Every finding on record at Prohealth Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during an EMERGENCY PREPAREDNESS SURVEY conducted 5/4/26 through 5/7/26. The agency reported 799 unduplicated annual admissions. The sample size was 17, and 7 home visits were conducted. The home health agency was found to be in compliance with 42 CFR, part 418.102 for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/4/26 through 5/7/26. The agency reported 799 unduplicated annual admissions. The sample size was 17, and 7 home visits were conducted.

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 interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services, (CMS)) data was transmitted within 30 days of completing the OASIS data sets, when 207 OASIS reports were submitted late during the time period of 4/1/26 through 5/7/26. This failure created the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA. Findings: A review of the agency’s “Oasis Error Detail Report,” report submission dated 4/1/26 through 5/7/26, indicated 207 data sets were submitted late, after more than 30 days from the assessment completion date as follows: April 1, 2026, 13 late submissions April 2, 2026, 3 late submissions April 3, 2026, 13 late submissions April 6, 2026, 7 late submissions April 7, 2026, 6 late submissions April 8, 2026, 5 late submissions April 9, 2026, 12 late submissions April 10, 2026, 8 late submissions April 13, 2026, 7 late submissions April 14, 2026, 2 late submissions April 15, 2026, 6 late submissions April 16, 2026, 6 late submissions April 17, 2026, 5 late submissions April 20, 2026, 4 late submissions April 21, 2026, 11 late submissions April 22, 2026, 2 late submissions April 23, 2026, 8 late submissions April 24, 2026, 8 late submissions April 27, 2026, 28 late submissions April 28, 2026, 3 late submissions April 29, 2026, 7 late submissions April 30, 2026, 16 late submissions May 1, 2026, 5 late submissions May 4, 2026, 10 late submissions May 5, 2026, 2 late submissions May 6, 2026, 10 late submissions Total 207 late submissions. During a concurrent interview and record review on 5/7/26 at 11:26 AM, with the Director of Patient Care Services (DPCS), the Oasis Error Detail Report dated 4/1/26 through 5/7/26, was reviewed. The DPCS confirmed a total of 207 data sets were submitted late, after more than 30 days from the completion date. The DPCS stated everyone understood the timeframes for submission. The DPCS confirmed the timeframes were not being met. The DPCS explained the importance of the timeframes for submission were to ensure accurate documentation, quality of patient care, and communication. The DPCS further explained the risks to the patient were a delay in delivery of care. During a review of the agency’s policy titled, “OASIS DATA TRANSMISSION,” dated 07/25, the policy indicated, “…The organization will adhere to all OASIS requirements as outlined in the Medicare Conditions of Participation…The organization may take up to thirty (30) calendar days after the date of completion…to enter the OASIS data into their computers using internet Quality Improvement Evaluation System (iQIES) [web based system used to collect analyze and report patient and provider data for Medicare and Medicaid programs]…The validation logs in iQIES will be reviewed for accuracy purposes and kept for twelve (12) months…”

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interviews and record review, the facility failed to document the initial assessment and care provided for two of seventeen sampled patients (Patient 4 and Patient 5) when the Outcome and Assessment Information Set (OASIS: a group of standard data elements integrated into the comprehensive assessment and reported to the Centers for Medicare & Medicaid Services [CMS] by the home health agency) RN (Registered Nurse) Start of Care form was not completed for Patient 4 and Patient 5. These failures had the potential to result in delayed care and services and decreased well-being for Patient 4 and Patient 5. Findings: 1.A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care in 2026 with diagnoses which included left tri malleolar fracture (broken bones in the lower left leg and ankle). A review of Patient 4’s “OASIS RN Start of Care,” form indicated that the start of care visit date was 4/21/2026. Patient 4’s “OASIS RN Start of Care,” was signed by the RN and Patient 4, but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 p.m., Patient 4’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, patient's plan of care was set up, and patient care orders were entered into the patient’s electronic medical record (EMR). The ADPCS added patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s EMR. The ADPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was blank except for RN’s and Patient 4’s signature. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/5/26 at 3:26 p.m., Patient 4’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s EMR. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was that continuity of care concerns would not be addressed, and the patient would not have received good quality of care. The DPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 4’s signature and was not completed within five business days. 2.A review of Patient 5’s “Patient Information Sheet,” indicated that Patient 5 started care in 2026 with diagnoses which included Alzheimer’s disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die), and dementia (a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities). A review of Patient 5’s “OASIS RN Start of Care,” form indicated that the start of care visit date was 04/17/2026. Patient 5’s “OASIS RN Start of Care,” form was signed by the RN and Patient 5’s family member but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 p.m., Patient 5’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, patient's plan of care was set up, and patient care orders were entered into the patient’s electronic medical record (EMR). The ADPCS added patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s EMR. The ADPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was not completed. The ADPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was blank except for RN’s and Patient 4’s signature. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/5/26 at 3:26 p.m., Patient 5’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s EMR. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was that continuity of care concerns would not be addressed, and the patient would not receive good quality of care. The DPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 5’s family member’s signature and was not completed within five business days.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medication safety for one out of 17 sampled patients (Patient 5) when Patient 5 had medications that were not verified during the comprehensive review (a systematic pharmacist-led evaluation of all a patient's medications to identify, resolve, and prevent medication-related problems). This failure had the potential to result in unsafe medication use and decreased well-being for Patient 5. Findings: A review of Patient 5’s “Patient Information Sheet,” indicated that Patient 5 started care in 2026 with diagnoses which included Alzheimer’s Disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die), Dementia (a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities), and chronic (long-term) cough. A review of Patient 5’s “Medication Profile,” during the certification period of 4/17/26 through 6/15/26, indicated an Albuterol inhaler (a medication ordered to treat difficulty breathing, shortness of breath, coughing, and chest tightness caused by lung diseases such as Chronic Obstructive Pulmonary Disease [COPD, a long-term disease that cause airflow blockage, breathing related problems, shortness of breath and cough]) was ordered as needed but had no time interval for doses (example - take every four to six hours as needed). During a concurrent interview, record review, and policy review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 3:42 PM, Patient 5’s “Medication Profile," during the certification period of 4/17/26 through 6/15/26 and the agency's policy and procedure (P&P) titled, “Medication Profile,” dated July 2025, were reviewed. The ADPCS stated that the expectation was that licensed staff reviewed the Medication Profiles with the patients and/or caregivers during the home visits for accuracy. The ADPCS acknowledged that Patient 5’s physician order for the Albuterol inhaler ordered as needed, should have had a time interval. The ADPCS stated the risk of not having a time interval for the Albuterol inhaler was that Patient 5 could have had a fast heart rate if the dosing of the Albuterol was given too frequently. The ADPCS acknowledged the agency's policy was not followed. An additional review of Patient 5’s “Medication Profile," during the certification period of 4/17/26 through 6/15/26, indicated Benzonatate (a medication prescribed to relieve coughs due to colds or flu) 100 milligrams (mg, unit of measurement) capsules were ordered as one capsule orally as needed without a time interval. During a concurrent interview, record review, and P&P review with the Assistant Director of Patient Care Services (ADPCS) on 5/7/26 at 11:23 AM, Patient 5’s “Medication Profile," during the certification period of 4/17/26 through 6/15/26 and the agency's P&P titled, "Medication Profile,” dated July 2025 were reviewed. The ADPCS stated that the expectation was that the agency's licensed clinical staff reviewed the medication list with the patient during the home visits. The ADPCS acknowledged that Patient 5’s “Medication Profile” indicated Patient 5 could take Benzonatate 100 mg capsule, one orally as needed, but didn’t have a time interval for dosing. The ADPCS stated that the risk of not having a time interval was that the medication could cause tachycardia (fast heart rate) and patient health decline. The ADPCS acknowledged that the agency's policy was not followed. A review of the agency's P&P titled, “Medication Profile,” dated July 2025, the P&P indicated, “…Purpose…To define the use of the medication profile in evaluating a patient’s medication regimen…Policy…Patients receiving medications will have a current, accurate medication profile in the clinical record…Procedure…2. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed…dose, strength, route, frequency…4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver…understand the medication regimen. This includes, but will not be limited to…B. Using the medication profile to teach…dosages…administration times…” A review of a agency's P&P titled, “Identification of Medication for Administration,” dated July 2025, the P&P indicated, “…Purpose…To provide general guidelines for the safe administration of medications in the home…Policy…Orders for the administration of patient medications must be given by a physician…and will include patient name…the name of the medication, dosage…frequency of administration…”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure patients received home health services in accordance with the individualized plan of care for 3 of 17 sampled patients when: Patient 7 did not receive the Occupational Therapy evaluation ordered in the plan of care; and,Patient 3 had a missed home health aide visit that the agency did not document or rescheduled; andPatient 2 had two plans of care that were not signed by the physician within the required 30 day time frame.These failures placed Patient 7, Patient 3, and Patient 2 at risk for unreviewed, missed, or delayed services, unmet needs, and delayed identification of changes in condition. 3. A review of Patient 2’s clinical document titled, “Plan of Care,” indicated Patient 2 was admitted for care with diagnoses which included muscle weakness and heart failure. A review of Patient 2's clinical document titled, "PLAN OF CARE," dated 10/1/25, indicated the physician did not sign the POC until 4/10/26. A review of Patient 2's clinical document titled, "PLAN OF CARE," dated 11/25/25, indicated the physician did not sign the POC until 4/10/26. During a concurrent interview and record review on 5/5/26 at 2:24 PM, of Patient 2's POC with the Director of Patient Care Services (DPCS), the DPCS confirmed the physician had not signed the POC's until 4/10/26. The DPCS explained the physician had 30 days to sign the POC's and did not sign them in the required time frame. The DPCS further explained the importance of the physician signing the POC's within the 30 days was to ensure Patient 2 continued to qualify for services. The DPCS stated the risk to Patient 2 was Patient 2's care was not being directed by the physician and Patient 2 was at risk for a decline in health or a poor outcome. A review of a facility policy and procedure (P&P) titled, “Rehabilitation Techniques,” dated July 2025, the P&P indicated, “…Purpose…To provide guidelines for the instruction of patients and family/caregivers in…rehabilitation techniques to facilitate adaptation and/or functional independence…Definitions…2. Rehabilitation…The combined and coordinated use of educational, medical, social, and vocational measures for training or retraining individuals disabled by disease or injury. The goal is to enable individuals to achieve their highest possible level of functional ability…Policy…Patients will be assessed for…rehabilitation potential, and they will receive referrals and information as needed…Procedure…1. Upon admission, the patient will be assessed regarding functional limitations that need to be addressed to ensure adaptation to the home environment…4. The patient’s physical status and functional abilities will be evaluated by a rehabilitation professional before instruction and treatment is initiated…” A review of a facility P&P titled, "Care Coordination," dated July 2025, the P&P indicated, "...Purpose...To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...Policy...Written evidence of care coordination will be recorded during the case conference...Procedure...4. Care coordination will include but not be limited to...D. Planned face-to-face conferences...7. Organization personnel will communicate changes in a timely manner via...case conferences..." Review of the agency policy titled “MISSED VISITS,” Policy No. 2-057.1, revised July 2025, indicated, “… Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record… 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor… B. Document in the patient’s clinical record…” Findings 2. Review of Patient 3’s “Patient Profile” indicated Patient 3 was admitted to the home health agency on 4/4/26 following a right total knee replacement (a surgical procedure that removes damaged parts in the knee joint and replaces them with artificial metal and plastic components). Review of Patient 3’s “Home Health Physician Orders,” dated 4/4/26, indicated, “HHA (home health aide- assist patients with personal care and daily living activities at home): 2 x week for 5 weeks starting 04/06/2026 (week 2),” with an end date of 5/10/26 for home health services. Review of Patient 3’s agency calendar for the certification period 4/4/26 through 6/2/26 indicated only one documented home health aide visit occurred on 5/1/26 during week 4 of the ordered home health aide services. Further review failed to show evidence additional home health aide visits, missed visit documentation, or rescheduled visits were documented in the patient’s electronic medical record (EMR – electronic chart used to document and track patient’s care by healthcare staff). During a concurrent interview and record review on 5/5/26 at 4:10 p.m., with the Assistant Director of Patient Care Services (DPCS/LN 4), Patient 3’s agency calendar and EMR were reviewed. The DPCS/LN 4 confirmed Patient 3 missed a physician- ordered HHA visit during week 4 of services and confirmed the agency did not notify the physician regarding the missed visit. The DPCS/LN 4 stated the agency should follow up with the clinician, notify the patient and administrator, and attempt to reschedule missed visits to ensure ordered services were provided. The DPCS/LN 4 further confirmed the missed visit was not in compliance with agency policy and placed the patient at risk for unmet care needs and delayed recovery following the right total knee replacement. During a telephone interview on 5/6/26 at 10:02 a.m., with the Home Health Aide (HHA 1), the HHA 1 confirmed she missed the scheduled visit during the week of 4/26/26. HHA 1 stated she notified the office by text message because no visit was scheduled and informed the patient regarding the missed visit. HHA 1 confirmed there was no documentation of the missed visit or the telephone communication with the patient in the clinical record. HHA 1 stated the missed visit could have been rescheduled on another day to ensure continuity of care and acknowledged the missed visit had the potential to affect patient’s care. HHA 1 further stated the case manager was responsible for notifying the physician and documenting the missed visit in the clinical record. Findings: 1. A review of Patient 7’s Plan of Care (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) dated 4/9/26, indicated Patient 7 had diagnoses which included a fracture of the lower end of the left femur (a broken thigh bone just above the knee) and a history of falling. A review of Patient 7’s POC dated 4/9/26, under the section titled, “FUNCTIONAL LIMITATIONS,” indicated, “…ACTIVITES PERMITTED: Perform exercises Prescribed…Use of Human Assistance for Ambulation [walking]…Use of Human Assistance for Transfers…Use of Wheelchair for Mobility…Weight Bearing Restriction: Non-weight Bearing (NWB -a medial restriction meaning you must not place any body weight on an injured leg) on left extremity [leg] Start Effective 4/09/26…” A review of Patient 7’s POC dated 4/9/26 under the section titled, “FREQUENCIES,” indicated, “…OT [occupational therapy] …1 x week [once a week] for 1 week starting 4/06/26 (week 1) …” During a concurrent interview and record review dated 5/6/26 at 11:52 AM with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 7’s POC, progress notes, and calendar of visits and confirmed that physician ordered intervention and service of the OT assessment did not occur and was missed for Patient 7. The DPCS stated the OT assessment was important to determine the needs and for optimal quality of care for Patient 7. The DPCS explained the expectation was that the OT evaluation was completed within 5 days of the ordered date, and the risk of Patient 7 not receiving the OT assessment was delayed care and a potential decline in recovery.

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 interview and record review, the facility failed to generate a Plan of Care (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) for one of 17 sampled patients, (Patient 3) when Patient 3's medical record was reviewed and determined to not have a POC for the benefit period of 4/4/26 through 6/2/26. This failure resulted in Patient 3 not receiving a copy of the POC and had the potential to affect the quality, continuity and frequency of visits to Patient 3. Findings: A review of Patient 3’s clinical record document titled, “OASIS RN START OF CARE,” (OASIS - Outcome and Assessment Information Set a group of standard data elements integrated into the comprehensive assessment and reported to the Centers for Medicare & [and] Medicaid Services [CMS] by the home health agency), indicated Patient 3 was admitted for care with diagnoses which included, aftercare joint replacement surgery (a procedure that removes a damaged or injured joint and replaces it with an artificial prosthesis made of metal, plastic, or ceramic), presence of right artificial knee joint (a prosthetic device surgically implanted to replace damaged bone and cartilage in a patient's right knee joint), and asthma (a chronic (long-term) disease that causes the airways in the lungs to become inflamed, narrow, and filled with mucus, making it difficult to breathe). During a concurrent interview and record review on 5/4/26 at 3:45 PM, with the DPCS, Patient 3’s medical record was reviewed for the Plan of Care, (POC, a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) for the benefit period of 4/4/26 through 6/2/26 and the agency's Policy and Procedure (P&P) titled, “ADMISSION CRITERIA AND PROCESS,” revised July 2025, was reviewed. The DPCS confirmed Patient 3’s medical record did not contain the POC for the benefit period of 4/4/26 through 6/2/26. The DPCS further confirmed that the POC was a required document that should have been generated after Registered Nurse (RN) 1 completed the initial comprehensive assessment. The DPCS stated the importance of the POC was that it contained all the required documentation for Patient 3’s goals of care, including the physician ordered services, Patient 3’s specific measurable goals, all diagnoses, equipment needed, visit frequencies with duration of care, types of services and providers ordered by the physician for Patient 3. Additionally, the DPCS stated the POC contained Patient 3’s rehabilitation potential, functional limitations, activities permitted, all medications and treatments, and patient/caregiver education. The DPCS added that a copy of the POC was required to be given to Patient 3 at the beginning of services and did not receive the POC since it was never created. The DPCS explained that the POC was important to have in the medical record, so all of the providers of care provided the expected care, measured if Patient 3 was achieving the goals of care, and evaluated Patient 3’s continued need for services from the Home Health Agency (HHA). The DPCS further explained the risk to Patient 3 for not having a POC generated was a decline in health status and not receiving optimal care. The DPCS confirmed not having a POC generated and in the Patient 3's medical record did not follow the agency's policy. During an interview on 5/5/26 at 10:03 AM, in Patient 3’s home, Patient 3 stated she had not seen the POC and was not familiar with what the POC would have contained. A review of the agency's P&P titled, “ADMISSION CRITERIA AND PROCESS,” revised July 2025, indicated, “…17. If the patient is accepted for home health, an initial plan of care will be developed in consultation with the physician and the patient and then submitted to the physician for signature…18. A. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day…” A review of the agency's P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” A review of the agency's P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the physician's orders were authenticated and/or signed by the physician in accordance with state law and facility policy for three of 17 sampled patients (Patient 2, Patient 3, and Patient 8) when: 1. Patient 2’s physician's orders were not signed by the physician for the orders dated 10/1/25, 11/7/25, 11/25/25, and 12/30/25 2. Patient 3's physician's orders did not include the date and time the verbal order was received and was not signed by the physician for the order dated 4/4/26 3. Patient 8's "Plan of Care", (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) dated 3/27/26 and physician's orders were not signed for orders dated 3/25/26 and 3/27/26. These failures had the potential for a delay in patient care, with the potential to negatively affect Patient 2, Patient 3, and Patient 8’s health and well-being. 2. During a concurrent interview and record review on 5/4/26 at 3:45 PM with the Director of Patient Care Services (DPCS), Patient 3’s clinical record was reviewed for the completeness of the physician's orders. The DPCS confirmed Patient 3’s clinical record document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 4/4/26, was incomplete and did not contain the date and time the verbal order was received. The DPCS further confirmed the order had not been signed by the ordering physician. The DPCS explained that physician orders were expected to be complete with the date and time of the order and signed by the ordering physician within 30 days. 3. During a concurrent interview, record review, and review of agency policies on 5/5/26 at 2:40 PM with the DPCS, Patient 8's Plan of Care, (POC) dated 3/27/26, the “HOME HEALTH PHYSICIAN ORDERS,” dated 3/25/26 and 3/27/26, the agency's Policy and Procedure (P&P) titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, and the P&P titled, “VERIFICATION OF PHYSICIAN ORDERS,” revised 7/25, were reviewed. The DPCS confirmed that the POC was not signed by the ordering physician. In addition, the DPCS confirmed the order dated 3/25/26 was incomplete and did not specify the type of order (verbal or non-verbal), and the date and time of the order was given was not documented. Additionally, the DPCS confirmed the physician orders dated 3/25/26 and 3/27/26 for Patient 8 were not signed by the physician within 30 days. The DPCS explained physician's orders should have been completed with the date and time of the order, and the physician was expected to sign them within 30 days. The DPCS acknowledged the facility P&P was not followed. A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” A review of the facility policy titled, “VERIFICATION OF PHYSICIAN ORDERS,” revised 7/25, the policy indicated, “… To ensure accurate physician (or allowed practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulations … Signed orders will be placed in the clinical record within 30 days …” Findings: 1. A review of Patient 2’s clinical document titled, “Plan of Care,” indicated Patient 2 was admitted for care for diagnoses which included muscle weakness and heart failure. A review of Patient 2’s clinical document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 10/1/25 was not signed by the physician. A review of Patient 2’s clinical document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 11/7/25 was not signed by the physician. A review of Patient 2’s clinical document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 11/25/25 was not signed by the physician. A review of Patient 2’s clinical document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 12/30/25 was not signed by the physician. During a concurrent interview and record review on 5/5/26 at 2:32 PM with the Director of Patient Care Services (DPCS), Patient 2’s clinical documents titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 10/1/25, 11/7/25, 11/25/25, and 12/30/25 were reviewed. The DPCS confirmed the physician’s orders had not been signed. The DPCS explained the physician’s orders were required to be signed within 30 days. The DPCS further explained the importance of signing the physician’s orders was to ensure the patient qualified for home health services by being under the care of a physician. The DPCS stated the risk to the patient was care would not be directed by the physician and there could be a potential for decline and/or a poor outcome.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate care to meet the needs of one of 17 sampled patients (Patient 10), when Patient 10 did not receive physical therapy services until two weeks after his start of care (SOC) date, due to agency staffing concerns and a scheduling miscommunication. This failure caused a delay in Patient 10 receiving services and had the potential to negatively affect Patient 10’s physical and psychosocial well-being. Findings: A review of Patient 10’s “PATIENT PROFILE,” indicated his SOC date as 4/13/26. During an interview on 5/5/26 at 11:39 AM with Family Member (FM) 1, FM 1 stated Patient 10 had Parkinson’s Disease (PD, a progressive disease of the nervous system marked by tremor, muscle rigidity and slow imprecise movement) and needed home health services for nursing care and physical therapy (treatment focused on improving movement, strength, and mobility). FM 1 further stated the family had to keep calling the agency to get physical therapy services started for Patient 10. FM 1 stated Patient 10’s therapy was delayed because the agency staff had a family emergency. During an interview on 5/5/26 at 12:19 PM with Physical Therapist (PT) 3, PT 3 stated she was unaware why patient 10’s therapy services were delayed. PT 3 further stated Patient 10 was at risk of falls and needed therapy services to improve his balance, strength and endurance. PT 3 stated Patient 10 received therapy services twice weekly but could benefit from services three times per week. During a review of Patient 10’s clinical document titled, “CARE COORDINATION NOTE,” dated 4/13/26, the document indicated, “Coordination of Care with Physician…RN [registered nurse]…PT/PTA [Physical Therapy Assistant] …recent post fall hospitalization…Functional mobility and endurance decreased, using WC [wheelchair] for ambulation…Plan for SN [skilled nurse] visit…Physical Therapy evaluation and treatment to assess mobility device, gait [walking pattern] training and for home exercise program…” During a review of Patient 10’s clinical document titled, “OASIS [Outcome and Assessment Information Set, a group of standard data elements home health agencies integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services] START OF CARE,” dated 4/13/26, the document indicated, “…CONSENT FOR CARE…The initial services to be provided have been explained to me and include…Nurse…PT Eval [evaluation] and treat…” During an interview on 5/5/26 at 3:01 PM with the Admission Coordinator (AC), the AC stated when she tried to schedule therapy services for Patient 10, she was not aware his address was different than the address listed on his referral. The AC stated she had difficulty scheduling PT for the referral address. The AC further stated when she discovered on 4/23/26 that Patient 10 was at a different address she reached out to the contracted PT staff in Patient 10’s location and was able to schedule therapy services. During a review of Patient 10’s clinical document titled, “PHYSICAL THERAPY EVALUATION-STANDARD,” dated 4/27/26 the document indicated, “… CARE PLANNING/COORDINATION…Assessment…Patient demonstrates decreased postural control, impaired balance, pain-limited mobility, and reduced endurance…Recommendation…Recommend continued skilled PT to address balance, gait training, postural control, pain management strategies, and fall recovery…goal is to progress patient to…safe return home with spouse…” During an interview on 5/6/26 at 9:19 AM with the Director of Patient Care Services (DPCS), the DPCS stated physical therapy services should have started within 24 to 48 hours of the SOC date for Patient 10, and they had not. The DPCS further stated that when services were delayed there was the potential for Patient 10 to suffer a physical decline and for Patient 10 and his family to feel stressed and insecure. During a review of a facility policy and procedure titled, “CARE COORDINATION,” the policy indicated, “…PURPOSE…To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services…POLICY…Each patient will be assigned a Case Manager…It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel…PROCEDURE…Care coordination will include…Integration of services…to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided…Coordination of care delivery to meet patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities…”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a licensed vocational nurse (LVN-focus on basic bedside care and must operate under an RN or doctor's supervision) visit was supervised by a registered nurse (RN-handle complex assessments, create care plans, and manage advanced procedures) for 1 of 17 sampled patients (Patient 2) when Patient 2's RN supervisory visit due on 10/28/25 was missed and did not occur within the required timeframe. This failure had the potential for Patient 2's Plan of Care (POC) not being followed with the potential for a decline in Patient 2's health. Findings: A review of Patient 2’s clinical document titled, “Plan of Care,” (POC) indicated Patient 2 was admitted for care with diagnoses which included muscle weakness and heart failure. A record review of Patient 2's clinical document titled, "SKILLED NURSING VISIT NOTE," dated 10/16/25, indicated a RN supervisory visit was conducted. A record review of Patient 2's clinical document titled, "SKILLED NURSING VISIT NOTE," dated 10/25/25, indicated a missed visit by the RN. During a concurrent interview and record review on 5/7/26 at 12:23 PM, with the Director of Patient Care Services (DPCS), the DPCS confirmed Patient 2's RN supervisory visit did not occur on 10/25/25. The DPCS explained the purpose of the RN supervisory visit was to ensure the LVN followed Patient 2's POC and if additional assessments of Patient 2's condition were needed the RN was there to perform any additional services. The DPCS further explained without the RN supervisory visit occurring Patient 2 had a potential for decline and suboptimal care. A review of a facility policy and procedure (P&P) titled, "RESPONSIBILITIES/SUPERVISION OF CLINICAL SERVICES" revised 7/2025, indicated, "...Purpose...To ensure a process is in place for the selection of a qualified individual for overseeing all clinical care and services...The Clinical Director will ensure that the following supervision is maintained within the organization...Licensed practical/vocational nurse [LVN]...will be supervised by a registered nurse as directed by the State Practice Act..." According to the California Code of Regulations "74709. Home Health Aide/Personal Care Services Supervision" "...the registered nurse...shall make an on-site visit to the patient's home no less frequently than every two weeks..." https://govt.westlaw.com/calregs/Document/IC1E3A6435B6111EC9451000D3A7C4BC3?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure supervisory assessments of home health aide services were completed at least every 14 days for 1 of 17 sampled patients reviewed for home health aide (HHA - assist patients with personal care and daily living activities at home) supervision when Patient 3 went approximately one month without a documented supervisory visit while receiving home health aide services. This failure placed Patient 3 at risk for home health aide services that were not evaluated for compliance with the plan of care, unmet care needs, delayed identification of changes in condition, and decline in health, safety, and functional status. Findings Review of Patient 3’s “Patient Profile” indicated Patient 3 was admitted to the agency on 4/4/26 following a right total knee replacement (a surgical procedure where the knee joint is removed and resurfaced with artificial metal and plastic components). Review of Patient 3’s “Home Health Physician Orders,” dated 4/4/26, indicated, “HHA...2 x [times] week for 5 weeks starting 04/06/2026...” with an end date of 5/10/26 for home health services. Review of Patient 3’s electronic medical record (EMR – electronic chart used to document and track patient’s care by healthcare staff) failed to show evidence the agency completed supervisory visits at least every 14 days while Patient 3 received HHA services. Further review showed Patient 3 went approximately one month without a documented supervisory visit. During a concurrent interview and record review on 5/6/26 at 10:46 a.m. with the Assistant Director of Patient Care Services (DPCS/LN 4), Patient 3’s agency calendar and EMR were reviewed. The DPCS/LN 4 verified that the HHA assigned to Patient 3 did not have a supervisory checkoff as required. The DPCS/LN 4 stated supervisory visits were necessary to ensure the home health aide followed the plan of care, addressed patient needs appropriately, and promoted patient safety. The DPCS/LN 4 stated supervisory visits should be completed at least every 14 days for patients receiving home health aide services and confirmed Patient 3 did not receive a supervisory visit for approximately one month while admitted to the agency. During a telephone interview on 5/6/26 at 10:02 a.m. with HHA (HHA) 1, HHA 1 stated supervisory visits were conducted by the nurse to ensure HHA services were provided according to the patient’s plan of care and agency requirements. HHA 1 confirmed she had not received a supervisory checkoff while caring for Patient 3 during the ordered service period. HHA 1 stated that supervisory checkoffs were normally scheduled by the nurse depending on their availability. Review of the agency policy titled “HOME HEALTH AIDE SUPERVISORY VISITS,” Policy No. 1-013.1, revised July 2025, indicated, “… 1. The frequency of supervisory assessments visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every fourteen (14) days or less if the patient is receiving skilled services… 8. Supervisory visits and overall supervision will be documented in the clinical record...”

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the personnel they hired were qualified for employment when: 1. Pre-employment background checks (screening for criminal history, offender registry checks and identity verification) were not completed prior to employment for 4 of 11 sampled employees’ (Licensed Nurse (LN) 3, LN 4, Physical Therapy Assistant (PTA) 1 and Home Health Aide (HHA) 1); 2. Pre-employment reference checks were not completed prior to employment for 2 of 11 sampled employees (LN 1 and PTA 1); 3. Required physical exam documentation was not done on hire in 1 of 11 sampled employee files (LN 2), and 4. Required tuberculosis (TB, a serious infection that mainly affects the lungs) screenings were not done on hire in 1 of 11 sampled employee files (LN 2). These failures had the potential to expose agency patients to abuse and to negatively affect the health and wellbeing of the patients cared for by the agency. Findings: 1. During a concurrent interview and record review on 5/6/26 at 10:29 AM with the Human Resources Manager (HRM), The HRM confirmed the following: LN 3 was hired on 1/16/2023 and LN 3’s background check was dated 7/17/25, LN 4 was hired on 8/29/2017 and LN 4’s background check was dated 11/5/2019, PTA 1 was hired on 2/24/23 and PTA 1’s background check was dated 7/17/25, HHA 1 was hired on 7/26/23 and HHA 1’s background check was dated 7/17/25. The HRM stated the purpose of employee background checks was to ensure the agency did not allow staff with criminal histories to go into patients’ homes. The HRM further stated the agency needed to protect their patients from the potential risk of physical harm, fraud and serious injury. 2. During a concurrent interview and record review on 5/6/26 at 10:29 AM with the HRM the HRM confirmed the following: LN 1 was hired on 3/17/25 and the pre-employment reference checks were dated 10/11/25 PTA 1 was hired on 2/24/23 and the reference checks were dated 11/24/25. 3. During a concurrent interview and record review on 5/6/26 at 10:29 AM with the HRM the HRM confirmed the following: LN 2 was hired on 3/4/25 and LN 2’s physical exam was dated 7/30/24 (physical exam provided on hire by LN 2 but was done 8 months prior to being hired). 4. During a concurrent interview and record review on 5/6/26 at 10:29 AM with the HRM the HRM confirmed the following: LN 2 was hired on 3/4/25 and LN 2’s TB screening was dated 7/30/24 (TB screening provided on hire by LN 2 but was done 8 months prior to being hired). During an interview on 5/6/26 at 1:11 PM with the Director of Patient Care Services (DPCS) the DPCS stated the purpose of pre-employment background and reference checks was to ensure staff had a clean background. The DPCS stated the risk of hiring staff with a criminal background was the potential of harm occurring to the patients. The DPCS stated the risks could include physical, emotional, financial and psychosocial harm. The DPCS stated Physical exams and TB screenings needed to be done on hire. During an interview on 5/7/26 at 11:48 AM with the HRM, the HRM stated the purpose of background checks was to make sure anyone the agency sent into a patient area did not have a criminal background. The HRM further stated the risks to patients’ safety included the potential for physical abuse, fraud, financial abuse and overmedication. The HRM stated the purpose of reference checks was to make sure the agency hired quality people with a good work ethic and to verify their employment and experience. The HRM further stated the purpose of employee health screenings was to make sure staff were physically fit to perform the job they were hired for and to make sure they did not spread infectious diseases to the patients or their coworkers. During a review of a facility policy and procedure titled “SELECTION/HIRING OF PERSONNEL,” revised 7/2025, the policy indicated, “…PURPOSE…To specify the criteria for the recruitment and hiring of staff to meet the care needs of appropriate patients…PROCEDURE…Candidates are screened to ensure that the candidate meets the job requirements…A criminal background check will be obtained for positions required by law, regulation or organizational policy…Applicable health screening requirements if required by law, regulation or organizational policy will be verified…Two (2) references…will be obtained prior to an offer of employment…An offer of employment will be contingent upon a current physical and TB test/chest X-Ray…”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure patient safety in accordance with professional standards of practice for one of ten sampled patients (Patient 1) when Physical Therapist (PT) 2 was escorting Patient 1 from her living room to her bedroom and did not place Patient 1’s feet in the wheel chair foot rests resulting in Resident 1’s left casted (a rigid, custom-fit device made of plaster or fiberglass used to immobilize bones while they heal) foot to drag under the wheel chair. This failure had the potential to worsen and/or cause additional injury to Patient 1’s left casted foot and ankle, potentially negatively impacting Patient 1’s health and wellbeing by delaying the healing process and causing pain and discomfort. Findings: A review of Patient 1’s clinical document titled, “Plan of Care [POC],” indicated Patient 1 was admitted into care with diagnoses including corticobasal degeneration (a rare, progressive neurological disorder where brain cells shrink and die over time primarily damaging areas controlling movement and thinking, causing severe stiffness, poor coordination, and involuntary muscle movements (often on one side of the body) along with cognitive decline). During a home visit observation on 5/5/26 at 10:40 AM, in Patient 1’s home, PT 2 was observed escorting Patient 1 from the living room to Patient 1’s bedroom via wheel chair. Patient 1’s left casted foot was noted to be dragging on the carpeted ground underneath the wheelchair. During an interview on 5/5/26 at 3:34 PM, with PT 2, PT 2 confirmed she did not double check to ensure the footrests on the wheelchair were engaged and Patient 1’s feet were in the footrests. PT 2 stated she should have double checked to ensure Patient 1’s feet were in the footrests. PT 2 explained the importance of ensuring Patient 1’s feet were in the footrests was to prevent injury. PT 2 further explained ensuring Patient 1’s feet were in the footrests was important for Patient 1’s safety. During an interview on 5/5/26 at 3:38 PM, with the Assistant Director of Patient Care Services (ADPCS), the ADPCS stated when moving a patient in a wheelchair, the person transporting the patient should ensure arms are in and to pay attention to the feet to make sure they are not dragging on the ground and the feet are placed in the footrests. The ADPCS explained it was very important to make sure the feet were in the footrests to prevent injury. The ADPCS further explained if the feet were not on the footrests, it could lead to injury. A review of the facility policy titled, “REHABILITATIVE CARE SERVICES,” revised 7/2025, the policy indicated, “…Rehabilitation plans and goals will guide the provision of rehabilitation services and are appropriate to the patient's environment, needs, and severity of disease. Rehabilitation outcomes will promote optimal level of functioning.…”

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure their clinical records (comprehensive, chronological documents detailing a patient's health history, including assessments, diagnoses, treatments, and plan of care) contained accurate documentation that met the standards of practice (a set of standards and guidelines ensuring that data in clinical records was accurate, complete, reliable, and trustworthy) and agency policies and procedures (G1012) for seven of 17 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, and Patient 9). Additionally, the HHA failed to document all interventions, treatments, services and patients responses to interventions in the clinical record to ensure the clinical records were complete, and appropriately authenticated (verified by the responsible clinician by signature to include the date and time. And approves the records for their completeness and accuracy) (G1014) for seven of 17 sampled patients (Patient 7 and Patient 8) and (G1024) for (Patient 3, Patient 4, Patient 5, Patient 8 and Patient 9). The cumulative effect of these systemic practices resulted in the failure of the agency's ability to ensure that the patients’ care and service needs were met because the agency did not maintain complete and accurate clinical records.

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 interview and record review the facility did not ensure current comprehensive assessments (a thorough, interdisciplinary evaluation process that gathers information about a patient's physical, psychological, social, and functional status), clinical notes (dated, written, or electronic records created by healthcare professionals to document a patient's health history, assessment, diagnosis, treatment, and progress during a, visit), care conference (a formal, structured meeting between a patient (or resident), their family/representatives, and an interdisciplinary care team—such as nurses, physicians, and social workers—to discuss, evaluate, and plan the patient’s health goals, care needs, and treatment, aimed at ensuring all parties are aligned), plan of care (a structured, written document that acts as a personalized roadmap for a patient's medical and support services), physician orders, and Outcome and Assessment Information Set (OASIS - a group of standard data elements integrated into the comprehensive assessment and reported to the Centers for Medicare & Medicaid Services [CMS] by the home health agency) Registered Nurse (RN) Start of Care, were current and completed for seven of 17 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, and Patient 9) when: 1. Patient 9’s, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, did not contain any of Patient 9’s visit data for the 5/4/26 visit, as of 5/7/26; and, 2. Patient 2's visit notes from various disciplines, licensed vocational nurses, registered nurses (RN), physical therapy assistants (PTA), and home health aides, were not signed within 48 hours of the visit; and, 3. Patient 3's "PLAN OF CARE," (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) from the initial comprehensive visit dated 4/4/26, was not in the clinical record. The "HOME HEALTH PHYISICIAN ORDERS," dated 4/4/26, was incomplete and did not contain the date and time of the order or the physicians signature for Patient 3; and, 4. Patient 8's "PHYISICAL THERAPY EVALUATION," dated 4/10/26, was incomplete and missing the physician orders for continued physical therapy, the physical therapists (PT) 1’s initial assessment, treatment plan for coordination of care, and the date and time the physician orders were obtained and was not signed or completed by PT 1 within 48 hours of the visit. Patient 8's "PLAN OF CARE," dated 3/27/26, was not updated with physical therapy frequency visits, the physical therapy treatment plan, and the date and time of the order and the signature of the physician. Patient 8's "PHYSICAL THERAPY DISCHARGE VISIT AND SUMMARY," dated 5/1/26, was incomplete and was not signed or completed by the physical therapist (PT) within 48 hours of the visit; and, 5. Patient 4's OASIS, RN [Registered Nurse trained and certified in the Outcome and Assessment Information Set [OASIS], a standardized clinical assessment] Start of Care" form was not complete; and, 6. Patient 5's "OASIS RN Start of Care" form was not complete; and, 7. Patient 6's "Case Conference" was not completed within 60 days. These failures had the potential to result in decreased well-being for Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 9, and had the potential to cause injury to Patient 8. 5. A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care in 2026 with diagnoses which included Left Tri Malleolar Fracture (broken bones in the lower leg and ankle). A review of Patient 4’s “OASIS RN Start of Care,” form indicated that the visit date was 04/21/2026 12:32 PM. Patient 4’s “OASIS RN Start of Care,” form was signed by the RN and Patient 4 but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the DPCS on 5/5/26 at 3:26 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was that continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 4’s signature and was not completed within five business days. The DPCS acknowledged that the facility policy was not followed. 6. A review of Patient 5’s “Patient Information Sheet,” indicated that Patient 5 started care in 2026 with diagnoses which included Alzheimer’s Disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities). A review of Patient 5’s “OASIS RN Start of Care,” form indicated that the visit date was 04/17/2026 2:40 PM. Patient 5’s “OASIS RN Start of Care,” form was signed by the RN and Patient 5’s family member but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/5/26 at 3:26 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 5’s family member’s signature and was not completed within five business days. The DPCS acknowledged that the facility policy was not followed. 7. A review of Patient 6’s “Patient Information Sheet,” indicated that Patient 6 started care in 2025 with diagnoses which included Acute Kidney Injury (A sudden and often reversible reduction in kidney function), and Alzheimer’s Disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die). A review of Patient 6’s closed clinical record indicated that the start of service date was 7/10/25, and the certification for services was 7/10/25 to 9/7/25 with a recertification from 9/9/25 to 11/6/25. The review of Patient 6’s closed clinical record further indicated that skilled nursing, physical therapy, and occupational therapy services were received during the certification and the recertification periods. The record review for Patient 6 did not indicate case conference notes during the certification period or the recertification period. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/5/26 at 3:02 PM, Patient 6’s closed clinical record was reviewed. The ADPCS stated that during the case conferences the staff discussed the patients with services in the prior week’s care needs and followed up with current patient care needs. The ADPCS stated that patients were followed during case conferences in the next week. The ADPCS stated that the facility had case conferences weekly, but the requirement was to complete case conferences every 60 days. The ADPCS confirmed that Patient 6 did not have case conference notes in the clinical record. The ADPCS confirmed that the notes entered on the “Case Conference” forms and the “Care Coordination Notes,” in Patient 6’s clinical record had entries for different dates and times by a registered nurse (RN), a Physical Therapist (PT), and an Occupational Therapist (OT). The ADPCS acknowledged that the notes in the “Case Conference” forms and the “Care Coordination Notes” did not fulfill the requirements for a case conference for Patient 6. The ADPCS acknowledged that the facility policy was not followed. A review of a facility policy and procedure (P&P) titled, “Rehabilitation Techniques,” dated July 2025, the P&P indicated, “…Purpose…To provide guidelines for the instruction of patients and family/caregivers in… rehabilitation techniques to facilitate adaptation and/or functional independence…Definitions…2. Rehabilitation…The combined and coordinated use of educational, medical, social, and vocational measures for training or retraining individuals disabled by disease or injury. The goal is to enable individuals to achieve their highest possible level of functional ability…Policy…Patients will be assessed for…rehabilitation potential, and they will receive referrals and information as needed…Procedure…1. Upon admission, the patient will be assessed regarding functional limitations that need to be addressed to ensure adaptation to the home environment…4. The patient’s physical status and functional abilities will be evaluated by a rehabilitation professional before instruction and treatment is initiated…” A review of a facility P&P titled, “Rehabilitative Care Services,” dated July 2025, the P&P indicated, “…Purpose…To provide clinical direction to therapists providing direct patient care…Procedure…1. When rehabilitation needs are identified, the patient’s physical status and functional abilities are evaluated by a rehabilitation professional before instruction and treatments are initiated…” A review of a facility policy and procedure (P&P) titled, “Case Conference/Progress Summary,” dated July 2025, the P&P indicated, “…Purpose…To define the process for case conferences and documenting patient progress in the clinical record…Policy…Case conferences will be held every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include, but will not be limited to, the type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress toward goals and any necessary revisions in the plan of care. Case conferences will include utilization review; therefore, all clinicians working with patients will participate in case conferences…Procedure…1. Each multidisciplinary patient will have a case conference during the month following the certification month…3. A record will be kept indicating who participated in the meeting…4. A case conference/progress summary, written by the appropriate discipline(s) treating the patient, will be placed in the patient’s clinical record after each case conference meeting…” A review of a facility P&P titled, "Care Coordination," dated July 2025, the P&P indicated, "...Purpose...To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...Policy...Written evidence of care coordination will be recorded during the case conference...Procedure...4. Care coordination will include but not be limited to...D. Planned face-to-face conferences...7. Organization personnel will communicate changes in a timely manner via...case conferences..." Findings: 1. A review of Patient 9’s clinical document titled, “PATIENT PROFILE,” indicated Patient 9 was admitted for care with diagnoses which included asthma Chronic Obstructive Pulmonary Disease (COPD) overlap syndrome (a chronic lung condition occurring when a patient exhibits key features of both asthma and COPD, specifically persistent airflow limitation combined with asthma-like symptoms). During a concurrent interview and record review on 5/6/26 at 11:43 AM with the Director of Patient Care Services (DPCS), of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, the DPCS confirmed Patient 9’s SKILLED NURSING VISIT NOTE did not contain any data from the 5/4/26 visit. The DPCS explained the expectation was for the visit note to be completed within 48 hours and should be documented by the end of business day on 5/6/26. A review on 5/7/26, of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, indicated seven blank pages as no data for the visit had been entered as of 5/7/26 for the 5/4/26 nursing visit. During an interview on 5/7/26 at 10:51 AM, with the Owner, the Owner stated it was the expectation that field staff complete their documentation within 48 hours. A review of the facility policy titled, “[Facility Name] Documentation Policy,” undated, the policy indicated, “… All documentation must be submitted withing 24-48 hours after each visit …” 2. A review of Patient 2’s clinical document titled, “Plan of Care,” (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) indicated Patient 2 was admitted for care for diagnoses which included muscle weakness and heart failure (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen, or is too stiff to fill properly). During a concurrent interview and record review on 5/7/26 at 3:17 PM, the DPCS confirmed the following visits were not completed and signed by the field staff within 48 hours: -10/8/25 visit was not signed by the Licensed Nurse (LN) until 10/24/25 -10/16/25 visit was not signed by the Registered Nurse (RN) until 10/25/25 -10/23/25 visit was not signed by the LN until 10/27/25 -11/3/25 visit was not signed by the LN until 11/9/25 -11/18/25 visit was not signed by the LN until 11/23/25 -11/25/25 visit was not signed by the RN until 12/3/25 The DPCS explained the above documentation was not in compliance for the field staff signing and/or documenting with 48 hours. During an interview on 5/7/26 at 10:51 AM, with the Owner, the Owner stated it was the expectation that field staff complete their documentation within 48 hours. A review of the facility policy titled, “[Facility Name] Documentation Policy,” undated, the policy indicated, “… All documentation must be submitted within 24-48 hours after each visit …” 3. During a concurrent interview and record review on 5/4/26 at 3:45 PM, with the DPCS, Patient 3’s clinical record was reviewed. The DPCS confirmed Patient 3’s clinical record did not contain the POC (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) for the benefit period of 4/4/26 through 6/2/26. Patient 3’s clinical record document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 4/4/26, was reviewed with the DPCS. The DPCS confirmed the orders dated 4/4/26 obtained by RN 1 were incomplete and did not contain the date and time the order was received from the physician. Additionally, the DPCS confirmed the physician orders had not been signed or authenticated by the physician within 30 days. DPCS further confirmed that the POC was a required document that should have been generated after Registered Nurse (RN) 1 completed the initial comprehensive assessment. The DPCS stated the importance of the POC was that it contained all the required documentation for Patient 3’s goals of care including the physician ordered services, Patient 3’s specific measurable goals, all diagnoses, equipment needed, visit frequencies with duration of care, types of services and providers ordered by the physician for Patient 3. Additionally, the DPCS stated the POC contained Patient 3’s rehabilitation potential, functional limitations, activities permitted, all medications and treatments and patient/caregiver education. The DPCS added that a copy of the POC was required to be given to Patient 3 at the beginning of services and did not receive the POC since it was never created. The DPCS explained that the POC was important to have in the clinical record, so all the providers of care provided the expected care, measured if Patient 3 was achieving the goals of care and evaluated Patient 3’s continued need for services. The DPCS further explained the risk of Patient 3 not having a POC generated was a potential decline in health status and not receiving optimal care. The DPCS added that it was her expectation and a standard of practice that physician orders and POC’s be signed and authenticated by the physician within 30 days. During an interview on 5/5/26 at 10:03 AM, in Patient 3’s home, Patient 3 stated she had not seen the POC and was not familiar with the contents in it. A review of the facility policy and procedure (P&P) titled, “ADMISSION CRITERIA AND PROCESS,” revised July 2025, indicated, “…17. If the patient is accepted for home health, an initial plan of care will be developed in consultation with the physician and the patient and then submitted to the physician for signature…18. A. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day…” A review of the facility P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” 4. A review of Patient 8’s POC, dated 3/27/26, indicated that Patient 8 was admitted to the HHA with diagnoses that included a displaced fracture of the right patella (a serious injury where the right kneecap breaks into two or more pieces that shift out of alignment), unsteadiness on the feet, and a history of falling. During a concurrent interview and record review on 5/5/26 at 2:40 PM, with the DPCS, Patient 8’s POC for the period of 3/27/26 through 5/25/26 was reviewed. The DPCS confirmed the POC initiated on 3/27/26 was not signed by the physician and it had been over 30 days since the assessment. A further review of Patient 8’s clinical record with the DPCS revealed that the document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 3/27/26, had not been signed by the physician. A review of Patient 8’s clinical record document, titled, “PHYSICAL THERAPY EVALUATION,” dated 4/10/26, was mostly blank and only contained a few sentences under the section titled, “Additional details – infection,” regarding Patient 8’s history of fall, date of surgery, how Patient 8 walks with a walker, and Patient 8’s living arrangements. The DPCS confirmed the initial physical therapists (PT) 1 evaluation was incomplete and did not include the required documentation of Patient 8’s goals of treatment, functional level, interventions or education provided to Patient 8, the plan of care, and orders from the physician for continued services. The DPCS further confirmed that Patient 8’s clinical record did contain visit notes from a physical therapy assistant (PTA) 1, with Patient 8 on 4/16/26, 4/17/26, 4/21/26, 4/24/26, and 4/27/26. The DPCS could not find any documentation in Patient 8’s clinical record where PTA 1 services were ordered by the physician and what treatment plan PTA 1 followed. The DPCS further confirmed that Patient 8’s POC was not updated to reflect additional PTA orders and only one initial assessment from a PT was ordered to occur between 3/31/26 and 4/4/26. The DPCS reviewed Patient 8’s clinical record and confirmed that on 5/1/26 PT 1 began documentation of a “PHYSICAL THERAPY DISCHARGE VISIT AND SUMMARY,” and confirmed the summary only contained Patient 8’s vital signs (measurements that check your body’s most basic, life-sustaining functions—heartbeat, breathing, temperature, and blood pressure) and the rest of the document was blank. The DPCS stated it was her expectation that when a PT completed an assessment the documentation must be accurate and completed in the patient’s clinical record within 24-48 hours of the assessment. The DPCS confirmed that PT 1 did not meet her expectations of documentation for the assessment dated 4/10/26 and the discharge summary dated 5/1/26. The DPCS stated the risk to Patient 8 for incomplete and inaccurate documentation was that the PTA was providing services to Patient 8 without a written treatment plan, and a physicians order. Additionally, the DPCS stated Patient 8 could be at risk for injury and falls if PTA 1 provided Patient 8 with the wrong therapy or education instructions. The DPCS added that all physicians orders are expected to be signed and authenticated by the physician within 30 days. During an interview on 5/7/26 at 1:15 PM with PTA 1, PTA 1 confirmed he visited Patient 8 on 4/16/26, 4/17/26, 4/21/26, 4/24/26, and 4/27/26. PTA 1 further confirmed that since PT 1 had not completed the written documentation of the initial assessment, PT 1 gave PTA 1 the directions of care and the treatment plan for Patient 8 over the phone. PTA 1 further stated that the goals of care and expectation of services provided to Patient 8 should have been documented in the clinical record. PTA 1 explained the documentation was important, so everyone understood the treatment plan and that Patient 8’s goals of care were met. During a phone interview on 5/12/26 at 11:49 AM, PT 1 confirmed that she called PTA 1 on the phone and discussed Patient 8’s treatment plan and goals. PT 1 confirmed she had not completed her documentation as required by the HHA policy. PT 1 stated upon hire with the HHA in late 2025, the agency reviewed their documentation policy and stated the clinical staff were required to document their assessments in writing within 24-48 hours of each visit. PT 1 stated that at times she was unable to meet the documentation requirement due to personal reasons and communicated with the PTA’s by telephone. PT 1 stated it was not uncommon for the PT’s and PTA’s to communicate patient care via telephone but added that the information should also be documented in the patient’s clinical record. PT 1 confirmed she changed the documentation on the initial assessment dated 4/10/26, deleted, modified, and added information. PT 1 further stated she used the section, “Additional details – infection,” as “scratch notes,” and later deleted it when she modified the initial assessment dated 4/10/26, on 5/6/26. PT 1 explained she understood that modifying assessments without noting why the documentation was changed appeared “like false documentation.” PT 1 further explained that she did not indicate on her assessments dated, 4/10/26 and 5/1/26 that they were late entries. PT 1 explained the risk of not completing the documentation was there could be a “mismatch” of information including a misunderstanding of the treatment plan and care needs for Patient 8. PT 1 further explained the risk of untimely and unwritten documentation to Patient 8 was injury, falls, delayed care, delayed progress and delayed healing. During a follow-up interview on 5/7/26 at 2:14 PM, the DPCS stated that the phone call communication of a treatment plan and goals of care between PT 1 and PTA 1 did not meet her expectations. The DPCS further stated she expected the treatment plan to be written with the patients goals clearly documented not just for PTA 1 but for anyone reviewing the clinical record. The DPCS explained it was important for the PTA to work from written documentation in the plan of care to prevent miscommunication. The DPCS further explained the risk to Patient 8 was that Patient 8 could receive the wrong treatment, could be injured, and not progress towards Patient 8’s goals of care. A review of the facility P&P titled, “[Facility Name] Documentation Policy,” undated, indicated, “…All documentation must be submitted within 24-48 hours after each visit…” A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” A review of the facility P&P titled, “VERIFICATION OF PHYSICIAN ORDERS,” revied July 2025, indicated, “…Orders will be obtained from a licensed physician…for care and services to be provided to home health patients…Verbal orders will be spoken to, taken and documented only by professional, licensed home health personnel (RN and qualified therapist)…A qualified individual will review each order or prescription before care is provided…A copy of the order will be kept in the patient’s clinical record…Signed orders will be placed in the clinical record within 30 days of initiation of the order…” A review of the facility P&P titled, “REHABILITATIVE CARE SERVICES,” revised July 2025, indicated, “…Qualified rehabilitation professionals will develop and implement the rehabilitation care plan with the patient, family, and caregivers. Rehabilitation plans and goals will guide the provision of rehabilitation services and are appropriate to the patient’s environment, needs, and severity of disease. Rehabilitation outcomes will promote optimal level of functioning. Discharge planning from services will be integrated into the functional rehabilitation assessment. All services will be provided in accordance with accepted standards of practice by or under the direction of a qualified physical…therapist…PROCEDURE 1. When rehabilitation needs are identified, the patient’s physical status and functional abilities are evaluated by a rehabilitation professional before instruction and treatments are initiated…6. Rehabilitation goals and plans will be designed to help patients achieve and maintain their optimal level of functioning… A review of the facility P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” Findings: 1. A review of Patient 9’s clinical document titled, “PATIENT PROFILE,” indicated Patient 9 was admitted for care with diagnoses which included asthma Chronic Obstructive Pulmonary Disease (COPD) overlap syndrome (a chronic lung condition occurring when a patient exhibits key features of both asthma and COPD, specifically persistent airflow limitation combined with asthma-like symptoms). During a concurrent interview and record review on 5/6/26 at 11:43 AM with the Director of Patient Care Services (DPCS), of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, the DPCS confirmed Patient 9’s SKILLED NURSING VISIT NOTE did not contain any data from the 5/4/26 visit. The DPCS explained the expectation was for the visit note to be completed within 48 hours and should be documented by the end of business day on 5/6/26. A review on 5/7/26, of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, indicated seven blank pages as no data for the visit had been entered as of 5/7/26 for the 5/4/26 nursing visit. During an interview on 5/7/26 at 10:51 AM, with the Owner, the Owner stated it was the expectation that field staff complete their documentation within 48 hours. A review of the facility policy titled, “[Facility Name] Documentation Policy,” undated, the policy indicated, “… All documentation must be submitted withing 24-48 hours after each visit …” 2. A review of Patient 2’s clinical document titled, “Plan of Care,” (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) indicated Patient 2 was admitted for care for diagnoses which included muscle weakness and heart failure (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen, or is too stiff to fill properly). During a concurrent interview and record review on 5/7/26 at 3:17 PM, the DPCS confirmed the following visits were not completed and signed by the field staff within 48 hours: -10/8/25 visit was not signed by the Licensed Nurse (LN) until 10/24/25 -10/16/25 visit was not signed by the Registered Nurse (RN) until 10/25/25 -10/23/25 visit was not signed by the LN until 10/27/25 -11/3/25 visit was not signed by the LN until 11/9/25 -11/18/25 visit was not signed by the LN until 11/23/25 -11/25/25 visit was not signed by the RN until 12/3/25 The DPCS explained the above documentation was not in compliance for the field staff signing and/or documenting with 48 hours. During an interview on 5/7/26 at 10:51 AM, with the Owner, the Owner stated it was the expectation that field staff complete their documentation within 48 hours. A review of the facility policy titled, “[Facility Name] Documentation Policy,” undated, the policy indicated, “… All documentation must be submitted within 24-48 hours after each visit …” 3. During a concurrent interview and record review on 5/4/26 at 3:45 PM, with the DPCS, Patient 3’s clinical record was reviewed. The DPCS confirmed Patient 3’s clinical record did not contain the POC (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) for the benefit period of 4/4/26 through 6/2/26. Patient 3’s clinical record document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 4/4/26, was reviewed with the DPCS. The DPCS confirmed the orders dated 4/4/26 obtained by RN 1 were incomplete and did not contain the date and time the order was received from the physician. Additionally, the DPCS confirmed the physician orders had not been signed or authenticated by the physician within 30 days. DPCS further confirmed that the POC was a required document that should have been generated after Registered Nurse (RN) 1 completed the initial comprehensive assessment. The DPCS stated the importance of the POC was that it contained all the required documentation for Patient 3’s goals of care including the physician ordered services, Patient 3’s specific measurable goals, all diagnoses, equipment needed, visit frequencies with duration of care, types of services and providers ordered by the physician for Patient 3. Additionally, the DPCS stated the POC contained Patient 3’s rehabilitation potential, functional limitations, activities permitted, all medications and treatments and patient/caregiver education. The DPCS added that a copy of the POC was required to be given to Patient 3 at the beginning of services and did not receive the POC since it was never created. The DPCS explained that the POC was important to have in the clinical record, so all the providers of care provided the expected care, measured if Patient 3 was achieving the goals of care and evaluated Patient 3’s continued need for services. The DPCS further explained the risk of Patient 3 not having a POC generated was a potential decline in health status and not receiving optimal care. The DPCS added that it was her expectation and a standard of practice that physician orders and POC’s be signed and authenticated by the physician within 30 days. During an interview on 5/5/26 at 10:03 AM, in Patient 3’s home, Patient 3 stated she had not seen the POC and was not familiar with the contents in it. A review of the facility policy and procedure (P&P) titled, “ADMISSION CRITERIA AND PROCESS,” revised July 2025, indicated, “…17. If the patient is accepted for home health, an initial plan of care will be developed in consultation with the physician and the patient and then submitted to the physician for signature…18. A. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day…” A review of the facility P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” 4. A review of Patient 8’s POC, dated 3/27/26, indicated that Patient 8 was admitted to the HHA with diagnoses that included a displaced fracture of the right patella (a serious injury where the right kneecap breaks into two or more pieces that shift out of alignment), unsteadiness on the feet, and a history of falling. During a concurrent interview and record review on 5/5/26 at 2:40 PM, with the DPCS, Patient 8’s POC for the period of 3/27/26 through 5/25/26 was reviewed. The DPCS confirmed the POC initiated on 3/27/26 was not signed by the physician and it had been over 30 days since the assessment. A further review of Patient 8’s clinical record with the DPCS revealed that the document titled, “HOME HEALTH PHYSICIAN ORDERS,” dated 3/27/26, had not been signed by the physician. A review of Patient 8’s clinical record document, titled, “PHYSICAL THERAPY EVALUATION,” dated 4/10/26, was mostly blank and only contained a few sentences under the section titled, “Additional details – infection,” regarding Patient 8’s history of fall, date of surgery, how Patient 8 walks with a walker, and Patient 8’s living arrangements. The DPCS confirmed the initial physical therapists (PT) 1 evaluation was incomplete and did not include the required documentation of Patient 8’s goals of treatment, functional level, interventions or education provided to Patient 8, the plan of care, and orders from the physician for continued services. The DPCS further confirmed that Patient 8’s clinical record did contain visit notes from a physical therapy assistant (PTA) 1, with Patient 8 on 4/16/26, 4/17/26, 4/21/26, 4/24/26, and 4/27/26. The DPCS could not find any documentation in Patient 8’s clinical record where PTA 1 services were ordered by the physician and what treatment plan PTA 1 followed. The DPCS further confirmed that Patient 8’s POC was not updated to reflect additional PTA orders and only one initial assessment from a PT was ordered to occur between 3/31/26 and 4/4/26. The DPCS reviewed Patient 8’s clinical record and confirmed that on 5/1/26 PT 1 began documentation of a “PHYSICAL THERAPY DISCHARGE VISIT AND SUMMARY,” and confirmed the summary only contained Patient 8’s vital signs (measurements that check your body’s most basic, life-sustaining functions—heartbeat, breathing, temperature, and blood pressure) and the rest of the document was blank. The DPCS stated it was her expectation that when a PT completed an assessment the documentation must be accurate and completed in the patient’s clinical record within 24-48 hours of the assessment. The DPCS confirmed that PT 1 did not meet her expectations of documentation for the assessment dated 4/10/26 and the discharge summary dated 5/1/26. The DPCS stated the risk to Patient 8 for incomplete and inaccurate documentation was that the PTA was providing services to Patient 8 without a written treatment plan, and a physicians order. Additionally, the DPCS stated Patient 8 could be at risk for injury and falls if PTA 1 provided Patient 8 with the wrong therapy or education instructions. The DPCS added that all physicians orders are expected to be signed and authenticated by the physician within 30 days. During an interview on 5/7/26 at 1:15 PM with PTA 1, PTA 1 confirmed he visited Patient 8 on 4/16/26, 4/17/26, 4/21/26, 4/24/26, and 4/27/26. PTA 1 further confirmed that since PT 1 had not completed the written documentation of the initial assessment, PT 1 gave PTA 1 the directions of care and the treatment plan for Patient 8 over the phone. PTA 1 further stated that the goals of care and expectation of services provided to Patient 8 should have been documented in the clinical record. PTA 1 explained the documentation was important, so everyone understood the treatment plan and that Patient 8’s goals of care were met. During a phone interview on 5/12/26 at 11:49 AM, PT 1 confirmed that she called PTA 1 on the phone and discussed Patient 8’s treatment plan and goals. PT 1 confirmed she had not completed her documentation as required by the HHA policy. PT 1 stated upon hire with the HHA in late 2025, the agency reviewed their documentation policy and stated the clinical staff were required to document their assessments in writing within 24-48 hours of each visit. PT 1 stated that at times she was unable to meet the documentation requirement due to personal reasons and communicated with the PTA’s by telephone. PT 1 stated it was not uncommon for the PT’s and PTA’s to communicate patient care via telephone but added that the information should also be documented in the patient’s clinical record. PT 1 confirmed she changed the documentation on the initial assessment dated 4/10/26, deleted, modified, and added information. PT 1 further stated she used the section, “Additional details – infection,” as “scratch notes,” and later deleted it when she modified the initial assessment dated 4/10/26, on 5/6/26. PT 1 explained she understood that modifying assessments without noting why the documentation was changed appeared “like false documentation.” PT 1 further explained that she did not indicate on her assessments dated, 4/10/26 and 5/1/26 that they were late entries. PT 1 explained the risk of not completing the documentation was there could be a “mismatch” of information including a misunderstanding of the treatment plan and care needs for Patient 8. PT 1 further explained the risk of untimely and unwritten documentation to Patient 8 was injury, falls, delayed care, delayed progress and delayed healing. During a follow-up interview on 5/7/26 at 2:14 PM, the DPCS stated that the phone call communication of a treatment plan and goals of care between PT 1 and PTA 1 did not meet her expectations. The DPCS further stated she expected the treatment plan to be written with the patients goals clearly documented not just for PTA 1 but for anyone reviewing the clinical record. The DPCS explained it was important for the PTA to work from written documentation in the plan of care to prevent miscommunication. The DPCS further explained the risk to Patient 8 was that Patient 8 could receive the wrong treatment, could be injured, and not progress towards Patient 8’s goals of care. A review of the facility P&P titled, “[Facility Name] Documentation Policy,” undated, indicated, “…All documentation must be submitted within 24-48 hours after each visit…” A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…The attending physician (or allowed practitioner) will participate in the care planning process by reviewing and revising the plan of care…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” A review of the facility P&P titled, “VERIFICATION OF PHYSICIAN ORDERS,” revied July 2025, indicated, “…Orders will be obtained from a licensed physician…for care and services to be provided to home health patients…Verbal orders will be spoken to, taken and documented only by professional, licensed home health personnel (RN and qualified therapist)…A qualified individual will review each order or prescription before care is provided…A copy of the order will be kept in the patient’s clinical record…Signed orders will be placed in the clinical record within 30 days of initiation of the order…” A review of the facility P&P titled, “REHABILITATIVE CARE SERVICES,” revised July 2025, indicated, “…Qualified rehabilitation professionals will develop and implement the rehabilitation care plan with the patient, family, and caregivers. Rehabilitation plans and goals will guide the provision of rehabilitation services and are appropriate to the patient’s environment, needs, and severity of disease. Rehabilitation outcomes will promote optimal level of functioning. Discharge planning from services will be integrated into the functional rehabilitation assessment. All services will be provided in accordance with accepted standards of practice by or under the direction of a qualified physical…therapist…PROCEDURE 1. When rehabilitation needs are identified, the patient’s physical status and functional abilities are evaluated by a rehabilitation professional before instruction and treatments are initiated…6. Rehabilitation goals and plans will be designed to help patients achieve and maintain their optimal level of functioning… A review of the facility P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” 5. A review of Patient 4’s “Patient Information Sheet,” indicated that Patient 4 started care in 2026 with diagnoses which included Left Tri Malleolar Fracture (broken bones in the lower leg and ankle). A review of Patient 4’s “OASIS RN Start of Care,” form indicated that the visit date was 04/21/2026 12:32 PM. Patient 4’s “OASIS RN Start of Care,” form was signed by the RN and Patient 4 but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the DPCS on 5/5/26 at 3:26 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was that continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 4’s signature and was not completed within five business days. The DPCS acknowledged that the facility policy was not followed. 6. A review of Patient 5’s “Patient Information Sheet,” indicated that Patient 5 started care in 2026 with diagnoses which included Alzheimer’s Disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities). A review of Patient 5’s “OASIS RN Start of Care,” form indicated that the visit date was 04/17/2026 2:40 PM. Patient 5’s “OASIS RN Start of Care,” form was signed by the RN and Patient 5’s family member but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/5/26 at 3:26 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 5’s family member’s signature and was not completed within five business days. The DPCS acknowledged that the facility policy was not followed. 7. A review of Patient 6’s “Patient Information Sheet,” indicated that Patient 6 started care in 2025 with diagnoses which included Acute Kidney Injury (A sudden and often reversible reduction in kidney function), and Alzheimer’s Disease (a gradual decline in memory, thinking, behavior and social skills which causes the brain to shrink and brain cells to eventually die). A review of Patient 6’s closed clinical record indicated that the start of service date was 7/10/25, and the certification for services was 7/10/25 to 9/7/25 with a recertification from 9/9/25 to 11/6/25. The review of Patient 6’s closed clinical record further indicated that skilled nursing, physical therapy, and occupational therapy services were received during the certification and the recertification periods. The record review for Patient 6 did not indicate case conference notes during the certification period or the recertification period. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/5/26 at 3:02 PM, Patient 6’s closed clinical record was reviewed. The ADPCS stated that during the case conferences the staff discussed the patients with services in the prior week’s care needs and followed up with current patient care needs. The ADPCS stated that patients were followed during case conferences in the next week. The ADPCS stated that the facility had case conferences weekly, but the requirement was to complete case conferences every 60 days. The ADPCS confirmed that Patient 6 did not have case conference notes in the clinical record. The ADPCS confirmed that the notes entered on the “Case Conference” forms and the “Care Coordination Notes,” in Patient 6’s clinical record had entries for different dates and times by a registered nurse (RN), a Physical Therapist (PT), and an Occupational Therapist (OT). The ADPCS acknowledged that the notes in the “Case Conference” forms and the “Care Coordination Notes” did not fulfill the requirements for a case conference for Patient 6. The ADPCS acknowledged that the facility policy was not followed. A review of a facility policy and procedure (P&P) titled, “Rehabilitation Techniques,” dated July 2025, the P&P indicated, “…Purpose…To provide guidelines for the instruction of patients and family/caregivers in… rehabilitation techniques to facilitate adaptation and/or functional independence…Definitions…2. Rehabilitation…The combined and coordinated use of educational, medical, social, and vocational measures for training or retraining individuals disabled by disease or injury. The goal is to enable individuals to achieve their highest possible level of functional ability…Policy…Patients will be assessed for…rehabilitation potential, and they will receive referrals and information as needed…Procedure…1. Upon admission, the patient will be assessed regarding functional limitations that need to be addressed to ensure adaptation to the home environment…4. The patient’s physical status and functional abilities will be evaluated by a rehabilitation professional before instruction and treatment is initiated…” A review of a facility P&P titled, “Rehabilitative Care Services,” dated July 2025, the P&P indicated, “…Purpose…To provide clinical direction to therapists providing direct patient care…Procedure…1. When rehabilitation needs are identified, the patient’s physical status and functional abilities are evaluated by a rehabilitation professional before instruction and treatments are initiated…” A review of a facility policy and procedure (P&P) titled, “Case Conference/Progress Summary,” dated July 2025, the P&P indicated, “…Purpose…To define the process for case conferences and documenting patient progress in the clinical record…Policy…Case conferences will be held every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include, but will not be limited to, the type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress toward goals and any necessary revisions in the plan of care. Case conferences will include utilization review; therefore, all clinicians working with patients will participate in case conferences…Procedure…1. Each multidisciplinary patient will have a case conference during the month following the certification month…3. A record will be kept indicating who participated in the meeting…4. A case conference/progress summary, written by the appropriate discipline(s) treating the patient, will be placed in the patient’s clinical record after each case conference meeting…” A review of a facility P&P titled, "Care Coordination," dated July 2025, the P&P indicated, "...Purpose...To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...Policy...Written evidence of care coordination will be recorded during the case conference...Procedure...4. Care coordination will include but not be limited to...D. Planned face-to-face conferences...7. Organization personnel will communicate changes in a timely manner via...case conferences..."

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to document all interventions, treatments, services, and responses to interventions for two of 17 sampled patients (Patient 7 and Patient 8) when: 1. An order for the intervention of an occupational therapy evaluation (OT -a comprehensive assessment conducted by an occupational therapist to identify an individual's strengths, limitations, and functional needs) for Patient 7 on the week of 4/9/26 did not occur; and, 2. A Physical Therapist (PT) 1 did not complete the documentation of an initial physical therapy evaluation on 4/10/26 for Patient 8, which included the interventions, treatment plan, physician orders for additional physical therapy services and the response to interventions. These failures had the potential to lead to ineffective treatment, miscommunication with other providers of service, injury, and delayed care to Patient 7 and Patient 8. 1. A review of Patient 7’s Plan of Care (POC - a structured, written document outlining a personalized roadmap for a patient's medical and supportive care) dated 4/9/26, indicated Patient 7 had diagnoses which included a fracture of the lower end of the left femur (a broken thigh bone just above the knee) and a history of falling. A review of Patient 7’s POC dated 4/9/26, under the section titled, “FUNCTIONAL LIMITATIONS,” indicated, “…ACTIVITIES PERMITTED: Perform exercises Prescribed…Use of Human Assistance for Ambulation [walking]…Use of Human Assistance for Transfers…Use of Wheelchair for Mobility…Weight Bearing Restriction: Non-weight Bearing (NWB-meaning you must not place any body weight on an injured body part) on left extremity [leg] Start Effective 4/09/26…” A review of Patient 7’s POC dated 4/9/26 under the section titled, “FREQUENCIES,” indicated, “…OT [occupational therapy] …1 x week [once a week] for 1 week starting 4/06/26 (week 1) …” During a concurrent interview and record review dated 5/6/26 at 11:52 AM with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 7’s POC, progress notes, and calendar of visits and confirmed that physician ordered intervention and service of the OT assessment did not occur and was missed for Patient 7. The DPCS stated the OT assessment was important to determine the needs and for optimal quality of care for Patient 7. The DPCS explained the expectation that the OT evaluation was completed within 5 days of the ordered date and the risk of Patient 7 not receiving the OT assessment was a delayed care and a potential decline in recovery. 2. A review of Patient 8’s POC, dated 3/27/26, indicated Patient 8 was admitted to the HHA with diagnoses which included a displaced fracture of the right patella (a serious injury where the right kneecap breaks into two or more pieces that shift out of alignment), unsteadiness on the feet, and a history of falling. A review of Patient 8’s POC, dated 3/27/26, indicated under the section titled, “FREQUENCIES…PT/PTA [physical therapist/physical therapy assistant]: (Eval) [Evaluation] 1 x week [once a week] for 1 week starting 03/31/26 (week 2) Start Date: 03/31/26 End Date: 04/04/2026…” During a phone interview on 5/12/26 at 11:49 AM, PT 1 confirmed she did not complete the documentation for the initial physical therapy assessment dated 4/10/26 within the physician ordered time frame and did not document Patient 8’s assessment, treatment plan, interventions, education and Patient 8’s response to the interventions. Additionally, PT 1 confirmed she only used the first portion of the assessment as a “scratch pad,” to make some notes and left the rest of the assessment blank. PT 1 confirmed she had a telephone call with physical therapy assistant (PTA) 1 and gave verbal instructions for the continued treatment plan of care and did not document the treatment plan per facility policy for PTA 1 to follow. PT 1 explained she understood the lack of documentation did not meet facility policy or professional standards and had the potential to lead to injury to Patient 8 of PTA 1 misunderstood the verbal instructions. During a concurrent interview and record review on 5/5/26 at 2:40 PM, with the DPCS, Patient 8’s clinical record document, titled, “PHYSICAL THERAPY EVALUATION,” dated 4/10/26, was reviewed. The DPCS confirmed the evaluation was mostly blank and only contained a few sentences under the section titled, “…Additional details – infection,”. The DPCS further confirmed the initial physical therapists (PT) 1 evaluation was incomplete and did not include the required documentation of Patient 8’s goals of treatment, functional level, interventions or education provided to Patient 8, the plan of care, and orders from the physician for continued physical therapy care, and Patient 8’s response to the interventions from the assessment. The DPCS stated it was her expectation that when PT completed an assessment the documentation must be accurate and completed in the patient’s clinical record within 24-48 hours of the assessment. The DPCS confirmed that PT 1 did not meet her expectations for documentation of the assessment dated 4/10/26. The DPCS could not find any documentation in Patient 8’s clinical record where PTA 1 services were ordered by the physician and what treatment plan PTA 1 followed. The DPCS further confirmed that Patient 8’s POC was not updated to reflect additional PTA orders and only one initial assessment from a PT was ordered to occur between 3/31/26 and 4/4/26. The DPCS stated the risk to Patient 8 for incomplete and inaccurate documentation was that the PTA was providing services to Patient 8 without a written treatment plan, and a physicians order. Additionally, the DPCS stated Patient 8 could be at risk for injury and falls if PTA 1 provided Patient 8 with the wrong therapy or education instructions. A review of a facility policy and procedure (P&P) titled, “Rehabilitation Techniques,” dated July 2025, the P&P indicated, “…Purpose…To provide guidelines for the instruction of patients and family/caregivers in…rehabilitation techniques to facilitate adaptation and/or functional independence…Definitions…2. Rehabilitation…The combined and coordinated use of educational, medical, social, and vocational measures for training or retraining individuals disabled by disease or injury. The goal is to enable individuals to achieve their highest possible level of functional ability…Policy…Patients will be assessed for…rehabilitation potential, and they will receive referrals and information as needed…Procedure…1. Upon admission, the patient will be assessed regarding functional limitations that need to be addressed to ensure adaptation to the home environment…4. The patient’s physical status and functional abilities will be evaluated by a rehabilitation professional before instruction and treatment is initiated…” A review of a facility P&P titled, "Care Coordination," dated July 2025, the P&P indicated, "...Purpose...To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services...Policy...Written evidence of care coordination will be recorded during the case conference...Procedure...4. Care coordination will include but not be limited to...D. Planned face-to-face conferences...7. Organization personnel will communicate changes in a timely manner via...case conferences..." A review of the facility P&P titled, “[Facility Name] Documentation Policy,” undated, indicated, “…All documentation must be submitted within 24-48 hours after each visit…”

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 interview and record review the facility did not ensure all entries to the patient’s clinical records were clear, complete, accurate and appropriately authenticated for five of 17 sampled patients (Patient 3, Patient 4, Patient 5, Patient 8 and Patient 9) when: 1. Patient 3’s “HOME HEALTH PHYSICAN ORDERS,” (signed only by the nurse on 4/14/26) for home health aide (a certified care professional who provides medical and personal assistance to elderly, ill, or disabled individuals in their own homes) and nursing services was an incomplete order and did not contain the date and time the order was received or the signature of the ordering physician; and, 2. Patient 4’s “OASIS RN [a Registered Nurse specialized in the Outcome and Assessment Information Set [OASIS], a standardized, federally mandated assessment tool] Start of Care,” form dated 4/21/26 was incomplete; and, 3. Patient 5’s “OASIS RN Start of Care,” form dated 4/17/26 was incomplete; and, 4. Patient 8’s “HOME HEALTH PHYSICIAN ORDERS,” (only signed by the nurse on 3/27/26) did not contain the type of order (verbal or non-verbal order), did not contain the date and time the order was obtained or the ordering physicians signature. Patient 8’s “PHYSICAL THERAPY EVALUATION,” dated 4/10/26 was incomplete and modified without noting the documentation was modified. Patient 8’s “PHYSICAL THERAPY DISCHARGE VISIT AND SUMMARY,” dated 5/1/26 was incomplete; and, 5. Patient 9’s “SKILLED NURSING VISIT NOTE,” dated 5/4/26, did not contain any visit documentation as of 5/7/26. These failures had the potential to disrupt continuity of care and lead to errors in the services provided to Patient 3, Patient 4, Patient 5, Patient 8 and Patient 9. Findings: 1. During a concurrent interview and record review on 5/4/26 at 3:45 PM with the Director of Patient Care Services (DPCS), Patient 3’s clinical record was reviewed. The DPCS confirmed Patient 3’s clinical record document titled, “HOME HEALTH PHYSICIAN ORDERS,” signed only by the nurse on 4/14/26, for home health aide and nursing services was incomplete and did not contain (in a separate area on the form) the date and time the order was received. The DPCS further confirmed the order had not been signed by the ordering physician. The DPCS explained that physician orders were expected to be completed with the date and time of the order and signed by the ordering physician within 30 days. 2. A review of Patient 4’s “OASIS RN Start of Care,” form indicated that the start of care visit date was 04/21/2026 12:32 PM. Patient 4’s “OASIS RN Start of Care,” was signed by the RN and Patient 4, but was not completed. During an interview and concurrent record review with the Assistant Director of Patient Care Services (ADPCS) on 5/4/26 at 2:47 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the DPCS on 5/5/26 at 3:26 PM, Patient 4’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 4’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 4’s signature and was not completed within five business days. The DPCS acknowledged that the facility policy was not followed. 3. A review of Patient 5’s “OASIS RN Start of Care,” form indicated that the start of care visit date was 04/17/2026 2:40 PM. Patient 5’s “OASIS RN Start of Care,” form was signed by the RN and Patient 5’s family member but was not completed. During an interview and concurrent record review with the ADPCS on 5/4/26 at 2:47 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The ADPCS stated that when a patient was admitted, the patient care orders were entered into the patient’s clinical record, the plan of care was set up and in place in the clinical record, and the patient’s status and “OASIS RN Start of Care” form was completed and placed in the patient’s clinical record. The ADPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was not completed. The ADPCS stated that the risk of not completing the “OASIS RN Start of Care” form was that there was potentially no follow up with the patient’s plan of care. The ADPCS confirmed that the facility policy was not followed. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/5/26 at 3:26 PM, Patient 5’s “OASIS RN Start of Care,” form was reviewed. The DPCS stated that the “OASIS RN Start of Care” documentation should be completed by a registered nurse (RN) within five business days and placed in the patient’s clinical record. The DPCS stated that risk of not completing the “OASIS RN Start of Care” form was continuity of care concerns would not be addressed, and the patient would not have good quality of care. The DPCS confirmed that Patient 5’s “OASIS RN Start of Care” form was blank except for the RN’s electronic signature and Patient 5’s family member’s signature and was not completed. The DPCS acknowledged that the facility policy was not followed. 4. During a concurrent interview and record review on 5/5/26 at 2:40 PM with the DPCS, Patient 8’s “HOME HEALTH PHYSICIAN ORDERS,” (only signed by the nurse on 3/27/26), were reviewed. The DPCS confirmed the order did not specify the type of order (verbal or non-verbal) and the date and time of the order was given from the physician was not documented. The DPCS further confirmed the order had not been signed by the ordering physician. An additional review of Patient 8’s document titled, “PHYSICAL THERAPY EVALUATION,” dated 4/10/26 was incomplete. The DPCS confirmed the evaluation only contained a few sentences under the section titled, “Additional details -infection,” and the information listed was not related to an infection or the evaluation conducted for Patient 8. The DPCS further confirmed the evaluation was not signed by the physical therapist (PT) 1. The DPCS confirmed the document titled, “PHYSICAL THERAPY DISCHARGE VISIT AND SUMMARY,” dated 5/1/26 in Patient 8’s clinical record was mostly blank and only contained Patient 8’s vital signs (measurements that check your body’s most basic, life-sustaining functions—heartbeat, breathing, temperature, and blood pressure) and no documentation to related to the evaluation (the final medical document of a care plan. It details the initial physical capabilities of the patient, progress toward functional goals, final status, and instructions for ongoing self-management). The DPCS confirmed that PT 1 did not sign the discharge visit and summary. The DPCS explained it was her expectation that when a PT completed an assessment the documentation must be accurate and completed in the patient’s clinical record within 24-48 hours of the assessment. The DPCS further explained physicians orders should be complete with the date and time of the order, and the physician was expected to sign them within 30 days. The DPCS acknowledged the facility policy was not followed. During a concurrent interview and record review on 5/7/26 at 12:29 PM with the ADPCS and DPCS, Patient 8’s “PHYSICAL THERAPY EVALUATION,” dated 4/10/26 was re-reviewed. The ADPCS and DPCS confirmed that PT 1 had deleted documentation from the section titled, “Additional details -infection,” and then modified the rest of the evaluation. The ADPCS confirmed that PT 1 did not document anywhere on the evaluation, “modified or late documentation,” The ADPCS explained that the expectation was when documentation was modified or entered late that the author noted it somewhere in the evaluation. During a phone interview on 5/12/26 at 11:49 AM with PT 1, PT 1 confirmed she changed the documentation on the initial assessment dated 4/10/26, deleted, modified, and added information. PT 1 further stated she used the section, “Additional details – infection,” as “scratch notes,” and later deleted it when she modified the initial assessment dated 4/10/26, on 5/6/26. PT 1 explained she understood that modifying assessments without noting why the documentation was changed appeared “like false documentation.” PT 1 further explained that she did not indicate on her assessments dated, 4/10/26 and 5/1/26 that they were late or modified entries. PT 1 explained the risk of not completing the documentation was there could be a “mismatch” of information including a misunderstanding of the treatment plan and care needs for Patient 8. PT 1 further explained the risk of untimely and unwritten documentation to Patient 8 was injury, falls, delayed care, delayed progress and delayed healing. 5. During a concurrent interview and record review on 5/6/26 at 11:43 AM with the Director of Patient Care Services (DPCS), of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, the DPCS confirmed Patient 9’s SKILLED NURSING VISIT NOTE did not contain any data from the 5/4/26 visit. The DPCS explained the expectation was for the visit note to be completed within 48 hours and should be documented by the end of business day on 5/6/26. A review on 5/7/26, of Patient 9’s clinical document titled, “SKILLED NURSING VISIT NOTE,” dated 5/4/26, indicated seven blank pages as no data for the visit had been entered as of 5/7/26 for the 5/4/26 nursing visit. During an interview on 5/7/26 at 10:51 AM, with the Owner, the Owner stated it was the expectation that field staff complete their documentation within 48 hours. A review of the facility policy titled, “[Facility Name] Documentation Policy,” undated, the policy indicated, “… All documentation must be submitted withing 24-48 hours after each visit …” A review of the facility P&P titled, “CARE COORDINATION,” revised July 2025, indicated, “…Integration of services, whether services are provided directly…to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines…5. All organization personnel involved in patient care…will have access to the plan of care and all other relevant information to ensure coordination and continuity of care…” A review of the facility P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised July 2025, indicated, “…When services are provided on the basis of a physician’s…verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders…The attending physician…will sign the individualized plan of care/treatment within 30 days of the start of care…” A review of the facility P&P titled, “VERIFICATION OF PHYSICIAN ORDERS,” revised July 2025, indicated, “…Orders will be obtained from a licensed physician…for care and services to be provided to home health patients…Verbal orders will be spoken to, taken and documented only by professional, licensed home health personnel (RN and qualified therapist)…A qualified individual will review each order or prescription before care is provided…A copy of the order will be kept in the patient’s clinical record…Signed orders will be placed in the clinical record within 30 days of initiation of the order…”

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/2/23 through 5/4/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 HFEN, 17069 HFEN, 32525 HFEN, 43247 HFEN, 45882 The agency reported 319 unduplicated annual admissions. The patient sample size was 12 and 4 home visits were conducted. The Department was unable to substantiate a violation of the Emergency Preparedness regulations.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/2/23 through 5/4/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 HFEN, 17069 HFEN, 32525 HFEN, 43247 HFEN, 45882 The agency reported 319 unduplicated annual admissions. The patient sample size was 12 and 4 home visits were conducted.

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 complete and submit the Outcome and Assessment Information Set (OASIS, a standardized data and assessment collection form) data in a timely manner for three of 12 sampled patients (Patient 3, Patient 10, and Patient 11). This failure resulted in the delay of initiating of Plan of Care (POC). 2. A review of "OASIS" assessment dated 3/9/23, indicated Patient 10 was initially admitted to the agency on 1/12/23 with diagnosis of diabetes (abnormally high blood glucose), high blood pressure, and depression. A review of the Patient 10's OASIS indicated that Registered Nurse (RN) collected the assessment data, electronically signed the form on 3/10/23 and submitted to the agency. Further review of the document revealed the section with Patient 10’s diagnoses was blank. The OASIS was not submitted to Centers for Medicare and Medicaid Services (CMS). During a concurrent interview and record review on 5/2/23, at 3:35 p.m., the DPCS confirmed that the OASIS form did not contain Patient 10’s diagnoses. The DPCS explained that the RN completed the portion of the patient’s assessment but could not enter the diagnoses because the diagnoses had to be coded by Quality Assessment team. The DPCS confirmed because the diagnoses section had not been coded, the OASIS was not submitted to CMS. The DPCS stated the agency’s policy was to complete and submit OASIS within 30 days of performing a comprehensive assessment. The DPCS stated the compliance director and other staff conduct the audit of patient electronic charts for compliance but apparently missed Patient 10’s records and the OASIS was not submitted within 30 days as required. 3. According to Patient 11’s Plan of Care for the period 3/10/23 through 5/8/23, the patient was admitted to the agency on 3/10/23 with diagnoses of bone disorders and pain in his shoulders. A review of Patient 11's OASIS document indicated that PT collected the assessment data, electronically signed the form on 3/10/23, and submitted to the agency. Further review of the document revealed the section with Patient 11’s diagnoses was blank and the OASIS was not submitted to CMS. During a concurrent interview and record review on 5/3/23, at 12:30 p.m., the DPCS confirmed that Patient 11’s diagnoses in OASIS form were not coded yet and the form was not submitted to CMS. The DPCS explained that QA and coders team must enter diagnoses codes after a clinician submits the OASIS with assessment data before submitting to CMS. The DPCS stated the OASIS should be completed within 30 days. The DPCS stated the compliance director and other staff conduct the audit of patient electronic charts for compliance but apparently missed Patient 11’s records and did not submit the OASIS within 30 days as required. A review of the agency’s policy and procedure titled, "OASIS DATA TRANSMISSION," dated 2020, indicated that the agency "will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation ...The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the ...date assessment completed ...All OASIS data items must be complete ...in order to accurately compute the information necessary for billing ...The organization will conduct clinical and data entry audits." A review of the agency’s policy and procedure titled, "CARE PLANNING PROCESS," revised 4/17, indicated, "The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient ...At the time of the initial assessment, the clinician, along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient's identified needs." Findings: According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A further review of Patient 3’s clinical record reflected an OASIS assessment that was dated 4/13/23 that had no diagnoses listed. During an interview and concurrent record review with the DPCS on 5/2/23 at 1:10 p.m., she validated Patient 3’s diagnoses portion of the OASIS data was blank. The DPCS indicated the Quality Assurance (QA) nurse was responsible for completing the diagnoses coding and stated, ‘not sure what is happening.’ The DPCS indicated the OASIS data populated the plan of care (CMS Form 485).

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide an accurate and complete medication profile for 2 of 12 (Patient 3 and Patient 8) sampled patients when: 1.Patient 8's medication profile did not reflect Patient 8's medications in the home and 2. Patient 3's medication profile was not completed. This failure had the potential for Patient 8 to receive incorrect medications, miss medication doses, or experience adverse reactions. Additionally, failure to complete a medication profile for Patient 3 resulted in drug-to-drug interactions not being identified and hindered patient/care-giver teaching by the clinicians on medication use, side effects, and need for compliance. According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. The referral documents included physician’s ordered medications for a total of 10 types which included, oxycodone ( a narcotic drug used to manage pain), aspirin ( a blood thinner to prevent blood clots), losartan and hydrochlorothiazide; (used to control high blood pressure), requip (for restless legs syndrome/abnormal sensations in legs), lansoprazole (for reducing acid in the stomach), Tylenol (manage pain); docusate sodium, dulcolax suppository and milk of magnesium (for bowel management) Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A further review of Patient 3’s clinical record reflected a ‘Medication Profile’ document that had no medication listed and no drug regimen review for potential drug interactions, ineffective drug therapy, drug interactions, duplication of therapy and no patient/caregiver instructions. During an interview and concurrent record review with the DPCS on 5/2/23 at 1:10 p.m., she validated Patient 3’s medication profile was not completed and stated it should have been completed on 4/13/23 by the clinician who completed the SOC assessment. A review of the agency’s undated policy titled ‘Medication Profile’ indicated, “Patients receiving medications will have a current, accurate medication profile in the clinical record … The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered. A drug regimen review will be performed at the time of admission … The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy omissions and unclear information … Using the medication profile to teach [patient/caregiver] the purpose of medication, dosages, routes, administration times, side effects, and contraindications … Each patient and /or family/caregiver will receive appropriate material for specific medications he/she is receiving … The medication profile and other relevant data will be available to all clinicians providing care. If a patient is taking a recalled drug, the prescribing physician and dispensing pharmacy will be notified …” Findings: A review of Patient 8’s “Plan of Care (POC),” for certification period 4/14/23 to 6/12/23, and clinical record, indicated Patient 8 had a Start of Care (SOC) date of 4/14/23 with the HHA for multiple diagnoses including aphasia (inability to express or understand speech), cerebral infarction (stroke- disrupted blood flow to the brain), and Parkinson’s disease (nervous system disorder that affects movement). A review of Patient 8's POC, for certification period 4/14/23 to 6/12/23, indicated visit frequencies: OT (Occupational Therapist) /COTA (Certified Occupational Therapy Assistant): 1 time a week for 1 week starting 4/17/23 (week 2) OT/COTA: 2 times a week for 2 weeks starting 4/23/23 (week 3) PT (Physical Therapist) /PTA (Physical Therapist Assistant): 1 time a week for 1 week starting 4/14/23 (week 1) PT/PTA: 2 times a week for 3 weeks starting 4/16/23 (week 2) RN (Registered Nurse)/LVN (Licensed Vocational Nurse): 1 time a week for 1 week starting 4/14/23 (week 1) RN/LVN: 2 times a week for 3 weeks starting 4/16/23 (week 2) A review of Patient 8's "Medication Profile," visit date 4/14/23, indicated medications including: Brimonidine Tartrate 0.2 % ml (milliliters), route ophthalmic (eye drops), dose 1 GTT (drop) OU (both eyes), frequency twice per day. A review of Patient 8’s “Occupational Therapy Visit Note,” dated 5/3/23, indicated “…Contacted MD [name of MD]’s office around 1130 am today to clarify the patient’s Eye-drop Medication: Brimonidine Titrate [sic]. This therapist was notified that this med prescription was still sitting on the MD’s computer since 4/17/23; it has not been processed. This therapist will be notified tomorrow regarding the status of the medication, as soon as [name of MD] sets foot at the office…” During an observation and interview on 5/3/23 at 10:48 a.m. with the Occupational Therapist (OT), the OT asked Patient 8 if there were any medication changes since last visit. Patient 8 responded, "No." When asked if medications are reconciled with the medication profile every visit, the OT stated that she asks if there are any new medications. The OT stated she relies on the family to say if there are any new medications and would then update the medication profile. The OT stated she fully reconciles the medications at discharge. Reviewed Patient 8's medications with the OT and Patient 8's family member. The OT and the family member confirmed that Patient 8 does not have Brimonidine Tartrate. The OT stated it may have been discontinued and will check with the physician. The OT acknowledged that this medication has been on the medication profile since the SOC on 4/14/23. During an interview on 5/3/23 at 1:15 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that all disciplines are expected to fully reconcile the medication profile with the medications in the home at every visit. The DPCS stated that the clinicians are to ask for any changes and to update the medication profile. The clinicians are expected to check the medication profile with the medications in the home. The DPCS acknowledged that reconciling medication changes is dependent on the reliability of the family reporting and may not be accurate. The DPCS stated that the OT should have reviewed Patient 8's medication profile and compared it with the medications in the home. The DPCS acknowledged that the medication had been on Patient 8’s medication profile since 4/14/23 and Patient 8 had several HHA visits since SOC where this inaccuracy of the medication profile had not been identified. A review of the agency policy titled “Medication Profile,” undated, indicated “…Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…A drug regimen review will be performed at the time of admission…During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the drug regimen. This includes…Using the medication profile…to evaluate the use of the drugs in the home setting…Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications…Using the medication profile as a communication tool for other clinicians involved in care…”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure discipline specific discharge summary for 1 of 12 sampled patients (Patient 4) was completed in timely manner. This failure had the risk potential for other disciplines/clinicians not to be aware if the patient had met her care planned goals. Findings: According to Patient 4’s Plan of Care (POC) physician orders dated 3/16/23, the Physical Therapist (PT) was to visit 2 times per week for one week starting 4/9/23 to provide exercises to improve balance, mobility and prevent falls. A review of the PT documentation of visits reflected a ‘pending’ discharge summary opened on 4/14/23 that was not completed. The patient outcomes in meeting the PT planned care goals, functional ability, discharge instructions, care coordination with other disciplines including the physician was not documented. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/2/23 at 2:03 p.m., she validated the PT discharge summary for Patient 4 was opened on 4/14/23 and was incomplete. The DPCS stated the summary should have been completed within 48 hours of discharge from PT services. A review of the agency’s policy titled ‘Entries into the Clinical Record’ dated 4/2017 indicated, “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.”

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 observation, interview, and record review, the agency failed to ensure 5 of 12 sampled patients (Patient 2, Patient 3, Patient 6, Patient 7, and Patient 10) had a Plan of Care (POC). This failure had the potential for goals and interventions to not be implemented for the care and services Patient 2, Patient 3, Patient 6, Patient 7, and Patient 10 received. During a concurrent interview and record review, on 5/2/23 at 12:28 p.m., with the DPCS, Patient 7's clinical record was reviewed. Review of Patient 7’s clinical record indicated he had a SOC date of 1/10/23 and was discharged from the home health agency (HHA) on 2/8/23. Patient 7’s diagnoses included dementia and diabetes. When the DPCS was asked to see Patient 7’s POC she stated it had not been generated yet. During a concurrent interview and record review, on 5/2/23 at 1:18 p.m., with the DPCS, Patient 6's clinical record was reviewed. Review of Patient 6’s clinical record indicated he had a SOC date of 3/16/23 and was discharged from the HHA on 3/31/23. Patient 6’s diagnoses included total knee arthroplasty (knee replacement). When the DPCS was asked to see Patient 6’s POC she stated it had not been generated yet. A review of the clinical records indicated Patient 10 was admitted to the agency on 1/12/23 with multiple diagnoses including diabetes (abnormally high blood glucose), high blood pressure, and depression. After 60 days, Patient 10 had been re-certified for the 2nd episode for the period from 3/13/23 through 5/11/23. A review of patient 10's clinical records for the certification period of 3/13/23 through 5/11/23 did not contain a Plan of Care. A concurrent interview and record review was conducted with the DPCS on 5/2/23, at 3:35 p.m. The DPCS confirmed that Patient 10's records did not include a POC. During an interview, the DPCS was asked how the agency assured that Patient 10's medications, services, and treatments were administered as ordered by his physician when there was no POC. The DPCS stated, "We had orders for disciplines and frequencies signed by his physician, and we had a POC from the previous episode." The DPCS stated that a new POC should have been generated as soon as the re-certification assessment was completed, but it was not done. A review of Patient 2’s clinical record indicated Patient 2 had a Start of Care (SOC) date with the Home Health Agency (HHA) on 4/25/23 for multiple diagnoses including coronary artery disease (damage or disease to the heart’s blood vessels), status post CABG (coronary artery bypass grafting-improves blood flow to the heart), acute kidney failure (kidneys unable to filter waste from the blood), and diabetes (too much sugar in the blood}. A review of Patient 2’s initial “Home Health Physician Orders,” effective date 4/25/23, indicated; “…Visit Frequency RN [Registered Nurse]/LVN [Licensed Vocational Nurse]: 1 x [times] week for 1 week starting 04/26/2023 (week 1), RN/LVN: 2 x week for 8 weeks starting 04/30/2023 (week 2) …” A review of Patient 2’s “OASIS [Outcome and Assessment Information Set- tool to collect assessment data] RN Start Of Care,” dated 4/25/23, indicated “…. Frequencies Active PT [Physical Therapist]/ PTA [Physical Therapist Assistant]: 2 x week for 4 weeks starting 04/25/2023 (week 1) …RN/LVN: 2 x week for 8 weeks starting 4/30/23 (week 2)…RN/LVN: 1 x week for 1 week starting 04/30/2023 (week 1) …” A review of Patient 2’s “Physical Therapy Evaluation – Standard,” dated 4/25/23, indicated “…Frequency/ Duration PT: PT/PTA 2 x week for 4 weeks starting 04/25/2023 (week 1) …” Patient 2’s clinical record reviewed on 5/2/23. A completed POC was not located in the clinical record. During a concurrent interview and record review on 5/2/23 at 1:40 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged that Patient 2’s clinical record did not contain a POC for SOC date of 4/25/23. The DPCS stated the POC is generated from the OASIS after review by QA (quality assurance). The DPCS acknowledged Patient 2’s OASIS was done on 4/25/23 and the POC should have been completed by 4/30/23. The DPCS stated agency policy is for the POC to be completed within 5 days after the SOC. The DPCS stated the “Home Health Physician Orders” are just the initial orders and contain only nursing orders. The POC combines the “Home Health Physician Orders” and the Physical Therapy Evaluation-Standard” recommendations.” Findings: According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A further review of Patient 3’s clinical records showed there was no POC. During an interview and concurrent record review with the DPCS on 5/2/23 at 1:10 p.m., she validated the POC for Patient 3 was missing and should have been generated on 4/13/23 during the initial assessment and sent to his physician for signature. A review of the agency’s policy titled ‘Care Planning Process’ dated 4/2017 indicated the purpose of the policy was ‘To provide clinical direction to clinicians providing direct patient care … A written plan of care will be initiated within five (5) days of start of care and updated every 60 days, or as patient’s condition warrants … All clinicians including the physician involved in the patient’s care … will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care … The care planning process will be documented on the plan of care …” The policy and procedure listed the elements to be included in the POC which included: Patient specific interventions, identified patient problems and needs, measurable goals and outcomes, actions to meet the goals, specific services to be provided including frequency of visits, patient/caregiver education, all medications etc.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure that services and treatments were administered as ordered by the physician for two of 12 sampled patients (Patient 5 and Patient 10). This failure resulted in Medical Social Services (MSW) not being provided to Patient 5 and Patient 10 as ordered by the physician. Findings: 1. A review of Patient 5's clinical records indicated a start of care (SOC) date of 3/13/23, with pertinent diagnoses of high blood pressure and diabetes (abnormally high blood glucose). Patient 5’s primary physician’s referral dated 3/9/23 indicated that the patient required supportive services and special transportation due to his weakness and history of a recent fall. A review of the physician order dated 3/14/23 included orders for skilled nurse (SN) to visit three times a week for two weeks, a physical therapy evaluation, and for MSW to evaluate the patient to assist with activities of daily living. A review of the SN visit note dated 4/7/23 indicated, “Explained to patient the importance of him being seen by a Podiatrist [foot doctor] due to 3 small black spots to his 2nd toe to right foot as well as MD seeing his wound…Instructed on the possibility of needed a Social Worker to assist him in getting food delivered and rides to appointments …Patient verbalized understanding to everything discussed …Decided a Social Worker maybe helpful.” A review of Patient 5’s visit history calendar on 5/2/23 indicated no MSW visit had been made as ordered by the physician. A review of another physician order dated 4/8/23 indicated, “Request for MSW 1wk1 [one time visit] for community services.” A review of Patient 5’s clinical records indicated that 24 days after the second order for MSW was placed, there was no MSW visit completed and patient’s needs for community services had not been addressed. During a concurrent interview and record review on 5/2/23, at 2:20 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 5’s records and confirmed that the physician’s orders were not followed and MSW had not evaluated patient’s needs for community services. The DPCS acknowledged that there was no evidence of the coordination of care or any communication between SN, MSW and clinical manager regarding patient’s needs for MSW assistance. The DPCS stated “Apparently [orders] were not communicated to MSW.” The DPCS was not able to find any documentation if Patient 5’s needs to assist with transportation to appointments and food were discussed in the weekly care conferences. During an interview and record review on 5/2/23, at 2:40 p.m., the MSW stated she was not aware that Patient 5 had two physician orders for MSW. The MSW could not locate any email or coordination note regarding need to evaluate Patient 5 with arranging transportation and food deliveries. The MSW explained that the agency normally informs her by a phone call or email if patient has an order for MSW. During a home visit on 5/3/23, at 9:10 a.m., Patient 5 was sitting in his recliner with his legs elevated and a front wheel walker was parked in front of the recliner. Patient 5 had a wound dressing on his right lower leg. Patient 5 stated he lived alone and was homebound. Patient 5 added, “I stopped driving about one and a half years ago due to difficulties with gas pedal …need help with taking me to appointments. I haven’t been able to see a doctor for a long time because I am not driving, and my nephew got injured and couldn’t take me to doctor. Then [LVN 1’s name] told me that social worker could help with arranging transportation to appointments, but nobody called, and nobody came to talk to me about it.” Patient 5 added, “If social worker helped with arranging for transportation, it would help me tremendously with appointments since I can’t rely on my nephew.” During an in interview on 5/3/23, at 9:55 a.m., Licensed Vocational Nurse (LVN 1) stated she was aware about patient’s difficulties with leaving home and seeing the doctor. LVN 1 stated, “He was reluctant to schedule an appointment because unable to drive himself and nephew could not take him …I offered to have MSW assist him with arranging the transportation and maybe with food deliveries and the patient agreed …obtained an order for MSW …did not follow up and the patient did not ask me again.” LVN 1 stated that normally she would email or call MSW if there was a new order for evaluation but could not recall if the new order for MSW evaluation was communicated to social worker, DPCS, or case manager RN. LVN 1 stated she could not recall if the team discussed patient’s need with transportation to appointments in one of the care conferences. 2. A review of Patient 10's clinical records indicated a SOC date of 1/12/23, with pertinent diagnoses of high blood pressure, diabetes (abnormally high blood glucose), and depression. Patient 10 was recertified for a new episode from 3/13/23 through 5/11/23. A review of the physician order dated 3/14/23 included order for skilled nurse to visit two times a week for six weeks and order for MSW for community resources starting week of 3/12/23. A review of Patient 10’s visit history calendar indicated MSW visit was scheduled for the week of 3/12/23 but had not been completed as ordered. During a concurrent interview and record review on 5/3/23, at 12:30 p.m., the DPCS acknowledged that there was no MSW visit completed the week of 3/12/23 as ordered. The DPCS stated, “No visit. I see the order, but no notes. Don’t know why – if the visit was postponed by patient, [I would] expect to see documentation in a progress note. Don’t see the physician was informed. Not sure if the order was communicated to MSW.” During a follow up interview on 5/4/23, at 12 p.m., the DPCS confirmed that social worker visits to assist Patient 5 and Patient 10 with community resources were not completed as ordered. The DPCS stated that the clinician was required to notify the physician if the order was not carried out. The DPCS explained that if the physician order was not followed, the agency’s process was to create an incident report, but there was none created for Patient 5 and Patient 10. A review of agency's policy titled, "Responsibilities/Supervision of Clinical Services," with the revision date of 11/20, indicated, "The clinical director is responsible for the clinical direction of the organization and will take reasonable steps to ensure that... Care and services provided by organization personnel... are coordinated and implemented... Recommendations for required resources are made in a timely and effective manner."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to adequately meet the patients’ needs and coordinate the care delivery between clinicians for two of 12 sampled patients (Patient 5 and Patient 10), when Medical Social Worker (MSW) services were not provided to Patient 5 and Patient 10 per physician’s orders. This failure had the potential for Patient 5 and Patient 10 not to receive information on how to benefit from outside services and resources. 1. A review of Patient 5's clinical records indicated a start of care (SOC) date of 3/13/23, with pertinent diagnoses of high blood pressure and diabetes (abnormally high blood glucose). Patient 5’s primary physician’s referral dated 3/9/23 indicated that the patient required supportive services and special transportation due to his weakness and history of a recent fall. A review of the physician order dated 3/14/23 included orders for skilled nurse (SN) to visit three times a week for two weeks, a physical therapy evaluation, and for MSW to evaluate the patient to assist with activities of daily living. A review of Patient 5’s visit history calendar on 5/2/23 indicated no MSW visit had been made as ordered by the physician. A review of the SN visit note dated 4/7/23 indicated, “Explained to patient the importance of him being seen by a Podiatrist [foot doctor] due to 3 small black spots to his 2nd toe to right foot as well as MD seeing his wound…Instructed on the possibility of needed a Social Worker to assist him in getting food delivered and rides to appointments …Patient verbalized understanding to everything discussed …Decided a Social Worker maybe helpful.” A review of the supplemental physician order dated 4/8/23 indicated, “Request for MSW 1wk1 [one time visit] for community services.” A review of Patient 5’s clinical records indicated that 24 days after the second order for MSW was placed, there was no MSW visit completed and patient’s needs for community services had not been addressed. During a concurrent interview and record review on 5/2/23, at 2:20 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 5’s records and confirmed that the physician’s orders were not followed and MSW had not evaluated patient’s needs for community services. The DPCS acknowledged that there was no evidence of the coordination of care or any communication between SN, MSW and clinical manager regarding patient’s needs for MSW assistance. The DPCS stated “Apparently [orders] were not communicated to MSW.” The DPCS was not able to find any documentation if Patient 5’s needs to assist with transportation to appointments and food were discussed in the weekly care conferences. During an interview and record review on 5/2/23, at 2:40 p.m., the MSW stated she was not aware that Patient 5 had two physician orders for MSW. The MSW could not locate any email or coordination note regarding need to evaluate Patient 5 with arranging transportation and food deliveries. The MSW explained that the agency normally informs her by a phone call or email if patient has an order for MSW. During a home visit on 5/3/23, at 9:10 a.m., Patient 5 was sitting in his recliner with his legs elevated and a front wheel walker was parked in front of the recliner. Patient 5 had a wound dressing on his right lower leg. Patient 5 stated he lived alone and was homebound. Patient 5 added, “I stopped driving about 1.5 years ago due to difficulties with gas pedal …need help with taking me to appointments. I haven’t been able to see a doctor for a long time because I am not driving, and my nephew got injured and couldn’t take me to doctor. Then [LVN 1’s name] told me that social worker could help with arranging transportation to appointments, but nobody called, and nobody came to talk to me about it.” Patient 5 added, “If social worker helped with arranging for transportation, it would help me tremendously with appointments since I can’t rely on my nephew.” During an in interview on 5/3/23, at 9:55 a.m., LVN 1 stated she was aware about patient’s difficulties with leaving home and seeing the doctor. LVN 1 stated, “He was reluctant to schedule an appointment because unable to drive himself and nephew could not take him …I offered to have MSW assist him with arranging the transportation and maybe with food deliveries and the patient agreed …obtained an order for MSW …did not follow up and the patient did not ask me again.” LVN 1 stated that normally she would email or call MSW if there was a new order for evaluation but could not recall if the new order for MSW evaluation was communicated to social worker, DPCS, or case manager RN. LVN 1 stated she could not recall if the team discussed patient’s need with transportation to appointments in one of the care conferences. 2. A review of Patient 10's clinical records indicated a start of care (SOC) date of 1/12/23, with pertinent diagnoses of high blood pressure, diabetes (abnormally high blood glucose), and depression. Patient 10 was recertified for a new episode from 3/13/23 through 5/11/23. A review of the physician order dated 3/14/23 included order for skilled nurse to visit two times a week for six weeks and order for MSW for community resources starting week of 3/12/23. A review of Patient 10’s visit history calendar indicated MSW visit was scheduled for the week of 3/12/23 but had not been completed as ordered. During a concurrent interview and record review on 5/3/23, at 12:30 p.m., the DPCS acknowledged that there was no MSW visit completed the week of 3/12/23 as ordered. The DPCS stated, “No visit. I see the order, but no notes. Don’t know why – if the visit was postponed by patient, [I would] expect to see documentation in a progress note. Don’t see the physician was informed. Not sure if the order was communicated to MSW.” During a follow up interview on 5/4/23, at 12 p.m., the DPCS confirmed that social worker visits to assist Patient 5 and Patient 10 with community resources were not completed as ordered. The DPCS stated that the clinician was required to notify physician if the order was not carried out. The DPCS explained that if the physician order was not followed, the agency’s process was to create an incident report, but there was none created for Patient 5 and Patient 10. A review of agency's policy titled, "Responsibilities/Supervision of Clinical Services," with the revision date of 11/20, indicated, "The clinical director is responsible for the clinical direction of the organization and will take reasonable steps to ensure that... Care and services provided by organization personnel... are coordinated and implemented... Recommendations for required resources are made in a timely and effective manner."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure therapy services (exercises to help a patient regain movement or strength) and nursing services were in accordance with the Plan of Care (POC) for six of 12 sampled patients (Patient 3, Patient 4, Patient 1, Patient 7, Patient 5, and Patient 9), and Patient 3 failed to receive Home Health Aide (HHA) services as ordered. These failures resulted in patients not receiving services that were ordered and had the potential for negative clinical outcomes. 3. A review of Patient 5's clinical records indicated a SOC date of 3/13/23, with pertinent diagnoses of high blood pressure, diabetes (abnormally high blood glucose), and pressure ulcer of right heel. A review of Patient 5’s primary physician’s referral dated 3/9/23 contained an order for physical therapy, including gait training, assistive device training, and to establish home exercise program. A review of POC for 3/13/23 through 5/11/23 indicated that physical therapy was scheduled to visit Patient 5 one time a week for one week, then two times a week for 2 weeks, and then one time a week for one week, starting the week of 4/2/23. A review of the last PT visit note dated 3/31/23 indicated Patient 5 had not reached his PT treatment plan. The therapist documented the following: “This patient is currently homebound due to general weakness and poor balance …The patient is a fall risk…Patient has an ongoing skilled need to reach 200 feet ambulation …Plans for next visit…teaching: Fall recovery techniques…assessment…balance test…Treatments…Continue LE [lower extremities] strengthening…” A review of Patient 5’s calendar visit history indicated no PT visit had been made on the week of 4/2/23. There was no documented evidence to explain why the PT visit was not conducted as ordered. Patient 5’s records did not contain the evidence the physician was notified of a missed visit. A review of Patient 5’s clinical records indicated there was no missed visit rescheduled for the same week. Patient 5’s ‘Physical Therapy Discharge Visit and Summary,’ dated 4/8/23 indicated that the patient was discharged with goals not met. During a concurrent interview and record review on 5/2/23, at 2:20 p.m., the DPCS confirmed there was no PT visit made the week of 4/2/23 as ordered by the physician. The DPCS acknowledged there was no missed visit documented in the patient’s record and no documentation that the physician was notified of a missed visit. A review of the agency’s policy titled, “Missed Visit,” with the revision date of 4/17 indicated that the purpose of the policy was to ensure that missed visits were documented and did not affect the quality of patient care. The policy indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.” A review of Patient 9’s “Plan of Care (POC),” for certification period 12/6/22 to 2/3/23, indicated Patient 9 had a Start of Care (SOC) date with the Home Health Agency (HHA) of 12/6/22 for multiple diagnoses including dysarthria (speech disorder caused by muscle weakness), cerebral infarction (stroke-disrupted blood flow to the brain), dysphagia (difficulty swallowing), and heart failure (the heart does not pump blood as well as it should). A further review of Patient 9’s POC, for certification period 12/6/22 to 2/3/23, indicated; “…Frequencies…OT [Occupational Therapist]/COTA [Certified Occupational Therapist Assistant]: 1 x [times] week for 1 week starting 12/25/22 (week 4) … OT/COTA: 2 x week for 2 weeks starting 12/11/2022 (week 2) …OT/COTA:1 x week for 1 week starting 12/10/22 (week 1) …” A review of Patient 9’s Schedule Calendar, indicated Patient 9 received OT services on 12/10/22, 12/14/22, 12/19/22, and 12/21/22. Patient 9’s Schedule Calendar indicated Patient 9 received one OT visit during week 2, 12/11/22 to 12/17/22 and no OT visits during week 4, 12/25/22 to 12/31/22. This was a total of 3 missed OT visits. A review of Patient 9’s “Occupational Therapy Patient Missed Visit” note, dated 12/17/22, indicated “…Reason for missed visit…OT clinician out sick…Notification(s) Individuals notified: Clinical Manager…” It was not documented in the “Occupational Therapy Patient Missed Visit” note, dated 12/17/22, that the physician was notified of the missed visit. A review of Patient 9’s “Occupational Therapy Patient Missed Visit” note, dated 12/28/22, indicated “…Reason for missed visit…OT clinician is out sick…Notification(s) Individuals notified: Clinical Manager…” It was not documented in the “Occupational Therapy Patient Missed Visit” note, dated 12/28/22, that the physician was notified of the missed visit. A review of Patient 9’s “Occupational Therapy Patient Missed Visit” note, dated 12/29/22, indicated “…Reason for missed visit…OT clinician is out sick…Notification(s) Individuals notified: Clinical Manager…” It was not documented in the “Occupational Therapy Patient Missed Visit” note, dated 12/29/22, that the physician was notified of the missed visit. During a record review and interview on 5/3/23 at 2:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged that Patient 9 had missed visit notes for OT services but no indication that the physician was notified of the missed visits on 12/17/22, 12/28/22, and 12/29/22. The DPCS stated the physician should have been notified of the missed visits. The clinician should call the physician or fax the missed visit note or obtain a new frequency order for the services. A review of the HHA policy titled “Missed Visits,” revised 4/17, indicated “…To ensure that missed visits are documented and does not affect the quality of patient care…Missed visits will be communicated to the clinical supervisor and the patient’s physician…If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that physician ordered frequency is maintained…If a visit is missed and not rescheduled the clinician will…Notify the physician and clinical supervisor of the missed visit…” A review of the HHA policy titled “Care Planning Process,” revised 4/17, indicated “…Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care…” Review of Patient 1’s clinical record indicated she had a start of care (SOC) date of 4/4/23 and diagnoses that included dementia and a femur (thigh bone) fracture. Review of Patient 1's “Plan of Care,” for the certification period of 4/4/23 to 6/2/23 contained an order for Skilled Nurse (SN) visits “2 x week for 1 week starting 04/04/2023” and 1 x week for 5 weeks starting 04/09/2023.” During a concurrent interview and record review, on 5/2/23 at 12:16 p.m., with the Director of Patient Care Services (DPCS), Patient 1's clinical record was reviewed. The clinical record indicated only one SN visit was made during the week of 4/4/23 to 4/8/23, instead of two as ordered and no SN visit was made the week of 4/9/23. The DPCS confirmed only one SN visit was made the week of 4/4/23 and no SN visit was made the week of 4/9/23. The DPCS confirmed there was no documentation the physician was notified of the missed visit or the reason for the missed visits were documented. Review of Patient 7’s clinical record indicated he had a SOC date of 1/10/23 and diagnoses included dementia and diabetes (elevated blood sugar). Review of Patient 7's “Plan of Care,” for the certification period of 1/10/23 to 3/10/23 contained an order for SN visits “2 x week for 3 weeks starting 01/10/2023.” During a concurrent interview and record review, on 5/2/23 at 12:28 p.m., with the DPCS, Patient 7's clinical record was reviewed. The clinical record indicated no SN visits were made the during the week of 1/29/23 to 2/4/23. The DPCS confirmed no SN visits were made the week of 1/29/23. The DPCS confirmed there was no documentation the physician was notified of the missed visit or the reason for the missed visits were documented. Review of Patient 7's “Plan of Care,” for the certification period of 1/10/23 to 3/10/23 contained an order for Home Health Aide (HHAide) visits “1 x week for 4 weeks starting 1/10/23.” During a concurrent interview and record review, on 5/2/23 at 12:28 p.m., with the DPCS, Patient 7's clinical record was reviewed. The clinical record indicated no HHAide visit was made the during the week of 1/15/23 to 1/21/23. The DPCS confirmed there was no documentation the physician was notified of the missed visit or the reason for the missed visits were documented. During a review of the agency’s policy “Missed Visits,” revised April 2017, indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. The policy also indicated, “If a visit is missed and not rescheduled the clinician will: A: Notify the physician and the clinical supervisor of the missed visit and the reason for the missed visit. B. Document in the patient 's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patient’s needs were met 5. Physician notification including date, time, physician name, method of notification and the staff reporting information 6. Any other follow up needed 7. Other person(s) that were notified of the missed visit 8. Signature of staff member reporting the information.” Findings: 1. According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A review of Patient 3’s SN visit orders indicated the SN was to visit the patient 2 times per week for 5 weeks starting 4/16/23 for medication management and patient/caregiver teaching on compliance with medication. During an interview and concurrent record review with the DPCS on 5/2/23 at 1:10 p.m., she validated a SN missed visit (MV) note was opened on 4/28/23 and was not completed including the reason for the MV, case manager and physician notification. The DPCS stated the nurse should have completed the note to include the reason for the MV and notification of the case manager and the physician. According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services following a left knee replacement surgery. Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A review of Patient 3’s assessment dated 4/13/23 indicated the HHA was to provide care once per week for 6 weeks. Patient 3’s HHA ‘Care Plan’ dated 4/18/23 indicated the aide was to provide a shower, check the skin, hair shampoo, foot care, assist with dressing, tidy the bathroom and bedroom and monitor vital signs and A review of Patient 3’s medical record indicated the first aide visit was not done until 4/26/23, 2 weeks after the SOC. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/4/23, at 10:30 a.m., she stated the HHA services should have been started within 5 days of SOC. The DPCS stated the Registered Nurse (RN) who completed the initial assessment and initiated the aides care plan should have included the effective start date under the HHA visit frequency for clarity. A review of the agency’s policy titled ‘Provision of Care, Treatment, and Service-Intake Process’ dated 11/2020 indicated in part, “The Intake Coordinators will assign personnel and schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral … Additional disciplines will schedule their visit within 5 days after initial assessment.” 2. According to Patient 4’s Plan of Care (POC) physician orders dated 3/16/23, the Physical Therapist (PT) was to visit 2 times per week for one week starting 4/9/23 to provide exercises to improve balance, mobility and prevent falls. A review of the PT documentation of visits reflected a ‘pending’ MV note opened on 4/12/23 that was not completed to include the reason for the MV, case manager and physician notification. During an interview and concurrent record review with the DPCS on 5/2/23 at 2:03 p.m., she validated the PT MV for Patient 4 was not completed and should have been completed with 48 hours of the missed visit or rescheduled. A review of the agency’s policy titled ‘Missed Visits’ dated 4/2017 indicated, “To ensure that missed visits are documented and does not affect the quality of patient care. Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.” Patient 4’s MV was not re-scheduled, and she was discharged from therapy (non-visit discharge) on 4/14/23. According to Patient 3’s ‘Referral Documents’ dated 4/6/23, he was referred to the agency for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services following a left knee replacement surgery. Patient 3’s ‘Profile’ was reviewed and indicated the Start of Care (SOC) date was 4/13/23. A review of Patient 3’s assessment dated 4/13/23 indicated the HHA was to provide care once per week for 6 weeks. Patient 3’s HHA ‘Care Plan’ dated 4/18/23 indicated the aide was to provide a shower, check the skin, hair shampoo, foot care, assist with dressing, tidy the bathroom and bedroom and monitor vital signs and A review of Patient 3’s medical record indicated the first aide visit was not done until 4/26/23, 2 weeks after the SOC. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 5/4/23, at 10:30 a.m., she stated the HHA services should have been started within 5 days of SOC. The DPCS stated the Registered Nurse (RN) who completed the initial assessment and initiated the aides care plan should have included the effective start date under the HHA visit frequency for clarity. A review of the agency’s policy titled ‘Provision of Care, Treatment, and Service-Intake Process’ dated 11/2020 indicated in part, “The Intake Coordinators will assign personnel and schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral … Additional disciplines will schedule their visit within 5 days after initial assessment.”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the registered nurse (RN) supervised the care provided by licensed vocational nurses (LVNs) for two of 12 sampled patients (Patient 5 and Patient 10), when there were no supervisory visits completed and no monitoring and evaluation of LVNs performance documented. This failure had the potential for Patient 5 and Patient 10 to receive unsupervised nursing care and services resulting in poor patient outcomes. 1. A review of Patient 5’s clinical record indicated a Start of Care (SOC) date of 3/13/23. Patient 5’s pertinent diagnoses included diabetes (abnormally high blood glucose), high blood pressure, and chronic venous edema with inflammation on right lower leg. Patient 5’s Plan of Care (POC) for certification period of 3/13/23 through 5/11/23 directed skilled nurses to provide patient’s teaching and management of high blood pressure, blood glucose management, diabetic foot care, and to provide wound care to right heel pressure ulcer. A review of Patient 5’s visit schedule calendar indicated that LVN 1 was assigned for visiting the patient starting on 3/31/23. A review of Patient 5 clinical records indicated a document titled "SKILLED NURSING SUPERVISORY VISIT” dated 4/24/23. The document’s sections for the name of staff member being supervised was blank. The other questions regarding staff’s performance, including questions if POC was followed, if the staff honored patient’s rights, and communicated well with the patient or patient’s family were blank. A further review of Patient 5’s clinical records, indicated here was no documented evidence that RN supervisory visits were completed to monitor and evaluate LVN 1’s performance in the provision of services and treatment to patient’s wound, data collection regarding patient’s status and health needs, and patient’s teaching. During a concurrent interview and records review on 5/2/23, at 2:20 p.m., the Director of Patient Care Services (DPCS) was asked how the agency supervised LVNs. The DPCS stated that RN was required to conduct supervisory visits to evaluate LVN’s performance every 30 days or more often as needed. The DPCS stated that the visit could be completed with a clinician present or without the LVN. When the DPCS was asked if any supervisory visits were conducted for Patient 5, the DPCS acknowledged that the supervisory visit form dated 4/24/23 was not completed. The DPCS confirmed that there were no supervisory visits completed for Patient 5. During a joint home visit to Patient 5’s residence on 5/3/23, at 9 a.m., LVN 1 stated she was assigned for visiting this patient for a while. LVN 1 informed that RN will be joining today for a supervisory visit. The LVN 1 was asked if the supervisory visits to evaluate her performance were completed in the past, she replied, “I can’t recall [if] there were any.” 2. A review of Patient 10’s clinical record indicated initial SOC date of 1/12/23 with multiple diagnoses including diabetes (abnormally high blood glucose), high blood pressure, depression, and anxiety. A review of the physician order dated 3/10/23 included an order for the skilled nurse (SN) to visit Patient 10 two times a week for medication management and diabetic teaching. A review of Patient 10’s visit schedule calendar for the certification period from 3/13/23 through 5/11/23 indicated that LVN was scheduled to visit Patient 10 two times a week since 3/14/23. A review of Patient 10 clinical records indicated a document titled “SKILLED NURSING SUPERVISORY VISIT” dated 4/11/23. The document’s sections for the name of staff member being supervised and other sections were blank. A further review of Patient 10’s clinical records, indicated there was no documented evidence that RN supervisory visits were completed to monitor and evaluate LVN’s performance in the provision of services and treatment, data collection regarding patient’s status and health needs, and patient’s diabetes teaching. During a concurrent interview and Patient 10’s records review on 5/2/23, at 3:35 p.m., the DPCS stated that RN was scheduled to conduct a supervisory visit on 4/11/23 to evaluate LVN’s performance. Upon reviewing supervisory visit form dated 4/11/23, the DPCS acknowledged that the supervisory visit form was not completed. The DPCS confirmed that there were no supervisory visits completed for Patient 10 since the SOC date on 3/13/23. A review of the agency’s policy titled, “Responsibilities/Supervision of Clinical Services,” dated 2020, indicated, “PURPOSE: To ensure a process is in place …for overseeing all clinical care and services …The Clinical Director is responsible for the clinical direction of the organization …The Clinical Director will monitor the care provided by organization personnel …The Clinical Director will ensure that the following supervision is maintained within the organization …LVN will be supervised by a registered nurse at least every month.”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA), failed to make supervisory onsite visits to the patient's home no less frequently than every 14 days for 3 of 10 sampled patients (Patient 1, Patient 7, Patient 8) receiving Home Health Aide (HHAide) services. This failure had the potential for the HHA to not monitor care being provided by the HHAide. A review of Patient 8’s “Plan of Care (POC)” for certification period 4/14/23 to 6/12/23 and clinical record, indicated Patient 8 had a Start of Care (SOC) date of 4/14/23 with the HHA for multiple diagnoses including aphasia (inability to express or understand speech), cerebral infarction (stroke- disrupted blood flow to the brain), and Parkinson’s disease (nervous system disorder that affects movement). A review of Patient 8’s POC, for certification period 4/14/23 to 6/12/23, indicated “…Home Health Aide Intervention: Aide to assist with personal care for ADL [Activities of Daily Living] assistance. Start Effective Date: 04/14/2023…Frequencies Active HHA [Home Health Aide]: 2 x [times] week for 5 weeks starting 04/17/2023 (week 2) …” A review of Patient 8’s clinical record indicated a “Home Health Aide Care Plan,” was initiated 4/14/23. A review of Patient 8’s “Skilled Nursing Visit Note,” dated 4/25/23, indicated “Supervisory Visit…Supervision performed this visit? …No…” A review of Patient 8’s “Skilled Nursing Visit Note,” dated 4/28/23, indicated “Supervisory Visit…Supervision performed this visit? ...No…” A review of Patient 8’s “Skilled Nursing Visit Note,” dated 5/1/23, indicated “Supervisory Visit…Supervision performed this visit? ...No..." During a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS acknowledged that Patient 8’s clinical record did not contain a Home Health Aide Supervisory Note within 14 days. Patient 8’s clinical record did not include a separate supervisory note or indication in “Skilled Nursing Visit Note,” for 4/25/23, 4/28/23, and 5/1/23, that a supervisory visit for Home Health Aide had been conducted. The DPCS stated the policy is that a Home Health Aide supervisory visit is done every 14 days. A review of the agency’s policy titled “Home Health Aide Plan of Care,” revised 4/17, indicated “…Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide…The Case Manager or other appropriate clinician will directly supervise the home health aide every 14 days to ensure care is provided according to plan…” A review of the agency’s policy titled “Responsibilities/Supervision of Clinical Services,” revised 11/20, indicated “…To ensure a process is in place for the selection of a qualified individual for overseeing all clinical care and services…The Clinical Director will ensure that the following supervision is maintained within the organization…Home Health aides: Home health aide supervisory visits will be conducted on-site at least every fourteen (14) days by skilled personnel. Supervisory visits can be made in conjunction with the home health aide or in his/her absence. A direct observation supervisory visit will be made at least every six (6) months…” Findings: Review of Patient 1’s clinical record indicated she had a start of care (SOC) date of 4/4/23 and diagnoses included dementia and a femur (thigh bone) fracture. Review of Patient 1's “Plan of Care,” for the certification period of 4/4/23 to 6/2/23 contained an order for HHAide services. During a concurrent interview and record review, on 5/2/23 at 12:28 p.m., with the Director of Patient Care Services (DPCS), Patient 7's clinical record was reviewed. The clinical record indicated no documentation a HHAide supervisory visit was conducted from 4/4/23 to 5/2/23. The DPCS confirmed there was no documentation a HHAide supervisory visit was made during this time period and stated it should be done every 14 days. Review of Patient 7’s clinical record indicated he had a SOC date of 1/10/23 and was discharged from the HHA on 2/8/23. Patient 7’s diagnoses included dementia and diabetes (elevated blood sugars). Review of Patient 7's “Plan of Care,” for the certification period of 1/10/23 to 3/10/23 contained an order for HHAide service. During a concurrent interview and record review, on 5/2/23 at 12:28 p.m., with the DPCS, Patient 7's clinical record was reviewed. The clinical record indicated no documentation a HHAide supervisory visit was conducted from 1/10/23 to 2/8/23. The DPCS confirmed there was no documentation a HHAide supervisory visit was made and stated it should be done every 14 days.