2025, 12/18/2025, 12/23/2025, and 12/25/2026 revealed the following aide interventions were documented as not applicable on the following dates: 12/16/2025: Blood pressure every visit; Pulse every visit; and Respirations every visit. 12/18/2025: Temperature every visit; Blood pressure every visit; Pulse every visit; and Respirations every visit. 12/23/2025: Blood pressure every visit; and Pulse every visit. 12/25/2025: Blood pressure every visit; Pulse every visit; and Respirations every visit. An interview was conducted with S5CNA on 04/30/2026 at 11:03 a.m. She stated not applicable documented on her visit notes meant the intervention was not provided during that visit. An interview was conducted with S1ADM on 04/30/2026 at 11:25 a.m. He stated the home health aide visit notes’ interventions populated directly from the home health aide care plan. He stated all interventions on the aide care plan should have been provided during each home health aide visit. He stated not applicable was not an acceptable response to a home health aide intervention. He reviewed the aforementioned home health aide visit notes and confirmed the interventions on the care plan were not provided and should have been.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure Physical Therapy vital sign entries were completed for 2 (#3 and #10) of 17 patient records reviewed. Findings: Review of the agency’s policy titled “Start of Care Assessment (SOC),” with a revision date of 12/01/2025, revealed the following, in part: Policy: The initial assessment will consist of the OASIS data set for Start of Care Assessments integrated with a patient specific comprehensive physical assessment. Procedure: During the initial patient assessment, all baseline data and other relevant information is documented in the patient’s clinical record, including at least the following information: Patient specific physical assessment information including at least the following: 1. Vital signs, including blood pressure, temperature, pulse, respirations… Vital signs are a key component of the home health visit and should be monitored accordingly. At minimum, blood pressure, heart and respiratory rate should be obtained at every visit. Patient #3 Review of Patient #3’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/20/2026, had a Certification Period of 01/20/2026 through 03/20/2026, and a current Certification Period of 03/21/2026 through 05/19/2026. Patient #3 had diagnoses, which included Parkinsonism, Corticobasal Degeneration, Essential Hypertension and Weakness. Review of Patient #3’s OASIS Start of Care Assessment signed by S8PT dated 01/20/2026 revealed no documented evidence of a temperature or respirations. Review of Patient #3’s Physical Therapy visits for Certification Period of 01/20/2026 through 03/20/2026 revealed the following, in part: 01/24/2026- no documented blood pressure, signed by S9PTA 01/28/2026- no documented blood pressure, signed by S9PTA 02/03/2026- no documented pulse or respirations, signed by S8PT 02/24/2026- no documented pulse or respirations, signed by S8PT 03/12/2026- no documented pulse or respirations, signed by S8PT Review of Patient #3’s in home document titled, “Home Care Vital Signs/Assessment/60 day Summarization” log revealed the following, in part: 01/24/2026- no documented blood pressure; 01/28/2026- no documented blood pressure; 02/03/2026- no documented respirations; 02/24/2026- no documented vital signs; and 03/12/2026- no documented vital signs. An interview was conducted with S9PTA on 04/30/2026 at 8:31 a.m. She stated at the start of each patient visit she obtained the patient’s blood pressure, pulse and respirations. She stated she documented the vital signs on the in home vital sign log and in the patient’s electronic clinical record. She was made aware of Patient #3’s therapy visit notes dated 01/24/2026 and 01/28/2026 with no blood pressure documented. She stated she obtained the blood pressure, but must have forgot to document it. She confirmed without the blood pressures documented the patient’s clinical record was not complete and accurate. Patient #10 Review of Patient #10’s Clinical Record revealed she began receiving services from the Home Health Agency on 03/05/2026, and had a current Certification Period of 03/05/2026 through 05/03/2026. Patient #10 had diagnoses, which included Essential Hypertension and Unspecified Dementia. Review of Patient #10’s OASIS Start of Care Assessment signed by S8PT dated 03/05/2026 revealed no documented evidence of a temperature, pulse or respirations. An interview was conducted with S8PT on 04/30/2026 at 9:40 a.m. He stated, during a patient’s comprehensive assessment, he obtained the patient’s blood pressure, pulse, oxygen saturation, respirations, height, and weight. He stated on a physical therapy visit he obtained the patient’s blood pressure, pulse and respirations. He was made aware of the above listed physical therapy visits with no documentation of a blood pressure, pulse, and/or respirations for Patient #3 and Patient #10. He stated he obtained the patient’s vital signs, but did not document them and he should have. He confirmed without the vital signs documented in the patient’s clinical record, it was not complete and accurate. An interview was conducted with S1ADM on 04/30/2026 at 11:30 a.m. He stated, on a start of care assessment, the clinicians should obtain and document the patient’s blood pressure, pulse, respirations, temperature, height and weight. He stated on each discipline visit, the patient’s blood pressure, pulse and respirations should be obtained and documented. He reviewed the clinical record for Patient #3 and #10 and confirmed the above listed therapy visits were missing documentation of vital signs. He confirmed without a complete set of vitals documented, the patient’s clinical record was not complete and accurate.

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

Recertification Survey Abbreviations: ADM- Administrator bpm- beats per minute CNA- Certified Nursing Assistant DON- Director of Nursing HCl- hydrochloride HRM- Human Resources Manager IU- International Unit LPN-Licensed Practical Nurse MD- Medical Doctor mmHg- millimeter of mercury mg- milligrams PTA-Physical Therapy Assistant PT- Physical Therapy RN-Registered Nurse SN-Skilled Nurse

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 during home visits, interviews, and record reviews, the agency failed to ensure the patient’s comprehensive assessment included a review of all medications the patient was currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications during subsequent home visits for 3 (#7, #8, and #10) of 7 (#6, #7, #8, #9, #10, #11 and #12) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Profile” revealed the following, in part: Purpose: To define the use of the medication profile in evaluating the patient’s current medication regimen. Policy: Patient’s receiving medications administered by the agency will have a current, accurate medication profile in the clinical record. Procedure: 2. At each visit each discipline will check all medications in the home that the patient is taking and compare to the medication profile in Netsmart. If there is a discrepancy the intake case manager is to be notified and MD called to verify correct medication for patient. 4. When there are new medications ordered or changed a review of all medications will be completed and documented. Patient #7 Review of Patient #7’s Clinical Record revealed a Start of Care of 07/10/2023 and a current Certification period of 07/10/2023 – 09/07/2023. Further review revealed diagnoses which included Infection Following a Procedure – Other Surgical Site, Status Post Split Thickness Skin Graft, and Status Post Debridement. Review of Patient #7’s current Plan of Care revealed Skilled Nursing Visits to be conducted once on the week of 07/14/2023 and three times weekly beginning 07/16/2023. A home visit was conducted for Patient #7 on 07/31/2023 at 2:30 p.m. with S3RN present in the home. A review of Patient #7’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #7 provided by the Home Health Agency: Furosemide 20mg by mouth twice daily – on medication profile but not present in the home Oxycodone HCl 5mg by mouth every six hours – on medication profile but not present in the home Triamterene-Hydrochlorothiazide 37.5-25mg by mouth daily – on medication profile but not present in the home Xtandi 80mg take two tablets by mouth once daily – present in the home but not on the medication profile Zinc 22mg by mouth daily – present in the home but not on the medication profile D3 5000 IU by mouth daily – present in the home but not on the medication profile Ferrous Gluconate 324mg by mouth daily – present in the home but not on the medication profile Calcium Citrate 600mg by mouth daily – present in the home but not on the medication profile COQ10 200mg by mouth daily – present in the home but not on the medication profile An interview was conducted with S3RN during the home visit on 07/31/2023 at 2:30 p.m. S3RN also reviewed Patient #7’s medications and confirmed the above discrepancies. S3RN stated Patient #7’s medications should have been reconciled every skilled nursing visit and the current Medication Profile should have been up to date. An interview was conducted with Patient #7 during the home visit on 07/31/2023 at 2:35 p.m. He stated he managed his own medications. He stated he had not taken Oxycodone in 4 weeks and he had not taken Furosemide and Triamterene-Hydrochlorothiazide since he admitted to the Home Health Agency. He further stated he had been taking Xtandi, Zinc, D3, Ferrous Gluconate, Calcium Citrate, and COQ10 since he admitted to the Home Health Agency. Patient #8 Review of Patient #8’s Clinical Record revealed a Start of Care of 06/21/2023 and a current Certification period of 06/21/2023-08/19/2023. Further review revealed diagnoses which included Unstageable Decubitus Ulcer of Sacral Region, Type 2 Diabetes Mellitus, Atrial Fibrillation, Congestive Heart Failure, and Morbid Obesity. Review of Patient #8’s current Plan of Care revealed Skilled Nursing Visits to be conducted three times weekly beginning 06/21/2023. A home visit was conducted for Patient #8 on 07/31/2023 at 2:45 p.m. with S11LPN present in the home. A review of Patient #8’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #8 provided by the Home Health Agency: Amiodarone HCl by mouth tablet 200 mg take 1 tab daily by mouth- on medication profile and the medication bottle instructions were to take 1 tablet by mouth twice daily Atorvastatin Calcium by mouth tablet 20 mg take one tablet at bedtime by mouth-on medication profile and the medication bottle instructions were to take one 40 mg tablet by mouth at bedtime An interview was conducted with Patient #8’s daughter during the home visit on 07/31/2023 at 2:45 p.m. She stated she managed Patient #8’s medications. She stated when Patient #8 discharged home from the hospital on 06/20/2023 his Amiodarone was decreased to 200 mg twice daily and his Atorvastatin was increased to 40 mg. Review of the hospital discharge paperwork in the home with the daughter confirmed the medication changes. An interview was conducted with S11LPN during the home visit on 07/31/2023 at 2:50 p.m. S11LPN stated Patient #8’s medications should have been reconciled every skilled nursing visit. S11LPN reviewed Patient #8’s Medication Profile, medication bottles in the home, handwritten medication list in the patient’s home health folder, and the medication list from the local hospital dated 06/20/2023. S11LPN verified the medication lists and medication bottles for the above discrepancies did not match and should have. Patient #10 Review of Patient #10’s Clinical Record revealed a Start of Care of 06/07/2023 and a current Certification period of 06/07/2023-08/05/2023. Further review revealed diagnoses which included Anemia, Type 2 Diabetes Mellitus with Stage 3 Chronic Kidney Disease, and History of Cerebrovascular Accident. Review of Patient #10’s current Plan of Care revealed Skilled Nursing Visits to be conducted once a week beginning 06/07/2023. A home visit was conducted for Patient #10 on 08/01/2023 at 8:30 a.m. with S12RN present in the home. A review of Patient #10’s medications were conducted during the home visit. The following medication discrepancies were identified when compared to the Current Medication Profile for Patient #10 provided by the Home Health Agency: Azelastine 0.05% ophthalmic solution place one drop in both eyes 2 times a day- present in the home but not on the medication profile Refresh Digital instill 1 drop in both eyes daily as needed for dryness- present in the home but not on the medication profile An interview was conducted with Patient #10 during the home visit on 08/01/2023 at 8:45 a.m. She stated she had been prescribed and taking the Azelastine eye drops since 2018. She stated she had been using the Refresh Digital eye drops as needed for dryness for “awhile”. An interview was conducted with S12RN during the home visit on 08/01/2023 at 8:46 a.m. S12RN stated Patient #10’s medications should have been reconciled every skilled nursing visit. She stated Patient #10 had been taking the Azelastine eye drops for years and was not sure why it was discontinued on the medication profile and the handwritten medication list in the patient’s home health folder. She confirmed both the eye drops should have been on the medication profile and were not. An interview was conducted with S1ADM on 08/01/2023 at 4:07 p.m. He was notified of the medication discrepancies found during the home visits for Patient’s #7, #8, and #10. He stated each patient’s medications should have been reconciled every visit by the Home Health Agency nurse. He verified the medication profiles should have been updated accordingly.

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 reviews and interviews, the facility failed to ensure each patient received the home health services written in the plan of care by failing to obtain and document weights for 2 (#4 and #13) of 2 (#4 and #13) patients reviewed for weights. Findings: Patient #4 Review of Patient #4’s Clinical Record revealed a current Certification Period of 06/29/2023 – 08/27/2023 and diagnoses which included Acute on Chronic Congestive Heart Failure. Review of Patient #4’s Plan of Care dated 06/29/2023-08/27/2023 revealed the following Physician Orders: Skilled Nursing Visits to be conducted once weekly. Obtain and instruct on daily weights. Report weight gain of 3 lb. in 24 hour or 5 lb. in one week. Review of Patient #4’s Skilled Nursing Visits for Certification Period 06/29/2023-08/27/2023 revealed no documented weight measurements on 07/11/2023 and 07/26/2023. An interview was conducted with S1ADM on 08/01/2023 at 2:55 p.m. He reviewed Patient #4’s Clinical Record at that time and confirmed there were no documented weights on the Skilled Nursing Visits conducted on 07/11/2023 and 07/26/2023, and there should have been. Patient #13 Review of Patient #13’s Clinical Record revealed a Certification Period of 07/11/2022 – 09/08/2022 and diagnoses which included Aftercare Following Other Surgery of Circulatory System, Atherosclerosis of Native Coronary Artery, Ischemic Cardiomyopathy, History of Percutaneous Coronary Intervention, and Venous Insufficiency. Review of Patient #13’s Plan of Care dated 07/11/2022 – 09/08/2022 revealed the following Physician Orders: Skilled Nursing Visits to be conducted once weekly for four weeks beginning 07/11/2023, twice weekly for one week beginning 07/31/2023, and once weekly for three weeks beginning 08/07/2023. Weigh every Skilled Nurse Visit. Report weight gain of 3 pounds in 24 hours or 5 pounds in one week. Review of Patient #13’s Skilled Nursing Visits for Certification Period 07/11/2022 – 09/08/2022 revealed no documented weight measurements on 07/18/2022, 07/26/2022, 08/11/2022, 08/17/2022, and 08/25/2022. An interview was conducted with S1ADM on 07/31/2023 at 11:26 a.m. He reviewed Patient #13’s Clinical Record at that time and confirmed there were no documented weights on the Skilled Nursing Visits conducted on 07/18/2022, 07/26/2022, 08/11/2022, 08/17/2022, and 08/25/2022, and there should have been.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the Home Health Agency failed to ensure a physician was notified of blood pressures outside of physician ordered parameters for 1 (Patient #17) of 17 (Patients #1-17) patients reviewed for physician notification. Findings: Review of the Agency’s Policy titled, “Physician Communication” revealed the following, in part: Purpose: To define expectations for communication with the physician. Policy: Physician communication will be established and maintained to ensure safe and appropriate care for the patient. Procedures: 1. Professional agency personnel contact the patient’s physician: B. When there are changes in the patient’s condition. 2. All conferences or attempts to communicate with physician will be included but not limited to: the physical chart and/or Allscripts clinical notes tab, assessment, or schedule notes. Review of Patient #17’s Clinical Record revealed a Start of Care date of 02/21/2023 with a Certification Period of 02/21/2023-04/21/2023. Patient #17’s primary diagnoses included Adenocarcinoma of Right Lung, Lung Cancer Metastatic to Brain, Hypotension due to Hypovolemia, Dehydration, Severe Protein-Calorie Malnutrition, and Human Immunodeficiency Virus Infection. Review of Patient #17’s Plan of Care dated 02/21/2023-04/21/2023 revealed the following Physician Orders: Skilled Nurse once weekly beginning 02/26/2023; Physical Therapy twice weekly beginning 02/21/2023; Notify MD of symptomatic vitals: Systolic Blood Pressure greater than 160 or less than 90, Diastolic Blood Pressure greater than 90 or less than 50. Review of Patient #17’s Physical Therapy Note dated 03/07/2023 by S9PTA revealed the following, in part: Treatment: Upon arrival to patient’s home, patient was seated in shower on bench. Shower transfer to chair performed with minimum-moderate assist. Patient’s daughter reports patient felt more fatigued this morning and required assistance to get out of bed. Patient’s blood pressure recorded at 78/60 mmHg with heart rate of 75 bpm, and following 5 minutes of seated rest, vitals were retaken. Blood pressure recorded at 75/61 mmHg with heart rate of 67 bpm. Patient’s nurse notified. Patient was placed in supine position with legs elevated, and patient was given water. Blood pressure recorded following 10 minutes of rest at 126/78 mmHg with heart rate of 67 bpm. Patient’s nurse scheduled to see patient today. Care Management: Physician Contact: No contact required/made. Review of Patient #17’s Skilled Nursing Note dated 03/07/2023 by S10LPN revealed the following, in part: Physical/Nutrition: Hydration: Fair Care Management: Physician contact: No contact required/made. Review of Patient #17’s SN/PT Communication Note dated 03/07/2023 by S10LPN revealed the following, in part: Skilled Nurse received call from Physical Therapist prior to Skilled Nurse Visit stating patient was weak, lethargic, with low blood pressure. Dehydration may be the cause of symptoms; patient with improvement on arrival. Encouraged frequent small meals, increase fluids. Review of Patient #17’s physician communication portion of the Clinical Record revealed there was no documentation S9PTA or S10LPN notified the physician on or after 03/07/2022 when the patient had blood pressures outside of physician ordered parameters. An interview was conducted with S9PTA on 08/02/2023 at 8:42 a.m. She said on 03/07/2023 when she arrived to Patient #17’s home he was in the shower. She said she assisted Patient #17 to transfer out of the shower, get dressed, and ambulate to his room. She said she took Patient #17’s blood pressure. She stated it was low, but she did not recall the exact readings. She said Patient #17 was weak, had no appetite, and was not drinking enough fluids. She said she notified S10LPN of Patient #17’s low blood pressure during her visit. Upon review of Patient #17’s blood pressure readings documented in S9PTA’s visit note dated 03/07/2023, S9PTA confirmed the blood pressure readings were out of parameters, and Patient #17’s physician was not notified. An interview was conducted with S10LPN on 08/02/2023 at 11:30 a.m. She said S9PTA notified her during the therapy visit on 03/07/2023 that Patient #17 had been in the shower, was lethargic and hypotensive. She did not recall what S9PTA reported Patient #17’s blood pressure readings were. Upon review of Patient #17’s blood pressure readings documented in S9PTA’s visit note dated 03/07/2023, S10LPN said she did not notify Patient #17’s physician of the blood pressure readings because his blood pressure was stable when she made her visit later that day on 03/07/2023. S10LPN confirmed the blood pressure readings were out of parameters, and Patient #17’s physician was not notified. An interview was conducted on 08/01/2023 at 4:15 p.m. with S1ADM. He reviewed Patient #17’s Clinical Record and the visit notes from S9PTA and S10LPN dated 03/07/2023. He confirmed the blood pressure readings obtained during S9PTA’s visit on 03/07/2023 were outside of the physician ordered parameters with no documented evidence Patient #17's blood pressures had been communicated to the patient's physician.

Recertification Re-licensing A COVID-19 Focused Infection Control Survey was conducted on 9/21/2021. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Total residents: 444

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to have evidence of documentation that patients' complaints had been accurately investigated, and failed to document a resolution of the complaint on the agency's form. Findings: The agency's policy for Complaints/Grievances/Concerns Policy was reviewed and revealed the following documentation - .....Procedure ... 2. The appropriate employee receiving the complaint will document the complaint appropriately on the patient complaint form. 3. The Supervisor will investigate the complaint after receipt and shall make every effort to resolve the complaint to the patient's satisfaction. If the complaint is resolved then the resolution is documented and filed in the complaint log.......... During the annual recertification survey, a review of the agency's complaint/grievance binder was conducted. Documentation of complaints/grievances received from various patients was observed in the binder. Multiple complaint forms included documentation of an investigation that did not accurately address the patients' complaint/grievances. Additionally, multiple complaint/grievance forms had incomplete or no documentation of an investigation, no results of an investigation, no action taken and/or by whom, and no final resolution of the complaint/grievances received. On 9/16/2021 at 11:37 am, an interview was conducted with S1ADM, and the investigation and documentation of the agency's complaints/grievances was discussed. After a review of the agency's investigation documents, he verified that the complaint/grievance forms were incomplete and further verified that there were multiple forms that had no documentation of a resolution of the complaint. On 9/21/2021 at 1:45 pm, an interview was conducted with S2DON, and the investigation and documentation of the agency's complaints/grievances was discussed. S2DON verified that it was her signature at the bottom of the majority of the complaint/grievance forms. After a review of the forms, she verified that the forms were incomplete and verified there were multiple forms with no documentation of an investigation or a resolution to the complaint. Additionally, S2DON verified that the investigations that she had conducted to address the patients' complaints and grievances did not accurately address the issues the patients had complained about.

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 Agency failed to follow the written individualized plan of care for 4 (#1, #3, #4 and #9) as evidenced by: 1. The skilled nurse failed to obtain a finger stick (FS) on the visit dated 9/9/2021 for Patient #1 and; 2. No evidence found of the skilled nurse and physical therapist following the frequency for visits on the PoC (Plan of Care) for Patient #3 and; 3. No evidence found of the physical therapist following the frequency for visits on the PoC for Patient #4 and; 4. No evidence found of the skilled nurse making a visit during the week of 8/29/2021 for Patient #9 out of a total of 17 (#1-17) sampled patients. Findings: 1. Patient #1. The patient was admitted to the agency on 9/9/2021 with the diagnoses that included Malignant Neoplasm of Oral Cavity, Debility, and Paraplegia. The certification period reviewed was 9/9/2021 to 11/7/2021. The patient's PoC was reviewed and the following documentation was found - Orders for Discipline and Treatments: SN (skilled nurse) 9/9/21 - 1 x week x 1 week (1 visit a week for 1 week). ....check glucose per finger stick weekly. Fax results ____ (patient's physician). The patient's electronic medical record was reviewed and the SN Start of Care progress notes dated 9/9/2021 were reviewed and there was no evidence found that the SN obtained a glucose reading for the patient per finger stick during the visit. On 9/20/21 at 12:47 pm, a phone interview was conducted with S3RN and he verified that he had conducted the visit with Patient #1. S3RN verified that he had not obtained a finger stick to check the patient's glucose during the visit on 9/9/2021. 2. Patient #3. The patient was admitted to the agency on 8/16/2021 with the diagnoses that included Right Lower Lobe Pneumonia, Essential Hypertension, and Falls. The certification period reviewed was 8/16/2021 to 10/14/2021. The patient's PoC was reviewed and the following documentation was found - Orders for Discipline and Treatments: SN (skilled nurse) 08/16/21 - 1 x week x 4 week (1 visit a week for 4 weeks) and 9/12/2021 - 1 x week for 5 weeks (1 visit a week for 5 weeks). 8/16/2021 -PT (Physical Therapy) 2 x week x 3 weeks (2 visits a week for 3 weeks). PT - 9/5/2021 2 x week for 3 weeks (2 visits a week for 3 weeks). The patient's electronic medical record was reviewed, and during the week of 8/29/2021, there was no evidence found that the physical therapist made 2 visits for the week or that the skilled nurse made 1 visit for the week. There was no evidence found that for the week of 9/5/2021 that the physical therapist made 2 visits for the week. There was no evidence found for the week of 9/12/2021 that the skilled nurse made 1 visit for the week with the patient. On 9/20/2021 at 2:26 pm, an interview was conducted with S2DON, and after review of the above listed patient's electronic medical records, she verified there was no evidence that the skilled nurse and physical therapy visits had been made. 3. Patient #4. The patient was admitted to the agency on 8/10/2021 with the diagnoses that included Cerebrovascular Accident and Spasticity Due to Old Stroke. The certification period reviewed was 8/10/2021 to 10/08/2021. The patient's PoC was reviewed and the following documentation was found - Orders for Discipline and Treatments: 8/10/2021 - PT (Physical Therapy) 2 x week x 3 weeks (2 visits a week for 3 weeks). The patient's electronic medical record was reviewed and for the week of 8/10/2021 and 8/15/2021, there was no evidence found that the physical therapist made 2 visits for the weeks. On 9/21/2021 at 12:23 am, an interview was conducted with S1ADM, and after review of the above listed patient's electronic medical records, he verified there was no evidence the physical therapy made 2 visits with the patient for the weeks of 8/10/2021 and 8/15/2021. 4. Patient #9. The patient was admitted to the agency on 8/10/2021 with the diagnoses that included Chronic Pain to Both Knees and Type 2 Diabetes Mellitus with Hyperglycemia. The certification period reviewed was 8/24/2021 to 10/22/2021. The patient's PoC was reviewed and the following documentation was found - Orders for Discipline and Treatments: Orders for Discipline and Treatments: SN (skilled nurse) 08/24/21 - 1 x week x 4 week (1 visit a week for 4 weeks). The patient's electronic medical record was reviewed and for the week of 8/29/2021 and there was no evidence found that the skilled nurse made 1 visit for the week. On 9/16/2021 at 2:23 pm, an interview was conducted with S4RDO (Regional Director of Operations), and after review of the patient's electronic medical records, he verified there was no evidence the skilled nurse made a visit with the patient during the week of 8/29/2021.

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 record review and interview, the Agency failed to ensure the individualized plan of care (PoC) included documentation of parameters for the services provided, as evidenced by no documentation parameters found on the PoC for the monitoring of the oxygen saturation by the skilled professional for 1 (#2) patients out of a total of 17 (#1-17) sampled patients. Findings: Patient #2. The patient was admitted to the agency on 8/19/2021 with the diagnoses that included Colonic Mass, and Encounter for Surgical Aftercare Following Surgery of Digestive System. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient's PoC was reviewed and there was no documentation found of parameters for the skilled professional to notify the physician of abnormal vital signs found during the visits. The patient's PoC revealed the following order - PT (Physical Therapy) 8/19/21- 2 x week x 3 weeks. (2 visits a week for 3 weeks) A review of the Physical Therapist's initial progress note dated 8/19/1021 was conducted, and revealed that during the visit, the therapist documented that the patient's pulse oximetry reading was 88%. There was no evidence found that the patient's physician had been notified of the low reading. On 9/21/2021 at 11:50 am, an interview was conducted with S2DON and she verified after a review of the patient's electronic medical record, that during the visit on 8/19/2021, the pulse oximetry reading was 88%, and confirmed that this was a low reading. S2DON stated she would have expected the therapist to notify the patient's physician of the low reading. S2DON verified there was no evidence in the electronic medical record that the physical therapist had notified the physician of the pulse oximetry reading of 88% on 8/19/2021.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that the plan of care (PoC) was signed and dated by the patient's physician as evidenced by failing to obtain the physician's signature on the Plan of Care within 30 days for 2 (#2 and #15) out of 17 (#1-17) sampled patients. Cross-referenced with State Regulations §9123. Patient Care Standards.... C. Plan of Care. The plan of care (PoC) for each patient must be individualized to address the patient's problems, goals, and required services. 1. The PoC, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: 1. Patient #2. The patient was admitted to the agency on 8/19/2021 with diagnoses that included Colonic Mass, and Encounter for Surgical Aftercare Following Surgery of Digestive System. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient's plan of Care (PoC) was reviewed and the agency did not have any evidence that the physician had signed the Home Health Certification and Plan of Care as of 09/21/2021. On 9/21/2021 at 10:15 am, an interview was conducted with S2DON, and after a review the electronic medical record for Patient #2, she verified the Home Health Certification and Plan of Care had not been returned to the agency and had not been signed within 30 days. S2DON stated that on 9/21/2021, Patient #2's PoC had been resubmitted to the physician for his signature. 2. Patient #15. The patient was admitted to the agency on 4/4/2021 with diagnoses that included Sepsis, Adenocarcinoma of Lung, and Metabolic Encephalopathy. The certification period reviewed was 4/4/2021 to 6/2/2021. The patient's plan of Care (PoC) was reviewed and the physician had signed the Home Health Certification and Plan of Care on 5/17/2021, which was not within 30 days from the start of care. On 9/20/2021 at 11:22 am, an interview was conducted with S2DON, and after a review the electronic medical record, she verified that Patient #15's Home Health Certification and Plan of Care had not been signed by the physician within 30 days.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure communication with the physician involved in the care for 1 (#2) patient as evidenced by: a. No evidence found of communication with the physician for Patient #2 that the patient's home health aide services ordered on 8/19/2021 had not been started until 9/9/2021 and; b. No evidence found that the Physical Therapist notified Patient #2's physician of a low pulse oximetry reading of 88% obtained during a visit on 8/19/2021 out of a total of 17 (#1-17) sampled patients. Findings: Patient #2. a. The patient was admitted to the agency on 8/19/2021 with diagnoses that included Colonic Mass, and Encounter for Surgical Aftercare Following Surgery of Digestive System. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient's plan of Care (PoC) was reviewed and revealed the order - AID 8-24-2021 2 x week x 3 weeks (2 visits a week for 3 weeks). The home health aide's progress notes were reviewed and the first home health aide visit with Patient #2 had occurred on 9/9/2021. There was no evidence found that the agency had notified the patient's physician of the delay in starting the patient's home health aide services. On 9/21/2021 at 11:20 am, an interview was conducted with S2DON, and after a review of the patient's electronic medical record, she confirmed that the aide services had not been provided by the agency until 9/9/2021. S2DON stated the agency had to wait for the patient's insurance company to approve of the home health aide visits, and verified there was no evidence the agency had notified the patient's physician of the delay in the start of the home health aide services. b. The Physical Therapist's progress note dated 8/19/1021 was reviewed. During the visit, Patient #2's pulse oximetry reading was documented by the therapist as 88%. There was no evidence found that the patient's physician had been notified of the low reading. On 9/21/2021 at 11:50 am, an interview was conducted with S2DON, and after she reviewed the patient's electronic medical record she verified that during the Physical Therapist's visit on 8/19/2021 the pulse oximetry reading was 88%, and she stated that this was a low reading. S2DON stated she would have expected the therapist to notify the patient's physician of the low reading. S2DON verified there was no evidence in the electronic medical record that the physician had been notified by the physical therapist of the pulse oximetry reading of 88% conducted on 8/19/2021.

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 agency failed to ensure the accuracy of the documentation of a supervisory visit for the home health aide for 1 (#2) patient, as evidenced by a supervisory visit documented on 9/8/2021, prior to the agency providing home health aide services to the patient beginning on 9/9/20210, out of a total of 17 (#1-17) sampled patient records. Findings: Patient #2. The patient was admitted to the agency on 8/19/2021 with diagnoses that included Colonic Mass, and Encounter for Surgical Aftercare Following Surgery of Digestive System. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient's plan of Care (PoC) was reviewed and revealed the order - AID 8-24-2021 2 x week x 3 weeks (2 visits a week for 3 weeks). The home health aide progress notes were reviewed and the first home health aide visit conducted with Patient #2 occurred on 9/9/2021. The SN (skilled nurse) - Nursing Routine Visit progress note dated 9/8/20210 was reviewed and under the section Supervision/Aide Supervision the following documentation was found - HHA (home health aide) Supervision: Yes Aide Employment: Employed by this company Is the Home Health Aide following the Care Plan? Yes Are the patient/family satisfied with care? Yes On 9/21/2021 at 11:48 am, an interview was conducted with S2DON (Director on Nursing) and a review of the patient's electronic medical records was conducted. S2DON stated that patient #2's home health aide services did not begin until 9/9/2021 due to the agency having to wait for the patient's insurance to approve of the aide services. S2DON verified the documentation of the supervisory visit for the home health aide on the skilled nurse's notes dated 9/8/2021 was inaccurate as the aide services did not begin until 9/9/2021.