Every finding on record at Split Rock Rehabilitation and Health Care Center, LLC

The following Statement of Deficiencies represents the results of a partial extended re-certification survey of Briah Home Care, located at 3525 Baychester Ave, Bronx, NY 10466 conducted on 12/01/2025 through 12/04/2025. A standard re-certification survey was initiated on 12/01/2025. Deficient practices were identified within Level 1 standards in 484.50 Patient Rights, 484.55 Comprehensive Assessment of Patients, 484.60 Care Planning Coordination of Services and Quality of Care, 484.75 Skilled Professional Services, 484.80 Home Health Aide Services and 484.110 Clinical Records resulting in a partial extended survey. The agency reported an active patient census of two (2). The survey consisted of a review of nine (9) clinical records (identified as Patient #1, #2, #3, #4, #5, #6, #7, #8 and #9) including seven (7) discharge records, two (2) active records - one (1) observational home visits - eight (8) personnel records for professional and paraprofessional personnel (identified as Employee #1, #2, #3, #4, #5, #6, #7, and #8), and three (3) contracts. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve (12) months, PIP (Performance Improvement Projects), the agency's Admission Packet, the Emergency Preparedness Plan, Complaint Log, three (3) contracts, and the agency's Infection Control and Flu policy and procedure. Pre-survey activities consisted of a review on 11/28/2025 of the agency's Health Commerce System account, Internet Quality Improvement and Evaluation System reports (iQIES), for the period 9/2024 to 8/2025, the agency compliance with report submissions for the 2023 Statistical Report and the Emergency Drill for 2019. The Administrator and Director of Patient Services were interviewed. Findings were reviewed at the exit conference on 12/04/2025. The following deficiencies were identified as a result of the survey G - 0434 Participate in care G - 0436 Receive all services in plan of care G - 0528 Health, psychosocial, functional, cognition G - 0536 A review of all current medications G - 0572 Plan of care G - 0574 Plan of care must include the following G - 0580 Only as ordered by a physician G - 0584 Verbal orders G - 0590 Promptly alert relevant physician of changes G - 0610 Patients receive education and training G - 0706 Interdisciplinary assessment of the patient G - 0710 Provide services in the plan of care G - 0798 Home health aide assignments and duties G - 0800 Services provided by HH aide G - 0818 HH aide supervision elements G - 1022 Discharge and transfer summaries G - 1024 Authentication J - 1444 Personnel

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patients were properly informed of the changes in the services to be provided and given the opportunity to participate in revising their plan of care. This was evident for two (2) of nine (9) clinical records reviewed (Patient: #5 and #8). Failure to ensure that patients were properly informed of the changes in the services to be provided and given the opportunity to participate in revising their plan of care, has the potential for negative patient outcomes. The Findings Are: 1.Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The Supplemental Orders from 03/28/2025 to 05/12/2025 document the following orders: 04/15/2025 PT 2 x week x 4 weeks discontinued on 05/12/2025 and 04/15/2025 OT 2 x week x 4 weeks discontinued on 05/12/2025 (starting the week of 04/15/205, Physical Therapy for 2 (two) visits per week, for 4 (four) weeks, to be discontinued on 05/12/2025 and starting the week of 04/15/2025 Occupational Therapy for 2 (two) visits per week, for 4 (four) weeks, to be discontinued on 05/12/2025). The clinical record documents the patient’s Physical Therapy and Occupational Therapy visits starting on 04/25/2025. There is no documented evidence of the agency informing the patient about the change in services including when Physical Therapy and Occupational Therapy would begin. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of Right Artificial Knee Joint, Essential (Primary) Hypertension, Unspecified Asthma, Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The Supplemental Orders from 02/04/2025 to 03/28/2025 document the following Physical Therapy (PT) orders: 02/12/2025 PT 2 x week x 4 weeks discontinued on 03/11/2025 (starting 02/12/2025, Physical Therapy for 2 (two) times a week, for 4 (four) weeks and to be discontinued on 03/11/2025). The Omit/Missed Visits dated 02/12/2025, 02/18/2025, 02/20/2025, and 02/21/2025 documents: "Therapist out sick with the flu, services to resume when therapist no longer ill.” There is no documented evidence of the agency informing the patient of a change in services including the Physical Therapy visits could not be provided. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patients receive all services as outlined in their individualized plan of care. This was evident for two (2) of nine (9) clinical records reviewed (Patient: #5 and #8). Failure to ensure that patients receive all services outlined in their individualized plan of care, has the potential for negative patient outcomes. The Findings Are: 1.Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular disease, unspecified, Essential (primary) Hypertension, Other abnormalities of gait and mobility, and Vascular dementia, unspecified severity, without behavioral disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The agency’s work week is Sunday to Saturday. The Supplemental Orders from 03/28/2025 to 05/12/2025 document the following orders: 04/15/2025 PT 2 x week x 4 weeks discontinued on 05/12/2025 and 04/15/2025 OT 2 x week x 4 weeks discontinued on 05/12/2025 (starting the week of 04/15/205, Physical Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025 and starting the week of 04/15/2025, Occupational Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025). There is no documented evidence of two (2) Physical Therapy and two (2) Occupational Therapy visits during the work week from 04/12/2025 to 04/18/2025 as ordered. The work week from 04/19/2025 to 04/25/2025 documents one (1) Physical Therapy visit on 04/25/2025 and one (1) Occupational Therapy visit on 04/25/2025. There is no documented evidence of a total of two (2) Physical Therapy and Occupational Therapy visits as ordered. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to underlying condition with foot ulcer, Unspecified atrial fibrillation, and Essential (primary) hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The Supplemental Orders from 02/13/2025 to 03/11/2025 documents the following Skilled Nursing (SN) orders: 02/26/2025 SN 2 x week x 2 weeks discontinued on 03/11/2025 (starting 02/26/2025 SN visits 2 times a week for 2 weeks, and to be discontinued on 03/11/2025). The agency’s work week is Sunday to Saturday. The work week beginning 02/23/2025 to 03/01/2025 documents one SN visit on 02/27/2025. There is no documented evidence of a total of two (2) SN visits as ordered. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the comprehensive assessment accurately reflect the patient's status. This was evident for 1 (one) of 9 (nine) clinical records reviewed (Patient #9). Failure to ensure the patients comprehensive assessment accurately reflect the patient's status has the potential risk for negative patient outcomes. The Findings are: 1.Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (Congestive) Heart Failure, Acute Pancreatitis Without Necrosis or Infection, Unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Physical Therapy Evaluation and Therapy Plan of Care dated 7/11/2025 documents: Primary Diagnosis: CVA (R) (Cerebral Vascular Accident, Right) Hemiplegia (L) (Left). Past Medical History: Pt (Patient) had a stroke in May 2025, went to SNF (Skilled Nursing Facility). The Progress note dated 6/24/2025 from the Rehabilitation Center documents: This is a 30-day follow-up of this patient who was admitted on 5/23/2025 following treatment at …Hospital for Pancreatitis. The Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025 documents: Nutritional Requirement: Mechanical Soft, Aspiration Precaution, Fluids provided with medication included in fluid restriction. No concentrated sweets. The Physician’s Order (Rehabilitation Discharge Orders) dated 07/03/2025 documents: 1500 ml (fifteen hundred milliliter) fluid restriction daily. The SN (Skilled Nurse) Routine Visit dated 07/15/2025 documents: Nutrition Education; ...Prescribed diet: low sodium, 1800 ADA (American Diabetic Association) frequent fluids. The HHA (Home Health Aide) Supervisory Visit Report and the Home Health Aide Plan of Care dated 7/11/2025 documents: Diet: Diabetic. There is no documented evidence of the patient with a diagnosis of Cerebral Vascular Accident, Right or Hemiplegia (L) (Left). The Physical Therapy Evaluation and Therapy Plan of Care lacks documented evidence of an accurate assessment and documentation of the patient’s current health status. The SN (Skilled Nurse) Routine Visit, HHA (Home Health Aide) Supervisory Visit Report and the Home Health Aide Plan of Care lacks documented evidence of a complete and accurate assessment and documentation of the patient’s current health status and health requirement. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications were accurately reviewed, reconciled and correctly documented in the patient's clinical record. This was evident for 4 (four) of 9 (nine) clinical records reviewed (Patients #1, #2, #3 and #9). Failure to ensure that all medications are accurately reviewed, reconciled and correctly documented in the patient's clinical record has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, and Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Printed Medication List as of 12/01/2025 documents: Metoprolol Tartrate by mouth Tablet 25 mg (milligram) 1 tablet twice a day PO (by mouth), Acetaminophen by mouth tablet 325 mg (milligram) tablet every 6 hours as needed PO (by mouth), Senna tablet 8.6 mg (milligram) 2 tablet daily as needed PO; Miralax powder 17 Gms/scoop (grams) 1 gram twice a day PO (by mouth); Vitamin D3 Tablet 25 mcg (microgram) (1000 units) 1 tablet daily as needed PO (by mouth) Special Instructions: every week on Wednesday at 9:00 AM. On 12/01/2025 at 02:03 PM a home visit was conducted, the Surveyor reviewed the patient’s medication that includes: Benzonatate with fill date 11/25/2025, Metoprolol Tartrate tablet 25 mg (milligram) ½ tablet twice a day PO (by mouth), Acetaminophen tablet 325 mg (milligram) 2 tablet every 6 hours as needed PO (by mouth), Vitamin D3 1,000 units was in the home with no label with the patient's name or instructions on how to take. The patient’s daughter was interviewed and state: "She has not taken Senna and Miralax since returning home; and is only taking Tylenol 325 milligram twice a day for pain. She is taking Vitamin D3 daily.” The clinical record lacks documented evidence of all current medications being accurately reviewed and reconciled for Vitamin D3, Metoprolol, Benzonatate, Tylenol and the discontinuation of Miralax and Senna. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care (SOC) date of 11/10/2025 with the following diagnoses: Chronic Respiratory Failure, Type 2 Diabetes Mellitus and Heart Failure as documented in the Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026. The Referral documents: Current medication Pantoprazole Sodium 20 mg (milligram) Oral Tablet Delayed Release 1 tablet daily oral and Famotidine 20 mg (milligram) Oral Tablet 1 tablet daily oral. The plan of care lacks documented evidence of the medications Pantoprazole and Famotidine. There is no documented evidence of the medication review and reconciliation. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses: Type 2 Diabetes Mellitus, Muscle Weakness, and Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The referral documents medication list include Tamsulosin 24 hr (hour) capsule 0.4 mg (milligram) Frequency: nightly Route: oral. The plan of care lacks documented evidence of the medication Tamsulosin. There is no documented evidence of the medication review and reconciliation. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (congestive) Heart Failure, Acute pancreatitis without necrosis or infection, Unspecified, Essential (primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Physician’s Order (Rehabilitation Discharge Orders) dated 07/03/2025 documents: Magnesium Oxide 400mg (241.3mg magnesium) tablet, give 2 (two) tablets by oral route 2 (two) times per day. The Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025 documents: Magnesium Oxide -mg (milligrams) Supplement by mouth capsule 400mg 1 tablet twice a day PO (by mouth). There is no documented evidence the Plan of Care includes an accurate order for the following medication: Magnesium Oxide 400 mg (milligrams) 2 (two) tablets twice a day. The clinical record lacks documented evidence of all current medications being accurately reviewed and reconciled. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the patients receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals . This was evident for 5 (five) of 9 (nine) clinical records reviewed (Patient #1, #3, #4, #8 and #9). Failure to ensure the patients received the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals has the potential risk for negative patient outcomes. The Findings are: 4. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of right artificial knee joint, Essential (primary) hypertension, Unspecified asthma, Type 2 diabetes mellitus without complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The Supplemental Orders from 02/04/2025 to 03/28/2025 documents the following Physical Therapy (PT) orders: 02/12/2025 PT 2 x week x 4 weeks discontinued on 03/11/2025 (starting 02/12/2025, PT for 2 times a week, for 4 weeks and to be discontinued on 03/11/2025). The Omit/Missed Visits dated 02/12/2025, 02/18/2025, 02/20/2025, and 02/21/2025 documents, “Therapist out sick with the flu, services to resume when therapist no longer ill.” There is no documented evidence of the agency attempting to re-schedule the Physical Therapy visits due to the Physical Therapist being sick. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses "Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Other Muscle Spasm" documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025 documents: PT (physical therapist) 1 x week x 1 week (once a week for one week). The Supplemental Orders from 10/15/2025 to 11/18/2025 documents: 10/22/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/18/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses "Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia" documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025 documents: PT (physical therapist) 10/10/2025 1 x week x 1 week (once a week for one week). The Supplemental Orders from 10/15/2025 to 11/13/2025 documents: 10/17/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/13/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses "Hemiplegia affecting Right Dominant Side, Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025 documents: PT (physical therapist) 02/27/2025 1 x week x 1 week (once a week for one week). The Supplemental Orders from 02/28/2025 to 04/06/2025 documents: 03/10/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 04/06/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 5. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (congestive) Heart Failure, Acute pancreatitis without necrosis or infection, Unspecified, Essential (primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025 documents: HHA 7/11/2025 5 X week x 2 weeks 4 hr duration (Home Health Aide 7/11/2025 five days a week for two weeks, four hours each day). Duty Sheets were requested for the period 7/11/15 to 7/24/2025. None were received from 7/12/2025 to 7/24/25. The Supplemental Orders dated 7/11/2025 to 8/11/1025 documents: PT (Physical Therapy) 2 X week X 4 weeks (two times a week for three weeks) discontinued on 8/11/2025. The Physical Therapy Evaluation and Therapy Plan of Care dated 7/11/2025 documents: Establish and Upgrade Home Exercise Program. A copy of the Home Exercise Program was requested. None was provided. The clinical care record lacks documented evidence of the patient receiving HHA (Home Health Aide) services from 7/12/2025 to 7/24/25. The Supplemental Orders lack documented evidence of an Intervention and Plan of Care specific to the patient’s care need. The clinical record lacks documented evidence of the Home Exercise Program including the frequency of the repetitions and sets of each exercise, and the pertinent instructions related to the patient's care and treatment that the HHA (Home Health Agency) will provide, specific to the patient's care needs. 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025 documents: PT (physical therapist) 1 x week x 1 week (once a week for one week). The Supplemental Orders from 10/15/2025 to 11/18/2025 documents: 10/22/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/18/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025 documents: PT (physical therapist) 10/10/2025 1 x week x 1 week (once a week for one week). The Supplemental Orders from 10/15/2025 to 11/13/2025 documents: 10/17/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/13/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses "Hemiplegia affecting Right Dominant Side, Abnormalities of Gait and Mobility as documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025 documents: PT (physical therapist) 02/27/2025 1 x week x 1 week (once a week for one week). The Supplemental Orders from 02/28/2025 to 04/06/2025 documents: 03/10/2025 PT (physical therapist) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 04/06/2025. The plan of care lacks documented evidence of the physical therapy patient-specific measurable outcomes and goals. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. There is no documented evidence of patient receiving services as written in the plan of care. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings. 4. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of right artificial knee joint, Essential (primary) hypertension, Unspecified asthma, Type 2 diabetes mellitus without complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The Supplemental Orders from 02/04/2025 to 03/28/2025 documents the following Physical Therapy (PT) orders: 02/12/2025 PT 2 x week x 4 weeks discontinued on 03/11/2025 (starting 02/12/2025, PT for 2 times a week, for 4 weeks and to be discontinued on 03/11/2025). The Omit/Missed Visits dated 02/12/2025, 02/18/2025, 02/20/2025, and 02/21/2025 documents, “Therapist out sick with the flu, services to resume when therapist no longer ill.” There is no documented evidence of the agency attempting to re-schedule the Physical Therapy visits due to the Physical Therapist being sick. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all pertinent information is included in the patient's individualized plan of care. This was evident for 7 (seven) of 9 (nine) clinical records reviewed (Patient #1, #2, #3, #4, #5, #6, and #8). Failure to ensure that all pertinent information is included in the patient's individualized plan of care has the potential risk for negative patient outcomes. The Findings are: 5. Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. Th Home Health Certification and Plan of Care (medical orders) from 03/19/2025 to 05/17/2025 documents the following orders: PT 03/20/2025 1 x week x 1 week, and OT 03/20/2025 1 x week x 1 week (Physical Therapy starting 03/20/2025 for one visit, for one week and Occupational Therapy starting 03/20/2025 for one visit, for one week). The Supplemental Orders from 03/28/2025 to 05/12/2025 documents the following orders: 04/15/2025 PT 2 x week x 4 weeks discontinued on 05/12/2025 and 04/15/2025 OT 2 x week x 4 weeks discontinued on 05/12/2025 (starting the week of 04/15/205, Physical Therapy for 2 (two) visits per week, for 4 (four) weeks, to be discontinued on 05/12/2025 and starting the week of 04/15/2025 Occupational Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025). The Plan of Care lacks documented evidence of including the treatments, interventions and education that are to be provided by the Physical Therapist and Occupational Therapist. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 6. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) as documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025 (medical orders) documents the following PT (Physical Therapy) orders: PT 10/17/2025 1 x week x 1 week (Physical Therapy starting 10/17/2025, for 1 visit for 1 week). The Supplemental Orders from 10/17/2025 to 11/17/2025 document the following PT (Physical Therapy) orders: 10/21/2025 PT 2 x week x 4 weeks discontinued on 11/17/2025 (starting the week of 10/21/2025, Physical Therapy for 2 visits per week, for 4 weeks, and to be discontinued on 11/17/2025) and PT eval (Physical Therapy evaluation) visit 10/17/2025, Therapist requested 8 follow up visits. MD (Medical Doctor) made aware. The Plan of Care lacks documented evidence of including the treatments, interventions and education that are to be provided by the Physical Therapist. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. The agency “Wound Care Policy and Procedure, Policy No. 2-034.4” with a revised date of 09/03/2025 documents, “Responsibilities, Registered Nurse (RN): Conducts initial and ongoing wound assessment, develops and updates care plans, and communicates changes to the physician,” and “Measurement: Wounds are measured weekly by the same RN.” The RN visit notes dated 10/23/2025, 10/27/2025 and 10/30/2025 documents the patient has two wounds on the right heel. The RN visit notes dated 10/23/2025, 10/27/2025 and 10/30/205 documents one of the right heel wounds as “pressure ulcer stage: stage 2” and “incision/wound tissue observed: slough % (percentage) ¼ (one quarter),” and no documented evidence of weekly wound measurements for this wound. The Plan of Care lacks documented evidence of including assessing the patient’s wounds and weekly measurements. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 7. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of Right Artificial Knee Joint, Essential (Primary) Hypertension, Unspecified Asthma, Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025 documents the following Physical Therapy (PT) orders: PT 02/03/2025 1 x week x 1 week (Physical Therapy starting 02/03/2025 times one visit, times one week). The Supplemental Orders from 02/04/2025 to 03/28/2025 documents the following Physical Therapy (PT) orders: 02/12/2025 PT 2 x week x 4 weeks discontinued on 03/11/2025 (starting 02/12/2025, PT (Physical Therapy) visits 2 times a week, for 4 weeks and to be discontinued on 03/11/2025). The Plan of Care lacks documented evidence of including the treatments, interventions and education that are to be provided by the Physical Therapist. The Plan of Care lacks documented evidence of including a description of the patient’s risk for emergency department visits and hospital re-admission. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025 documents: Nutritional requirement: NCS (no concentrated sweet). The Charts / Clinical Notes documents: 10/15/2025 BS (blood sugar) today was 114 non-fasting. 10/23/2025 BS (blood sugar today was 169 non-fasting. 10/29/2025 BS (blood sugar) today was 108 non-fasting. 11/21/2025 BS (blood sugar) today was 150 non-fasting. The plan of care lacks documented evidence of the vital sign parameter, diagnosis of Diabetes Mellitus, frequency of fingerstick monitoring with the parameter, a description of the patient’s risk for emergency department visits and hospital re-admission. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care (SOC) date of 11/10/2025 with the following diagnoses of Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Heart Failure as documented in the Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026. The Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026 documents: Patient is required to check BS (blood sugar) every other day. The SN (skilled nurse)- Nursing Start of Care dated 11/10/2025 documents: Respiratory Frequency of Oxygen Use: continuous, Method of Oxygen Delivery: Cannula, and Liter Flow Per Minute: At rest: 2.5L (liters). The plan of care lacks documented evidence of the parameter for the blood sugar, the order for Oxygen, and the date registered nurse made the plan of care/medical orders. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The referral dated 10/09/2025 documents: PMH (primary medical history) Achalasia s/p (status post) multiple Botox procedures, DM (Diabetes Mellitus), COPD (Chronic Obstructive Pulmonary Disease), CKD (Chronic Kidney Disease) who presents for worsening Dysphagia x 1wk (times one week). The plan of care lacks documented evidence of the vital signs parameter, diagnosis of Achalasia and Dysphagia, the date the registered nurse made the plan of care/medical orders, and a description of the patient’s risk for emergency department visits and hospital re-admission. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses of Hemiplegia Affecting Right Dominant Side, Abnormalities of Gait and Mobility as documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Service Authorization dated 02/17/2025 documents: Primary Diagnosis: Personal History of Traumatic Brain Injury. The plan of care lacks documented evidence of the vital signs parameter, diagnosis of Traumatic/Brain Injury, and a description of the patient’s risk for emergency department visits and hospital re-admission. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications, services and treatments are provided in accordance with the orders of a physician or allowed practitioner. This was evident for 4 (four) of 9 (nine) clinical records reviewed (Patient #5, #6, #7 and #9). Failure to ensure that all medications, services and treatments are provided in accordance with the orders of a physician or allowed practitioner has the potential risk for negative patient outcomes. The Findings are: 1.Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The Supplemental Orders from 03/28/2025 to 05/12/2025 documents the following orders: 04/15/2025 PT 2 x week x 4 weeks discontinued on 05/12/2025 and 04/15/2025 OT 2 x week x 4 weeks discontinued on 05/12/2025 (starting the week of 04/15/205, Physical Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025 and starting the week of 04/15/2025 Occupational Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025). The clinical record documents an Occupational Therapy visit on 05/14/2025 and a Physical Therapy visit on 05/15/2025. There is no documented evidence of orders for the Occupational Therapy and Physical Therapy visits to be conducted after the services were to be discontinued on 05/12/2025. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The clinical record documents the Home Health Aide providing home care services to the patient for four (4) hours per day on 10/21/2025 to 10/24/2025 and from 10/27/2025 to 10/31/2025. There is no documented evidence of orders for the Home Health Aide services that were provided. On 12/4/2025 at 2:00 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Unspecified Atrial Fibrillation, and Essential (Primary) Hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care (medical orders) from 02/12/2025 to 04/12/2025 documents the following wound care orders: Patient has stitch to right RLE (right lower extremity) 5th toe. Current orders are bacitracin to RLE 5th toe, cover with gauze and Kerlix daily. The Charts/Clinical Notes dated 02/19/2025, 02/27/2025, 03/03/2025, 03/06/2025, 03/10/2025, and 03/13/2025 documents the following: Current order is saline wet to dry tip of gauze into wound, cover with gauze and Kerlix daily. There is no documented evidence of a medical order changing the patient’s wound care from bacitracin to RLE 5th toe, cover with gauze and Kerlix daily, to saline wet to dry tip of gauze into wound, cover with gauze and Kerlix daily. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (Congestive) Heart Failure, Acute Pancreatitis Without Necrosis or Infection, Unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Physician’s Order (Rehabilitation Discharge Orders) dated 07/03/2025 documents: 1500 ml (fifteen hundred milliliter) fluid restriction daily. Fingerstick blood sugar TID (three times a day). Notify MD (Medical Doctor) if fingerstick blood sugar > 320mg/dl (greater than 320 (three hundred and twenty) milligrams per deciliter or

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the verbal orders in the patient's clinical record have the signature and date the orders were taken. This was evident for 3 (three) of 9 (nine) clinical records reviewed (Patients #1, #3 and #4). Failure to ensure the verbal orders in the patient's clinical record have the signature and date the orders were taken has the potential risk for negative patient outcomes. The Findings are: 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Supplemental Orders dated 10/22/2025, 10/23/2025 to 10/28/2025, 10/30/2025 to 11/04/2025, and 11/14/2025 to 12/04/2025 lack documented evidence of the signature and date of the verbal orders. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Supplemental Orders from 10/15/2025 to 11/13/2025 documents: 10/17/2025 PT (Physical Therapy) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/13/2025. The Supplemental Orders dated 10/15/2025 to 11/13/2025 lack documented evidence of the signature and date of the verbal orders. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses of Hemiplegia Affecting Right Dominant Side, Abnormalities of Gait and Mobility as documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Supplemental Orders from 02/28/2025 to 04/06/2025 documents: 03/10/2025 PT (Physical Therapy) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 04/06/2025. The Supplemental Orders dated 02/28/2025 to 04/06/2025 lack documented evidence of the signature and date of the verbal orders. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the relevant physician(s) or allowed practitioner(s) were alerted to changes in the patient's condition or needs that suggest outcomes are not being achieved and that the plan of care should be altered. This was evident for 7 (seven) of 9 (nine) clinical records reviewed (Patient: #1, #2, #3, #6, #7, #8, and #9). Failure to ensure the relevant physician(s) or allowed practitioner(s) were alerted to changes in the patient's condition or needs that suggest outcomes are not being achieved and that the plan of care should be altered has the potential risk for negative patient outcomes. The Findings are: 1. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The agency “Wound Care Policy and Procedure, Policy No. 2-034.4” with a revised date of 09/03/2025 documents, “Responsibilities, Registered Nurse (RN): Conducts initial and ongoing wound assessment, develops and updates care plans, and communicates changes to the physician." The initial Registered Nurse (RN) assessment dated 10/16/2025 and RN visit dated 10/20/2025 documents, the patient has one (1) wound, located on the right heel, measuring 4.0 centimeters in length and 4.0 centimeters wide, and the “incision/wound tissue observed: slough % (percentage) 1/4 % (one-fourth percentage), granulation % (percentage):1/3 % ( one-third percentage).” The RN visit notes dated 10/23/2025, 10/27/2025 and 10/30/2025 documents the patient has two wounds on the right heel. The RN visit notes dated 10/23/2025, 10/27/2025 and 10/30/205 documents one of the right heel wounds as “pressure ulcer stage: stage 2” and “incision/wound tissue observed: slough % (percentage) ¼ (one quarter).” The RN visit notes dated 10/23/2025, 10/27/2025 and 10/30/2025 documents the other right heel wound as “Type: pressure ulcer; pressure ulcer stage: unstageable; wound measurement: length in centimeters: 4.0 cm, width in centimeters: 4.0; and incision/wound tissues observed: other: necrotic.” There is no documented evidence of the RN informing the patient’s physician of change in the condition of the patient’s right heel wound status. On 12/04/2025 at 12:45 PM, the Director of Patient services was interviewed and stated "the patient already had that wound (with the necrotic tissue), it was not what was being treated, and there was nothing further to be done." 2. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Unspecified Atrial Fibrillation, and Essential (Primary) Hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care (medical orders) from 02/12/2025 to 04/12/2025 documents the following wound care orders: Patient has stitch to right RLE (right lower extremity) 5th toe. Current orders is bacitracin to RLE 5th toe, cover with gauze and Kerlix daily. The Charts/Clinical Notes dated 02/12/2025 documents: SN (Skilled Nurse) educated patient regarding infection control and infection control practices, verbalized understanding patient desired to leave OTA (open to air) despite wound care orders from SNF (Skilled Nursing Facility) presented at discharge. Current order is bacitracin to RLE (right lower extremity) 5th toe, cover with gauze and Kerlix daily. The Charts/Clinical Notes dated 02/19/2025, 02/27/2025, 03/03/2025, 03/06/2025, 03/10/2025, and 03/13/2025 documents the following: SN (Skilled Nurse) educated patient regarding infection control and infection control practices, verbalized understanding patient desired to leave OTA (leave wound open to air) despite wound care orders from SNF (Skilled Nursing Facility) presented at discharge. Current order is saline wet to dry tip of gauze into wound, cover with gauze and Kerlix daily. There is no documented evidence of the SN informing the patient’s physician about the patient wanting to keep the wound open to air instead of being covered. On 12/03/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of Right Artificial Knee Joint, Essential (Primary) Hypertension, Unspecified Asthma, Type 2 Diabetes Mellitus without Complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025 documents the following: notify physician if blood pressure is outside of the range of: systolic , 160 (less than 90 or greater than 160), diastolic 100; notify physician if pulse is outside the range of 100; notify physician if respirations are outside the range of 24; notify physician if temperature greater than 100 degrees Fahrenheit. On 03/07/2025 the Physical Therapist visit note documents the patient’s blood pressure was 178 (systolic)/116 (diastolic) and “Patient states that her high blood pressure is because of what she ate today which was high in sodium.” There is no documented evidence of the Physical Therapist informing the physician that the patient’s blood pressure was out of range. On 12/03/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Physical Therapy notes documents: 10/21/2025 unable to assess secondary to increase pain. 11/06/2025 and 11/10/2025 Pain Location: right side of the body; Pain Severity Level: 5. 11/24/2025 and11/26/2025 Pain Location: right side of the body; Pain Severity Level: 6. The clinical care record lacks documented evidence of the notification or communication with the physician regarding the patient's increase pain resulting in the Physical Therapist being unable to complete an assessment. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care (SOC) date of 11/10/2025 with the following diagnoses of Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Heart Failure as documented in the Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026. The Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026 documents: PT 11/11/2025 1 x week x 1 week (Physical Therapy once a week for one week). The Physical Therapy Evaluation and Therapy Plan of Care dated 11/20/2025 documents: “Frequency/Duration: 2x/wk for 8 wks, 2x/wk for 4 wks (twice a week for eight weeks, twice a week for four weeks).” No further documentation or order for physical therapy. The clinical record lacks documented evidence of the notification or communication to the physician for additional physical therapy visits. The skilled nurse visit was dated 11/26/2025, no further order. The clinical record lacks documented evidence of the notification and communication with the physician for additional skilled nurse visits or the plan (patient not discharged but no orders for services) to continue services or for discharge. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Charts/Clinical Notes dated 10/10/2025 and 10/17/2025 documents: “As per family, patient has not been required to check her blood glucose daily prior to hospitalization and SNF (skilled nursing facility) stay. Nurse will follow up with PMD (primary medical doctor).” The clinical care record lacks documented evidence of the notification or communication with the physician regarding the need for monitoring blood glucose. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (Congestive) Heart Failure, Acute Pancreatitis Without Necrosis or Infection, Unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025 documents: Assess/instruct patient/caregiver on pain medication administration, actions and side effects. The SN (Skilled Nurse) Start of Care dated 7/8/2025 documents: Sleep disturbances: Pain. There is no documented evidence of pain medication on the patient plan of care. There is no documented evidence the physician was alerted to changes in the patient’s condition so the plan of care could be altered. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to document the patient/caregiver's response to the education leading to independence with wound care. This was evident for one (1) of nine (9) clinical records reviewed (Patient: #7). Failure to document the patient/caregiver's response to the education leading to independence with wound care, has the potential for negative patient outcomes. The Findings are: #1. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Unspecified Atrial Fibrillation, and Essential (Primary) Hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025 documents under goals, “Patient/caregiver demonstrates independence with wound care by: 1- 2 SN (one to two Skilled Nursing) visits.” The SN Charts/Clinical Notes dated 02/12/2025 documents, “Educated patient’s son on wound care and to follow MD (Medical Doctor) orders as directed and the need for daily foot care and proper sharps disposal; verbalized understanding." There is no documented evidence of the patient/caregiver demonstrating independence with wound care. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to provide periodic discussions among the interdisciplinary team regarding the patient's health status and reason for multiple refusal of services. This was evident for one (1) of nine (9) clinical records reviewed (Patient: #1). Failure to provide periodic discussions among the interdisciplinary team regarding the patient's health status and reason for multiple refusal of services impacts the patient care and has the potential for negative patient outcomes. The Findings are: 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025 documents: PT (Physical Therapy) 1 x week x 1 week (once a week for one week). The Missed Visit Note dated 10/23/2025, 10/28/2025, 10/30/2025, and 11/04/2025 documents: "Patient refused visit." (Four consecutive missed visits.) The clinical care record lacks documented evidence of the discussions with the interdisciplinary team regarding the reason for the refusal of visit: identifying and addressing the reason for the refusal. There is no documented evidence of an ongoing assessment of the patient needs. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to provide services that are ordered by the Physician or allowed practitioner as indicated in the plan of care. This was evident for five (5) of nine (9) clinical records reviewed (Patient: #1, #2, #3, #4, and #5). Failure to provide services that are ordered by the Physician or allowed practitioner as indicated in the plan of care, has the potential for negative patient outcomes. The Findings are: 5. Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The Home Health Certification and Plan of Care (medical orders) from 03/19/2025 to 05/17/2025 documents the following: notify Physician if blood pressure is outside of the range of: systolic , 160 (less than 90 or greater than 160), diastolic 100; notify Physician if pulse is outside the range of 100; notify Physician if respirations are outside the range of 24; notify Physician if temperature greater than 100 degrees Fahrenheit. The Physical Therapy visits dated 04/25/2025, 04/26/2025, 05/03/2025, 05/04/2025, 05/10/205 and 05/11/2025 lack documented evidence of the Physical Therapist evaluating the patient’s blood pressure, pulse, respirations and temperature to assess that the patient’s vital signs (blood pressure, pulse, respirations, and temperature) are within range. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 10/15/2025 with the following diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Other Muscle Spasm as documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025 documents: PT (Physical Therapy) 1 x week x 1 week (once a week for one week). The Supplemental Orders from 10/15/2025 to 11/18/2025 documents: 10/22/2025 PT (Physical Therapy) 2 x week x 4 weeks (two times a week for four weeks) discontinued on 11/18/2025. The patient care record lacks documented evidence of the Physical Therapy services between 10/17/2025 to 10/18/2025 – missed one visit, and between 11/12/2025 to 11/18/2025 – missed 1 visit. There is no documented evidence that the Physical Therapist is providing services that are ordered by the Physician as indicated in the plan of care. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care (SOC) date of 11/10/2025 with the following diagnoses of Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Heart Failure as documented in the Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026. The Home Health Certification and Plan of Care for the Certification Period 11/10/2025 to 01/08/2026 documents: PT (Physical Therapy) 11/11/2025 1 x week x 1 week (once a week for one week). The patient care record lacks documented evidence of the Physical Therapy services between 11/11/2025 to 11/15/2025 – missed one visit. There is no documented evidence that the Physical Therapist is providing services that are ordered by the Physician as indicated in the plan of care. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025 documents: PT (Physical Therapy) 10/10/2025 1 x week x 1 week (once a week for one week). The patient care record lacks documented evidence of the Physical Therapy services between 10/10/2025 to 10/11/2025 – missed one visit. There is no documented evidence that the Physical Therapist is providing services that are ordered by the Physician as indicated in the plan of care. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses of Hemiplegia Affecting Right Dominant Side, Abnormalities of Gait and Mobility as documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Supplemental Orders from 02/28/2025 to 03/13/2025 documents: 02/28/2025 SN (Skilled Nurse) 1 x week x 2 weeks (once a week for two weeks) discontinued on 03/13/2025. The patient care record lacks documented evidence of the Skilled Nurse providing services between 02/28/2025 to 03/06/2025 – missed one visit. There is no documented evidence that the Skilled Nurse is providing services that are ordered by the Physician as indicated in the plan of care. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that the Home Health Aide is given patient specific instructions on parameters and to notify the Registered Nurse when the parameters are out of range. This was evident for one (1) of nine (9) clinical records reviewed (Patients #6). Failure to ensure that the Home Health Aide is given patient specific instructions on parameters and to notify the Registered Nurse when the parameters are out of range has the potential for negative patient outcomes. The findings are: 1.Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The Home Health Aide Plan of Care dated 10/21/2025 documents for the Home Health Aide to assist with “Take Pulse, daily/PRN (as needed) and “Take Blood Pressure, daily/PRN.” The Home Health Aide Plan of Care lacks documented evidence of including parameters (out of range values) for the patient’s blood pressure and pulse, and instructions for the Home Health Aide to notify the nurse when the parameters are out of range. On 12/4/2025 at 2:00 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that Home Health Aides follow the paraprofessional plan of care for completion of the assigned tasks. This was evident for two (2) of nine (9) clinical records reviewed (Patients #6 & #9). Failure to ensure that Home Health Aides follow the paraprofessional plan of care for completion of the assigned tasks has the potential for negative patient outcomes. The findings are: 2. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (congestive) Heart Failure, Acute pancreatitis without necrosis or infection, Unspecified, Essential (primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Home Health Aide Plan of Care dated 7/11/2025 documents: daily - sponge bath, mouth/denture care, dressing, skin care, commode, toilet, transferring, assist with walking and diet diabetic. PRN (as needed) - shower, hair care comb, shampoo, shave, and foot care. The Home Health Aide Duty Sheet dated 7/11/2025 documents: Assist with feeding, Record intake - Food, Record intake - fluid, Assist with walking crutches, diet regular, diet low salt no added salt, diet 2 gm (gram) sodium, diet low fat, and diet low cholesterol. The Home Health Aide duty sheets lack documented evidence of the Home Health Aide providing care according to the Home Health Aide Plan of Care dated 07/11/2025. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings. 1. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The Home Health Aide Plan of Care dated 10/21/2025 documents for the Home Health Aide to assist with the following tasks daily: bathing, hair care, dressing, diaper, prepare breakfast and lunch, transferring, take pulse, take blood pressure, and remind to take medications. The Home Health Aide duty sheets dated from 10/21/2025 to 10/24/2025 lacks documented evidence of what tasks the aide provided on those days. The Home Health Aide duty sheets dated 10/27/2025 to 10/29/2025 lack documented evidence of the Home Health aide taking the patient’s pulse. The Home Health Aide duty sheets dated 10/27/2025 and 10/28/2025 lack documented evidence of the Home Health Aide taking the patient’s blood pressure. The Home Health Aide duty sheets dated 10/27/2025 lack documented evidence of the Home Health Aide performing medication reminders. The Home Health Aide duty sheets dated 10/27/2025 to 10/31/2025 lack documented evidence of the Home Health Aide preparing breakfast. The Home Health Aide duty sheets lack documented evidence of the Home Health Aide providing care according to the Home Health Aide Plan of Care dated 10/21/2025. On 12/4/2025 at 2:00 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that home health aide supervision includes aides providing care in a safe and effective manner. This was evident for two (2) of nine (9) clinical records reviewed (Patients #6 and #9). Failure to ensure that supervision of Home Health Aides establishes that they provide care in a safe and effective manner has the potential for negative patient outcomes. The findings are: 2. Patient #9 has a start of care date of 07/08/2025, with a diagnosis of Chronic Systolic (congestive) Heart Failure, Acute Pancreatitis Without Necrosis or Infection, Unspecified, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Hyperlipidemia, Unspecified, Hypokalemia as documented on the Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025. The Home Health Certification and Plan of Care for Period 07/08/2025 to 09/05/2025 documents: Nutritional Requirement: Mechanical Soft, Aspiration Precaution, Fluids provided with medication included in fluid restriction. No concentrated sweets. The HHA (Home Health Aide) Supervisory Visit Report dated 7/11/2025 and signed by the Registered Nurse and Home Health Aide documents: Prepare meals: Breakfast, Lunch and Snack, Diabetic Diet. Blood pressure (HHA PRN [Home Health Aide as needed]). Aide understands POC (Plan of Care) Yes/No boxes were left blank. Aide Competent box was left blank. The Home Health Aide Plan of Care dated 7/11/2025 and signed by the Registered Nurse documents: Diet: Diabetic. The box “Aide to do” - Take Blood Pressure - was left blank. There’s no documented evidence the aide understood the plan of care or was competent to provide care to the patient. There is no documented evidence the Registered Nurse provided the aide with a Home Health Aide Plan of Care that is accurate and consistent with the Home Health Certification and Plan of Care. On 12/3/2025 at 3:30 PM the Director of Nursing Services was interviewed, and no explanations were given for the findings. 1.Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The Registered Nurse (RN) supervision of the Home Health Aide (HHA) on 10/23/2025 lacks documented evidence of the RN supervising the HHA on the following: maintaining an open communication process with the patient or family; complying with infection prevention and control policies and procedures; reporting changes in the patient’s condition; and honoring patient rights. The Physical Therapist (PT) supervision of the Home Health Aide (HHA) on 10/21/2025, 10/23/2025, and 10/28/2025 lacks documented evidence of the PT (Physical Therapy) supervising the HHA (Home Health Aide) on the following: maintaining an open communication process with the patient or family; complying with infection prevention and control policies and procedures; and honoring patient rights. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that a copy of the patient's discharge summary is sent to the patient’s primary physician with all pertinent information within five (5) business days of the patient’s discharge. This was evident for six (6) of nine (9) clinical records reviewed (Patients #3, #4, #5, #6, #7, and #8). Failure to ensure that copy of the patient's discharge summary is sent to the patient’s primary physician with all pertinent information within five (5) business days of the patient’s discharge has the potential for negative patient outcomes. The Findings are: 3. Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The patient was discharged from the agency on 05/16/2025. The discharge summary documents, “Date Completed: 05/16/2025.” There is no documented evidence of a copy of the discharge summary was sent to the patient’s primary physician within five (5) business days of the patient’s discharge. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The patient was discharged from the agency on 11/03/2025. The discharge summary documents, “Date Completed: 11/03/2025.” There is no documented evidence of a copy of the discharge summary was sent to the patient’s primary physician within five (5) business days of the patient’s discharge. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 5. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Unspecified Atrial Fibrillation, and Essential (Primary) Hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The patient was discharged from the agency on 03/20/2025. The discharge summary documents, “Date Completed: 03/20/2025.” There is no documented evidence that a copy of the discharge summary was sent to the patient’s primary physician within five (5) business days of the patient’s discharge. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 6. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of Right Artificial Knee Joint, Essential (Primary) Hypertension, Unspecified Asthma, Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The patient was discharged from the agency on 03/25/2025. The discharge summary documents, “Date Completed: 03/25/2025.” There is no documented evidence that a copy of the discharge summary was sent to the patient’s primary physician within five (5) business days of the patient’s discharge. On 12/03/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #3 has a Start of Care (SOC) date of 10/10/2025 with the following diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness, Hypercholesterolemia as documented in the Home Health Certification and Plan of Care for the Certification Period 10/10/2025 to 12/08/2025. The Discharge Summary dated 10/24/2025 lacks documented evidence of the medication list, date sent to the physician, and name or signature who completed the discharge summary. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #4 has a Start of Care (SOC) date of 02/21/2025 with the following diagnoses of Hemiplegia Affecting Right Dominant Side, Abnormalities of Gait and Mobility as documented in the Home Health Certification and Plan of Care for the Certification Period 02/21/2025 to 04/21/2025. The Discharge Summary dated 03/28/2025 lacks documented evidence of the medication list, date sent to the physician, and name or signature who completed the discharge summary. On 12/03/2025 at 01:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

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 clinical record reviews, and staff interviews, the agency failed to ensure appropriate authentication of a primary author who has reviewed and approved the entry. This was evident for four (4) of nine (9) clinical records reviewed (Patient: #5, #6, #7 and #8). Failure to ensure appropriate authentication of a primary author who has reviewed and approved the entry, has the potential for negative patient outcomes. The Findings Are: 1.Patient #5 has a Start of Care Date of 03/19/2025 and diagnoses of Cerebrovascular Disease, Unspecified, Essential (Primary) Hypertension, Other Abnormalities of Gait and Mobility, and Vascular Dementia, Unspecified Severity, without Behavioral Disturbance documented on the Home Health Certification and Plan of Care from 03/19/2025 to 05/17/2025. The patient was discharged from the agency on 05/16/2025. The computerized discharge summary documents, “Date Completed: 05/16/2025.” The computerized discharge summary lacks documented evidence of being authenticated by the individual who completed the discharge summary. The computerized Supplemental Orders from 03/28/2025 to 05/12/2025 documents the following orders: 04/15/2025 PT 2 x week x 4 weeks discontinued on 05/12/2025 and 04/15/2025 OT 2 x week x 4 weeks discontinued on 05/12/2025 (starting the week of 04/15/205, Physical Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025 and starting the week of 04/15/2025 Occupational Therapy for 2 visits per week, for 4 weeks, to be discontinued on 05/12/2025). The computerized Supplemental Orders lacks documented evidence of being authenticated by the individual who reviewed and approved the computerized entry of the orders. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 10/16/2025 and diagnoses of Venous Insufficiency (Chronic) (Peripheral), Muscle Weakness (Generalized), Essential (Primary) Hypertension, Unspecified Glaucoma, and Other Iron Deficiency Anemias) documented on the Home Health Certification and Plan of Care from 10/16/2025 to 12/14/2025. The patient was discharged from the agency on 11/03/2025. The computerized discharge summary documents, “Date Completed: 11/03/2025.” The computerized discharge summary lacks documented evidence of being authenticated by the individual who completed the discharge summary. The computerized Supplemental Orders from 10/17/2025 to 11/17/2025 document the following PT (Physical Therapy) orders: 10/21/2025 PT 2 x week x 4 weeks discontinued on 11/17/2025 (starting the week of 10/21/2025, Physical Therapy for 2 visits per week, for 4 weeks, and to be discontinued on 11/17/2025) and PT eval (evaluation) visit 10/17/2025, Physical Therapist requested 8 follow up visits. MD (Medical Doctor) made aware. The computerized Supplemental Orders lacks documented evidence of being authenticated by the individual who reviewed and approved the computerized entry of the orders. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #7 has a Start of Care date of 02/12/2025 and diagnoses of Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Unspecified Atrial Fibrillation, and Essential (Primary) Hypertension documented on the Home Health Certification and Plan of Care from 02/12/2025 to 04/12/2025. The patient was discharged from the agency on 03/20/2025. The computerized discharge summary documents, “Date Completed: 03/20/2025.” The computerized discharge summary lacks documented evidence of being authenticated by the individual who completed the discharge summary. On 12/3/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. interviewed and did not provide an explanation for the findings. 4. Patient #8 has a Start of Care date of 01/31/2025 and diagnoses of Presence of Right Artificial Knee Joint, Essential (Primary) Hypertension, Unspecified Asthma, Type 2 Diabetes Mellitus Without Complications documented on the Home Health Certification and Plan of Care from 01/01/31/2025 to 03/31/2025. The patient was discharged from the agency on 03/25/2025. The computerized discharge summary documents, “Date Completed: 03/25/2025.” The computerized discharge summary lacks documented evidence of being authenticated by the individual who completed the discharge summary. On 12/03/2025 at 2:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.