Every finding on record at Shining Star Home Care, LLC

This Statement of Deficiencies is a result of an on-site investigation of complaint 2973352, conducted at Shining Star Home Health Care, located at 6024 14th Ave., Brooklyn, NY 11219 on 04/30/2026. The active patient census is 220. The investigation consisted of a review of three (3) clinical records (identified as Patient’s #1, #2, and #3), three (3) personnel records (Employees #1, #2, and #3), the agency's complaint log, active patient census, and interviews with the Administrator and the Assistant Administrator. Pre-survey activities consisted of review on 04/29/2026 of the agency's Health Commerce System account. Findings were reviewed at the exit conference on 04/30/2026. The allegation was determined substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G - 0434 - Participate in Care G - 0572 - Plan of Care G - 0602 - Communication with all physicians G - 0606 - Integrate all Services J - 0320 - Patient Care J - 0736 - Clinical Records J - 1444 - Personnel

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to inform patients about the changes with the start of services. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #2). Failure to inform patient about the changes with the services has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 03/27/2026 with the following diagnoses "Unspecified Intracapsular Fracture of the Right Femur, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026. The Patient Consent/Acknowledgement Agreement signed on 03/27/2026 documents: Physical Therapy 2XWKX3WK (twice a week for three weeks) and home health aide 3DX4HRS (three days times four hours a day). The Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026 documents: hha (home health aide) effective 03/29/2026 3WK1, 5WK7, 1WK1 (three times a week for one week, five times a week for seven weeks, once a week for one week). The Visit Note Report by the registered nurse dated 03/27/2026 documents: Patient has functional decline, limited mobility, rolling walker dependent. I want to improve how I am walking. The Physical Therapy Initial Examination dated 04/07/2026 documents: plan 2 times a week with duration of 4 weeks; and the subsequent visit was 04/18/2026; evaluation done 11 days after the start of care and visit done 11 days after evaluation. The initial home health aide services were provided on 04/20/2026. The Client Coordination Note Report documents: 04/22/2026 Date of missed visit: 04/01/26 – 04/17/26; Reason visit is missed: Vendor hha changed due to previous vendor being unable to staff. 04/30/2026 A comprehensive review of the case was conducted following identified delays in initiation of ordered home health aide (hha) and physical therapy (PT) services. Timeline review indicates that hha (home health aide) services, ordered on 04/01/26, were not initiated timely, with a lapse of over two weeks before confirmation of service delay. Similarly, PT services were delayed due to scheduling conflicts and vendor-related communication issues, resulting in postponed evaluation (completed 04/04/26) and subsequent missed or unverified visits. The clinical care record lacks documented evidence of the patient / family being informed of the timeline or delay with physical therapy evaluation and visits, and aide services. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 03/20/2026 with the following diagnoses "Severe Persistent Asthma with Exacerbation, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2026 to 05/18/2026. The Client Coordination Note Report dated 03/21/2026 documents: MD (medical doctor) recommend hha (home health aide) hours to assist with ADLS/IADLS (activities of daily living / instrumental activities of daily living) and ensure patient’s safety and well-being at home. The initial home health aide services were provided on 03/30/2026. The Client Coordination Note Report dated 03/31/2026 documents: Date of missed visit: 03/23/26 - 03/27/26, reason visit is missed: patient under family care, (not a clear reason - did the family refused the visit) and no documentation of the contact. The Visit Note Report by the nurse documents supervision was done on 03/24/2026, but no aide services were provided until 03/30/2026. The clinical care record lacks documented evidence of the patient / family being informed of the timeline or delay with aide services. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings.

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 clinical care record review and staff interviews, the governing authority failed to ensure that all patients have a plan of care including services to be provided and received care as written in the plan of care. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #2). Failure to ensure that all patients have a plan of care including services to be provided and received care as written in the plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 03/27/2026 with the following diagnoses "Unspecified Intracapsular Fracture of the Right Femur, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026. The Referral Discharge Summary from the hospital and the face to face encounter dated 03/26/2026 documents: needs referral to physical therapy services. The Patient Consent/Acknowledgement Agreement signed on 03/27/2026 documents: Physical Therapy 2XWKX3WK (twice a week for three weeks) and home health aide 3DX4HRS (three days times four hours). The Physical Therapy visits were conducted on 04/07/2026 (evaluation) and 04/18/2026. The Client Coordination Note Report dated 04/30/2026 documents: Identified delays in initiation of ordered home health aide (hha) and Physical therapy (PT) services. PT services were delayed due to scheduling conflicts and vendor related communication issues, resulting in postponed evaluation (completed 04/07/206), and subsequent missed or unverified visits. The Plan of Care lacks documented evidence of the timely order and visits for physical therapy. The Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026 documents: hha (home health aide) effective 03/29/2026 3WK1, 5WK7, 1WK1 (three times a week for one week, five times a week for seven weeks, once a week for one week). The initial home health aide services were provided on 04/20/2026. The Client Coordination Note Report dated 04/22/2026 documents: Date of missed visit: 04/01/26 – 04/17/26; Reason visit is missed: Vendor hha changed due to previous vendor being unable to staff. The Plan of Care lacks documented evidence of the timely visits for aide services. There is no documented evidence of the patient receiving aide services as ordered on the plan of care – missed visit from 03/29/2026 to 04/19/2026. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 03/20/2026 with the following diagnoses "Severe Persistent Asthma with Exacerbation, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2026 to 05/18/2026. The Client Coordination Note Report dated 03/21/2026 documents: MD (medical doctor) recommend hha (home health aide) hours to assist with ADLS/IADLS (activities of daily living / instrumental activities of daily living) and ensure patient’s safety and well-being at home. The initial home health aide services were provided on 03/30/2026. The Client Coordination Note Report dated 03/31/2026 documents: Date of missed visit: 03/23/26 - 03/27/26, reason visit is missed: patient under family care, (not a clear reason - did the family refuse) and no documentation of the contact with patient. The Plan of Care lacks documented evidence of the timely visits for home health aide services. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to communicate with the physician. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to communicate with the physician has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 03/27/2026 with the following diagnoses "Unspecified Intracapsular Fracture of the Right Femur, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026. The Patient Consent/Acknowledgement Agreement signed on 03/27/2026 documents: Physical Therapy 2XWKX3WK (twice a week for three weeks). The Visit Note Report by the registered nurse dated 03/27/2026 documents: Patient has functional decline, limited mobility, rolling walker dependent. I want to improve how I am walking. The Physical Therapy Initial Examination dated 04/07/2026 documents: plan 2 times a week with duration of 4 weeks and the subsequent visit was 04/18/2026; evaluation conducted 11 days after the start of care and the visit conducted 11 days after evaluation. The Client Coordination Note Report documents: 04/22/2026 Date of missed visit: 04/01/26 – 04/17/26; Reason visit is missed: Vendor hha changed due to previous vendor being unable to staff. 04/30/2026 A comprehensive review of the case was conducted following identified delays in initiation of ordered home health aide (hha) and physical therapy (PT) services. PT services were delayed due to scheduling conflicts and vendor-related communication issues, resulting in postponed evaluation (completed 04/04/26) and subsequent missed or unverified visits. The clinical care record lacks documented evidence of the communication with the physician regarding the delay (11 days after the start of care) of physical therapy evaluation and visits. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to integrate services that are provided under arrangement. This was evident for one (1) of three (3) patient care records reviewed (Patient #1 Patients #2). Failure to integrate services that are provided under arrangement has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 03/27/2026 with the following diagnoses "Unspecified Intracapsular Fracture of the Right Femur, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026. The Patient Consent/Acknowledgement Agreement signed on 03/27/2026 documents: Physical Therapy 2XWKX3WK (twice a week for three weeks) and home health aide 3DX4HRS (three times for four hours). The Home Health Certification and Plan of Care for the Certification Period 03/27/2026 to 05/25/2026 documents: hha (home health aide) effective 03/29/2026 3WK1, 5WK7, 1WK1 (three times a week for one week, five times a week for seven weeks, once a week for one week). The Visit Note Report by the registered nurse on 04/01/2026, 04/04/2026, 04/06/2026, 04/08/2026, 04/17/2026 documents: SN (skilled nurse) did not conduct hha (home health aide) supervision because the patient did not start hha (home health aide) services. The Physical Therapy Initial Examination dated 04/07/2026 documents: plan 2 times a week with duration of 4 weeks; and the subsequent visit was 04/18/2026; evaluation conducted 11 days after the start of care and the visit conducted 11 days after the evaluation. The initial home health aide services were provided on 04/20/2026. The Client Coordination Note Report documents: 04/22/2026 Date of missed visit: 04/01/26 – 04/17/26; Reason visit is missed: Vendor hha changed due to previous vendor being unable to staff. 04/30/2026 A comprehensive review of the case was conducted following identified delays in initiation of ordered home health aide (hha) and physical therapy (PT) services. Timeline review indicates that hha (home health aide) services, ordered on 04/01/26, were not initiated timely, with a lapse of over two weeks before confirmation of service delay. Similarly, PT services were delayed due to scheduling conflicts and vendor-related communication issues, resulting in postponed evaluation (completed 04/04/26) and subsequent missed or unverified visits. The clinical care record lacks documented evidence of the orders being integrated, provided under the arrangement, to provide services timely that are needed by the patient. On 04/30/2026 at 3:23PM, the Administrator and the Assistant Administrator were interviewed and did not provide an explanation for the findings.

The following statement of deficiencies is the result of a partial extended recertification survey of Shining Star Home Health Care, located at 6024 14th Avenue, Brooklyn, NY, 11219 conducted on 12/16/2025 through 12/22/2025. A standard re-certification survey was initiated on 12/16/2025. Deficient practices were identified within Level 1 standards in 484.50 Patient Rights, 484.55 Comprehensive Assessment of Patients, 484.60 Care Planning Coordination of Services and Quality of Care, 484.75 Skilled Professional Services, 484.80 Home Health Aide Services and 484.110 Clinical Records resulting in a partial extended survey. The agency reported an active patient census of one hundred sixty-eight (168). The survey consisted of a review of eighteen (18) clinical records (identified as Patient #1, #2, #3, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) including five (5) discharge records, thirteen (13) active records ,six (6) observational home visits , fifteen (15) personnel records for professional and paraprofessional personnel (identified as Employee #1, #2, #3, #4, #5, #6, #7, #8 #9, #10, #11, #12, #13, #14, and #15), and three (3) contracts. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve (12) months, PIP (Performance Improvement Projects), the agency's Admission Packet, the Emergency Preparedness Plan, Complaint Log, three (3) contracts, and the agency's Infection Control and Flu policy and procedure. Pre-survey activities consisted of a review on 12/15/2025 of the agency's Health Commerce System account, Internet Quality Improvement and Evaluation System reports (iQIES), for the period10/2024 to 9/2025, the agency compliance with report submissions for the 2023 Statistical Report and the Emergency Drill for 2019. The Administrator and Director of Patient Services were interviewed. Findings were reviewed at the exit conference on 12/22/2025. The following deficiencies were identified as a result of the survey: G - 0372 Encoding and transmitting OASIS G - 0436 Receive all services in plan of care G - 0528 Health, psychosocial, functional, cognition G - 0534 Patient's needs G - 0536 A review of all current medications G - 0574 Plan of care must include the following G - 0590 Promptly alert relevant physician of changes G- 0592 Revised plan of care G - 0754 A qualified HH aide successfully completed: G - 0798 Home health aide assignments and duties G - 0800 Services provided by HH aide G - 0818 HH aide supervision elements G - 1022 Discharge and transfer summaries J - 1168 Governing authority J - 1172 Governing authority J - 1184 Governing authority J - 1424 Personnel J - 1444 Personnel

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 the HHA (Home Health Agency) Error Summary by Agency Report and staff interviews, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This was evident for one hundred and five (105) clinical records based on review of the HHA (Home Health Agency) Error Summary by Agency Report. Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: The HHA Error Summary by Agency Report for the period 01/01/2025 through 12/15/2025 documents: "Error # -3330 Record Submitted Late: The submission date is more than 30 days after M0090 (Start of Care) on this new record ... # of Assessments with error: one hundred and five (105). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 12/17/2025 at 11:00 AM, the Administrator was interviewed and stated, “most of that was earlier this year, since then we have implemented a system to prevent late submissions.” No additional explanations were given.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patients receive all services as outlined in their individualized plan of care. This was evident for 1 (one) of 18 (eighteen) clinical records reviewed (Patients #15). Failure to ensure that patients receive all services outlined in their individualized plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #15 has a start of care date of 7/23/2025, with a diagnosis of Pneumonitis due to Inhalation of Food and Vomit, Type 2 Diabetes Mellitus Without Complications, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Hypothyroidism, Unspecified, Essential (Primary) Hypertension, Bradycardia, Unspecified as documented on the Home Health Certification and Plan of Care for Period 07/23/2025 to 09/20/2025. The agency’s work week is Sunday to Saturday. The Home Health Certification and Plan of Care dated 07/23/2025 documents: PT 1wk1 (Physical Therapy once a week for one week). There is no documented evidence of the patient receiving Physical Therapy for the week of 07/23/2025, as outlined in the plan of care. On 12/18/2025 at 2:30 PM, The Rehabilitation Director was interviewed, and no explanations were given for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the comprehensive assessment accurately reflect the patient's status. This was evident for 3 (three) of 18 (eighteen) clinical records reviewed (Patient #13, #15 and # 17). Failure to ensure the patients comprehensive assessment accurately reflect the patient's status has the potential risk for negative patient outcomes. The Findings are: 1. Patient #13 has a start of care date of 08/09/2025, with a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart failure and stage 1 - 4 Unspecified Chronic Kidney Disease, Acute on Chronic Systolic (Congested) Heart Disease, Chronic Kidney Disease Stage 3 Unspecified, Pulmonary Hypertension, Unspecified, Acute Embolism and Thrombus Unspecified Deep Veins of Right Lower Extremity, and Unspecified Atrial Fibrillation as documented on the Home Health Certification and Plan of Care for Period 08/09/2025 to 10/07/2025. The Home Health Certification and Plan of Care dated 08/09/2025 documents: Mental Status; Oriented; Comatose; Forgetful. The RN (Registered Nurse) Visit Note Report/OASIS (Outcome and Assessment Information Set) dated 08/09/2025 and the RN (Registered Nurse) Visit Note Report dated 08/11/2025, 08/14/2025, 08/19/2025, 08/23/2025, 08/26/2025, 09/05/2025 document: Alert, Oriented to Person, Oriented to Time, Oriented to Place, Forgetful. The Home Health Certification and Plan of Care lacks documented evidence of an accurate assessment and documentation of the patient’s current health status. On 12/18/2025 at 4:00 PM, Clinical Supervisor was interviewed, and no explanations were given for the findings. 2. Patient #15 has a start of care date of 7/23/2025, with a diagnosis of Pneumonitis due to Inhalation of Food and Vomit, Type 2 Diabetes Mellitus Without Complications, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Hypothyroidism, Unspecified, Essential (Primary) Hypertension, Bradycardia, Unspecified as documented on the Home Health Certification and Plan of Care for Period 07/23/2025 to 09/20/2025. The Home Health Certification and Plan of Care dated 07/23/2025 documents: Pt’s CG (patient’s caregiver) able to check BSL (blood sugar levels) weekly. The RN (Registered Nurse) Visit Note Report (Narrative) dated 07/25/2025 documents: RN (Registered Nurse) teaching included reinforcing the importance of checking blood glucose at least daily… The RN (Registered Nurse) Visit Note Report (Narrative), and The Home Health Certification and Plan of Care lack documented evidence of an accurate assessment and documentation of the patient’s current health requirements. On 12/18/2025 at 12:30 PM, Clinical Supervisor was interviewed, and stated, “Blood glucose monitoring on Home Health Certification and Plan of Care should have been daily not weekly.” No additional explanations were given for the findings. 3. Patient #17 has a start of care date of 09/24/2024, with a diagnosis of Venous Insufficiency (Chronic) (Peripheral), Non-Pressure Chronic Ulcer Other Part Left Lower Leg Limited to Breakdown Skin, Non-Pressure Chronic Ulcer Other Part Right Lower Leg With Fat Exposed, Chronic Embolism and Thrombosis of Right Tibial Vein, Hypertensive Heart Disease with Heart Failure, Acute Combined Systolic and Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, as documented on the Home Health Certification and Plan of Care for Period 05/22/2025 to 07/20/2025. The RN (Registered Nurse) Visit Note Report (Wound Assessment and Wound Images) dated 05/22/2025 documents: #1 Rt - Dist Pretibial, Rt, Vensts Ulcer (Right - Distal Pretibial, Right, Venous Stasis Ulcer) and #3 Lt – Pretibial, Mid, Lt, Unspecified Wound (Left – Pretibial, Mid, Left, Unspecified Wound). The RN (Registered Nurse) Visit Note Report (Narrative), dated 05/22/2025 documents: #1: Venous Ulcer on Right Pretibial … and #2: Unspecified Wound on Left Pretibial… The RN (Registered Nurse) Visit Note Report (Narrative), and (Wound Assessment and wound images), lack documented evidence of an accurate assessment and documentation of the patient’s current wounds. On 12/18/2025 at 3:30 PM, the Clinical Supervisor was interviewed, and no explanations were given for the findings.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews the agency failed to ensure that all patients received the appropriate referral to assist them in meeting their required need. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient #13). Failure to ensure the patients receive the appropriate referrals to meet their required need has the potential risk for negative patient outcomes. The Findings are: 1. Patient #13 has a start of care date of 08/09/2025, with a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart failure and Stage 1 - 4 Unspecified Chronic Kidney Disease, Acute on Chronic Systolic (Congested) Heart Disease, Chronic Kidney Disease Stage 3 Unspecified, Pulmonary Hypertension, Unspecified, Acute Embolism and Thrombus Unspecified Deep Veins of Right Lower Extremity, and Unspecified Atrial Fibrillation as documented on the Home Health Certification and Plan of Care for Period 08/09/2025 to 10/07/2025. The RN (Registered Nurse) Visit Note Report/OASIS (Outcome and Assessment Information Set) dated 08/09/2025 documents: "A1250 Transportation: Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? A. Yes, it has kept me from medical appointments or from getting my medications." The clinical record lacks documented evidence of the plan of care including a follow up or a referral to the Social Worker to assist the patient with transportation needs which include keeping the patient's scheduled medical appointments and getting their medications, to prevent exacerbation of their condition and maintain their expressed goals of “staying home without hospitalization.” On 12/18/2025 at 4:00 PM, Clinical Supervisor was interviewed, and no explanations were given for the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications were accurately reviewed, reconciled and correctly documented in the patient's clinical record. This was evident for 1 (one) of 18 (eighteen) clinical records reviewed (Patients #1). Failure to ensure that all medications are accurately reviewed, reconciled and correctly documented in the patient's clinical record has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a start of care date 12/03/2025 with the following diagnoses: Bilateral Primary Osteoarthritis of Knee, Unspecified Open Wound of Right Hand, Subsequent Encounter, and Essential Primary Hypertension as documented on the Home Health Certification and Plan of Care for Certification Period 12/03/2025 to 01/31/2026. On 12/16/2025 a home visit was conducted. The following medications were observed in the home and not documented on the Home Health Certification and Plan of Care or the Medication Profile: Tylenol 325 mg 2 tablets by mouth PRN (as needed), Senna 8.6 mgs (milligrams) tablet by mouth daily, and Cyanocobalamin B-12 inj (injection) 1000 mcg, 1ml IM (1000 micrograms, 1 milliliter intramuscularly) monthly. Patient #1's caregiver was interviewed and stated, “patient takes these medications.” The clinical record lacks documented evidence of a complete review and reconciliation of all medications the patient is currently taking. On 12/19/2025 at 11:10 AM the Administrator, Assistant Administrator, Rehab Director and Clinical Supervisor were interviewed and did not provide an explanation for finding.

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 clinical record reviews, and staff interviews, the agency failed to ensure that all pertinent information is included in the patient's individualized plan of care. This was evident for 8 (eight) of 18 (eighteen) clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, #11 and #12). Failure to ensure that all pertinent information is included in the patient's individualized plan of care has the potential risk for negative patient outcomes. The Findings are: 1.Patient #1 has a start of care date of 12/3/2025 with a diagnosis of Bilateral Primary Osteoarthritis of Knee, Unspecified Open Wound of Right Hand, Subsequent Encounter, and Essential Primary Hypertension as documented on the Home Health Certification and Plan of Care for Certification Period 12/3/2025 to 1/31/2026. The Home Health Certification and Plan of Care for Certification Period 12/3/2025 to 1/31/2026 documents: DME (Durable Medical Equipment) and Supplies: Cane; Walker; Wheelchair. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) dated 12/3/2025 documents: Equipment/Supplies DME (Durable Medical Equipment) Available: Standard Walker, Wheelchair and Tub Chair. The Physical Therapy ADD-On Evaluation visit note dated 12/3/2025 documents: Equipment/Supplies Durable Medical Equipment Available: Rolling Walker and Tub Chair. The clinical record lacks documented evidence of a complete list of the supplies and equipment medically necessary for patient’s care. On 12/19/2025 at 11:10 AM the Administrator, Assistant Administrator, Rehab Director and Registered Nurse Clinical Supervisor were interviewed and did not provide an explanation for finding. Patient #5 has a Start of Care Date 11/26/2025 with a diagnosis of Unspecified Atrial Fibrillation, Essential Primary Hypertension, and Nonrheumatic Aortic (Valve) Stenosis for the Certification Period 11/26/2025 to 1/24/2026. The Home Health Certification and Plan of Care for Certification Period 11/26/2025 to 1/24/2026 documents: DME (Durable Medical Equipment) and Supplies: Shower/Tub Equipment; Walker; Wheelchair. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) dated 11/26/2025 documents: Equipment/Supplies Durable Medical Equipment Available: Rolling Walker, Tub Chair. The clinical record lacks documented evidence of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) having a complete list of all the supplies and equipment medically necessary for patient’s care. On 12/19/2025 at 11:20 AM the Administrator, Assistant Administrator, Rehab Director and Registered Nurse Clinical Supervisor were interviewed and did not provide an explanation for finding. 2. Patient #2 has a Start of Care Date 11/6/2025 with a diagnosis of Non-ST Elevation (NSTEMI) Myocardial Infarction, Ischemic Cardiomyopathy and Hypertensive Heart Disease with Heart Failure for the Certification Period 11/6/2025 to 1/4/2026. The Home Health Certification and Plan of Care for Certification Period 11/6/2025 to 1/4/2026 documents: Orders of Discipline and Treatments: Skilled Nurse for monitoring and management of effectiveness of anticoagulation therapy regimen and skilled teaching related to anticoagulation management. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) dated 11/6/2025; RN Subsequent Visit dated 11/8/2025; RN Subsequent Visit dated 11/13/2025 and RN Subsequent Visit dated 11/18/2025 lack documented evidence of skilled teaching related to anticoagulation management. On 12/19/2025 at 11:15 AM the Administrator, Assistant Administrator, Rehabilitation Director and Clinical Supervisor were interviewed and did not provide an explanation for finding. ***Patient #3 has a Start of Care date of 03/26/2025 with diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Endometrium, and Type 2 Diabetes Mellitus without complications as documented on the Home Health Certification and Plan of Care for Period 11/21/2025 to 01/19/2026. The Registered Nurse (RN) recertification visit note dated 11/17/2025 documents: “How frequent are blood sugars checked? Daily by self.” The Home Health Certification and Plan of Care from 11/21/2025 to 01/19/2026 lacks documented evidence of an order for the patient to check blood sugar daily. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed. The Clinical Supervisor stated it was a not a skilled case anymore. The Home Health Certification and Plan of Care lacks documented evidence of including psychosocial status. On 12/22/2025 at 10:30 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the finding. ***Patient #4 has a Start of Care date of 12/02/2025 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 Unspecified Chronic Kidney Disease as documented on the Home Health Certification and Plan of Care for Period 12/02/2025 to 01/30/2025. The Physical Therapy visit note dated 12/08/2025 documents the patient has the following DME (Durable Medical Equipment): wheelchair, bed side commode and hospital bed. The Home Health Certification and Plan of Care lacks documented evidence the wheelchair, bed side commode and hospital bed included in the DME (Durable Medical Equipment). On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ***Patient #6 has a Start of Care date of 08/29/2024 with diagnoses of Type 2 Diabetes Mellitus with Other Skin Ulcer, Non-pressure Chronic Ulcer of Right Ankle with Fat Layer Exposed, and Non-pressure Chronic Ulcer of Left Ankle with Fat Layer Exposed as documented on the Home Health Certification and Plan of Care for Period 10/23/2025 to 12/21/2025. The Home Health Certification and Plan of Care lacks documented evidence of including the patient's psychosocial status. On 12/22/2025 at 10:30 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the finding. ***Patient #11 has a Start of Care date of 11/25/2025 with diagnoses of Hemiplegia Following Non-traumatic Intracerebral hemorrhage Affecting the Left, Non-dominant Side of the Body, Memory Deficit Following Non-traumatic Intracerebral Hemorrhage, Hydrocephalus, Unspecified, and Unspecified Convulsions as documented on the Home Health Certification and Plan of Care for Period 11/25/2025 to 01/23/2025. The Registered Nurse initial comprehensive assessment visit dated 11/25/2025 documents the patient has a history of seizures. The Home Health Certification and Plan of Care dated 11/25/2025 to 01/23/2025 documents the patient has a diagnosis of Unspecified Convulsions and has an order to take the medication Levetiracetam 500 mg (milligram) tablet two times daily. Levetiracetam is a medication used to control seizures. The Home Health Certification and Plan of Care dated 11/25/2025 to 01/23/2025 lacks documented evidence of seizure precautions. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ****Patient #12 has a Start of Care date of 08/22/2025 with diagnoses of Type 1 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Autistic Disorder, and Unspecified Intellectual Disabilities documented on the Home Health Certification and Plan of Care for Period 10/21/2025 to 12/19/2025. The Home Health Certification and Plan of Care dated 10/21/2025 to 12/19/2025 lacks documented evidence of including the patient’s psychosocial and cognitive status. The Home Health Certification and Plan of care dated 10/21/2025 to 12/19/2025 documents the patient continues to require CHHA (Certified Home Health Aide) services under Medicaid for assistance with personal care tasks and the RN (Registered Nurse) is needed to supervise HHA (Home Health Aide) every other week and PRN (as needed). There is no documented evidence of the Plan of Care including the number of hours per day for Home Health Aide services. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings.

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 reviews, and staff interviews, the agency failed to ensure the relevant physician(s) or allowed practitioner(s) were alerted to changes in the patient's condition or needs that suggest outcomes are not being achieved and that the plan of care should be altered. This was evident for 2 (two) of 18 (eighteen) clinical records reviewed (Patient: #4, and #10). Failure to ensure the relevant physician(s) or allowed practitioner(s) were alerted to changes in the patient's condition or needs that suggest outcomes are not being achieved and that the plan of care should be altered has the potential risk for negative patient outcomes. The Findings are 1. Patient #4 (Home Visit) has a start of care date of 12/02/2025 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4/ Unspecified Chronic Kidney Disease as documented on the Home Health Certification and Plan of Care for Period 12/02/2025 to 01/30/2025. The Home Health Certification and Plan of Care (medical orders) from 12/02/2025 to 01/30/2025 documents the following orders: SN (Skilled Nurse) to notify physician if patient has a weight gain of 3 (three) pounds in one day or 5 (five)pounds in 1 (one)week. A home visit was made with the SN (Skilled Nurse) on 12/16/2025; the clinical note for the patient was requested on 12/17/2025 and was given on 12/18/2025. The SN (Skilled Nurse) visit note dated 12/16/2025 documents: On assessment :VS WNL (vital signs within normal limits), weight 165 lbs (one hundred and sixty-five pounds), as per patient’s caregiver (they weighing patient in the morning daily). The SN (Skilled Nurse) visit, prior to 12/16/2025 was on 12/12/2025. The SN (Skilled Nurse) visit note dated 12/12/2025 documents the patient’s weight was 157 (one hundred and fifty-seven) pounds. There is no documented evidence of the SN (Skilled Nurse) informing the patient’s physician of the patient’s weight gain of 8 pounds in four (4) days. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. On 12/22/2025, the Clinical Supervisor provided a Client Coordination Report dated 12/21/2025 that documents the following: Notes correction for RN (Registered Nurse) visit on 12/16/2025. On assessment patient’s wife told that patient’s weight was in the morning 165 lbs (pounds). (They monitoring weight every morning.) On assessment patient was in the bed, usually he is sleeping afternoon from 2-5 PM. On assessment patient had no symptoms of CHF (Congestive Heart Failure) exacerbation, no SOB (shortness of breath) with activity or lying flat, lung sounds was clear bl (bilateral), no swelling on abdomen, no cough. SN (Skilled Nurse) called to PMD (name of Primary Medical Doctor), left message, MD (Medical Doctor) called back next day, as per MD (Medical Doctor) to continue monitoring weight daily, and continue same medications. And will see patient in 1 (one) week. He made appointment on 12/26/2025. As per MD (Medical Doctor) if weight will be gain 3 lbs (three pounds) in 1 (one) day, 5 lbs (five pounds) in 1 (one) week in the same time, call 911. SN (Skilled Nurse) called to caregiver and informed MD (Medical Doctor) visit and notified to monitoring weight daily, and using the same medications as per MD (Medical Doctor). There is no documented evidence of the SN (Skilled Nurse) following the weight gain guidelines provided by the physician and promptly alerting the physician of changes in the patient's weight. On 12/22/2025 at 11: 55 AM, the Clinical Supervisor was interviewed about when the patient’s physician was notified. The Clinical Supervisor stated, “I spoke with the Nurse after we had the discussion (on 12/19/2025). She didn’t realize at the time (12/16/2025) the weight difference. She called the wife Friday morning and the weight was 155 lbs (pounds)." No further explanations were provided. 2. Patient #10 has a start of care date of 11/21/2025 with diagnoses of Pressure Ulcer of Sacral Region, Stage 3, Essential (Primary) Hypertension, and Unspecified Dementia documented on the Home Health Certification and Plan of Care for the Period 11/21/2025 to 01/19/2025. The Registered Nurse (RN) Initial Comprehensive Assessment visit dated 11/21/2025 and RN (Registered Nurse) visit notes dated 11/24/2025, and 11/27/2025 documents: Indicate abnormal neurologic findings: dizziness, vertigo. There is no documented evidence of the SN (Skilled Nurse) promptly alerting the patient’s physician of the abnormal neurologic findings. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to revise a plan of care that reflects the current information from the patient's comprehensive assessment. This was evident for 1 (one) of 18 (eighteen) clinical records reviewed (Patient #6). Failure to document a plan of care that is revised to reflect the current information from the patient's comprehensive assessment has the potential for negative outcomes. The Findings are: 1. Patient #6 (Home Visit) has a start of care date of 08/29/2024 with diagnoses of Type 2 Diabetes Mellitus with Other Skin Ulcer, Non-pressure Chronic Ulcer of Right Ankle with Fat Layer Exposed, and Non-pressure Chronic Ulcer of Left Ankle with Fat Layer Exposed documented on the Home Health Certification and Plan of Care for Period 10/23/2025 to 12/21/2025. The Home Health Certification and Plan of Care dated 10/23/2025 to 12/21/2025 documents: Unna Boot under DME (Durable Medical Equipment) and Supplies. An Unna Boot is a special gauze impregnated with zinc oxide, calamine, or glycerin. The Registered Nurse Recertification (Comprehensive Assessment) dated 10/18/2025, prior to the Home Health Certification and Plan of Care dated 10/23/2025 to 12/21/2025, lacks documented evidence of the patient requiring the use of an Unna Boot. A home visit was conducted on 12/17/2025 at 10:30 AM, the Registered Nurse was interviewed and stated, "the Unna Boot was discontinued several months ago." There is no documented evidence of the Home Health Certification and Plan of Care dated 10/23/2025 to 12/21/2025 being revised to discontinue the use of the Unna Boot. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on employee record reviews and staff interviews, the agency failed to ensure that the employees providing services for the HHA (Home Health Agency) met the required training to carry out the assigned patient care tasks, in a safe, effective, and efficient manner. This was evident for 1 (one) of 15 (fifteen) personnel records reviewed. Failure to ensure all employees providing services to the HHA (Home Health Agency) meet the required training to carry out the assigned patient care tasks, in a safe, effective, and efficient manner has the potential for negative patient outcomes. The Findings are: 1. Employee #13 has a hire date of 06/27/2025. Employee #13 was assigned to Patient #8. The Home Health Certification and Plan of Care (medical orders) dated 11/15/2025 to 01/13/2026 documents orders from 11/20/2025: HHA 7Dx4H (Home Health Aide 7 days a week, for 4 hours per day). The personnel record for Employee #13 documents the employee successfully completing a Personal Care Aide (PCA) training program on 10/08/2024. There is no documented evidence of Employee #13 being a qualified Home Health Aide. On 12/22/2025 at 1:20 PM, the Administrator, Assistant Administrator, Clinical Supervisor, Rehabilitation Director, and Human Resources employee were interviewed and stated, " we requested an HHA (Home Health Aide) and the agency that provided the aide said she was an HHA (Home Health Aide). No additional explanations were given.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews the agency failed to provide the Home Health Aide (HHA) services together with a skilled professional or provide written patient care instructions for the Home Health Aide (HHA) that included observations the aide should reported to the agency supervisor. This was evident for four (4) of fifteen (15) clinical records reviewed (Patient #3, #11, #12 and #18). Failure to provide Home Health Aide (HHA) services together with a skilled professional or provide written patient care instructions for the Home Health Aide (HHA) that includes observations the aide should reported to the agency supervisor has the potential for negative patient outcomes. The Findings are: ***Patient #3 has a start of care date of 03/26/2025 with diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Endometrium, and Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care for the Period 11/21/2025 to 01/19/2026. The Aide Care Plan Report dated 11/21/2025 to 01/19/2026 lacks documented evidence of instructions or observations the aide should reported to the agency supervisor. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ***Patient #11 has a start of care date of 11/25/2025 with diagnoses of Hemiplegia following Non-traumatic Intracerebral Hemorrhage Affecting the Left, Non-dominant Side of the Body, Memory Deficit Following Non-traumatic Intracerebral Hemorrhage, Hydrocephalus, Unspecified, and Unspecified Convulsions documented on the Home Health Certification and Plan of Care for the Period 11/25/2025 to 01/23/2025. The Home Health Certification and Plan of Care dated 11/25/2025 to 01/23/2025 documents the patient has a diagnosis of Unspecified convulsions and is ordered the medication Levetiracetam 500 mg (milligram) tablet two times daily. Levetiracetam is a medication used to control seizures. The Aide Care Plan Report dated 11/25/2025 to 01/23/2026 lacks documented evidence of instructions to include seizure precautions or observations the aide should reported to the agency supervisor. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ****Patient #12 has a start of care date of 08/22/2025 with diagnoses of Type 1 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Autistic Disorder, and Unspecified Intellectual Disabilities documented on the Home Health Certification and Plan of Care dated 10/21/2025 to 12/19/2025. The Aide Care Plan Report dated 10/21/2025 to 12/19/2025 lacks documented evidence of instructions or observations the aide should reported to the agency supervisor. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. Patient #18 has a start of care date of 08/13/2025, with a diagnosis of Polyosteoarthritis, Unspecified, Hypertensive Heart Disease with Heart Failure, Heart Failure, Unspecified, Unspecified Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Obstructive Pulmonary Disease, Unspecified, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care for Period 08/13/2025 to 10/11/2025. The Discharge-Transfer Summary Report documents: Episode End Date 08/29/2025 and Status: Discharge, Date: 08/29/2025. The Supplemental Order dated 9/16/2025 documents: Case D/C (discharge) from agency 08/29/2025. The Home Health Aide Duty Sheet for 09/01/2025 documents the task the Home Health Aide provided for the patient and the Time In: 6:59 and Time Out: 13:00. The clinical record lacks documented evidence of the Home Health Aide (HHA) services being provided together with a skilled professional and written patient care instructions after 08/29/2025. On 12/18/2025 at 12:00 PM, Clinical Supervisor was interviewed and stated, “The agency was unable to cancel the Home Health Aide for 09/01/2025 since the patient cancelled services late.” No additional explanations were given.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to ensure the aides provided services that were ordered by the physician or allowed practitioner or following the plan of care. This was evident for six (6) of eighteen (18) clinical records reviewed. Patient: #3, #7, #8 #10, #11, and #12. Failure to ensure the aides provide services that are ordered by the physician or allowed practitioner or follow the plan of care has the potential for negative outcomes. The Findings are: ***Patient #3 has a start of care date of 03/26/2025 with diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Endometrium, and Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care for the Period 11/21/2025 to 01/19/2026. The Aide Care Plan Report dated 11/21/2025 to 01/19/2026 documents the following Home Health Aide (HHA) assignments: light housekeeping (change bed linens, clean refrigerator and stove, empty trash, personal laundry, tidy kitchen/bath/living area) weekly and PRN (as needed); bath (shower) every visit and PRN; hair care (shampoo) every visit and PRN; and toileting (toilet) every visit and PRN. The Home Health Aide (HHA) duty sheets from 11/24/2025 to 11/28/2025, 12/01/2025 to 12/05/2025, and 12/08/2025 to 12/12/2025 lack documented evidence of the Home Health Aide (HHA) performing light housekeeping, bath (shower), hair care (shampoo), and toileting (toilet), as assigned on the Aide Care Plan. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ***Patient #10 has a start of care date of 11/21/2025 with diagnoses of Pressure Ulcer of Sacral Region, Stage 3, Essential (Primary) Hypertension, and Unspecified Dementia documented on the Home Health Certification and Plan of Care for the Period 11/21/2025 to 01/19/2025. The Home Health Certification and Plan of Care (medical orders) dated 11/21/2025 to 01/19/2025 documents an order for Home Health Aide (HHA) services 3Dx4H (3 (three) days a week, for 4 (four) hours per day). The Home Health Aide (HHA) duty/time sheet dated 11/26/2025 documents the patient received one (1) hour of Home Health Aide (HHA) services. There is no documented evidence of the patient receiving a total of four (4) hours of Home Health Aide services on 11/26/2025 as ordered. The Aide Care Plan Report dated 11/21/2025 to 01/19/2026 documents the Home Health Aide is to provide toileting (toileting diaper) and toileting (toilet) every visit and PRN (as needed). The Home Health Aide (HHA) duty sheets dated 11/26/2025, 11/28/2025, 11/30/2025, 12/7/2025, 12/10/2025, and 12/12/2025 lack documented evidence of the Home Health Aide performing toileting (toileting diaper) and toileting (toilet) according to the Aide Care Plan. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ***Patient #11 has a start of care date of 11/25/2025 with diagnoses of Hemiplegia Following Non-traumatic Intracerebral Hemorrhage Affecting the Left, Non-dominant Side of the Body, Memory Deficit Following Non-traumatic Intracerebral Hemorrhage, Hydrocephalus, Unspecified, and Unspecified Convulsions documented on the Home Health Certification and Plan of Care for the Period 11/25/2025 to 01/23/2026. The Home Health Certification and Plan of Care (medical orders) dated 11/25/2025 to 01/23/2026 documents orders for HHA (4Dx5H) (Home Health Aide for 4 (four) days a week, 5 (five) hours per day). The Home Health Aide (HHA) duty sheet for 12/08/2025 documents the patient received a total of 4 (four) hours and 20 (twenty) minutes of HHA (Home Health Aide) services and not 5 (five) hours, as ordered. The Aide Care Plan Report dated 11/25/2025 to 01/23/2026 documents the following Home Health Aide (HHA) assignments: light housekeeping (change bed linens, clean refrigerator and stove, personal laundry, tidy kitchen/bath/living area) weekly and PRN (as needed); empty trash every visit and PRN (as needed); bath (shower) weekly and PRN (as needed) ; hair care (shampoo) weekly and PRN (as needed); hair care (brush) every visit and PRN (as needed); dressing every visit and PRN (as needed) ; toileting (toilet) and toileting (diaper) every visit and PRN (as needed). The Home Health Aide (HHA) duty sheets from 12/08/2025 to 12/11/2025 lack documented evidence of the Home Health Aide (HHA) performing light housekeeping weekly; empty trash every visit; bath (shower) weekly; hair care (shampoo) weekly; hair care (brush) every visit; and toileting (toilet) and toileting (diaper) every visit, as assigned on the Aide Care Plan Report. The Home Health (HHA) Aide duty sheet dated 12/08/2025 lacks documented evidence of the aide assisting with dressing. The Home Health Aide (HHA) duty sheets from 12/08/2025 to 12/11/2025 documents the aide performing empty foley bag. The clinical record lacks documented evidence the patient has a foley bag. There is no documented evidence of the Home Health aide (HHA) being assigned to empty foley bag. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. ****Patient #12 has a start of care date of 08/22/2025 with diagnoses of Type 1 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Autistic Disorder, and Unspecified Intellectual Disabilities documented on the Home Health Certification and Plan of Care for the Period 10/21/2025 to 12/19/2025. The Aide Care Plan Report dated 10/21/2025 to 12/19/2025 documents the Home Health Aide (HHA) is assigned to provide toileting (diaper) every visit and PRN (as needed). The Home Health Aide (HHA) duty sheets dated 10/21/2025 to 10/23/2025, 10/28/2025 to 10/31/2025, 11/04/25 to 11/07/2025, 11/11/20205 to 11/14/2025, 11/18/20205 to 11/21/2025, 11/24/2025 11/28/2025, 12/02/2025 to 12/05/2025, and 12/09/2025 to 12/13/2025 lack documented evidence of the Home Health Aide (HHA) assisting the patient with toileting (diaper), as assigned on the aide Plan of Care. On 12/22/2025 at 10:30 AM, the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. Patient #7 has a start of care date of 11/18/2025 with the following diagnoses of Obstructive Hydrocephalus, Bilateral Primary Osteoarthritis of Knee and Chronic Obstructive Pulmonary Disease, Unspecified as documented on the Home Health Certification and Plan of Care for Certification Period 11/18/2025 to 1/16/2026. The Aide Care Plan Report dated 11/18/2025 to 1/16/2026 documents the following tasks to be completed daily: Standby Assistance with Ambulation, Home Exercise Program, Provide Medication Reminders, Skin Care, Perineal Care, Prepare Meals (breakfast, lunch, snacks), Dressing and Toileting (toilet). On 11/26/2025 and 12/5/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Grooming-Shave. On 11/26/2025 and 12/5/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Foot Care. On 11/26/2025 and 12/5/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA) : Toileting- Diaper and Toileting- Commode. On 11/21/2025, 11/26/2025, 12/3/2025, 12/5/2025, 12/10/2025 and 12/12/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Prepare Meals -Dinner. On 12/1/2025, 12/8/2025 and 12/12/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Bath-Shower. On 11/24/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Hair- comb. There is no documented evidence of the Home Health aide (HHA) being assigned to the following task: Grooming - Shave, Foot Care, Toileting- Diaper and Toileting- Commode, Prepare Meals - Dinner, Bath - Shower and Hair - Comb. The aide duty sheets lack documented evidence of Standby Assistance with Ambulation being completed on the following days: 12/8/2025. The aide duty sheets lack documented evidence of Home Exercise Program being completed on the following days: 11/24/2025, 12/1/2025 and 12/8/2025. The aide duty sheets lack documented evidence of Provide Medication Reminders being completed on the following days: 11/21/2025, 11/24/2025 and 12/12/2025. The aide duty sheets lack documented evidence of Skin Care being completed on the following days: 12/1/2025, 12/3/2025 and 12/8/2025. The aide duty sheets lack documented evidence of Perineal Care being completed by the aide on the following days: 11/20-11/21/2025, 11/24/2025, 11/26/2025, 11/28/2025, 12/3/2025, 12/5/2025, 12/8/2025 and 12/10/202. The aide duty sheets lack documented evidence of Prepare Meals (breakfast) being completed by the aide on the following days: 11/20/2025, 11/28/2025, 12/1/2025, 12/5/2025, 12/3/2025, 12/8/2025 12/10/2025 and 12/12/2025. The aide duty sheets lack documented evidence of Prepare Meals (lunch) being completed by the aide on the following days: 11/20/2025, 11/28/2025, 12/3/2025, 12/5/2025, 12/10/2025 and 12/12/2025. The aide duty sheets lack documented evidence of Prepare Meals(snack) being completed by the aide on the following days: 12/1/2025 and 12/8/2025. The aide duty sheets lack documented evidence of Toileting (toilet) being completed by the aide on the following days: 11/20/2025, 11/24/2025, 11/28/2025, 12/1/2025, 12/3/2025, 12/8/2025, 12/10/2025 and 12/12/2025. There is no documented evidence of the aide providing services that were ordered by the physician or allowed practitioner or following the plan of care. On 12/19/2025 at 11:15 AM the Administrator, Assistant Administrator, Rehab Director and Registered Nurse Clinical Supervisor were interviewed and did not provide an explanation for finding. Patient # 8 has a start of care date 11/15/2025 with the following diagnoses: Unilateral Primary Osteoarthritis of Left Knee, Pain in Right Hip and Chronic Systolic (Congestive) Heart Failure as documented on the Home Health Certification and Plan of Care for Certification Period 11/15/2025 to 1/13/2025. The Aide Care Plan Report dated 11/15/2025 to 12/08/2025 documents the following aide tasks to be completed daily: provide medication reminders, empty trash, hair care (brush) skin care, prepare meals (breakfast, lunch, dinner and snack), dressing, bath (shower), toileting (diaper), toileting (toilet). On 11/19-20/2025, 11/22/2025, 11/24/2025, 11/26/2025, 12/3/2025, 12/4/2025, and 12/5/2025 The aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): mouth care/denture care. On 11/25/2025, 11/29/2025, 12/1-12/4/2025 the aide duty sheets document the following tasks being completed by the Home Health Aide (HHA): Bath (bed). There is no documented evidence of the Home Health aide (HHA) being assigned to the following task: mouth care/denture care and bath (bed) on the Aide Care Plan Report. The Aide Care Plan Report dated 11/15/2025 to 12/08/2025 documents the following aide tasks to be completed daily: provide medication reminders, empty trash, hair care (brush) skin care, prepare meals (breakfast, lunch, dinner and snack), dressing, bath (shower), toileting (diaper), toileting (toilet). The aide duty sheets lack documented evidence of empty trash being completed on the following days: 11/19/2025, 11/21/2025, 11/22-11/23/2025, 11/25/2025, 11/29-11/30/2025, 12/1-12/2/2025. The aide duty sheets lack documented evidence of provide medication reminders on the following days: 11/19-11/25/2025, 11/29/2025, 12/2-12/5/2025, 12/7-12/8/2025. The aide duty sheets lack documented evidence of toileting (toilet) and toileting (diaper) being completed on the following days: 11/17-12/8/2025. The aide duty sheets lack documented evidence of dressing being completed on the following days: 11/22-26/2025, 11/29-20/2025, 12/1-2/2025, 12/4-6/2025. The aide duty sheets lack documented evidence of bath (shower) being completed on the following days: 11/17-18/2025,11/21/2025. The aide duty sheets lack documented evidence of hair care (brush) being completed on the following days: 11/20-11/21/2025, 11/23-11/25/2025, 11/29-11/30/2025 12/2/2025, 12/4-12/8/2025. The aide duty sheets lack documented evidence of prepare meals (lunch) being completed on the following days: 11/19-11/26/2025, 11/29-11/30/2025, 12/1-12/2/2025, 12/4-12/5/2025, 12/7-12/8/2025. The aide duty sheets lack documented evidence of prepare meals (dinner) 11/19-11/21/2025, 11/23-11/26/2025 11/29-11/30/2025, 12/1-12/2/2025, 12/4-12/8/2025. The aide duty sheets lack documented evidence of prepare meals (snack) being completed on the following days: 11/19-11/21/2025, 11/23-11/26/2025 11/29-11/30/2025, 12/1-12/2/2025, 12/4-12/8/2025. The aide duty sheets lack documented evidence of prepare meals (breakfast) being completed on the following days: 11/17-12/5/2025, 12/7-12/8/2025. There is no documented evidence of the aide providing services that were ordered by the physician or allowed practitioner or following the plan of care. On 12/19/2025 at 11:15 AM the Administrator, Assistant Administrator, Rehab Director and Registered Nurse Clinical Supervisor were interviewed and did not provide an explanation for finding.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that home health aide (HHA) supervision include aides providing care in a safe and effective manner and demonstrating competency with assigned tasks. This was evident for six (6) of eighteen (18) clinical records reviewed (Patients #3, #10, #11, #12, #16 and #18). Failure to ensure that supervision of Home Health Aides establishes that they provide care in a safe and effective manner and demonstrate competency with assigned tasks has the potential for negative patient outcomes. The findings are: 1.Patient #3 has a Start of Care date of 03/26/2025 with diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Endometrium, and Type 2 Diabetes Mellitus Without Complications as documented on the Home Health Certification and Plan of Care for Period 11/21/2025 to 01/19/2026. The Home Health Aide Supervision dated 11/17/2025, 12/03/2025, and 12/16/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. 2. Patient #10 has a Start of Care date of 11/21/2025 with diagnoses of Pressure Ulcer of Sacral Region, Stage 3, Essential (Primary) Hypertension, and Unspecified Dementia as documented on the Home Health Certification and Plan of Care for Period 11/21/2025 to 01/19/2025. The Home Health Aide (HHA) Supervision dated 12/03/2025, 12/05/2025 and 12/09/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. 3. Patient #11 has a Start of Care date of 11/25/2025 with diagnoses of Hemiplegia Following Non-traumatic Intracerebral Hemorrhage Affecting the Left, Non-dominant Side of the Body, Memory Deficit Following Non-traumatic Intracerebral Hemorrhage, Hydrocephalus, Unspecified, and Unspecified Convulsions documented on the Home Health Certification and Plan of Care for Period 11/25/2025 to 01/23/2025. The Home Health Aide Supervision dated 12/05/2025 documents, “Supervisory Functions: Were supervisory functions performed? Yes. Indicate discipline of employee being evaluated: Home Health Aide. Indicate name of Home Health Aide being evaluated if applicable: HHA (Home Health Aide) will start next Monday, patient agreed with plan of care. Is the client satisfied with the current care being provided by the HHA? Yes. Does the HHA notify the client or caregiver in timely fashion of changes in the plan of care/schedule/time changes? Yes. Does the HHA respect the client’s rights related to privacy, dignity, confidentiality, personal belongings and property? Yes.” The Home Health Aide duty sheets documents Home Health Aide services started on 12/08/2025. The Home Health Aide supervision dated 12/05/2025 documents supervision of Home Health Aide services that had not yet started. The Home Health Aide Supervision dated 12/10/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. 4. Patient #12 has a Start of Care date of 08/22/2025 with diagnoses of Type 1 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Autistic Disorder, and Unspecified Intellectual Disabilities documented on the Home Health Certification and Plan of Care for Period 10/21/2025 to 12/19/2025. The Home Health Aide Supervision dated 10/27/2025, 11/14/2025, 11/26/2025 and 12/12/2025, lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. #1. Patient #3 has a Start of Care date of 03/26/2025 with diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Endometrium, and Type 2 Diabetes Mellitus Without Complications as documented on the Home Health Certification and Plan of Care for Period 11/21/2025 to 01/19/2026. The Home Health Aide Supervision dated 11/17/2025, 12/03/2025, and 12/16/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. #2. Patient #10 has a Start of Care date of 11/21/2025 with diagnoses of Pressure Ulcer of Sacral Region, Stage 3, Essential (Primary) Hypertension, and Unspecified Dementia as documented on the Home Health Certification and Plan of Care for Period 11/21/2025 to 01/19/2025. The Home Health Aide (HHA) Supervision dated 12/03/2025, 12/05/2025 and 12/09/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. #3. Patient #11 has a Start of Care date of 11/25/2025 with diagnoses of Hemiplegia Following Non-traumatic Intracerebral Hemorrhage Affecting the Left, Non-dominant Side of the Body, Memory Deficit Following Non-traumatic Intracerebral Hemorrhage, Hydrocephalus, Unspecified, and Unspecified Convulsions documented on the Home Health Certification and Plan of Care for Period 11/25/2025 to 01/23/2025. The Home Health Aide Supervision dated 12/05/2025 documents, “Supervisory Functions: Were supervisory functions performed? Yes. Indicate discipline of employee being evaluated: Home Health Aide. Indicate name of Home Health Aide being evaluated if applicable: HHA (Home Health Aide) will start next Monday, patient agreed with plan of care. Is the client satisfied with the current care being provided by the HHA? Yes. Does the HHA notify the client or caregiver in timely fashion of changes in the plan of care/schedule/time changes? Yes. Does the HHA respect the client’s rights related to privacy, dignity, confidentiality, personal belongings and property? Yes.” The Home Health Aide duty sheets documents Home Health Aide services started on 12/08/2025. The Home Health Aide supervision dated 12/05/2025 documents supervision of Home Health Aide services that had not yet started. The Home Health Aide Supervision dated 12/10/2025 lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. #4. Patient #12 has a Start of Care date of 08/22/2025 with diagnoses of Type 1 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Autistic Disorder, and Unspecified Intellectual Disabilities documented on the Home Health Certification and Plan of Care for Period 10/21/2025 to 12/19/2025. The Home Health Aide Supervision dated 10/27/2025, 11/14/2025, 11/26/2025 and 12/12/2025, lack documented evidence of the Registered Nurse supervising the Home Health Aide (HHA) on the following: following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; and complying with infection prevention and control policies and procedures. On 12/19/2025 at 10:55 AM the Administrator, Assistant Administrator, Clinical Supervisor and Rehabilitation Director were interviewed and did not provide an explanation for the findings. #5. Patient #16 has a start of care date of 7/22/2025, with a diagnosis of Primary Generalized Osteoarthritis, Unspecified Tear of Unspecified Meniscus, Current Injury Tight Knee, Radiculopathy Cervical Region, Migraine, Unspecified Not Intractable, Without Status Migrainosus, Essential (Primary) Hypertension and Nontoxic Single Thyroid Nodule, as documented on the Home Health Certification and Plan of Care for Period 07/22/2025 to 09/19/2025. The Home Health Aide Duty Sheet documents the first day for the Home Health Aide as 07/23/2025 with a Time In: 11:00 and Time Out: 13:00. The Occupational Therapist (OT) - Visit Note Report - dated 07/23/2025 documents: In-home time began: 07/23/2025 11:51 AM. Were supervisory functions performed: Yes; Indicate Discipline of Employee being evaluated: None of the above. There is no documented evidence of the Occupational Therapist (OT) providing supervision to the Home Health Aide (HHA) to ensure that the Home Health Aide is competent to perform the assigned tasks; can furnish care in a safe and effective manner, follow infection prevention and control policies and procedures and was instructed when to report changes in the patient's condition. On 12/19/2025 at 11:00 AM, Administrator, Clinical Supervisor and the Rehabilitation Director was interviewed, and no explanations were given for the findings. #6. Patient #18 has a start of care date of 08/13/2025, with a diagnosis of Polyosteoarthritis, Unspecified, Hypertensive Heart Disease with Heart Failure, Heart Failure, Unspecified, Unspecified Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Obstructive Pulmonary Disease, Unspecified, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care for Period 08/13/2025 to 10/11/2025. The Home Health Aide Duty Sheet documents the first day for the Home Health Aide as 8/15/2025 with a Time In: 07:00 and Time Out: 13:02. The Registered Nurse - Visit Note Report - dated 08/15/2025 documents: In-home time began: 8/15/2025 10:22 AM. Were supervisory functions performed: No. Are HHA (Home Health Aide) services being provided: Yes. Additional Comments: HHA (Home Health Aide) placement pending. There is no documented evidence of the Registered Nurse providing supervision to the Home Health Aide (HHA) to ensure that the Home Health Aide is competent to perform the assigned tasks; can furnish care in a safe and effective manner, follow infection prevention and control policies and procedures and was instructed when to report changes in the patient's condition. On 12/19/2025 at 11:00 AM, Administrator, Clinical Supervisor and the Rehabilitation Director was interviewed, and no explanations were given for the findings.

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 clinical record reviews, and staff interviews, the agency failed to ensure the discharge summary 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 - within five (5) days of discharge. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient: #18). Failure to ensure the discharge summary is sent to the primary care practitioner or other health care professional within five (5) days of discharge, has the potential for negative patient outcomes. The Findings Are: 1. Patient #18 has a start of care date of 08/13/2025, with a diagnosis of Polyosteoarthritis, Unspecified, Hypertensive Heart Disease with Heart Failure, Heart Failure, Unspecified, Unspecified Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Obstructive Pulmonary Disease, Unspecified, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care for Period 08/13/2025 to 10/11/2025. The Discharge-Transfer Summary Report documents: Episode End Date 08/29/2025 and Status: Discharge, Date: 08/29/2025. The Supplemental Order dated 9/16/2025 documents: Case D/C (discharge) from agency 08/29/2025. The (RN) Registered Nurse Visit Note Report dated 09/16/2025 documents: RN66 – RN (Registered Nurse) Discharge Data Collection Only – No Visit Made and (M0090) Date Assessment Completed: 09/16/2025. The clinical record lacks documented evidence of the discharge summary being 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) within five (5) days of discharge. On 12/18/2025 at 12:00 PM, Clinical Supervisor was interviewed, and no explanations were given for the findings.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and Governing Body President interview, the Governing Body failed to assume full legal authority and responsibility for the agency's overall management and operation and its quality assessment and performance improvement program. Failure to ensure the Governing Body provides oversight and direction to the agency has the potential for agency wide unmet patient needs and negative patient outcomes. The findings are: The Statement of Deficiencies and Plan of Corrections (Form CMS-2567) signed and dated 12/19/2023 by the Administrator documents the plan of corrections includes the following for monitoring the corrective actions: “The Administrator oversees the initiative, and the (audit) results will be reported in the Quarterly Quality Performance meetings to keep the Governing Body informed;” and “The outcomes of these evaluations (audits) will be formally presented to the Governing Body through the Quarterly Improvement meetings.” The quarterly Quality Improvement 2024 meeting agenda(a) document meetings on 03/25/2024 (Quarter 1), 07/24/2024 (Quarter 2), and 09/20/2024 (Quarter 3). There is no documented evidence of Quality Performance meeting minutes for the meetings held on 03/25/2024, 07/24/2024, and 09/20/2024. There is no documented evidence of the agency’s plan of correction audit results being reported in the quarterly Quality Performance meetings and to the Governing Body. There is no documented evidence of the Governing Body ensuring Quality Performance meeting minutes are maintained as evidence of ongoing oversight of and accountability for the agency’s Quality Assessment and Performance Improvement. On 10/29/2024 at 4:45 PM the Governing Body President was interviewed and stated the previous Administrator/Director of Patient Services "left the agency suddenly" in August 2024 and “has the meeting minutes” for the 1st Quarter and 2nd Quarter. The Governing Body President stated, the agency “did not write meeting minutes” for the 3rd Quarter meeting held on 09/20/2024.