Every finding on record at Simple Touch Home Health Care, Inc

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Release of patient identifiable OASIS information was met as follows: 1. The Home Health Agency failed to ensure the OASIS accurately reflected the patients status for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to G374). The cumulative effect of these systemic practices resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12, not having an accurate OASIS, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians; and affect the patients’ care and services that could lead to hospitalization and death.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the OASIS accurately reflected the patients status for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12): 1. Patient 8 had a start of care (SOC) on 3/27/2025, with diagnosis of radiculopathy lumbar region. The OASIS-start of care assessment, dated 3/27/2025, indicated the Owner (OW), who is not a licensed nurse, completed the assessment. 2. Patient 9 had SOC on 4/7/2025, with Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 4/7/2025, indicated the OW, who is not a licensed nurse, completed the assessment. 3. Patient 10 had a SOC on 3/28/2025 with diagnoses of Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 3/28/2025 and OASIS-transfer, dated 5/10/2025 indicated the OW, who is not a licensed nurse, completed the assessment. 4. Patient 11 had a SOC on 4/7/2025, with diagnoses of Type 2 DM with hyperglycemia. The OASIS-start of care assessment, dated 4/7/2025 and OASIS-transfer, dated 5/8/2025 indicated the OW, who is not a licensed nurse, completed the assessment. 5. Patient 12 had a SOC on 4/9/2025, with diagnoses of chronic pain syndrome. The OASIS-start of care assessment, dated 4/9/2025, indicated the OW, who is not a licensed nurse, completed the assessment. The cumulative effect of these systemic practices resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12, not having an accurate OASIS, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians; and affect the patients’ care and services that could lead to hospitalization and death. On 5/16/2025, at 11:51 a.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Owner (OW) for failing to ensure the OASIS accurately reflected the patients status for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). On 5/26/2025 at 4:00 pm, the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). During an interview on 5/13/2025, at 1:34 p.m., the owner (OW) stated she was not a licensed nurse. During an interview on 5/15/25 at 10:41 a.m. Registered Nurse 1 (RN 1) stated the start of care (SOC) assessment was on paper. RN 1 stated he brings the SOC assessment to the office within 2 days at the latest and gives the documents to the OW. RN 1 stated “someone” (stated doesn’t know who) puts it in in the electronic medical record (EMR) and he reviews it, makes sure it is okay. During an interview on 5/15/2025, at 11:00 a.m., the OW stated that the doctor’s orders for Patients 8,9,10,11, and 12 should have been in the EMR. The OW reviewed the EMR and stated the doctor’s orders were not in the patient records and did not understand why they were not there. The OW stated she had uploaded the orders on 5/14/2025 and stated the EMR “sometimes doesn’t work.” The OW stated she would email the doctor’s orders to the survey team. During an interview on 5/15/2025, at 11:12 a.m., RN 1 stated he did not document the SOC assessments (OASIS) because he did not have access to the EMR. RN 1 then stated he reviewed the OASIS for accuracy and signed the documents. On 5/15/2025, at 1:35 p.m., the OW stated she did all of the OASIS for all the patients. The OW stated she used information from RN 1, the consultant, and doctors orders. The OW stated she signed the OASIS assessment so it can be complete because if it is not complete, visits cannot be added, and the plan of care cannot be done. The OW stated she documented all of the information on the OASIS assessment for all the patients. A record review of Patient’s 8,9,10,11, and 12, did not indicate RN 1 had signed the OASIS. On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of a doctor’s order indicating the treatments and services needed for Patients 8,9,10,11, and 12. 1. During a review of Patient 8’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 8 was a fifty five-year-old female, who was admitted to the HHA on 3/27/2025, with diagnosis that included radiculopathy (occurs when a nerve root in the spine is compressed or irritated, which can lead to symptoms like pain, weakness, numbness, or tingling in the area served by the affected nerve), lumbar (the area of the spine between the thoracic [chest] area and the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) region and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 8’s OASIS Start of Care Assessment, dated 3/27/2025, the OASIS Start of Care Assessment was signed by the OW and by Consultant 1. The OASIS Start of Care Assessment indicated that Patient 8 had impaired hearing (speaker has to increase volume and speak distinctly), impaired vision (limited vision; not able to see newspaper headlines but can identify objects), and constant delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The OASIS Start of Care Assessment indicated that Patient 8 was dependent on a walker (a mobility aid, specifically a frame with four legs, designed to assist individuals who have difficulty walking due to age-related mobility issues, injury, or other medical conditions) and lived with other people in the home around the clock. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 5/1/4/2025, at 11 a.m., Patient 8 was observed alert and oriented to person, place, time, and situation (fully aware of who they are, where they are, what day it is, and what is happening around them). Patient 8 was also observed walking independently without any assistive device. Patient 8 stated she did not need a walker. Patient 8 stated she lived on her own. There was no other person observed at Patient 8’s home during the visit. Patient 8 was able to read the home visit consent on her own, verbalize understanding, and sign the consent on the designated space. No delirium was observed. Patient 8 was able to hear the surveyor and LVN 2 within normal distance and without the speaker having to increase the volume. During an interview with Patient 8 on 5/14/2025 at 11:25 a.m., Patient 8 stated she was a published author. Patient 8 showed the surveyor and LVN 2 one of her books that was recently published. 2. During a review of Patient 9’s SOC Worksheet, the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 9’s OASIS Start of Care Assessment, dated 4/7/2025, the OASIS Start of Care Assessment was not signed. During a concurrent interview and record review with the OW on 5/15/2025, at 2:05 p.m., the OW reviewed the OASIS Start of Care Assessment for Patient 8 and Patient 9. The OW stated that she was the one who documented the OASIS Start of Care for Patient 8 and Patient 9 with the help of Consultant 1. The OW stated that neither she nor Consultant 1 had seen Patient 8 and Patient 9. The OW stated that she based the information that she put in the OASIS Start of Care Assessment on the Registered Nurse (RN) who admitted the patients and conducted the comprehensive assessment. The OW stated that she and Consultant 1 were not RNs. The OW was not able to provide the full name, contact information, or contract/agreement she had for Consultant 1. The OW stated that Consultant 1 “only worked for a week.” The OW stated she did not know Consultant 1’s full name. When the OW was requested to provide the surveyor with the comprehensive assessment done by the RN for Patient 8 and Patient 9, the OW was not able to provide the RN assessment for Patient 9. The OW stated that RN 2, who conducted the start of care assessment for Patient 9, was currently on vacation and was unavailable. The OW stated that RN 2 had Patient 8’s start of care assessment with her, as it was paper based. During a review of an untitled document, with Patient 8’s name on it, who the OW stated was the start of care assessment done by RN 1, the document indicated the completion date was 4/3/2025. The document was not signed to indicate it was completed by RN 1. The document indicated that Patient 8 was alert, oriented, disoriented, and forgetful (all boxes were checked). The document did not indicate that Patient 8 had impaired vision or impaired hearing. There was no other assessment of Patient 8’s body system. On 5/15/2025, at 11:25 a.m., RN 1 stated he had to leave the HHA’s office because he had to see patients and therefore, he was not able to review Patient 8’s Start of Care Assessment. The survey requested RN 1 to rejoin the survey the following day. The OW stated that RN 1 was not available the following day since he had to visit patients. 3a. During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/13/2025 of Patient 10’s OASIS start of care assessment, dated 3/28/2025, indicated the assessment was completed by a Registered Nurse (RN, also known as a licensed nurse). Further review of the record indicated the OW signed the document. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 10’s records. During an interview on 5/13/2025 at 2:55 p.m., the OW added Patient 10 to the census. The OW stated she had just added Patient 10 to the census because she was discharged from the hospital on 5/11/2025. During an interview on 5/12/2025, at 3:21 p.m., the OW stated Patient 10 had agreed for a home visit on 5/14/2025. During an interview on 5/13/2025, at 9:24 p.m., the OW stated the home visit for 5/14/2025 was cancelled because Patient 10 was in a rehabilitation unit since 5/11/2025. During an interview on 5/15/2025 at 11:12 a.m. RN 1 reviewed the paper documents for Patient 10. RN 1 stated none of those documents were a start of care assessment because there was no information about mobility and DME (durable medical equipment). RN 1 stated he did an assessment for Patient 10 on 4/3/2025. During a concurrent interview and record review, on 5/15/2025, at 11:15 a.m., RN 1 reviewed the SOC paper documents and OASIS-start of care assessment, dated 3/28/2025. The OASIS indicated the assessment was done on 3/28/2025. RN 1 stated the OASIS had components that were incorrect such as vital signs and immunizations. Further record reviews of the documents indicated discrepancies with the paper document and the OASIS. This included insulin. The paper document mentioned the dose of 13 units, but there was no name of the medication. The OASIS indicated the name of the medication Novolog, but no additional information was documented. The paper document indicated Patient 10 needed SN (skilled nurse) services twice a week for 2 weeks (2w2), followed by 5 times a week for 1 week (5w1), PT (physical therapy) services, and Medical Social Work (MSW) services. The OASIS did not reflect the need for MSW. The OASIS indicated SN and PT services, but no frequency was mentioned. The OASIS indicated all interventions were to be based on doctor’s orders. During an interview on 5/15/2025, at 1:35 p.m., the OW stated Patient 10’s start of care OASIS assessment was done on 3/28/2025, not 4/3/2025. The OW stated RN 1’s assessment date was wrong. 3b. A record review on 5/15/2025 of Patient 10’s records indicated the presence of another OASIS assessment. The OASIS E1 transfer document indicated Patient 10 was hospitalized for the reason of dehydration, and an RN had completed the assessment on 5/10/2025. Further review of the record did not indicate a signature to indicate who had completed the document. During an interview on 5/15/2025, at 1:43 p.m., the OW stated she had documented the information on the OASIS E1 transfer assessment. The OW stated she obtained all of the information documented from the consultant and Patient 10’s husband. The OW stated she did not have medical knowledge. The OW stated the consultant was not an RN. 4a. During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/13/2025 of Patient 11’s OASIS start of care assessment, dated 4/7/2025, indicated the assessment was completed by an RN. There was no signature on the document to specify the RN who did the assessment. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 11’s records. During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments. The OW stated she documented the information on the OASIS based on doctor’s orders and the information sent by the doctor. During an interview on 5/13/25 at 3:20 p.m., the OW stated Patient 11 was hospitalized, and unable to do home visit. 4b. A record review of Patient 11’s medical records on 5/15/25 indicated the presence of an additional OASIS assessment. This document was an OASIS transfer without discharge assessment, dated 5/8/2025. The document indicated the visit date was on 5/8/2025, but the assessment was completed on 5/7/2025. Further review of the document indicated the RN completed the assessment. The document was signed by the OW. The document indicated the reason Patient 11 was hospitalized was due to pneumonia (a condition that makes breathing difficult). During an interview on 5/15/2025 at 1:56 p.m., the OW stated she had documented on the OASIS transfer assessment based on what the nurse and consultant told her. 5. During a review of Patient 12’s SOC Worksheet, the SOC Worksheet indicated that Patient 12 was admitted to the HHA on 4/9/2025, with diagnosis of chronic pain syndrome. A record review of Patient 12’s, OASIS-start of care assessment, dated 4/9/2025, indicated the OW, who is not a licensed nurse, completed the assessment. During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments. A record review of the HHA’s undated document titled, Who Can Complete the OASIS, indicated, the Registered Nurse, primary clinician for most OASIS assessments, especially the start of care and recertification was responsible in completing the assess

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for care planning, coordination of services, and quality of care was met as follows: 1. The HHA failed to ensure that three of five sampled patients (Patient 9, Patient 10, and Patient 11) received home health services that are written in an individualized plan of care (a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. (Refer to G572). This failure resulted in Patient 9, Patient 10, and Patient 11 receiving home health services without an individualized, written plan of care that included management of their medical conditions. The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (decided and controlled by law) mandated compliance with federal regulation for care planning, coordination of services, and quality of care to ensure quality patient care was provided to the patients.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that three of five sampled patients (Patient 9, Patient 10, and Patient 11) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 9, Patient 10, and Patient 11 receiving home health services without an individualized, written plan of care that included management of their medical conditions. On 5/16/2025, at 12:12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agency’s Owner (OW) related to the agency’s failure to provide home health services that are written in an individualized plan of care (a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients for three of five sampled patients (Patient 9, Patient 10, and Patient 11). On 5/26/2025 at 4:00 p.m., the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). During a telephone interview with the Director of Patient Care Services (DPCS) on 5/13/2025, at 1:42 p.m., the DPCS stated that she did not go to the interdisciplinary meetings in person due to distance. The DPCS stated she lived far away from the HHA’s office. The DPCS stated she participated in the meetings through group texts and phone calls. When the DPCS was asked if she had access to the electronic health record system used by the HHA, the DPCS stated that she did not have access yet. The DPCS stated she was not sure if she could join the revisit survey because she had to attend to her own businesses, and she did not have time. During an interview on 5/15/2025 at 10:44 a.m., Registered Nurse 1 (RN 1) stated he tried to do the plan of care (POC). The POC was based on what the doctor ordered. If after the assessment, additional interventions were needed, the doctor was notified, and the additional interventions were added to the POC. RN 1 stated he wrote the orders received from the doctor and gave it to the OW, for the purpose of amendments of the documentation. RN 1 stated he did not create the POC in the electronic medical record (EMR) and did not know who created the POC. During an interview on 5/15/2025, at 11:00 a.m., the OW stated that the doctor’s orders for Patients 9,10, and 12 should have been in the EMR. The OW reviewed the EMR and stated the doctor’s orders were not in the patient records and did not understand why they were not there. The OW stated she had uploaded the orders on 5/14/2025 and stated the EMR “sometimes doesn’t work.” The OW stated she would email the doctor’s orders to the survey team. On 5/15/2025, at 11:10 a.m., the OW stated the plan of care for all patients had been completed and the survey team should be able to view it on the EMR. During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated she created the plan of care for Patient 9, Patient 10, and Patient 11 and uploaded them to the EMR on the evening of 5/14/2025 with the help of a consultant. The OW stated the consultant gave her the information for the POC by e-mail, which she then transcribed to the EMR of Patient 9, Patient 10, and Patient 11. The OW stated she also received help from her other friends for the POC. The OW stated the consultant was not a Registered Nurse. The OW also stated the consultant had never seen the patients. The OW stated that it was the responsibility of a clinician, such as the DPCS, to complete the POC, but she completed the plan of care because she wanted to “take care of her business.” a. During a review of Patient 9’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). On 5/13/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. The sections for the patient’s diagnosis, medications, DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) and supplies, safety measures, nutritional requirements, allergies, mental status, prognosis, orders for disciplines and treatments including amount/frequency/duration, and goals/rehabilitation potential/discharge plans were blank. There was no nurse’s signature and no physician’s signature to indicate that a Registered Nurse received the physician’s orders, and a physician reviewed the Home Health Certification and Plan of Care. On 5/14/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. During a concurrent record review and interview with the Owner (OW) on 5/15/2025, at 11:55 a.m., the OW reviewed Patient 9’s Home Health Certification and Plan of Care on the electronic health record system. The OW confirmed the Home Health Certification and Plan of Care for Patient 9 was not completed. The OW stated, “Sometimes you can see it, sometimes you cannot see it.” b. During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review of Patient 10’s medical records on 5/13/2025, did not indicate the presence of a POC. A POC template was present, but there was no clinical information. During an interview on 5/12/2025, at 3:21 p.m., the OW stated Patient 10 had agreed for a home visit on 5/14/2025. During an interview on 5/13/2025, at 9:24 p.m., the OW stated the home visit for 5/14/2025 was cancelled because Patient 10 was in a rehabilitation unit since 5/11/2025. A record review on 5/15/2025 of Patient 10’s records indicated the presence of The OASIS E1 transfer assessment, dated 5/10/2025. This document was not present on 5/13/2025, the day the revisit survey began. The document indicated Patient 10 was hospitalized for the reason of dehydration. A record review on 5/15/2025 of Patient 10’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 3/28/2025 to 5/26/2025. The record included nursing interventions as follows: -Skilled nurse (SN) frequency as per MD ordered. -SN to note blood pressure (BP) trends and report to doctor if BP less than 90/60, greater than 200/100, heart rate less than 60 beats per minute (bpm) or greater than 100 bpm. SN to report to MD in a timely manner of any significant findings or negative outcome. During an interview on 5/15/2025, at 1:56 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she found out Patient 10 was hospitalized due to “drastically low blood pressure”. LVN 1 stated Patient 10 was on dialysis (a mechanical process of removing waste from the body, when the kidneys do not work). LVN 1 stated she called Patient 10 on 5/5/2025 to confirm her home visit for 5/7/2025. At this time, she was already hospitalized and could not visit Patient 10 on 5/7/2025. LVN 1 stated prior to hospitalization, LVN 1 visited Patient 10 on 4/30/2025. LVN 1 stated Patient 10 had returned from the doctor’s office and new medications were prescribed. LVN 1 stated she had checked Patient 10’s blood pressure and it was “101 over 50 something, and the blood sugar was fine.” LVN 1 stated she had all her nursing note visit documents at home and wrote her visit notes in the EMR. LVN 1 stated no one wrote her notes. LVN 1 stated she entered the notes for Patient 10, but would have to double check. A record review of Patient 10’s unsigned nursing visit notes indicated visits were made on 4/2/2025, 4/9/2025, 4/16/2025, 4/23/2025, 4/30/2025, and 5/7/2025. A record review of Patient 10’s nursing visit note on 4/30/2025, indicated Patient 10’s blood pressure was 138/83. The blood pressure document did not support LVN 1’s interview of Patient 10’s blood pressure being “101 over 50 something” on 4/30/2025. A record review of Patient 10’s nursing visit notes indicated a visit was documented on 5/7/2025, the day LVN 1 could not do a home visit due to Patient 10 being hospitalized. A record review of Patient 10’s EMR, did not indicate any notes to indicate LVN 1 called the doctor to report Patient 10’s blood pressure of “101 over 50 something”. c. During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review of Patient 11’s medical records on 5/13/2025, did not indicate the presence of a POC. A POC template was present, but there was no clinical information. During an interview on 5/13/25 at 3:20 p.m., the OW stated Patient 11 was hospitalized, and unable to do home visit. A record review on 5/15/2025 of Patient 11’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 4/7/2025 to 6/5/2025. The primary diagnosis was listed as acute and chronic respiratory failure. Further review of the POC, did not indicate Patient 11 had Type 2 diabetes. The record included nursing interventions as follows: -Skilled nurse (SN) frequency as per MD ordered. -SN to monitor oxygen saturations every SN visit. During an interview on 5/15/2025, at 2:02 p.m., LVN 1 stated Patient 11 had a scheduled home visit on 5/7/2025. LVN 1 stated she texted Patient 11’s daughter on 5/6/2025 to confirm the visit. LVN 1 stated Patient 11’s daughter texted LVN 1 back on 5/7/2025, to let her know he was back in the hospital but did not mention the reason. LVN 1 could not get more information about his hospitalization. A record review of Patient 11’s unsigned nursing visit notes indicated visits were made on 4/10/2025, 4/14/2025, 4/17/2025, 4/22/2025, 4/19/2025, and 5/6/2025. A record review of Patient 11’s SN visit note for 4/17/2025, did not indicate the SN monitored Patient 11’s oxygen saturation. A record review of Patient 11’s nursing visit notes indicated a visit was documented on 5/6/2025, the day LVN 1 texted Patient 11’s daughter to confirm the scheduled HV on 5/7/2025. During a review of the HHA’s undated policy and procedure, titled “Plan of Care,” the policy and procedure indicated the HHA will develop and maintain a Plan of Care for each patient that is individualized, based on a comprehensive assessment, and established under the direction of the patient’s physician. The plan shall guide the home health team in delivering medically necessary services and will be reviewed and updated as the patient’s condition changes. The policy and procedure indicated the plan of care must include but is not limited to: • Diagnoses and medical history • Functional limitations • Medications and treatments • Services and disciplines required (e.g., nursing, PT, OT, ST, MSW, HHA) • Visit frequency and duration • Nutritional needs • Safety measures • Discharge planning • Patient-specific goals and outcomes • Physician's signature and date

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Organization and administration of service was met as follows: 1. The Home Health agency failed to ensure a governing body assume responsibility for the operations of the HHA by failing to: a. Ensure the agency’s Director of Patient Care Services provided oversight to ensure the clinical records were completed for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). b. Ensure the agency has a qualified Administrator who assumed responsibility for the day-to-day operations of the agency. c. Ensure the agency’s Administrator ensured a clinical manager was available during all operating hours. (Refer to G942). The cumulative effect of these systemic practices resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have clinical notes to validate the services being received were according to a doctor’s orders and based on the needs of the patients. The lack of oversight placed all patients at risk of injury, hospitalization, and/or death by not ensuring patients were receiving quality care.

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 interview and record review, the Home Health Agency (HHA) failed to ensure a governing body assume responsibility for the operations of the HHA by failing to: a. Ensure the agency’s Director of Patient Care Services provided oversight to ensure the clinical records were completed for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). b. Ensure the agency has a qualified Administrator who assumed responsibility for the day-to-day operations of the agency. c. Ensure the agency’s Administrator ensured a clinical manager was available during all operating hours. This failure resulted in Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have clinical notes to validate the services being received were according to a doctor’s orders and based on the needs of the patients. The lack of oversight placed all patients at risk of injury, hospitalization, and/or death by not ensuring patients were receiving quality care. On 5/16/2025, at 12:17 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Owner (OW) for failing to ensure a governing body assume responsibility for the operations of the HHA. On 5/26/2025 at 4:00 pm, the HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). Patient 8 had a start of care (SOC) on 3/27/2025, with diagnosis of radiculopathy lumbar region. Patient 9 had SOC on 4/7/2025, with Type 2 DM with hyperglycemia. Patient 10 had a SOC on 3/28/2025 with diagnoses of Type 2 DM with hyperglycemia. Patient 11 had a SOC on 4/7/2025, with diagnoses of Type 2 DM with hyperglycemia. Patient 12 had a SOC on 4/9/2025, with diagnoses of chronic pain syndrome. a. A record review of the HHA’s organizational chart indicated the Director of Patient Care Services (DPCS) was also the Administrator (ADM). DON-Director of Nurses. An administrator designee (DPCS D) was also listed. The record indicated the owner’s (OW) role was Governing body/board of directors. CO/CFO/Secretary 100% ownership. During an interview on 5/13/2025, at 12:22 p.m., the OW stated the DPCS and DPCSD were responsible for patient care. During an interview on 5/13/2025, at 1:34 p.m., the OW stated she was responsible for the day-to-day operation of the HHA because this was a small home health agency, and she just needed a Registered Nurse to see the patients. The OW stated the last time the DPCS was in the agency was two weeks ago. The OW stated the ADM designee and DPCS designee as listed on the organizational chart, was a “designee on paper”, and had not worked at the HHA. The OW stated the DPCS was also the designee. The OW stated Registered Nurse 1 could cover the DPCS role as ADM, but RN 1 could not cover the DPCS role because he did not have at least 3 years experience. On 5/13/2025, at 1:42 p.m., the DPCS stated she oversaw the nursing staff along with the OW. The DPCS stated the nurses consult with her through the phone and email. The DPCS stated she lived far away. The DPCS stated she did not do home visits. The DPCS supervised the nursing staff through calls, text messages, and “stuff like that”. The DPCS stated RN 1 did management duties. The DPCS stated she was not the administrator. The DPCS stated the last time she came to the office was in April 2025. The DPCS was asked if she was available to participate in the revisit survey: the DPCS stated, “I’m not sure if I am available with all of that.” The DPCS stated she preferred not to participate in the survey. The DPCS stated she had all of her businesses that she needed to attend to and did not have a lot of time. The DPCS stated her designee was RN 1. The DPCS stated she was not the administrator, and was under the impression that the OW was the ADM. The DPCS stated she did not have access to the electronic medical record (EMR). During an interview on 5/15/2025 at 10:12 a.m., the OW stated that the DPCS was the ADM. The OW stated the DPCS doesn’t know that she is the ADM because the DPCS thinks the ADM is an office person who answers calls and does paperwork. During an interview on 5/15/2025, at 10:33 a.m., RN 1 stated he was not hired to any management role including DPCS, supervisory, ADM, and administrator designee duties. RN 1 stated he had not supervised any Licensed Vocational Nurses for this HHA. On 5/13/2025, 5/14/2025, 5/15/2025, and 5/16/2025, the DPCS was not available. The effect of the DPCS not being in the agency with the patient care and the clinical operations was no oversight to ensure plan of care was done, visit notes entered in the medical record, doctor notes present, and OASIS done accurately. b. During a review of clinical records on 5/13/2025, there was no plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) available for Patient 9, Patient 10, and Patient 11 on the electronic health record. During a review of clinical records on 5/14/2025, there was no POC available for Patient 9, Patient 10, and Patient 11 on the electronic health record. During a review of clinical records on 5/15/2025, Patient 9, Patient 10, and Patient 11 had completed POC on the electronic health record. During an interview with the Owner (OW) on 5/15/2025 at 11 a.m., the OW stated she generated the POC for the three patients the night before (5/14/2025). During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated she created the POC for Patient 9, Patient 10, and Patient 11 and uploaded them to the electronic health record on the evening of 5/14/2025 with the help of a consultant. The OW stated the consultant gave her the information for the plan of care by e-mail, which she then transcribed to the electronic health record of Patient 9, Patient 10, and Patient 11. The OW stated she also received help from her other friends for the POC. The OW stated the consultant was not a Registered Nurse. The OW also stated the consultant had never seen the patients. The OW stated that it was the responsibility of a clinician, such as the DPCS, to complete the POC, but she completed the plan of care because she wanted to “take care of her business.” During a review of clinical records on 5/13/2025, 5/14/2025, and 5/15/2025, there were no physician orders available for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. During an interview with the OW on 5/15/2025, at 1:13 p.m., the OW stated the only order the physician wrote was the home health referral. During a review of the physician order, the document did not indicate the type of home health services, interventions, medications, treatments, and goals for the patients. The referral document indicated “Home Health.” During a review of clinical records on 5/13/2025, there were no nursing visit notes available for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 on the electronic health record. During an interview with the OW on 5/15/2025 at 3:05 p.m., the OW that Licensed Vocational Nurse 1 (LVN 1) endorsed to her (OW) the patient’s information over the phone, which the OW then transcribed into the nursing visit note. The OW stated that has always been the practice of the HHA. Per OW, she entered the nursing visit notes for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. The OW acknowledged she was not a clinician. 1. During a review of Patient 8’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 8 was a fifty five-year-old female, who was admitted to the HHA on 3/27/2025, with diagnosis that included radiculopathy (occurs when a nerve root in the spine is compressed or irritated, which can lead to symptoms like pain, weakness, numbness, or tingling in the area served by the affected nerve), lumbar (the area of the spine between the thoracic [chest] area and the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) region and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 8’s OASIS Start of Care Assessment, dated 3/27/2025, the OASIS Start of Care Assessment was signed by the OW and by Consultant 1. The OASIS Start of Care Assessment indicated that Patient 8 had impaired hearing (speaker has to increase volume and speak distinctly), impaired vision (limited vision; not able to see newspaper headlines but can identify objects), and constant delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). The OASIS Start of Care Assessment indicated that Patient 8 was dependent on a walker (a mobility aid, specifically a frame with four legs, designed to assist individuals who have difficulty walking due to age-related mobility issues, injury, or other medical conditions) and lived with other people in the home around the clock. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 5/1/4/2025, at 11 a.m., Patient 8 was observed alert and oriented to person, place, time, and situation (fully aware of who they are, where they are, what day it is, and what is happening around them). Patient 8 was also observed walking independently without any assistive device. Patient 8 stated she did not need a walker. Patient 8 stated she lived on her own. There was no other person observed at Patient 8’s home during the visit. Patient 8 was able to read the home visit consent on her own, verbalize understanding, and sign the consent on the designated space. No delirium was observed. Patient 8 was able to hear the surveyor and LVN 2 within normal distance and without the speaker having to increase the volume. During an interview with Patient 8 on 5/14/2025 at 11:25 a.m., Patient 8 stated that she had been visited by a nurse (LVN 1) and by a physical therapist from the HHA once a week. Patient 8 stated she was a published author. Patient 8 showed the surveyor and LVN 2 one of her books that was recently published. 2. During a review of Patient 9’s SOC Worksheet, the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). On 5/13/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. The sections for the patient’s diagnosis, medications, DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) and supplies, safety measures, nutritional requirements, allergies, mental status, prognosis, orders for disciplines and treatments including amount/frequency/duration, and goals/rehabilitation potential/discharge plans were blank. There was no nurse’s signature and no physician’s signature to indicate that a Registered Nurse received the physician’s orders, and a physician reviewed the Home Health Certification and Plan of Care. During a review of Patient 9’s clinical records on 5/13/2025, the Nurses Notes section in the electronic health record indicated there were 0 (zero) notes entered for the certification episode of 4/7/2025 to 6/5/2025. The Nurses Notes section indicated “empty category.” During a review of Patient 9’s OASIS Start of Care Assessment, dated 4/7/2025, the OASIS Start of Care Assessment was not signed. During a concurrent interview and record review with the OW on 5/15/2025, at 2:05 p.m., the OW reviewed the OASIS Start of Care Assessment for Patient 8 and Patient 9. The OW stated that she was the one who documented the OASIS Start of Care for Patient 8 and Patient 9 with the help of Consultant 1. The OW stated that neither she nor Consultant 1 had seen Patient 8 and Patient 9. The OW stated that she based the information that she put in the OASIS Start of Care Assessment on the Registered Nurse (RN) who admitted the patients and conducted the comprehensive assessment. The OW stated that she and Consultant 1 were not RNs. The OW was not able to provide the full name, contact information, or contract/agreement she had for Consultant 1. The OW stated that Consultant 1 “only worked for a week.” The OW stated she did not know Consultant 1’s full name. When the OW was requested to provide the surveyor with the comprehensive assessment done by the RN for Patient 8 and Patient 9, the OW was not able to provide the RN assessment for Patient 9. The OW stated that RN 2, who conducted the start of care assessment for Patient 9, was currently on vacation and was unavailable. The OW stated that RN 2 had Patient 8’s start of care assessment with her, as it was paper based. During a review of an untitled document, with Patient 8’s name on it, who the OW stated was the start of care assessment done by RN 1, the document indicated the completion date was 4/3/2025. The document was not signed to indicate it was completed by RN 1. The document indicated that Patient 8 was alert, oriented, disoriented, and forgetful (all boxes were checked). The document did not indicate that Patient 8 had impaired vision or impaired hearing. There was no other assessment of Patient 8’s body system. On 5/15/2025, at 11:25 a.m., RN 1 stated he had to leave the HHA’s office because he had to see patients and therefore, he was not able to review Patient 8’s Start of Care Assessment. The survey requested RN 1 to rejoin the survey the following day. The OW stated that RN 1 was not available the following day since he had to visit patients. 3. During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/13/2025 of Patient 10’s OASIS start of care assessment, dated 3/28/2025, indicated the assessment was completed by a Registered Nurse. Further review of the record indicated the OW signed the document. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 10’s records. During an interview on 5/13/2025 at 2:55 p.m., the OW added Patient 10 to the census. The OW stated she had just added Patient 10 to the census because she was discharged from the hospital on 5/11/2025. During an interview on 5/12/2025, at 3:21 p.m., the OW stated Patient 10 had agreed for a home visit on 5/14/2025. During an interview on 5/13/2025, at 9:24 p.m., the OW stated the home visit for 5/14/2025 was cancelled because Patient 10 was in a rehabilitation unit since 5/11/2025. During an interview on 5/15/2025 at 11:12 a.m. RN 1 reviewed the paper documents for Patient 10. RN 1 stated none of those documents were a start of care assessment because there was no information about mobility and DME (durable medical equipment). RN 1 stated he did an assessment for Patient 10 on 4/3/2025. During a concurrent interview and record review, on 5/15/2025, at 11:15 a.m., RN 1 reviewed the SOC paper documents and OASIS-start of care assessment, dated 3/28/2025. The OASIS indicated the assessment was done on 3/28/2025. RN 1 stated the OASIS had components that were incorrect such as vital signs and immunizations. Further record reviews of the documents indicated discrepancies with the paper document and the OASIS. This included insulin. The paper document mentioned the dose of 13 units, but there was no name of the medication. The OASIS indicated the name of the medication Novolog, but no additional information was documented. The paper document indicated Patient 10 needed SN (skilled nurse) services twice a week for 2 weeks (2w2), followed by 5 times a week for 1 week (5w1), PT (physical therapy) services, and Medical Social Work (MSW) services. The OASIS did not reflect the need for MSW. The OASIS indicated SN and PT services, but no frequency was mentioned. The OASIS indicated all interventions were to be based on doctor’s orders. During an interview on 5/15/2025, at 1:35 p.m., the OW stated Patient 10’s start of care OASIS assessment was done on 3/28/2025, not 4/3/2025. The OW stated RN 1’s assessment date was wrong. 4a. During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/13/2025 of Patient 11’s OASIS start of care assessment, dated 4/7/2025, indicated the assessment was completed by an RN. There was no signature on the document to specify the RN who did the assessment. On 5/13/2025, there was only 1 OASIS assessment (start of care assessment). No other OASIS assessment was in Patient 11’s records. During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments. The OW stated she documented the information on the OASIS based on doctor’s orders and the information sent by the doctor. During an interview on 5/13/25 at 3:20 p.m., the OW stated Patient 11 was hospitalized, and unable to do home visit. 4b. A record review of Patient 11’s medical records on 5/15/25 indicated the presence of an additional OASIS assessment. This document was an OASIS transfer without discharge assessment, dated 5/8/2025. The document indicated the visit date was on 5/8/2025, but the assessment was completed on 5/7/2025. Further review of the document indicated the RN completed the assessment. The document was signed by the OW. The document indicated the reason Patient 11 was hospitalized was due to pneumonia (a condition that makes breathing difficult). During an interview on 5/15/2025 at 1:56 p.m., the OW stated she had documented on the OASIS transfer assessment based on what the nurse and consultant told her. 5. During a review of Patient 12’s SOC Worksheet, the SOC Worksheet indicated that Patient 12 was admitted to the HHA on 4/9/2025, with diagnosis of chronic pain syndrome. During a record review, Patient 12’s OASIS-start of care assessment, dated 4/9/2025, indicated the OW, who is not a licensed nurse, completed the assessment. During an interview on 5/15/2025, at 3:15 p.m., the OW stated she did not have paper documents that the nurse did for the start of care assessment for Patient 11, to indicate the accuracy of the OASIS assessments. A record review of the HHA’s undated document, titled Governing Body indicated, “Simple Touch Home Health shall maintain an active Governing Body with full legal authority and responsibility for the management, oversight, and operation of the agency. The Governing Body shall define the organization’s mission, ensure the provision of quality care, approve policies, and oversee fiscal and administrative operations. Composition: The Governing Body may include the agency’s owners, executives, Administrator, Director of Patient Care Services (DPCS), and other appointed members as appropriate.” A record review of the HHA’s undated document titled, Job Description Summary for the Executive Director/Administrator, indicated the job responsibilities included ensuring organizational compliance with legal, regulatory, and accreditation standards; ensuring program personnel have current clinical information and current practices; assuring appropriate personnel supervision during all operating hours; is responsible for all day-to-day operation of the HHA; ensures that a clinical manager is available during all operating hours; the administrator or a pre-designated person is available during all operating hours. A record review of the HHA’s undated document titled, Job Description Summary for the Clinical Director/Director of Patient Care Services, indicated the job responsibilities included: oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities; assures proper maintenance of clinical records in compliance with local, state and federal laws; if the DPCS is also acting as the clinical manager: the clinical manager’s oversight must include the following:...coordinating patient care...assuring that patient needs are continually assessed, assuring the development, implementation, and updates of the individualized plan of care.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency failed to ensure that all clinical record entries were clear, complete, and appropriately authenticated, signed, dated, and timed for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential for the patients’ clinical records to be lacking validity. a. During a review of Patient 8’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 8 was a fifty five-year-old female, who was admitted to the HHA on 3/27/2025, with diagnosis that included radiculopathy (occurs when a nerve root in the spine is compressed or irritated, which can lead to symptoms like pain, weakness, numbness, or tingling in the area served by the affected nerve), lumbar (the area of the spine between the thoracic [chest] area and the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) region and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 8’s OASIS Start of Care Assessment, dated 3/27/2025, the OASIS Start of Care Assessment was signed by the OW and by Consultant 1. During a review of Patient 8’s Home Health Certification and Plan of Care, for the certification episode of 3/27/2025 to 5/25/2025, the Home Health Certification and Plan of Care had no nurse’s signature and no physician’s signature to indicate that a Registered Nurse received the physician’s orders, and a physician reviewed the Home Health Certification and Plan of Care. During a review of Patient 8’s clinical records on 5/13/2025, the Nurses Notes section in the electronic health record indicated there were 0 (zero) notes entered for the certification episode of 3/27/2025 to 5/25/2025. The Nurses Notes section indicated “empty category.” b. During a review of Patient 9’s SOC Worksheet, the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 9’s OASIS Start of Care Assessment, dated 4/7/2025, the OASIS Start of Care Assessment was not signed. On 5/13/2025, during a review of Patient 9’s Home Health Certification and Plan of Care, for the certification episode of 4/7/2025 to 6/5/2025, the Home Health Certification and Plan of Care was not completed. The sections for the patient’s diagnosis, medications, DME (Durable Medical Equipment, any medical equipment used in the home to aid in a better quality of living) and supplies, safety measures, nutritional requirements, allergies, mental status, prognosis, orders for disciplines and treatments including amount/frequency/duration, and goals/rehabilitation potential/discharge plans were blank. There was no nurse’s signature and no physician’s signature to indicate that a Registered Nurse received the physician’s orders, and a physician reviewed the Home Health Certification and Plan of Care. During a review of Patient 9’s clinical records on 5/13/2025, the Nurses Notes section in the electronic health record indicated there were 0 (zero) notes entered for the certification episode of 4/7/2025 to 6/5/2025. The Nurses Notes section indicated “empty category.” During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on 5/15/2025, at 2:04 p.m., LVN 1 stated she was the visiting nurse for Patient 8 and Patient 9. According to LVN 1, she visited both patients once a week. LVN 1 stated that she documented her visit notes on paper, and she would later upload them to the electronic health record, depending on how busy she was. LVN 1 stated she had access to the electronic health record. During a concurrent interview and record review with the OW on 5/15/2025, at 2:05 p.m., the OW reviewed the OASIS Start of Care Assessment for Patient 8 and Patient 9. The OW stated that she was the one who documented the OASIS Start of Care for Patient 8 and Patient 9 with the help of Consultant 1. The OW stated that neither she nor Consultant 1 had seen Patient 8 and Patient 9. The OW stated that she based the information that she put in the OASIS Start of Care Assessment on the Registered Nurse (RN) who admitted the patients and conducted the comprehensive assessment. The OW stated that she and Consultant 1 were not RNs. The OW was not able to provide the full name, contact information, or contract/agreement she had for Consultant 1. The OW stated that Consultant 1 “only worked for a week.” The OW stated she did not know Consultant 1’s full name. When the OW was requested to provide the surveyor with the comprehensive assessment done by the RN for Patient 8 and Patient 9, the OW was not able to provide the RN assessment for Patient 9. The OW stated that RN 2, who conducted the start of care assessment for Patient 9, was currently on vacation and was unavailable. The OW stated that RN 2 had Patient 9’s start of care assessment with her, as it was paper based. RN 2 was not listed in the staff list provided to the survey team. During a review of clinical records on 5/13/2025, there were no nursing visit notes available for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 on the electronic health record. During an interview with the OW on 5/15/2025 at 3:05 p.m., the OW that Licensed Vocational Nurse 1 (LVN 1) endorsed to her (OW) the patient’s information over the phone, which the OW then transcribed into the nursing visit note. The OW stated that has always been the practice of the HHA. Per OW, she entered the nursing visit notes for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. The OW acknowledged she was not a clinician. c. During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/15/2025 of Patient 10’s records indicated the presence of an OASIS assessment. The OASIS E1 transfer document indicated Patient 10 was hospitalized for the reason of dehydration, and an RN had completed the assessment on 5/10/2025. Further review of the record did not indicate a signature to indicate who had completed the document. A record review on 5/15/2025 of Patient 10’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 3/28/2025 to 5/26/2025. A record review of Patient 10’s nursing visit notes indicated visits were made on 4/2/2025, 4/9/2025, 4/16/2025, 4/23/2025, 4/30/2025, and 5/7/2025. None of these visit notes were signed by the author of the note. During an interview on 5/15/2025, at 1:56 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she had all of Patient 10’s nursing notes at her home. LVN 1 stated she wrote her visit notes on paper, then put them in the EMR. LVN 1 stated she tried to put the notes in the EMR the same day or the next day the latest. LVN 1 stated she thought she had entered Patient 10’s notes into the EMR, but would have to double check. d. During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). A record review on 5/15/2025 of Patient 11’s records indicated the presence of an unsigned plan of care titled, Home Health Certification and Plan of Care, for certification period 4/7/2025 to 6/5/2025. A record review of Patient 11’s nursing visit notes indicated visits were made on 4/10/2025, 4/14/2025, 4/17/2025, 4/22/2025, 4/19/2025, and 5/6/2025. None of these visit notes were signed by the author of the note. e. During a review of Patient 12’s SOC Worksheet, the SOC Worksheet indicated that Patient 12 was admitted to the HHA on 4/9/2025, with diagnosis of chronic pain syndrome. A record review of Patient 12’s nursing visit notes indicated visits were made on 4/12/2025, 4/15/2025, 4/18/2025, 4/25/2025, 5/2/2025, and 5/9/2025. None of these visit notes were signed by the author of the note. A record review of the HHA’s undated document titled, Contents of Medical records, indicated, “2. Documentation Standards: Entries must be legible, dated, times, and signed with credentials...Documentation should be completed within 24-48 hours of the visit or service, depending on urgency.” A record review of the HHA’s undated document titled, Job Description Summary for the Clinical Director/Director of Patient Care Services, indicated the job responsibilities included: oversees the maintenance of patient clinical records, statistics, reports and records for purposes of evaluation and reporting of organization activities; assures proper maintenance of clinical records in compliance with local, state and federal laws.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to ensure the safeguarding of clinical records against unauthorized access or loss for five of five sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential to result in the patients’ protected health information (PHI, any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) being accessed or used by unauthorized personnels, and loss of clinical records. a. During a review of Patient 8’s SOC Worksheet (Start of Care Worksheet, a document used by the HHA that contains patient’s personal information such as name, date of birth, insurance, primary physician, diagnosis, and the date the patient was admitted to the HHA), the SOC Worksheet indicated that Patient 8 was a fifty five-year-old female, who was admitted to the HHA on 3/27/2025, with diagnosis that included radiculopathy (occurs when a nerve root in the spine is compressed or irritated, which can lead to symptoms like pain, weakness, numbness, or tingling in the area served by the affected nerve), lumbar (the area of the spine between the thoracic [chest] area and the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) region and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 8’s OASIS Start of Care Assessment, dated 3/27/2025, the OASIS Start of Care Assessment was signed by the OW and by Consultant 1. During a review of Patient 8’s clinical records on 5/13/2025, the Nurses Notes section in the electronic health record indicated there were 0 (zero) notes entered for the certification episode of 3/27/2025 to 5/25/2025. The Nurses Notes section indicated “empty category.” b. During a review of Patient 9’s SOC Worksheet, the SOC Worksheet indicated that Patient 9 was an eighty one-year-old female, who was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose), essential hypertension (high blood pressure where the cause is not definitively known), and Alzheimer’s disease (a progressive, irreversible brain disorder that destroys nerve cells and damages the brain, which causes a gradual decline in memory, thinking, and behavior). During a review of Patient 9’s OASIS Start of Care Assessment, dated 4/7/2025, the OASIS Start of Care Assessment was not signed. During a concurrent interview and record review with the OW on 5/15/2025, at 2:05 p.m., the OW reviewed the OASIS Start of Care Assessment for Patient 8 and Patient 9. The OW stated that she was the one who documented the OASIS Start of Care for Patient 8 and Patient 9 with the help of Consultant 1. The OW stated that neither she nor Consultant 1 had seen Patient 8 and Patient 9. The OW stated that she based the information that she put in the OASIS Start of Care Assessment on the Registered Nurse (RN) who admitted the patients and conducted the comprehensive assessment. The OW stated that she and Consultant 1 were not RNs. The OW was not able to provide the full name, contact information, or contract/agreement she had for Consultant 1. The OW stated that Consultant 1 “only worked for a week.” The OW stated she did not know Consultant 1’s full name. When the OW was requested to provide the surveyor with the comprehensive assessment done by the RN for Patient 8 and Patient 9, the OW was not able to provide the RN assessment for Patient 9. The OW stated that RN 2, who conducted the start of care assessment for Patient 9, was currently on vacation and was unavailable. The OW stated that RN 2 had Patient 9’s start of care assessment with her, as it was paper based. RN 2 was not listed in the staff list provided to the survey team. c. During a review of Patient 10’s SOC Worksheet, the SOC Worksheet indicated that Patient 10 was admitted to the HHA on 3/28/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). During an interview on 5/15/2025, at 1:56 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she had all of Patient 10’s nursing notes at her home. LVN 1 stated she wrote her visit notes on paper and then put them in the EMR. LVN 1 stated she tried to put the notes in the EMR the same day or the next day the latest. d. During a review of Patient 11’s SOC Worksheet, the SOC Worksheet indicated that Patient 11 was admitted to the HHA on 4/7/2025, with diagnosis that included type 2 diabetes mellitus (a chronic condition that occurs when the body cannot use insulin correctly and glucose [sugar] builds up in the blood) with hyperglycemia (excessively high blood glucose). On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of paper documents used by the nurse for the start of care of Patient 11. There was no paper consents present at the HHA. e. During a review of Patient 12’s SOC Worksheet, the SOC Worksheet indicated that Patient 12 was admitted to the HHA on 4/9/2025, with diagnosis of chronic pain syndrome. On 5/13/2025, 5/14/2025, and 5/15/2025, there was no evidence of paper documents used by the nurse for the start of care for Patient 12. There was no paper consents present at the HHA. During an interview with the Owner (OW) on 5/13/2025, at 12:53 p.m., when the OW was asked how the HHA maintained the patients’ clinical records, the OW stated there were no paper documents in the HHA’s office for Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12. The OW stated that all records were either uploaded into the electronic health records (EMR) or in her e-mail. During an observation on 5/13/2025 at 12:54 p.m., the OW called Registered Nurse 1 (RN 1) on the cell phone and placed the call on speaker. The OW inquired about the patients’ consent forms. RN 1 told the OW that he had all the consents with him and would bring to the HHA today, 5/13/2025. During an interview on 5/15/2025, at 10:41 a.m., RN 1 stated he brought the admission paperwork and patients consents to the office within 2 days of the start of care. RN 1 stated he gave the documents to the OW, then someone puts in in the EMR. RN 1 stated he did not know who documents into the patients’ EMR. During an interview with the OW on 5/15/2025, at 2:55 p.m., the OW stated the plan of care (POC) for Patient 9, Patient 10, and Patient 11 was uploaded to the EMR on the evening of 5/14/2025 with the help of a consultant. The OW stated the consultant gave her the information for the POC by e-mail, which she then transcribed to the EMR of Patient 9, Patient 10, and Patient 11. The OW stated she also received help from her other friends for the POC. The OW stated the consultant was not a Registered Nurse. A record review of the HHA’s undated document titled, Safeguarding of Medical Records, indicated that the HHA shall maintain all patient medical records in a secure, confidential, and retrievable manner. Medical records shall be protected against loss, unauthorized access, alteration, or destruction and retained in accordance with state and federal laws...Physical Safeguards: Medical records in paper form are stored in locked file cabinets or secured rooms with restricted access...Access is limited to authorized personnel only...Electronic Safeguards: Electronic Health Records (EHRs) are maintained in a secure, encrypted system with role-based access. User IDs and passwords are required for all access to electronic records.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey, conducted from 2/11/2025 to 2/13/2025. Complaint Number: 112075 Active Patients- 5 Unduplicated admissions: 7 Sample Size - 7 Home visits – 3 The following Condition of Participation not met: 484.55 Comprehensive assessment of patients 484.110 Clinical records

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: a. The Home Health Agency (HHA) failed to assess the patient's continuing need for home care services for two of 7 sampled patients (Patient 1 and Patient 2). This deficient practice resulted in the continued certification of the patients to receive the skilled nursing (SN) services. (Refer to G532) b. The HHA failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) for two of seven sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. (Refer to G544). The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all certified patients for home health services receive the highest quality of patient care. 1. The HHA failed to ensure a registered nurse completed the initial patient assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4). This deficient practice can result in the patient’s needs not being identified and assessed thoroughly and had the potential in the provision of poor-quality nursing care necessary to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agency’s care. (Refer to G514) 2. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor-quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520) 3. The HHA failed to assess the patient's continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6). This deficient practice resulted in the provision of an unnecessary home health services to the patient who do not need skilled nursing services. (Refer to G532) 4. The HHA failed to maintain an accurate, current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536) 5. The HHA failed to update the comprehensive assessment for two of seven sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. This deficient practice had the potential to result in Patient 1 and Patient 2’s identified needs not being met. (Refer to G544) The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all patients certified for home health services receive the highest quality of patient care in a safe environment. 1. The HHA failed to ensure the registered nurse completed the initial comprehensive assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4). This deficient practice has the potential to result in the patient’s immediate care needs will not be identified and assessed to formulate the individualized plan of care (POC) needed for the patient's certification to receive the Medicare home health services. (Refer to G514) 2. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor-quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520) 3. The HHA failed to assess the patient's continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6). This deficient practice resulted in the continued provision of the skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. (Refer to G532) 4. The HHA failed to maintain an accurate, current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536) 5. The HHA failed to update the comprehensive assessment for two of 7 sampled patients, (Patient 1 and Patient 2) after a certification for another 60 days of continuous skilled nurse services. This deficient practice had resulted in the recertification of these patients for home health services lacking the documented evidence of an updated comprehensive assessments that clearly demonstrate the continuing provision of the Medicare home health benefits. (Refer to G544) The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure all patients certified for home health services receive the highest quality of patient care in a safe environment.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a registered nurse (RN) completed the initial comprehensive assessment within 48 hours of the physician’s referral and/or the start of care for one of 7 sampled patients (Patient 4). This deficient practice has the potential to result in the patient’s immediate care needs will not be identified and assessed to formulate the individualized plan of care (POC) needed for the patient's certification to receive the Medicare home health services. Findings: During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 2/5/2025. During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4's diagnoses included stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). Patient 4 was wheelchair dependent and was referred for home health services to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025. During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse (RN) conducted Patient 4's initial assessment 4 in the morning of 2/12/2025, or 1 week after the SOC. During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence of Patient 4’s RN initial assessment visit and stated it was not available for review. The DPCS stated the initial RN assessment should be conducted within 48 hours of the physician’s referral to determine and assess the needs of the patient. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or another authorized licensed practitioner).

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. Findings: During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) of 2/5/2025. During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4 had a diagnosis including stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). Patient 4 had dependence on wheelchair and was referred for home health services for the nurse to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025. During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse (RN) conducted the initial assessment of Patient 4 in the morning of 2/12/2025, or 1 week after the SOC. During a concurrent interview and record review on 2/13/2025 at 12:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence Patient 4’s RN comprehensive assessment was completed and stated it was not available for review. The DPCS stated the patient’s comprehensive assessment should be conducted, completed and available for review within 5 days from the start of care. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patients' continuing need for home care services for four of 7 sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6). This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. c. During a review of Patient 5's Face Sheet, the Face Sheet indicated a SOC date of 11/1/2024. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 11/1/2024 to 12/30/2024, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. The goals and outcomes included patient’s blood pressure will be maintained within established parameters without signs and symptoms (s/sx) of hypotension (low blood pressure) or hypertension (high blood pressure) with compliance to prescribed medication, will demonstrate knowledge of medication and diet, and will remain safe at home, free from fall/injury/hospitalization throughout the certification period. Discharge planning indicated to discharge patient under self/caregiver’s assistance with regular MD (physician) follow-up when all goals were met, when medical condition was stable and patient no longer in need of skilled services. During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 5 she goes visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and can managed her medication and diet regimen independently. Patient 5 stated she does not have a caregiver or needed one. During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 5’s clinical records. The DPCS stated Patient 5’s blood pressure and vital signs were within normal parameters, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 5 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 5 should have been discharged because her goals have been met and there was no need for skilled nursing services. d. During a review of Patient 6's Face Sheet, the Face Sheet indicated a SOC date of 9/30/2024. During a review of Patient 6’s Home Health Certification and POC for the certification period from 9/30/2024 to 11/28/2024, the POC indicated Patient 6’s diagnosis which included spondylosis (age-related wear and tear of the spinal disks), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. The goals included patient will demonstrate fair to moderate improvement on functional abilities, will maintain vital signs within normal parameters, skin integrity will remain intact, will demonstrate compliance with medication and diet, and will be free from falls/injuries/hospitalizations. Discharge planning indicated to discharge patient under self/caregiver’s assistance with regular MD (physician) follow-up when all goals were met, when medical condition was stable and patient no longer in need of skilled services. During a phone interview, on 2/13/2025 at 9:15 a.m., Patient 6 stated she was doing fine. During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 6’s clinical records. The DPCS stated Patient 6’s vital signs were within normal parameters, that she had no recent admissions to the hospital, no episodes of falls, no documented evidence of wound care treatment, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 6 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 6 should have been discharged at the end of the first benefit period because her goals have been met and there was no need for skilled nursing services. During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, dated April 2020, the P&P indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable. a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 11/28/2024 to 1/26/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a phone interview, on 2/12/2025 at 2:30 p.m., with family member (FM 1), FM 1 stated Patient 1 was able to ambulate using a walker, goes to visit his physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and manages his own medications. During a concurrent interview and record review, on 2/13/2025 at 12:50 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 11/28/2024 to 1/26/2025, Patient 1’s vital signs were within normal range, that he had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 1 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 1 should have been discharged because his goals have been met and there was no need for skilled nursing services. b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period from 11/20/2024 to 1/18/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a phone interview, on 2/12/2025 at 2:30 p.m., with family member (FM 1), FM 1 stated Patient 2 was able to ambulate without using any assistive device and drives a car to do errands, goes to visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and manages her own medications. During a concurrent interview and record review, on 2/13/2025 at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 11/20/2024 to 1/18/2025, Patient 2’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 2 should have been discharged because his goals have been met and there was no need for skilled nursing services. During a review of the agency’s undated policy and procedure (P&P) titled, Patient Discharge Process, the P&P indicated discharge planning is initiated for every home care patient at the time of the patient’s admission for home care. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. Criteria for discharge may include but are not limited to the following: the patient has reached defined goals and is no longer in need of home care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 5). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 5's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) of 11/1/2024. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 12/31/2024 to 2/28/2025, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During a review of Patient 5’s current medication, on 2/12/2025 at 3:32 p.m., with LVN 1, it was noted the bottle of lorazepam (used to treat anxiety disorders) 1 milligram (mg, a unit of measurement) 1 tablet orally daily could not be found. Patient 5’s current medication list provided by the HHA indicated Patient 5 was still taking this medication. During a concurrent interview with Patient 5 stated she was not taking lorazepam daily for several months. During an interview, on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated nursing staff need to review the patient’s current medication every nurse visit and update the medication profile in the patient’s clinical record. During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, dated April 2020, the P&P indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to update the comprehensive assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) for two of seven sampled patients, (Patient 1 and Patient 2) for the continuing need for skilled nurse services. This deficient practice had resulted in the recertification of these patients for home health services lacking the documented evidence of an updated comprehensive assessment that clearly demonstrate the continuing provision of the Medicare home health benefits. a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 1/27/2024 to 3/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a concurrent interview and record review, on 2/13/2025, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated and acknowledged there was no documented evidence an updated comprehensive assessment was conducted and completed for Patient 1 to be recertified for another 60 days for continuous skilled nursing services for the period of 1/27/2025 to 3/27/2025. The DPCS further stated the comprehensive assessment should be done within the last 5 days of every 60 days of re-certification, but it was not done. b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period of 1/19/2025 to 3/19/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a concurrent interview and record review, on 2/13/2025 at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing notes, nursing assessment and the POC. The DPCS stated that for the month of 11/20/2024 to 1/18/2025, Patient 2’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. DPCS further stated Patient 2 should have been discharged because his goals have been met and there was no need for skilled nursing services. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, the P&P indicated a comprehensive patient assessment will be completed within five calendar days of the patient’s start of care. This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: 1. The last five days of every 60-day episode beginning with the start of care date (recertification) 2. Upon transfer 3. Significant change in condition resulting in a new case mix 4. Within 48 hours of the patient’s return home or of this Organization’s knowledge of the patient’s return from a 24-hour hospital admission for other than diagnostic testing, or on the physician-ordered resumption date 5. At discharge

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the Condition of Participation for Clinical Records was met as follows: a. The Home Health Agency (HHA) staff failed to submit nursing clinical notes within the timeframe as indicated in the agency's policy and procedure for two of seven sampled patients (Patient 1 and Patient 2). (Refer to G1012). b. The HHA failed to ensure the patient’s discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) was completed and filed in the clinical record for one of seven sampled patients (Patient 3). (Refer to G1022). The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure all certified patients for home health services receive the highest quality of patient care. 1. The HHA staff failed to submit nursing clinical notes and nursing assessment within the timeframe as indicated in the agency's policy and procedure for four of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). For Patient 1, Patient 2 and Patient 5, there was no documented evidence in the patient’s electronic health records that the skilled nurse (SN) submitted their visit notes in a timely manner. For Patient 4, the HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care. This failure resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. (Refer to G1012) 2. The HHA failed to follow their discharge policy by not completing the discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) within 72 hours of discharge from home health service for two of 7 sampled patients (Patient 3 and Patient 7). This deficient practice had the potential to result in miscommunication and poor hand-off, and can affect the care and services needed in the continuation of care for the affected patient. (Refer to G1022) The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure all certified patients for home health services receive the highest quality of patient care.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) staffs failed to submit nursing clinical notes within five (5) calendar days of the patient start of care as indicated in their policy and procedure for four of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). For Patient 1, Patient 2, and Patient 5 indicated no documented evidence in their electronic health records the skilled nurses (SN) submitted their visit notes within 5 days from the start of care. For Patient 4, the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was not completed within 5 days from the start of care. This failure resulted in patients' incomplete clinical records that could lead to misinformation and lack of care and services provided to the patient. Findings: c. During a review of Patient 4's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 2/5/2025. During a review of the Physician’s (MD 1) referral form, the referral form indicated Patient 4 had a diagnosis including stroke (loss of blood flow to a part of the brain), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and dependence on wheelchair, and was referred to a home health nurse to assist with medication management and daily activities to ensure safety and prevent falls. The Physician’s referral form was dated 2/3/2025. During an interview with the HHA’s Owner/CEO on 2/12/2025 at 2:15 p.m., the Owner/CEO stated the registered nurse conducted the initial assessment of Patient 4 in the morning of 2/12/2025, or 1 week after the SOC. During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 4’s clinical records. The DPCS was unable to provide documented evidence Patient 4’s comprehensive assessment was completed and stated it was not available for review. The DPCS stated the patient’s comprehensive assessment should be conducted, completed and available for review within 5 days from the start of care. d. During a review of Patient 5's Face Sheet, the Face Sheet indicated a SOC date of 11/1/2024. During a review of Patient 5’s Home Health Certification and POC for the certification period from 12/31/2024 to 2/28/2025, the POC indicated Patient 5’s diagnosis which included hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), essential hypertension (HTN-high blood pressure), and constipation (infrequent or difficult bowel movements). The POC included an order for the skilled nurse to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and patient’s response and compliance to medication and diet regimen, home safety and psychosocial adjustment. During a joint home visit, on 2/12/2025 at 3:05 p.m., at Patient 5’s residence with the licensed vocational nurse (LVN 1), Patient 5 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 5 stated she was being visited by the agency’s SN at least once a week since the SOC. During a concurrent interview and record review on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 5’s SN Clinical Visit Notes for the month of January 2025 to February 2025. The DPCS stated and confirmed the visiting nurse have not submitted their visit notes on the electronic health records from January 2025 to February 2025. The DPCS stated field nurses ideally should submit their visit notes on the day the visit was conducted, dated and timed, and signed by them, but have 5-7 days to submit in accordance with the agency’s policy. The DPCS further stated it was important to document visit notes in a timely manner to keep the patient’s status up to date so that all staff involve can see the progress of the patient. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. During a review of the agency’s P&P titled, Contents of the Clinical Record, dated April 2020, the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. The following information will be available in the clinical record for patients receiving skilled care…. Signed and dated progress notes for each discipline rendering service. Clinical notes shall be signed and incorporated into the patient’s health record at least every seven working days. a. During a review of Patient 1's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 9/29/2024, with a diagnosis of unspecified hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone). During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the re-certification period from 1/27/2025 to 3/27/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. On 2/13/2025, at 10 a.m., during a review of Patient 1's License Vocational Nurse (LVN) Visit Calendar, it indicated the last submitted LVN note was dated 2/2/2025. b. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 11/20/2024, with a diagnosis of unspecified epilepsy (a chronic brain disorder characterized by recurrent seizures, which are brief episodes of abnormal brain activity that can cause involuntary movements, loss of consciousness, or other symptom). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the certification period from 1/19/2025 to 3/25/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. On 2/13/2025, at 10:30 a.m., during a review of Patient 2's License Vocational Nurse (LVN) Visit Calendar, it indicated the last submitted LVN note was dated 1/26/2025. During an interview on 2/13/2025 at 11:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated the visit notes from LVN 1 for Patient 1 and Patient 2 were late. The DPCS further stated LVN 1 supposed to submit her visit notes within 5-7 days after each visit but has not been able to because of her workload. During a review of the agency’s undated policy and procedure (P&P) titled, Clinical Documentation, the P&P indicated agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care. Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided.

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 interview and record review, the home health agency (HHA) failed to follow their discharge policy by not completing the discharge summary (a written document by a health facility that includes the reason for discharge, the patient discharge condition, and patient and family instructions) within 72 hours of discharge from home health service for two of 7 sampled patients (Patient 3 and Patient 7). This deficient practice had the potential to result in miscommunication that can affect the care and services needed in the continuation of care for the affected patients. b. During a review of Patient 7's Face Sheet, the Face Sheet indicated a start of care date (SOC) date of 4/25/2024. During a review of Patient 7’s Home Health Certification and POC for the certification period from 10/22/2024 to 12/20/2024, the POC indicated Patient 7’s diagnosis which included spondylosis (age-related wear and tear of the spinal disks), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks to perform skilled assessment and evaluation of all body systems, assess vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and to perform medication reconciliation once a week and inform the agency of any changes in medication regimen. During a concurrent interview and record review, on 2/13/2025 at 12:45 p.m. with the DPCS, the DPCS reviewed Patient 7’s clinical records. The DPCS stated Patient 7 was discharged on 12/20/2024 due to goals have been met. The DPCS stated there was no documented evidence in Patient’ 7s electronic health record a discharge summary was completed and signed by a registered nurse. The DPCS further stated a discharge summary should have been completed on the day the patient was discharged from service and will be provided to the patient’s physician. During a review of the agency’s policy and procedure (P&P) titled, Discharge Summary, dated April 2020, the P&P indicated each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. During a review of the agency’s P&P titled, Contents of Clinical Record, dated April 2020, the P&P indicated a clinical record will be maintained for each patient receiving care. The following information will be available in the clinical record for patients receiving skilled care…. Transfer/discharge summaries and other summary reports sent to the physician, as required by law and regulation and organization policy. The discharge statement shall include the date of discharge, reason for termination of services, and condition upon discharge. During a record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a SOC date of 7/15/2024, with a primary diagnosis of alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking and other cognitive functions, eventually leading to dementia). During a record review of Patients 3’s Home Health Certification and Plan of Care (POC) for the certification period starting from 9/13/2024 to 11/24/2024, with Skilled Nurse (SN) frequency visits of once a week for nine weeks for skilled observation and assessment of all body systems, perform vital signs (measure the basic functions of your body that includes your body temperature, blood pressure [the force of your blood pushing against the walls of your arteries], pulse and respiratory [breathing] rate, pain assessment using pain scale 0-10 (0=no pain, 10=worst pain), and medication compliance and effectiveness. During a concurrent interview and record review, on 2/13/2025, at 12:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated and acknowledged there was no documented evidence a discharge summary was completed for Patient 3 when Patient 3 was discharged on 11 11/2024. The DPCS further stated a discharge summary was not done for Patient 3. During a record review of the HHA’s (undated) policy and procedure titled, “Discharge Summary,” the policy indicated that the discharge summary and other relevant clinical record documents will be completed within 72 hours of discharge from service.