Every finding on record at Pruitthealth Home Health, Inc.

An unannounced, onsite recertification survey was conducted 5/18/26-5/20/26. No deficiencies to the Emergency Preparedness Plan were identified.

An onsite, unannounced recertification survey was conducted 5/18/26-5/20/26. A condition level deficiency was identified at at G700. Standard level deficiencies were identified as well.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the comprehensive assessment was not updated during the last 5 days of every 60 days for 1 of 13 active records reviewed [#9]. The findings included: Patient # 9 had a Start of Care date of 9/10/25. Review of the Plan of Care [POC] for the certification period 5/8/26-7/6/26 included diagnoses of cellulitis of right lower limb [infection of the skin], lymphedema [buildup of protein-rich lymph fluid in the body's soft tissues], type 2 diabetes mellitus, and old myocardial infarction [heart attack]. The POC also included orders for SN [skilled nursing] visits 1 time a week for 1 week, 2 times a week for 7 weeks. Review of the clinical record revealed RN # 1 completed the recertification visit on 5/12/26. The new episode started on 5/8/26. During an interview with the area Vice President [VP] on 5/19/26 at approximately 4 p.m. the VP stated, “The clinician failed to plot enough visits to do the recertification visit within the last 5 days. He then had to ask for an order to see the patient.” The VP confirmed the recertification visit was not conducted in the appropriate time frame.

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 agency policy, direct observation, clinical record review, patient/caregiver interviews, and staff interviews, the Plan of Care failed to include all the current/correct medications the patient was taking for 2 of 3 patients who received a home visit [#9 and 11]; and failed to include appropriate safety measures for 4 of 15 records reviewed [#9, 10, 5, and 13]; and failed to include units of insulin to be given based on sliding scale for 1 of 1 patient with an insulin pump [#6]; and failed to include the type of gastrostomy feeding for 1 of 1 patient with a gastrostomy [#15]. The findings included: The policy, Plans of Care for Home Health Patients [reviewed 11/17/25], was provided by the area Vice President on 5/19/26 at approximately 2 p.m. The policy stated, “...The individual plan of care will specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment... The plan of care serves to document the specific physician orders for each individual patient... When services are provided based on a physician’s verbal order, a registered nurse, or qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s [home health agency] policy must document the order in the patient’s clinical record, sign, date, and time the order... The Plan of care will include the following... Nutritional requirements...All medications and treatments...Safety measures to protect against injury...” 1A. Patient # 9 had a Start of Care date of 9/10/25 with an admitting diagnosis of cellulitis [infection of the skin]. Review of the Plan of Care [POC] for the certification period 5/8/26-7/6/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week and “Assess current medications...” On 5/19/26 at 9 a.m. a joint visit was made with RN # 1. During the visit a medication review was completed using a medication profile provided by the agency. The following discrepancies were noted: The medication profile [POC] included Atorvastatin [high cholesterol] 80 mg daily. The patient reported he takes 40 mg of Atorvastatin each day. The patient reported he takes Lisinopril/HCTZ [blood pressure/diuretic] 12.5 mg each day. This medication was not included on the POC. 1B. Patient # 9 had a Start of Care date of 9/10/25. Review of the Plan of Care [POC] for the certification period 5/8/26-7/6/26 included diagnoses of cellulitis of right lower limb [infection of the skin], lymphedema [buildup of protein-rich lymph fluid in the body's soft tissues], type 2 diabetes mellitus, and old myocardial infarction [heart attack]. The POC also included orders for Metformin [diabetic medication] 1000 mg two times a day. Further review of the clinical record revealed “Diabetic Precautions” was not included in the safety measures. 2. Patient # 11 had a Start of Care date of 3/2/26 and admitting diagnosis of sarcopenia [the natural, age-related loss of skeletal muscle mass, strength, and function].Review of the Plan of Care [POC] for the certification period 5/1/26-6/26/26 included orders for OT [occupational therapy] 0 times a week for 1 week, 1 time a week for 4 weeks, 0 times a week for 1 week, 1 time a week for 1 week, 0 times a week for 1 week, 1 time a week for 1 week and “Assess current medications...” On 5/19/26 at approximately 2:30 p.m. a joint visit was made with OT # 4. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile [POC] included famotidine [reflux] 10 mg. Take 1 tablet daily as needed for heartburn. The caregiver presented a bottle of famotidine 20 mg. Take 1 tablet 2 times a day as needed for heartburn with a start date of 10/11/25. During an interview with the agency Vice President [VP] on 5/20/26 at approximately 6 p.m., the VP stated that clinicians should be checking medications each visit to ensure the POC is accurate. 3. Patient # 10 had a Start of Care date of 10/28/24. Review of the Plan of Care [POC] for the certification period 4/21/26-6/19/26 included diagnoses of venous insufficiency [damaged vein walls and valves in the legs struggle to return blood to the heart], non-pressure chronic ulcer of other part of right lower leg, non-pressure chronic ulcer of right ankle and type 2 diabetes mellitus with diabetic neuropathy [nerve damage caused by prolonged high blood sugar in people with diabetes]. Further review of the POC revealed the “Diabetic Precautions” was not included in the safety section of the POC. During an interview with RN # 3 on 5/20/26 at 6:30 p.m. it was confirmed the POC should have included diabetic precautions. 4. Patient # 5 had a Start of Care date of 5/5/26 with an admitting diagnosis of encounter for orthopedic aftercare following a surgical amputation and type 2 diabetes peripheral angiopathy without gangrene [a diabetes complication involving narrowed or blocked arteries in the extremities]. Review of the Plan of Care for the certification period 5/5/26-7/3/26 revealed diabetic precautions were not included. During an interview with RN # 3 on 5/20/26 at 6:30 p.m. it was confirmed the POC should have included diabetic precautions. 5. Patient # 6 had a Start of Care date of 3/4/26 and admitting diagnoses of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of left heel and midfoot with other specified severity, encounter for adjustment and management of VAD [vascular access device- a sterile, flexible tube [catheter] inserted into a blood vessel. It is used to draw blood, deliver medications, administer chemotherapy, or provide nutritional support. VADs eliminate the need for repeated needle sticks and ensure safe delivery of intravenous therapies. Review of the Plan of Care [POC] for the certification period 3/4/26-5/2/26 included an order for insulin lispro [diabetes medication] 100 units per ml. Inject up to 100 units per 24 hours into pump device. The POC did not include any specific parameters for how many units in relation to the blood glucose readings. During an interview with the area vice president on 5/20/26, the VP confirmed the POC was incomplete. 6. Patient # 13 had a Start of Care date of 3/5/26. Review of the Plan of Care [POC] for the certification period 5/4/26-7/2/26 revealed the patient was ordered Aspirin 81 mg daily for anti-platelet [hampers blood clotting]. Further review of the clinical record revealed “Bleeding Precautions” were not included on the POC. During an interview with RN # 3 on 5/20/26 at 6:30 p.m. it was confirmed the POC should have included diabetic precautions. 7. Patient # 15 had a Start of Care date of 1/8/26. Review of the Plan of Care [POC] for the certification period 3/9/26-5/7/26 included diagnoses of flu due to identified novel influenza A virus with other respiratory manifestations, gastrostomy status [feeding tube directly into the stomach through the abdominal wall. It provides a direct route for liquid nutrition, fluids, and medications for individuals who cannot eat safely or consume enough calories by mouth], and type 2 diabetes mellitus without complications. Further review of the POC revealed “Nutrition- Regular Diet; Tube Feeding”. The type or amount/rate of tube feeding was not included on the POC. In addition, the POC did not include the type of feeding in the medication section.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the Plan of Care failed to include all orders related to wound care for 1 of 1 patient with an order for a dry dressing to a surgical site [#5]. The findings included: The policy, Plans of Care for Home Health Patients [reviewed 11/17/25], was provided by the area Vice President on 5/19/26 at approximately 2 p.m. The policy stated, “...The individual plan of care will specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment... The plan of care serves to document the specific physician orders for each individual patient... When services are provided based on a physician’s verbal order, a registered nurse, or qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s [home health agency] policy must document the order in the patient’s clinical record, sign, date, and time the order... The Plan of care will include the following... Nutritional requirements...All medications and treatments...Safety measures to protect against injury...” Patient # 5 had a Start of Care date of 5/5/26 with an admitting diagnosis of encounter for orthopedic aftercare following a surgical amputation and type 2 diabetes peripheral angiopathy without gangrene [a diabetes complication involving narrowed or blocked arteries in the extremities]. Review of the Plan of Care for the certification period 5/5/26-7/3/26 included orders for SN [skilled nursing] 1 time a week for 4 weeks. The clinical record indicated the patient had a right sided below the knee amputation closed with staples. On 5/11/26 LPN # 7 conducted a routine visit and documented, “...Removed dressing from rt [sic] BKA [below knee amputation] site...placed a dry dressing to cover...” LPN # 7 conducted a routine visit on 5/18/26 and documented “...Dry dressing and border applied...” Further review of the clinical record revealed no order for a dry dressing. During an interview with the area Vice President [VP] on 5/20/26 at approximately 6:30 p.m. the VP stated, “I spoke with _______ [RN # 8]. She said she called and got the order. She just forgot to write it.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to notify the physicain when vital signs were outside the give parameters for 5 of 15 records reviewed [ #1, 3, 11, 14, 15]. The findings included: 1. Patient # 1 had a Start of Care date of 11/8/25 with admitting diagnoses of pressure ulcer of right hip, stage 4 [full-thickness skin and tissue loss, exposing underlying bone, tendon, or muscle], pressure ulcer of right heel, stage 3 [full-thickness skin loss. The damage extends into the subcutaneous (fatty) tissue, creating a deep, crater-like wound. While fatty tissue is visible, underlying muscles, tendons, and bones are not exposed], pressure ulcer of sacral [base of spine] region, unstageable [full-thickness skin and tissue loss, where the true depth and severity of the damage cannot be determined because it is completely or partially obscured by dead tissue], and orthostatic hypotension [a sudden, significant drop in blood pressure that occurs when you stand up after sitting or lying down]. Review of the Plan of Care [POC] for the certification period 11/8/25-1/6/26 included orders for SN [skilled nursing] 3 times a week for 8 weeks, PT [physical therapy] 1 time a week for 4 week and “Assess and monitor vital signs every visit. Report parameters to MD/NPP [sic] outside: Systolic [top number] blood pressure greater than 140 or less than 90, Diastolic [bottom number] greater than 90 or less than 60...” Review of the clinical record revealed PT documented a blood pressure of 84/44 on 11/14/25. The RN documented a blood pressure reading of 84/54 on 11/14/25 and 84/48 on 11/17/25. The clinical record revealed no evidence that the physician was notified of the blood pressure readings. 2. Patient # 3 had a Start of Care date of 4/5/25 with an admitting diagnosis of type 2 diabetes mellitus with foot ulcer. Review of the Plan of Care [POC] for the certification period 4/5/25-6/23/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 9 weeks; PT [physical therapy] 1 time a week for 1 week, 2 times a week for 4 weeks, 1 time a week for 1 week; OT [occupational therapy] 1 time a week for 1 week, 1 time a week for 7 weeks and “...Licensed professional to report vital signs falling outside the following established parameters...Systolic [top number] blood pressure less than 90 or greater than 160, Diastolic [bottom number] blood pressure less than 60 or greater than 110...”Review of the clinical record revealed the patient’s blood pressure was outside the given parameters 21 times from 4/25/25-6/4/25. Further review of the clinical record revealed the physician was not notified of the blood pressure reading 17 of the 21 times. During an interview with the area Vice President on 5/20/26 at 7 p.m. it was confirmed the clinicians failed to report the blood pressure readings outside the given parameters. 3. Patient # 11 had a Start of Care date of 1/12/26. Review of the clinical record for the Plan of Care [POC] for the certification period 3/13/26-5/11/26 included a diagnosis of other sequelae of cerebral infarction [stoke]. The POC included the following orders: OT [occupational therapy] 0 times a week for 1 week, 1 time a week for 8 weeks and “ Assess and monitor vital signs every visit. Report parameters to MD/NPP [sic] outside: Systolic [top number] blood pressure greater than 140 or less than 90, Diastolic [bottom number] greater than 90 or less than 60. Review of the clinical record revealed OT # 8 conducted a routine visit on 5/4/26 and documented a blood pressure of 99/59 [outside the parameters]. OT # 8 documented, “Patient reports he feels ok-had him drink water...” Further review of the clinical record revealed no evidence the MD was notified. 4. Patient # 14 had a Start of Care date of 1/12/26. Review of the Plan of Care [POC] for the certification period 5/4/26-7/2/26 revealed a diagnosis of other sequelae cerebral infarction [stroke]. The POC included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks; OT [occupational therapy] 0 times a week for 1 week, 1 time a week for 8 weeks and “Assess and monitor vital signs every visit. Report parameters to MD/NPP [sic] outside: Systolic [top number] blood pressure greater than 160 or less than 95, Diastolic [bottom number] blood pressure greater than 100 or less than 60...” Review of the clinical record revealed on 3/31/26 PT and OT recorded blood pressures outside the given parameters; on 4/9/26 PT and OT recorded blood pressures outside the given parameters; on 4/12/26, 4/24/26, 4/30/26, and 5/5/26 OT recorded a blood pressure outside the given parameters. The record revealed no evidence that the physician was notified of the blood pressures being outside the given parameters. During an interview with the area Vice President [VP] on 5/20/26 at approximately 6:30 p.m. it was confirmed the physician was not notified of the blood pressure readings. 5. Patient # 15 had a Start of Care date of 1/8/26. Review of the Plan of Care [POC] for the certification period 3/9/26-5/7/26 included diagnoses of flu due to identified novel influenza A virus with other respiratory manifestations, gastrostomy status [feeding tube directly into the stomach through the abdominal wall. It provides a direct route for liquid nutrition, fluids, and medications for individuals who cannot eat safely or consume enough calories by mouth], and type 2 diabetes mellitus without complications. The POC included orders for PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 1 week, 0 times a week for 1 week, 1 time a week for 1 week, 0 times a week for 1 week, 1 time a week for 1 week, 0 times a week for 1 week, 1 time a week for 1 week and “ Assess and monitor vital signs every visit. Report parameters to MD/NPP [sic] outside: Systolic [top number] blood pressure greater than 140 or less than 90, Diastolic [bottom number] greater than 90 or less than 60...Blood glucose greater than 250 or less than 70...” Review of the clinical record revealed PT # 9 documented a blood pressure of 142/76 [outside the parameters] on 3/13/26. On 4/22/26, PT # 9 documented a blood glucose of 344 and documented the following information, “..._____ [daughter’s name] will administer 5 units of insulin...” There was no evidence that the PT notified the MD.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on agency policy, direct observation, and staff interviews, the agency failed to follow proper hand hygiene technique for 1 of 2 patients receiving a home visit with wound care [#9]; and failed to dispose of used dressings appropriately for 1 of 2 patients receiving a home visit with wound care [#10]. The findings included: The policy, Bag Technique Policy for Home Health and Hospice [revised 9/18/25], was provided by the area Vice President on 5/20/26 at 9:20 a.m. The policy stated, “...Perform hand hygiene before accessing the bag...If additional equipment or supplies are needed from the bag during the visit, the handwashing procedure must be repeated...Perform hand hygiene after equipment use...Return the equipment to the clean side of the bag...Close the bag and perform final hygiene...” 1. Patient # 9 had a Start of Care date of 9/10/25 with an admitting diagnosis of cellulitis [infection of the skin]. Review of the Plan of Care [POC] for the certification period 5/8/26-7/6/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week. On 5/19/26 at 9 a.m. a joint visit was made with RN # 1. The RN was noted to complete hand hygiene at the beginning of the visit. He then removed vital sign equipment and placed it on the barrier. After obtaining the patient’s vital signs he did not complete hand hygiene and began documenting the visit. The RN re-entered the nursing bag to retrieve a wipe to clean the vital sign equipment. No hand hygiene was completed prior to re-entering the nursing bag. After wiping the vital sign equipment off he placed the equipment back in the bag. He did not complete hand hygiene prior to entering the bag to place the clean vital sign equipment back into the bag. During the visit the RN placed his documentation device on the patient’s kitchen table without a barrier. The RN handed the device to the patient at the conclusion of the visit for the patient to sign. After the patient used the device, the RN concluded the visit and exited the home. The device was not wiped down prior to the visit or at the conclusion of the visit. 2. Patient # 10 had a Start of Care date of 10/28/24. Review of the Plan of Care [POC] for the certification period 4/21/26-6/19/26 included diagnoses of venous insufficiency [damaged vein walls and valves in the legs struggle to return blood to the heart], non-pressure chronic ulcer of other part of right lower leg, and non-pressure chronic ulcer of right ankle. The POC also included orders for SN [skilled nursing] 2 times a week for 9 weeks. On 5/19/26 am at 10:30 a.m. a joint visit was made with RN # 5 to observe wound care. During the visit, the RN removed the soiled dressing [visibly soiled with drainage] from bilateral legs and placed the soiled dressings directly on the patient’s carpeted floor. The RN failed to place the soiled dressings on a barrier or place them in a trash bag. After the wound care was completed, the RN stated, “I guess I should have not put those used dressings on the floor.” During an interview with the area Vice President on5/20/26 at approximately 6:30 p.m. it was confirmed the used dressings should not have been placed directly onto the patient’s floor.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on agency policy, direct observation, clinical record review, staff interviews, and patient/caregiver interviews the skilled professional failed to assess a PICC line/measure PICC line weekly [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] for 1 of 1 patient and documented a wound was debrided during a nursing visit for 1 of 1 patient [refer to G0702]; applied an adaptic dressing without an order to a wound receiving negative pressure therapy for 1 of 1 patient, failed to change a PICC line dressing [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] weekly in accordance with the plan of care for 1 of 1 patient, failed to follow the physician's order related to wound care for 1 of 1 patients receiving wound care during home visit, and failed to follow the Plan of Care for visit frequency for SN [skilled nursing] visits for 1 of 3 patients who recieved a home with with orders for nursing services [refer to G0710]; the occupational therapist [OT] failed to complete 2 visit notes within an appropriate time for 1 of 8 patients receiving OT services [refer to G0716]; and failed to notify the physicain promptly when a patient complained of cardiac symptoms for 1 of 1 patient who reported cardiac symptoms [refer to G0718]. Cross refer to 484.75 (a) G0702 Cross refer to 484.75 (b) (3) G0710 Cross refer to 484.75 (b) (6) G0716 Cross refer to 484.75 (b) (7) G0718

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the Registered Nurse failed to assess a PICC line/measure PICC line weekly [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] for 1 of 1 patient with a PICC line [#6]; and documented a wound was debrided during a nursing visit for 1 of 1 patient [#6]. The findings included: 1A. Patient # 6 had a Start of Care date of 3/4/26 and admitting diagnoses of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of left heel and midfoot with other specified severity, encounter for adjustment and management of VAD [vascular access device- a sterile, flexible tube [catheter] inserted into a blood vessel. It is used to draw blood, deliver medications, administer chemotherapy, or provide nutritional support. VADs eliminate the need for repeated needle sticks and ensure safe delivery of intravenous therapies. Review of the Plan of Care [POC] for certification period 3/4/26-5/2/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks and “...PICC [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] ...Please apply biopatch with PICC dressing changes weekly...” Review of the clinical record revealed RN # 1 admitted Patient # 6 on 3/4/26. There was no assessment of the PICC line site at the time of admission. Routine SN visits were made on 3/6/26, 3/9/26, 3/13/26, and 3/18/26. Further review of the clinical record revealed no PICC line measurement/site assessment for 3 of the 4 routine visits. During an interview with the area Vice President [VP] reported the expectation is that PICC lines sites are to be inspected each visit and PICC line measurements are to be obtained at least weekly. 1B. Patient # 6 had a Start of Care date of 3/4/26 and admitting diagnoses of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of left heel and midfoot with other specified severity, encounter for adjustment and management of VAD [vascular access device- a sterile, flexible tube [catheter] inserted into a blood vessel. It is used to draw blood, deliver medications, administer chemotherapy, or provide nutritional support. VADs eliminate the need for repeated needle sticks and ensure safe delivery of intravenous therapies. Review of the Plan of Care [POC] for certification period 3/4/26-5/2/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks. A supplemental order was noted on 3/13/26 for wound care. The order was “Please see patient three times weekly. Please DC [discontinue] wound vac... For the toe area cleanse with Vashe. Please place a petroleum dressing across the incision site. For the heel, please cleanse wound with Dakins. Add collagen. Apply a heel foam boarder dressing. Wrap with gauze, cover with coban...” RN # 1 conducted a routine visit on 3/18/26 and documented the following, “...Wound care performed this HH [home health] SN visit. Wound bed to heel 80% pearly white...small amount of slough gently debrided [clean a wound and remove dead, damaged, or infected tissue] from heel wound bed...” RN # 1 was not available for interview. During an interview with RN # 3 on 5/20/26 at approximately 5:30 p.m., RN # 3 stated, “He absolutely knows he can’t do that.”

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 agency policy, clinical record review, and staff interviews, the Registerd Nurse applied adaptic without an order to a wound receiving negative pressure therapy for 1 of 1 patient with a wound vac [#1]; and failed to change a PICC line dressing [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] weekly in accordance with the plan of care for 1 of 1 patient with a PICC line [#6]; and failed to follow the physician's order related to wound care for 1 of 1 patients receiving wound care during home visit [#10]; failed to follow the Plan of Care for visit frequency for SN [skilled nursing] visits for 1 of 3 patients who recieved a home with with orders for nursing services [#10]. The findings included: The policy, Plans of Care for Home Health Patients [reviewed 11/17/25], was provided by the area Vice President on 5/19/26 at approximately 2 p.m. The policy stated, “...The individual plan of care will specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment... The plan of care serves to document the specific physician orders for each individual patient... When services are provided based on a physician’s verbal order, a registered nurse, or qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s [home health agency] policy must document the order in the patient’s clinical record, sign, date, and time the order... The Plan of care will include the following... Nutritional requirements...All medications and treatments...Safety measures to protect against injury...” 1. Patient # 1 had a Start of Care date of 11/8/25 with admitting diagnoses of pressure ulcer of right hip, stage 4 [full-thickness skin and tissue loss, exposing underlying bone, tendon, or muscle], pressure ulcer of right heel, stage 3 [full-thickness skin loss. The damage extends into the subcutaneous (fatty) tissue, creating a deep, crater-like wound. While fatty tissue is visible, underlying muscles, tendons, and bones are not exposed], pressure ulcer of sacral [base of spine] region, unstageable [full-thickness skin and tissue loss, where the true depth and severity of the damage cannot be determined because it is completely or partially obscured by dead tissue], and orthostatic hypotension [a sudden, significant drop in blood pressure that occurs when you stand up after sitting or lying down]. Review of the Plan of Care [POC] for the certification period 11/8/25-1/6/26 included orders for SN [skilled nursing] 3 times a week for 8 weeks and “...SN to provide negative pressure, dressing change using clean technique...pack with green color foam or ordered dressing cut to fit...Set negative pressure to 125mmhg...” RN # 10 made routine visits for wound vac change on 11/10/25, 11/12/25, 11/12/25, and 11/17/25. RN # 10 documented an adaptic dressing was placed under the foam for the wound vac. Review of the physician’s order revealed no order for adaptic. RN # 10 was unavailable for interview. During an interview with RN # 3 on 5/20/26 at approximately 6:30 p.m. it was confirmed there was no order for adaptic. 2. Patient # 6 had a Start of Care date of 3/4/26 and admitting diagnoses of type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of left heel and midfoot with other specified severity, encounter for adjustment and management of VAD [vascular access device- a sterile, flexible tube [catheter] inserted into a blood vessel. It is used to draw blood, deliver medications, administer chemotherapy, or provide nutritional support. VADs eliminate the need for repeated needle sticks and ensure safe delivery of intravenous therapies. Review of the Plan of Care [POC] for certification period 3/4/26-5/2/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks and “...PICC [peripherally inserted central catheter- a long, flexible, and thin tube inserted through a vein in the upper arm and threaded into a larger vein near the heart. It provides safe, reliable central venous access for long-term treatments like intravenous antibiotics, chemotherapy, or liquid nutrition] ...Please apply biopatch with PICC dressing changes weekly...” Review of the clinical record revealed RN # 1 admitted Patient # 6 on 3/4/26. The clinical record revealed no documentation related to the PICC line. RN # 1 conducted routine visits on 3/6/26, 3/9/26, 3/13/26, and 3/18/26. There was no evidence that the PICC line dressing was changed in accordance with the physician’s order. During an interview RN # 3 on 5/20/26 at 7:00 p.m. RN 3 confirmed the PICC line dressing was not completed in accordance with the physician’s order. 3A. Patient # 10 had a Start of Care date of 10/28/24. Review of the Plan of Care [POC] for the certification period 4/21/26-6/19/26 included diagnoses of venous insufficiency [damaged vein walls and valves in the legs struggle to return blood to the heart], non-pressure chronic ulcer of other part of right lower leg, and non-pressure chronic ulcer of right ankle. The POC also included orders for SN [skilled nursing] 2 times a week for 9 weeks. A supplemental wound care order was dated 5/14/26. The supplemental order stated, “...Wash extremity/periwound with warm water and a gentle skin cleanser...Clean wound with normal saline...Right leg-apply aquacel ag to all open areas, Sorbion [right leg lateral only, ABD...Right foot: Aquacel AG on wound and between toes, sorbion [sic] Left Lateral foot: Aquacel AG...” A joint visit was made with RN # 5 on 5/19/26 at approximately 10:30 a.m. to observe wound care. The RN failed to use warm water to wash the extremity. The RN used a wound cleanser. Also, the RN failed to apply Aquacel AG between the toes on the right foot and the open areas on the left lateral foot. During an interview with RN # 5 on 5/20/26 at approximately 5 p.m., the RN confirmed he failed to follow the physician’s order. 3B. Patient # 10 had a Start of Care date of 10/28/24. Review of the Plan of Care [POC] for the certification period 4/21/26-6/19/26 included diagnoses of venous insufficiency [damaged vein walls and valves in the legs struggle to return blood to the heart], non-pressure chronic ulcer of other part of right lower leg, and non-pressure chronic ulcer of right ankle. The POC also included orders for SN [skilled nursing] 2 times a week for 9 weeks. Review of the clinical record revealed the patient did not receive a nursing visit the weeks of 4/21/26, 4/26/26, nor 5/2/26. There were no missed visits documented. During an interview with RN # 5 pm 5/20/26 at approximately 5 p.m. the RN stated, “I am still new at this, and I am not sure what I did to make the visits not populate. I just missed those visits.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the occupational therapist [OT] failed to complete 2 visit notes within an appropriate time for 1 of 8 patients receiving OT services [#8]. The findings included: Patient # 8 had a Start of Care date of 4/21/26 with an admitting diagnosis of urinary tract infection. Review of the Plan of Care for the certification period 4/21/26-6/19/26 included orders for OT [occupational therapy] 1 time a week for 7 weeks. Review of the clinical record revealed OT # 6 conducted routine visits on 4/29/26 and 5/15/26. When attempts were made to review the visit notes for these dates, the visits were not completed. During an interview with the area Vice Present [VP] at 6:45 p.m. the VP stated, “Routine documentation is to be completed withing 24 hours of the visit. She is already on an action plan because her documentation is so far behind.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on direct observation, clinical record review and patient/staff interviews the Registered Nurse failed to notify the physicain promptly when a patient complained of cardiac symptoms for 1 of 1 patient who reported cardiac symptoms [#9]. The findings included: Patient # 9 had a Start of Care date of 9/10/25. Review of the Plan of Care [POC] for the certification period 5/8/26-7/6/26 included diagnoses of cellulitis of right lower limb [infection of the skin], lymphedema [buildup of protein-rich lymph fluid in the body's soft tissues], type 2 diabetes mellitus, and old myocardial infarction [heart attack]. The POC also included orders for SN [skilled nursing] visits 1 time a week for 1 week, 2 times a week for 7 weeks. On 5/19/26 at approximately 9 am, a joint visit was made with RN # 1. During the visit the patient stated, “...I have had a miserable night. I almost called 911...I had pain in the left side of my chest, it went up into my left arm and shoulder and then into my left jaw. I never did throw up; I was just nauseated. I took 3 aspirins [the patient is ordered aspirin 81 mg daily] and then in about 15 minutes I chewed 3 more...I still feel weak now. It may have been something I ate yesterday.” During the visit, RN # 1 asked the patient how he felt at the present time. The patient stated, “I am still having pain in my left shoulder.” The RN continued with the visit and advised the patient, “You know that is classical signs of a heart attack.” At the conclusion of the visit, the RN stated, “I will let your doctor know about the chest pain.” Review of the clinical record revealed the RN entered a note on 5/19/26 at 2:35 p.m. The RN documented the following information, “...Patient states the [sic] had a rough night last night, c/o [complained of] nausea. Patient states that he had heart attack symptoms, patient 3, 81 mg aspirin under the tongue. Patient states that the aspirin was effective...Patient c/o pain in left shoulder...Call placed to primary care to give report on patient’s symptoms and current status this am. Primary care to call patient and follow up on his symptoms. No new orders at this time...” During an interview with RN # 1 on 5/20/26 at approximately 11 am, this surveyor shared with RN # 1 that patient had actually advised the RN he had taken 6 aspirins in 15 minutes [surveyor shared notes taken during the visit] RN # 1 stated, “I guess I didn’t hear him say he had actually taken 6 aspirins in a time frame of 15 minutes. During an interview with the area vice president on 5/20/26 at 6 pm, the area vice president stated, “We will speak to this nurse, he should have contacted the physician during the visit, not in the car and he should have called the physician back to inform him the patient had actually taken 6 aspirin in a 15 minute span. This is not acceptable at this agency.”

An unannounced, onsite recertification survey was conducted 6/5/23-6/7/23. No deficiencies to the Emergency Preparedness Plan was identified.

An unannounced onsite recertification survey was conducted 6/5/23-6/7/23. Standard level deficiencies to the Medicare CoP were identified.

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 policy review, clinical record review, and staff interview, the agency failed to accurately assess patients’ medications on the OASIS (Outcome and Assessment Information Set—standardized assessment) for 3 of 13 patients (#6, 4, and 8). Findings included: A policy, OASIS Data (revised 2/8/23), was provided by the agency administrator on 6/7/23 at 12:00 p.m. The policy stated, “The encoded OASIS must accurately reflect the patient’s status at the time of assessment.” 2. Patient # 4 had a Start of Care [SOC] date of 5/13/23 and an admitting diagnosis of collapsed vertebra, cervicothoracic region [region between the cervical and thoracic sections of the spinal cord]. Review of the Plan of Care for the certification period 5/13/23 to 7/11/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 6 weeks, 1 time a week for 2 weeks. The POC included an order for Cyanocobalamin [Vitamin B 12] 1,000 mcg/ml. 1 ml IM [intramuscular] every 21 days. Review of the SOC OASIS [The Outcome and Assessment Information Set-tool used to collect and report assessment information] question M2030 [regarding injectable medications] completed by RN # 3 on 5/13/23 revealed an answer of “NA-No injectable medications prescribed”. RN # 3 was not available for interview. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the OASIS question was answered incorrectly. 3. Patient # 8 had a Start of Care [SOC] date of 5/30/23 and admitting diagnoses of hypertension and ataxia [poor muscle control]. Review of the Plan of Care [POC] for the certification period 5/30/23 to 7/28/23 included orders for PT [physical therapy] 1 time a week for 5 weeks. Review of the SOC OASIS [The Outcome and Assessment Information Set-tool used to collect and report assessment information] completed by PT # 5 on 5/30/23 question NO415 indicated the patient was receiving an antiplatelet medication [medications that prevent platelets from sticking together and forming blood clots]. Review of the POC revealed the patient was not taking any antiplatelet medication. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the OASIS information was inaccurate. 1. Patient #6 was admitted on 5/2/23 with a diagnosis of left femur (thigh bone) fracture. The initial assessment was conducted on 5/2/23. The patient was not identified as taking an antipsychotic medication (medication used to treat psychosis, delusions, hallucinations paranoia, or disordered thought) in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care for 5/2/23-6/30/23 included orders for quetiapine (an antipsychotic medication) 25 mg twice daily. An interview with the agency director on 6/6/23 at 1:56 p.m. confirmed the OASIS was not coded accurately.

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 policy review, clinical record review, and staff interview, the agency failed to include all medications orders on the Plan of care for 4 of 13 patients (#10, 12, 1 and 8); to include equipment the patient was using a CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) for 1 of 1 patient using a CPAP (#9); and to obtain vital signs of 1 of 13 patients (#4); and to included site care to 1 of 2 patients with a vascular access device (#13). The findings included: A policy, Plans of Care for Home Health Patients (reviewed 9/29/2020), was provided by the agency administrator on 6/6/23 at 8:30 a.m. The policy stated, “The Plan of care will include the following…All medications and treatments…” A policy, Medication Management for Home Health (revised 7/21/2021), was provided by the agency administrator on 6/6/23 at 8:30 a.m. The policy stated, “Upon the patient’s admission, all medications, including prescribed, OTC [over-the-counter] and herbal, will be identified on the medication profile…When multiple PRN [as needed] pain medications are ordered, documentation in the medication profile must include describing what medication should be taken for what type of pain…The home health agency will maintain accurate documentation of all medications the patient is currently taking…” 3. Patient # 1 had a Start of Care [SOC] date of 7/25/22 and diagnoses of hemiplegia [paralysis of ½ of the body] following a cerebral infarction [stroke] and type 2 diabetes with diabetic neuropathy [a type of nerve damage that can occur in diabetics. High blood sugar can injure nerves throughout the body].6Review of the Plan of Care [POC] for the certification period 7/25/22 to 9/22/22 included orders for SN [skilled nursing] 1 time a week for 4 weeks. Review of the clinical record revealed RN # 3 conducted the SOC. Review of the POC revealed Nitroglycerin [medication that relaxes the blood vessels and increases the supply of blood and oxygen to the heart] 0.4 mg sublingual [under the tongue] PRN [as needed] chest pain. The POC did not include the frequency of the medication. RN # 3 was not available for interview. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the POC lacked the frequency for the Nitroglycerin. 4. Patient # 8 had a Start of Care date of 5/30/23 and admitting diagnoses of hypertension and ataxia [poor muscle control]. Review of the Plan of Care [POC] for the certification period 5/30/23 to 7/28/23 included orders for PT [physical therapy] 1 time a week for 5 weeks. On 6/7/23 at approximately 12 pm, a joint visit was conducted with physical therapy assistant [PTA] # 5. During the visit, a medication review was conducted. The following discrepancy was noted: The patient presented a bottle of Ultram [pain medication] 50 mg. Take 1 tablet every 6 hours PRN [as needed] for pain. The bottle had a start date of 5/3/23. The POC did not include the Ultram. During an interview with the patient on 6/6/23 at 12:15 pm, the patient confirmed she was taking the medication prior to her admission to home health. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the POC did not include all medications the patient was using. 5. Patient # 9 had a Start of Care [SOC] date of 5/29/23 and an admitting diagnosis of dizziness and giddiness. Review of the Plan of Care [POC] for the certification period 5/29/23 to 7/27/23 included orders for PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 5 weeks. Review of the SOC OASIS [The Outcome and Assessment Information Set-tool used to collect and report assessment information] revealed PT # 2 completed the OASIS. The OASIS indicated the patient had a CPAP [continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep] in the home. During an interview with the caregiver on 6/6/23 at approximately 10 am, the caregiver confirmed the patient used a CPAP machine in the home. Review of the POC revealed the CPAP was not included. During an interview with the agency administrator on 6/7/23 at approximately 9 am, the administrator confirmed the CPAP machine should have been included on the POC. 6. Patient # 4 had a Start of Care date of 5/13/23 and admitting diagnosis of collapsed vertebra, cervicothoracic region [region between the cervical and thoracic sections of the spinal cord]. Review of the Plan of Care for the certification period 5/13/23 to 7/11/23 included orders for PT [physical therapy] 1 time a week for 8 weeks. Review of the clinical record revealed PT # 4 conducted the physical therapy evaluation on 5/17/23 and “Licensed professional to report vital sings falling outside the established parameters…” Review of the evaluation revealed no blood pressure reading. During an interview with the agency administrator on 6/7/23 at approximately 9 am, the administrator stated, “All disciplines should obtain vital signs each visit”. 7. Patient # 13 had a Start of Care date of 3/23/23 and admitting diagnoses of osteomyelitis [infection of the bone] and encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics]. Review of the Plan of Care [POC] for the certification period 3/23/23 to 5/21/23 included orders for SN [skilled nursing] 1 time a week for 8 weeks and “…. perform IV site care using chlorhexidine swabs, apply biopatch, cover with transparent dressing and aseptic technique…” The order did not include the frequency the IV site care should be done. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the order on the POC was incomplete. 1. Patient #10 was admitted on 5/22/23 with diagnoses of encounter for orthopedic aftercare and spinal stenosis. The Plan of Care (POC) included orders for physical therapy weekly for five weeks, then every other week for four weeks. A home visit was conducted on 6/6/23 at 10:30 a.m. with PT #2. · The POC included Celecoxib 200 mg twice daily as an analgesic, anti-inflammatory, or anti-pyretic (fever). During the home visit, the patient revealed the medication was taken once daily. · The POC included Hydrocodone 5mg-Acetaminophen 325 mg every four hours as needed for pain. The patient stated that it was taken every six hours as needed. The prescription bottle stated that it was taken every eight hours. · The POC omitted Tadalafil (used for pulmonary hypertension or erectile dysfunction) 5 mg daily. An interview with PT #2 during the home visit confirmed the medications were not updated on the POC. 2. Patient #12 was admitted on 5/27/23 with a diagnosis of interstitial pulmonary disease (a lung disease that causes progressive scarring of lung tissue). A home visit was conducted with RN #9 on 6/7/23 at 11:00 a.m. A review of the medications revealed the following medication discrepancies: · Hydrocodone/Acetaminophen 10 mg/325 mg twice daily for pain was omitted from the POC · Acetaminophen 500 mg as needed for breakthrough pain was omitted from the POC · Aspirin 81 mg daily for heart health was omitted from the POC · Flonase nasal spray as needed for allergy symptoms was omitted from the POC · Naproxen 200 mg 1 ½ tablets at night for pain was omitted from the POC · Moisturizing eye drops 2 drops each eye as needed for dry eyes was omitted from the POC · AZO as needed for bladder pain was omitted from the POC An interview with the patient’s caregiver during the home visit revealed the patient had been taking the omitted medications prior to the start of care. An interview with the RN during the home visit confirmed all medications were not included in the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to follow the Plan of Care for 1 of 1 patient with an order to measure abdominal girth (#2); and to obtain an order for compression stockings for 1 of 1 patient wearing compression stockings (#7); and failed to obtain an order for peg [percutaneous endoscopic gastrostomy - is a procedure to place a feeding tube. The tube allows nutrition directly through the stomach] tube dressings for 1 of 1 patients with a peg tube (#11); and failed to obtain an order for huber (type of needle) needle changes for 1 of 1 patient using a huber needle (#11). Findings included: A policy, Plans of Care for Home Health Patients (reviewed 9/29/20), was provided by the agency administrator on 6/6/23 at 8:30 a.m. The policy stated, “The plan of care serves to document the specific physician orders for each individual patient.” A policy, Coordination and management of Home Health Services (revised 6/22/17), was provided by the agency administrator on 6/6/23 at 8:30 a.m. The policy stated, “Services are provided in accordance with the attending physician’s orders and the written care plan…” A policy, Skilled Nursing Services for Home Health (revised 11/21/22), was provided by the agency administrator on 6/7/23 at 12:00 p.m. The policy stated, “Nursing visits are individually based on the need, but not necessarily limited to…Perform skilled procedures as ordered by the physician.” 3A. Patient # 11 had a Start of Care [SOC] date of 4/8/23 and admitting diagnoses of encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics] and malignant neoplasm of connective and soft tissue of abdomen [cancer]. Review of the Plan of Care for the certification period 4/8/23 to 6/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 4 times a week for 4 weeks, 3 times a week for 2 weeks. Review of the SOC visit note completed by RN # 8 revealed the following information, “…During hospital stay patient was started with the TPN [Total parenteral nutrition is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein] and peg [percutaneous endoscopic gastrostomy - is a procedure to place a feeding tube. The tube allows nutrition directly through the stomach] to [sic] place for drainage.” Further review of the clinical record revealed RN # 3 made routine visits on 4/10/23, 4/14/23,4/19/23,5/2/23 and 5/22/23. Review of the SN visit notes for those dates revealed the RN placed a dressing to the peg site. Review of the POC revealed no order for dressings to the peg site. RN # 3 was unavailable for interview. During an interview with the agency director on 6/7/23 at 9 am, the administrator confirmed there was no physician’s order for a dressing to the site. 3B. Patient # 11 had a Start of Care [SOC] date of 4/8/23 and admitting diagnoses of encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics] and malignant neoplasm of connective and soft tissue of abdomen [cancer]. Review of the Plan of Care for the certification period 4/8/23 to 6/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 4 times a week for 4 weeks, 3 times a week for 2 weeks and “Skilled nurse to obtain IV access via port using huber [type of needle] and aseptic technique…” Review of the clinical record revealed RN # 3 changed the huber needle on 4/14/23, 4/21/23, 4/28/23, 5/8/22 and 5/22/23. Review of the clinical record revealed no order to change the huber needle. During an interview with the agency administrator on 6/7/23 at approximately 9 am, the administrator stated, “Yes, we should have written an order with the frequency of huber needle changes.” 1A. Patient #2 was admitted on 8/1/22 with a diagnosis of chronic diastolic (congestive) heart failure. The Plan of Care (POC) for 8/1/22-9/29/22 included orders for skilled nursing visits weekly for four weeks then one time every two weeks for four weeks; and “skilled nurse to obtain abdominal girth measurements and/or teach patient/caregiver to obtain abdominal girth measurements daily.” Between 8/1/22-9/29/22, there were no abdominal girth measurements for 7 of 7 nursing visits. An interview with the agency administrator on 6/6/23 at 1:20 p.m. confirmed there were no measurements. 1B. Patient #2 was admitted on 8/1/22 with a diagnosis of chronic diastolic (congestive) heart failure. The Plan of Care (POC) for 8/1/22-9/29/22 included orders for skilled nursing visits weekly for four weeks then once every two weeks for four weeks. On 8/8/23, a physician’s order was received to obtain urine for urinalysis. The urine may be collected clean catch if possible or via in and out catheter in needed. The visit note on 8/8/23 stated, “…labs drawn per MD orders via venipuncture to right hand.” There was no evidence the urine was collected. There was a urinalysis lab report for 8/18/23. An interview with the agency administrator on 6/6/23 at 1:20 p.m. confirmed there was no evidence the urinalysis was completed on 8/8/23. 2. Patient #7 was admitted on 4/19/23 with a diagnosis of hypertensive heart and chronic kidney failure. The patient was rehospitalized 5/2/23-5/8/23. A resumption of care assessment (a comprehensive assessment conducted after an inpatient hospitalization) was conducted on 5/10/23. The nurse documented the patient had “compression stockings in place.” The nurse also noted that the patient was wearing compression stocking on the 5/22/23 visit. There was no evidence of an order for compression stockings. An interview with the agency administrator on 6/6/23 at 2:08 p.m. confirmed there was no order for compression stockings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview that agency failed to report vital signs/pain levels out of parameters for 2 of 13 patients (#3 and 11); to notify the physician that services were on hold due to lack of insurance authorizations for 1 of 13 patients (#6); and to notify the physician of weights out of parameters for 2 of 3 patients with weight monitoring orders (#7 and 5). Findings included: A policy, Plans of Care for Home Health Patients (reviewed 9/29/2020), was provided by the agency administrator on 6/6/23 at 8:30 a.m. The policy stated, “The HHA [home health agency] must promptly alert the physician who is responsible for the HHA plan of care to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.” 4. Patient # 5 had a Start of Care date of 5/13/23 and diagnoses of acute respiratory failure with hypoxia [low oxygen] and congestive heart failure [heart doesn’t pump adequately]. Review of the Plan of Care for the certification period 5/13/23 to 7/11/23 included orders for SN [skilled nursing] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks; PT [physical therapy] 1 time a week for 8 weeks; OT [occupational therapy] 1 time a week for 6 weeks and “…obtain weight every day and notify MD/RN of weight gain greater than 3 pounds within 1 day or 5 pounds in 1 week.” Review of the clinical record revealed an admission weight of 171 pounds. RN # 3 conducted a routine visit on 5/17/23 and recorded a weight of 171 pounds. PT # 4 conducted a PT evaluation on 5/18/23 and recorded a weight of 175.5 pounds. Further review of the clinical record revealed no evidence PT # 4 notified the RN or the physician of the weight gain. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed PT did not notify the physician of the weight gain. 5. Patient # 11 had a Start of Care [SOC] date of 4/8/23 and admitting diagnoses of encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics] and malignant neoplasm of connective and soft tissue of abdomen [cancer]. Review of the Plan of Care for the certification period 4/8/23 to 6/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 4 times a week for 4 weeks, 3 times a week for 2 weeks and “Licensed professional to report vital signs falling outside the following established parameters…pain greater than 7…” Review of the SOC visit completed by RN # 8 revealed a pain level of 8. There was no evidence the physician was notified of the pain level being outside the given parameter. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the physician was notified of the pain level being outside the given parameter. 1. Patient #3 was admitted on 2/7/23 with diagnoses of aftercare following surgery on the circulatory system, presence of heart assist device, and hypertensive heart and chronic kidney failure. The Plan of Care (POC) for 2/7/23-4/7/23 included orders for physical therapy weekly for seven weeks, then every other week for two weeks; occupational therapy weekly for nine weeks; and skilled nursing weekly for eight weeks beginning the week 2/12/23. The POC also included to report vital signs outside of the parameters. The blood pressure parameters were systolic blood pressure less than 90 or greater than 140 or diastolic blood pressure less than 60 or greater than 90. On 2/9/23, the occupational therapist noted that they were unable to obtain a blood pressure. The note stated that a note was faxed and the clinic was aware. There was no evidence the physician office was called related to the inability to obtain a blood pressure. A visit on 2/13/23 revealed a blood pressure of 75/55. The note says the physician was aware that the blood pressure was sometimes below normal. The physician’s office was faxed, but there was no evidence the physician’s office was called. An interview with the agency director on 6/6/23 at 1:47 p.m. revealed the clinician should have called the physician for blood pressures outside parameters. The interview revealed there was no evidence the physician was called. 2. Patient #6 was admitted on 5/2/23 with a diagnosis of left femur (thigh bone) fracture. The Plan of Care for 5/2/23-6/30/23 included orders for physical therapy twice weekly for six weeks, then weekly for three weeks; and occupational therapy one time for one week, twice weekly for three weeks, then weekly for four weeks. There were no visits made the weeks of 5/7/23, 5/14/23, and 5/21/23. On 5/30/23, there was an order written that stated, “Due to no insurance [authorization] patient on hold from 5/8/23-5/30/23. There was no evidence the physician was notified the patient was on hold. In an interview with the agency director on 6/6/23 at 1:51 p.m., the director stated, “I don’t see anything where the doctor was notified.” 3. Patient #7 was admitted on 4/19/23 with a diagnosis of hypertensive heart and chronic kidney failure. The patient was hospitalized on 5/2/23 and had services resumed on 5/22/23. The resumption of care (ROC) included orders for skilled nursing weekly for four weeks and physical and occupational therapy evaluations. The ROC orders also included for “Skilled nurse to obtain weight and/or teach patient/caregiver to obtain weight [every] day and notify RN/MD of weight gain greater than 3 lbs within 1 day or 5lbs [sic] in one week.” On 5/22/23, the patient’s weight was 249.6. On 5/30/23, the patient weighed 259. The visit note stated, “Pt [patient] indicated he has some selling in his LE’s [lower extremities] and his weight is up slightly.” There was no evidence the physician was notified of a 10 lbs. weight gain in 8 days. An interview with the agency director on 6/6/23 at 2:17 p.m. confirmed there was no evidence the physician was notified of the weight gain or increased swelling in the lower extremities.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, home visit observations, and staff interviews, the agency failed to perform hand hygiene for 1 of 4 home visits (#12); and to follow clinical bag technique for 2 of 4 home visits (#12 and 8). Findings included: The policy, Bag Technique Policy for Home Health and Hospice [10/11/22] was provided by the agency administrator on 6/6/23 at 3 pm. The policy states, “…Return to the clinical bag, open it and remove necessary items for the visit. Keep the bag closed during the visit…” 2. Patient # 8 had a Start of Care date of 5/30/23 and admitting diagnoses of hypertension and ataxia [poor muscle control]. Review of the Plan of Care [POC] for the certification period 5/30/23 to 7/28/23 included orders for PT [physical therapy] 1 time a week for 5 weeks. On 6/6/23 at approximately 12 pm, a joint visit was conducted with physical therapy assistant [PTA] # 5. During the visit, the PTA removed vital sign equipment from her bag and placed the equipment on the barrier. The PTA continued with the assessment and obtaining vital signs. The PTA left the bag unzipped during the entire visit and did not rezip the bag until after the vital sign equipment had been cleaned at the end of the visit. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the bag should have been zipped up after the PTA removed the vital sign equipment. 1. Patient #12 was admitted on 5/27/23 with a diagnosis of interstitial pulmonary disease (a lung disease that causes progressive scarring of lung tissue). A home visit was conducted with RN #9 on 6/7/23 at 11:00 a.m. The RN cleansed hands with soap and water at the beginning of the home visit. The RN checked vital signs, removed gloves from the bag, cleaned vital sign equipment, removed gloves, reviewed medications, and documented on tablet, and placed vital sign equipment in the bag prior to hand hygiene the second time. The clinical bag remained unzipped throughout the visit.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, the registered Nurse failed to follow up on lab work for 3 of 3 patients with orders for lab work (#2, 11 and 13); and failed to assess for skin breakdown for 1 of 4 patients with a wound (#5). Findings included: A policy, Skilled Nursing Services for Home Health (revised 11/21/22), was provided by the agency administrator on 6/7/23 at 12:00 p.m. The policy stated, “Nursing visits are individually based on the need, but not necessarily limited to…Assess and reassess the patient’s condition and response to the treatment plan…Inform the physician of the patient’s condition…” 2. Patient # 5 had a Start of Care [SOC] date of 5/13/23 and admitting diagnoses of acute respiratory failure with hypoxia [low oxygen] and congestive heart failure [heart doesn’t pump adequately]. Review of the Plan of Care for the certification period 5/13/23 to 7/11/23 included orders for SN [skilled nursing] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. Review of the clinical record revealed RN # 3 documented the following information on 5/13/23, “Patient has an old blister to right heel. Area is not open, instructed to paint area with iodine.” RN # 3 conducted routine visits on 5/17/23 and 5/23/23. The clinical record revealed RN # 3 advised the patient to continue using iodine to the right heel. Further review of the clinical record revealed no evidence the area on the right heel was assessed by the RN. RN # 3 was not available for interview. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed there was no evidence the right heel was assessed by a nurse after the SOC. 3A. Patient # 11 had a Start of Care [SOC] date of 4/8/23 and admitting diagnoses of encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics] and malignant neoplasm of connective and soft tissue of abdomen [cancer]. Review of the Plan of Care for the certification period 4/8/23 to 6/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 4 times a week for 4 weeks, 3 times a week for 2 weeks and “Skilled nurse to obtain labs on Monday [4/10/23] obtain CBC with differential, CMP [comprehensive metabolic panel], phosphorus, magnesium pre-albumin, triglyceride, manganese, selenium, zinc, chromium, copper, iron study, vitamin B12, folate and vitamin D…” Review of the clinical record revealed the lab work obtained on 4/10/23 was not resulted until 4/27/23. There was no evidence the physician was notified of the lab results until 4/27/23. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator stated, “the nurses should have followed up on the lab work well before that time.” 3B. Patient # 11 had a Start of Care [SOC] date of 4/8/23 and admitting diagnoses of encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics] and malignant neoplasm of connective and soft tissue of abdomen [cancer]. Review of the Plan of Care for the certification period 4/8/23 to 6/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 4 times a week for 4 weeks, 3 times a week for 2 weeks and “Skilled nurse to obtain labs on Monday [4/10/23] obtain CBC with differential, CMP [comprehensive metabolic panel], phosphorus, magnesium pre-albumin, triglyceride, manganese, selenium, zinc, chromium, copper, iron study, vitamin B12, folate and vitamin D…” Review of the laboratory results obtained on 4/14/23 revealed the chromium and manganese were not resulted due to insignificant amount of blood sample. Review of the clinical record revealed no evidence the physician was notified when the chromium and manganese levels were not processed due to an insignificant amount of blood. 4. Patient # 13 had a Start of Care date of 3/23/23 and admitting diagnoses of osteomyelitis [infection of the bone] and encounter for adjustment and management of VAD [vascular access device- allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics]. Review of the Plan of Care [POC] for the certification period 3/23/23 to 5/21/23 included orders for SN [skilled nursing] 1 time a week for 8 weeks and “…obtain weekly labs on Monday to include CBC [complete blood count] with differential, CMP [comprehensive metabolic panel] and C Reactive Protein [CRP – a protein made by the liver. The level of CRP increases when there is inflammation in the body]”. Review of the clinical record revealed labs were obtained on 3/27/23, 4/3/27, 4/10/23, 4/17/23 and 4/24/23. Review of the lab results revealed the glucose and the potassium in the CMP were not resulted due to the compromised blood sample. Further review of the clinical record revealed no follow up related to the lab work. During an interview with the agency administrator on 6/7/23 at 9 am the administrator confirmed the physician was not notified the lab results were not available. 1..Patient #2 was admitted on 8/1/22 with a diagnosis of chronic diastolic (congestive) heart failure. The Plan of Care (POC) for 8/1/22-9/29/22 included orders for skilled nursing visits weekly for four weeks then once every two weeks for four weeks. On 9/14/23, a physician’s order was received to collect urine via clean catch for urinalysis, may use in and out catheter if needed. The RN visit note for 9/15/23 stated, “UA [urinalysis] collected…” Skilled nursing discharged the patient on 9/23/23 with no evidence of follow up on the urinalysis results. The results identified a moderate amount of bacteria in the urine. On 9/28/23, an antibiotic for an urinary tract infection was discovered in the home. An interview with the agency director on 6/6/23 at 1:20 p.m. confirmed there was no coordination with the physician on the urinalysis results between the RN and the physician prior to the nursing discharge.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the Registered Nurse provided patient education related to wound care without a physician’s order for 1 of 4 patients with a wound [#5]. The findings included: Patient # 5 had a Start of Care date of 5/13/23 and admitting diagnoses of acute respiratory failure with hypoxia [low oxygen] and congestive heart failure [heart doesn’t pump adequately]. Review of the Plan of Care for the certification period 5/13/23 to 7/11/23 included orders for SN [skilled nursing] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. Review of the clinical record revealed RN # 3 conducted the SOC visit. Review of the SOC visit note revealed the following information, “…Patient has an old blister to right heel. Area is not open, instructed to paint area with iodine…” Further review of the clinical record revealed no evidence the physician was notified prior to the RN advising the patient to “paint the heel with iodine”. RN # 3 was not available for interview. An interview was conducted with the agency administrator on 6/7/23 at 9 am. During the interview the administrator confirmed the RN educated the patient to use iodine without an order.

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 policy review, clinical record review, and staff interview, the agency documentation failed to include documentation of lab collection for 1 of 3 patients with labs ordered (#2); and to accurately document medications for 1 of 13 patients (#4). Findings included: A policy, Skilled Nursing Services for Home Health (revised 11/21/22), was provided by the agency administrator on 6/7/23 at 12:00 p.m. The policy stated, “Nurses will document all care given in the medical record.” 2. Patient # 4 had a Start of Care [SOC] date of 5/13/23 and an admitting diagnosis of collapsed vertebra, cervicothoracic region [region between the cervical and thoracic sections of the spinal cord]. Review of the Plan of Care [POC] for the certification period 5/13/23 to 7/11/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 6 weeks, 1 time a week for 2 weeks. Review of the clinical record, SN Visit Note, dated 5/15/23 and completed by RN # 3, indicated the patient was taking an anticoagulant [blood thinner]. RN # 3 conducted a routine visit on 3/17/23 and indicated the patient was not using an anticoagulant. The routine visit dated 5/22/23 and completed by RN # 3 indicated the patient was using an anticoagulant. Review of the POC revealed the patient was not prescribed an anticoagulant. RN # 3 was not available for interview. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator confirmed the clinical record was inaccurate related to the use of an anticoagulant. 1A. Patient #2 was admitted on 8/1/22 with a diagnosis of chronic diastolic (congestive) heart failure. The Plan of Care (POC) for 8/1/22-9/29/22 included orders for skilled nursing visits weekly for four weeks then once every two weeks for four weeks. On 8/8/23, a physician’s order was received to obtain blood for multiple lab tests and to obtain urine for urinalysis. The urine may be collected clean catch if possible or via in and out catheter in needed. The visit note on 8/8/23 stated, “…labs drawn per MD orders via venipuncture to right hand.” There was no documentation of how many attempts for the venipuncture or how the patient tolerated the venipuncture. An interview with the agency administrator on 6/6/23 at 1:20 p.m. confirmed the documentation was not completed. 1B. Patient #2 was admitted on 8/1/22 with a diagnosis of chronic diastolic (congestive) heart failure. The Plan of Care (POC) for 8/1/22-9/29/22 included orders for skilled nursing visits weekly for four weeks then once every two weeks for four weeks. On 9/14/23, a physician’s order was received to collect urine via clean catch for urinalysis, may use in and out catheter if needed. The RN visit note for 9/15/23 stated, “UA [urinalysis] collected…” There was no evidence of how the urine was collected. An interview with the agency director on 6/6/23 at 1:20 p.m. confirmed the documentation was not completed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to complete a discharge summary for 1 of 4 discharged patients [#1]. The findings included: The policy, Home Health Discharge Policy [no date], was provided by the agency administrator on 6/7/23 at approximately 12 pm. The policy stated, “…A discharge summary will be completed for every patient. A completed discharge summary will be sent to the primary care practitioner…within 5 business days of the patient’s discharge.” Patient # 1 had a Start of Care [SOC] date of 7/25/22 and admitting diagnoses of hemiplegia [paralysis of ½ of the body] following a cerebral infarction [stoke] and type 2 diabetes with diabetic neuropathy [a type of nerve damage that can occur in diabetics. High blood sugar can injure nerves throughout the body]. Review of the Plan of Care [POC] for the certification period 7/25/22 to 9/22/22 included orders for SN [skilled nursing] 1 time a week for 4 weeks; PT [physical therapy] 1 time a week for 5 weeks; OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week. Review of the clinical record revealed the patient was sent to the hospital on 8/4/22 for elevated blood sugar. The patient was not admitted to the hospital. Missed visits for the week of 8/7/22 and the week of 8/14/22 were entered by PT, OT and SN due to the disciplines not being able to reach the patient via phone. On 8/26/22 OT # 7 completed a non-visit discharge. Review of the clinical record revealed no evidence a discharge summary was completed. OT # 7 was not available for interview. During an interview with the agency administrator on 6/7/23 at 9 am, the administrator stated, “She completed a non-visit discharge, so she couldn’t do a discharge summary.”

An onsite recertification survey was conducted May 4-6, 2021. No deficiencies to Emergency Preparedness program were identified.

An onsite recertification survey was conducted May 4-6. 2021. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 policy review, clinical record review and staff interviews, the clinical record failed to include vital signs in the clinical record for 6 of 10 patients (#1, 2, 3, 4, 5, and 6). Findings include: Based on policy review, clinical record review and staff interviews, the clinical record failed to include vital signs in the clinical record for 6 of 10 patients (#1, 2, 3, 4, 5, and 6). Findings include: A policy, Home Health Clinical Record (revised 11/12/18), was provided by the regional administrator on 5/6/21 at 1:40 pm. The policy stated "The clinical record documentation provides patient information specific to care and services provided (not provided), current client status, and progress to goals and outcomes of care. Documentation includes: Entries that are ...consistent with agency polices and procedures; Dates, types of intervention, assessments and coordination of care ..." 1. Patient #1 was admitted on 3/30/21 with diagnoses of acute osteomyelitis of right ankle, foot, cellulitis of right lower limb, hypertensive heart and chronic kidney disease with heart failure, and presence of aortocoronary bypass graft. The Plan of Care (POC) for 3/30/21-5/28/21 included orders for physical therapy 2 times per week for 4 weeks, 1 time every 2 weeks for 2 weeks, 2 visits every 2 weeks for 2, and 1 time for 1 week. The POC also included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 60 or greater than 120, respirations less than 12 or greater than 24, systolic blood pressure less than 90 or greater than 164, diastolic blood pressure less than 60 or greater than 90 ...O2 sat less than 88%. PTA #1 conducted a visit on 4/2/21. There was no blood pressure documented. PTA #1 conducted visits on 4/5/21 and 4/12/21 with no vital signs documented. PT #2 conducted a reassessment on 4/21/21. There were no vital signs documented. The visit note stated, "Patient in agreement PT and PTA will be monitoring patient's blood pressure and signs and symptoms of dizziness." For 4 of 7 physical therapy visits, there was no evidence complete vital signs were assessed. 2. Patient #2 was admitted on 3/8/21 with diagnoses of non-pressure chronic ulcer to left lower leg, fluid overload, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, and presence of a prosthetic heart valve. The POC for 3/8/21-5/6/21 included orders for physical therapy 2 times for 1 week, then weekly for 5 weeks. The POC also included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 60 or greater than 120, respirations less than 12 or greater than 24, systolic blood pressure less than 90 or greater than 170, diastolic blood pressure less than 58 or greater than 90 ...O2 sat less than 88%. PTA #1 visited the patient on 3/11/21 and 4/6/21 with no vital signs documented. PT #2 conducted a reassessment on 3/30/21. There were no vital signs documented. For 3 of 7 physical therapy visits, there was no evidence vital signs were assessed. 3. Patient #3 was admitted on 3/25/21 with diagnoses of pressure ulcer to sacral region and hypertensive chronic kidney disease. The Plan of Care (POC) for 3/25/21-5/23/21 included orders for physical therapy 1 time per week for 2 weeks, the 1 visit every 5 weeks for 5. The POC included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 60 or greater than 120, respirations less than 12 or greater than 24, systolic blood pressure less than 74 or greater than 140, diastolic blood pressure less than 54 or greater than 90 ...O2 sat less than 88%. The patient was hospitalized prior to the physical therapy evaluation. The resumption of care was conducted on 4/10/21 by the RN. The physical therapy evaluation was conducted on 4/12/21 with plan for physical therapy 2 times for 1 week, then weekly for 5 weeks. PTA #1 visited the patient on 4/19/21 with temperature the only vital sign documented. PT #2 conducted a reassessment on 5/3/21. There were no vital signs documented. For 2 or 4 physical therapy visits, there was no evidence vital signs were assessed. 4. Patient #4 was admitted on 4/5/21 diagnoses of hypertensive chronic kidney disease and atherosclerotic heart disease. The POC for 4/5/21-6/3/21 included orders for physical therapy 2 times for 1 week, then weekly for 6 weeks. The POC also included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 50 or greater than 100, respirations less than 12 or greater than 24, systolic blood pressure less than 100 or greater than 165, diastolic blood pressure less than 60 or greater than 90 ...O2 sat less than 90%. PTA #1 visited the patient on 4/7/21 and 4/20/21 with no vital signs documented. PT #2 conducted a reassessment on 5/4/21. There were no vital signs documented. For 3 of 5 physical therapy visits, there was no evidence vital signs were assessed.. 5. Patient #5 was admitted on 3/19/21 with a diagnosis of essential hypertension. The POC for 3/19/21-5/17/21 included orders for physical therapy 1 time for 1 week, then 2 times per week for 4 weeks. The POC also included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 60 or greater than 100, respirations less than 12 or greater than 24, systolic blood pressure less than 100 or greater than 160, diastolic blood pressure less than 60 or greater than 90 ...O2 sat less than 90%. PTA #1 visited the patient on 3/23/21, 3/25/21, 3/30/21, 4/1/21, 4/8/21, 4/14/21, and 4/27/21 with no vital signs documented. PT #2 conducted a reassessment on 4/16/21. There were no vital signs documented. For 8 of 10 physical therapy visits, there was no evidence vital signs were assessed. 6. Patient #6 was admitted on 4/14/21 with a diagnosis of chronic obstructive pulmonary disease (COPD-lung disease). The POC for 4/14/21-6/12/21 included orders for physical therapy 2 times per week for 3 weeks, then 1 time per week for 2 weeks. The POC also included orders for "Licensed professional to report vital signs falling outside the following established parameters." Temperature less than 96 or greater than 101, pulse less than 60 or greater than 100, respirations less than 12 or greater than 24, systolic blood pressure less than 90 or greater than 140, diastolic blood pressure less than 60 or greater than 90 ...O2 sat less than 90%. PTA #1 visited the patient on 4/23/21 and 4/30/21 with no vital signs documented. For 2 of 5 physical therapy visits, there was no evidence vital signs were assessed. An interview with PTA #1 was conducted on 5/6/21 at 12:45 p.m. The PTA stated, "I take [a full set of vital signs] on every patient, every visit. I don't know why they're not there, but that is the first thing I get ..." An interview with the regional administrator 5/6/21 at 12:45 p.m. confirmed the agency's expectation was to obtain a full set of vital signs (temperature, pulse, respirations, and blood pressure) on each visit.