Every finding on record at Summit Home Health LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/18/25.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to have a communication plan that meets the requirements. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/17/25. The Emergency Preparedness Plan lacked the Agency's current staff names and their contact information. 2. The above finding regarding the lack of updated communication plan was confirmed during an interview with the Executive Director and Clinical Services Manager on 12/18/25 at 11:30 AM.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to conduct testing of the Agency's Emergency Preparedness Plan since 2023. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/17/25. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted any testing of the Plan. 2. During an interview with the Executive Director and Clinical Service Manager on 12/18/25 at 11:30 AM the Executive Director confirmed the Agency has no documentation supporting the Agency conducted testing of the Emergency Preparedness Plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/18/25. Standard level deficiencies were cited. Abbreviations: - = to x = times wk = week # = number AM = morning abd = abdominal SN = Skilled Nurse POC = Plan of Care SOC = Start of Care BP = Blood Pressure PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients HHA = Home Health Aide MSW = Medical Social Worker PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist COTA = Certified Occupational Therapy Assistant > = greater than

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on home visit observations and staff interviews, the Agency failed to provide the name and contact information of the Administrator to the Pts. and their families on admission. This was found in 5 of 7 home visits (Pts.# 1, 2, 3, 5, and 7). Findings include: 1. The following patient home visits were conducted with an Agency staff between 12/15/25 and 12/17/25. During the home visits it was observed that the Agency's admission booklet page that includes the name and contact information for the Administrator were blank. Pt. # 1 SOC 12/06/25 - PT visit Pt. # 2 SOC 12/06/25 - PT visit Pt. # 3 SOC 10/24/25 - Aide visit Pt. # 5 SOC 12/04/25 - SN visit Pt. # 7 SOC 06/24/25 - PT visit 2. During an interview with the Executive Director and Clinical Service Manager on 12/18/25 at 11:30 AM, the Executive Director stated and confirmed that staff should write the name and contact information of the Administrator on admission.

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 a review of clinical records and staff interviews, for 6 of 17 (Pts. #3, 15, 6, 7, 12 and 14) clinical records reviewed, the Agency failed to ensure the PsOC were reviewed by the Physician and the orders were followed. 5. Pt. #12 was admitted to home health services on 11/27/25 with the diagnoses of, but not limited to, pneumonia unspecified organism and pressure ulcer of sacral region stage 3. The clinical records were reviewed on 12/17/25. The clinical record included the POC for the certification period of 11/27/25 to 01/25/26. The Frequency/Duration of Visits included MSW Effective 12/07/2025 1WK1. As of 12/18/25, the Agency failed to ensure a MSW visited the patient. 6. Pt. #14 was admitted to home health services on 10/19/24 with the diagnoses of, but not limited to, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease, unspecified systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, dependance on renal dialysis, long term (current) use of insulin, kidney transplant status. The clinical records were reviewed on 12/17/25. The clinical record included the POC for the certification period of 02/16/25 to 04/16/25. The POC was signed by the Physician on 08/22/25, after the certification period ended and after the patient’s discharge. The Agency failed to ensure the Physician reviewed and signed the POC when there were changes in the patient’s condition or POC. 7. During interviews with the Clinical Services Manager and the Executive Director between 8:50 AM and 11:30 AM, the above findings were confirmed. 3. Pt. # 6 was admitted to home health services on 10/22/25 with diagnosis of acute leukemia of unspecified cell type not achieve remission. The clinical record was reviewed on 12/17/25. The clinical record included a physician order dated 11/03/25 that required "Referral for RN weekly to assist with medication reconciliation". The clinical records lacked the SN assessment visit. 4. Pt. # 7 was admitted to home health services on 06/24/25 with diagnosis of hemiplegia following cerebral infarction affecting right dominant side. The clinical record was reviewed on 12/17/25. The POC for certification period 1022/25 to 12/20/25 required Aide services 1 time a week for 8 weeks. The clinical record lacked Aide visits for certification period. Findings include: 1.Pt. #3 was admitted for home health services on 10/24/25 with the diagnoses of but not limited to Hypertensive heart and chronic kidney disease with heart failure, Congestive Heart Failure and End Stage Heart Failure. The clinical record was reviewed on 12/17/25. The POC effective 10/24/25 required, “Frequency/Duration of visits…SN: 1 week 10…” The record lacked an SN visit for the week of 11/16/25 to 11/22/25. The same POC also required, “to report vital signs falling outside the following established parameters…Systolic BP150…” The Home Health Aide visit note report included the documentation…” Vital sign alert… reading: 156/80, Physician contacted: N (no)…” The record lacked documentation the blood pressure reading was reported to the physician. 2. Pt. #15 was admitted for home health services on 05/10/25 with the diagnoses of but not limited to Type 1 Diabetes Mellitus with foot ulcer, non-pressure chronic ulcer other part right lower leg. The clinical record was reviewed on 12/17/25 and included a POC effective 05/10/25. The POC required, “Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications… Skilled nurse to report significant changes to physician for early intervention.” The record lacked documentation of obtaining orders from physician for interventions and treatment of the new wounds. The clinical record also included modification of wound orders dated 05/28/25: "Wound #1 Left Plantar Foot...Wound #3 Left Lateral Knee...Wound #4 Right Anterior Knee...Wound #5 Left Lateral Plantar Foot: Cleanse wound with wound cleanser...apply alginate/silver to wound base; Wound #6 Left Dorsal Foot, Cleanse with wound cleanser, Paint eschar with betadine... Wound #7, Right Great Toe, Cleanse wound with wound cleanser, skin prep to peri-wound, apply Xeroform gauze to wound base..." The SN notes dated 06/06/25 and 06/11/25 included documentation of the same treatment for all of Pt. #15's wounds: "wound cleansed with wound cleanser, abd pad and kerlix wrap applied…" The record lacked documentation that the modified wound orders were followed.

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 a review of clinical records and staff interviews, for 9 of 17 (Pts. #2, 3, 8, 15, 4, 11, 12, 13 and 14)clinical records reviewed, the Agency failed to ensure that the PsOC included all the requirements. 6. Pt. #11 was admitted to home health services on 11/13/25 with the diagnoses of, but not limited to, secondary malignant neoplasm of right lung, secondary malignant neoplasm of left lung, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential (primary) hypertension, and unspecified open wound of left breast subsequent encounter. The clinical records were reviewed on 12/17/25. The clinical record included the POC for the certification period of 11/13/25 to 01/11/26. The POC included an order for SN, “for instructions/reinforcement of…administration of insulin.” Patient’s medication list does not include insulin. The POC lacked an accurate medication list. The POC included an order for SN, “for instructions/reinforcement of…blood glucose testing” and under category of Goals/Rehabilitation/Discharge Plans, “Patient/caregiver will verbalize/demonstrate knowledge of …stabilization of blood glucose within parameters set by physician approved parameters.” The POC does not include parameters for when to call the physician when blood glucose is out of range. The patient’s blood glucose was documented by the SN on 11/13/25, 11/17/25, 11/21/25, 11/24/25, 11/28/25, and 12/1. The POC lacked physician approved blood glucose parameters. The POC included a medication list containing the pain medication Hydrocodone 5mg- Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. The POC lacked specific pain level parameters defined by the physician as a trigger for contact/intervention. 7. Pt. #12 was admitted to home health services on 11/27/25 with the diagnoses of, but not limited to, pneumonia unspecified organism and pressure ulcer of sacral region stage 3. The clinical records were reviewed on 12/17/25. The clinical record included the POC for the certification period of 11/27/25 to 01/25/26. On 12/04/25 the SN documented 7/10 wound pain. The POC lacked specific pain level parameters defined by the physician as a trigger for contact/intervention. 8. Pt. #13 was admitted to home health services on 03/13/25 with the diagnoses of, but not limited to, Encounter for surgical aftercare following surgery on the digestive system Type 2 diabetes mellitus without complications, and Essential (primary) hypertension. The clinical records were reviewed on 12/17/25. The clinical records included the POC for the certification period of 03/13/25 to 05/11/25. The POC Goals/Rehabilitation Potential/ Discharge Plans for the Pt. included, “increased pain or ineffective pain control measures will be identified and promptly reported to the physician.” Patient’s medication list contains as needed pain medications, Acetaminophen and Tramadol. The POC lacked specific pain level parameters defined by the physician as a trigger for contact/intervention. 9. Pt. #14 was admitted to home health services on 10/19/24 with the diagnoses of, but not limited to, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease, Unspecified systolic (congestive) heart failure, Type 2 diabetes mellitus with diabetic chronic kidney disease, Dependance on Renal Dialysis, Long Term (Current) Use of Insulin, Kidney Transplant Status. The clinical records were reviewed on 12/17/25. The closed clinical record included the POC for the certification period of 02/16/25 to 04/16/25. The POC states under the category of “Orders of Discipline and Treatments: Skilled Nurse to evaluate and develop plan of care to be countersigned by Physician. Skilled Nurse to assess/evaluate co-morbid conditions including DM2 (diabetes mellitus 2), HF (heart failure), kidney transplant…identify changes and intervene to minimize complications.” The POC lacked specific Skilled Nurse interventions for patient diagnoses. The medication list included in the POC listed sliding scale insulin lispro and lantus solostar insulin. The POC does not specify orders for blood glucose checks and the parameters or critical values at which the physician is to be notified for out-of-range readings. 5. Pt. #4 was admitted to home health services on 11/12/25 with diagnoses of hypertensive heart disease with heart failure. The clinical record was reviewed on 12/17/25. The POC dated 11/12/25 lacked documentation of pain parameters to report to the physician. Findings include: 1. Pt. #2 was admitted for home health services on 12/06/25 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 12/17/25 and included a POC effective 12/06/25. The POC lacked documentation of pain parameters to report to the physician. 2. Pt. #3 was admitted for home health services on 10/24/25 with the diagnoses of but not limited to Hypertensive heart and chronic kidney disease with heart failure, Congestive heart failure and End stage heart failure. The clinical record was reviewed on 12/17/25 and included a POC effective 10/24/25. The POC lacked documentation of weight parameters to report to the physician. 3. Pt. #8 was admitted for home health services on 06/28/25 with the diagnoses of but not limited to Hypertensive heart and chronic kidney disease with heart failure and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/17/25 and included a POC effective 10/26/25. The POC lacked documentation blood glucose monitoring and weight parameters to report to the physician. 4. Pt. #15 was admitted for home health services on 05/10/25 with the diagnoses of but not limited to Type 1 Diabetes Mellitus with foot ulcer, non-pressure chronic ulcer other part right lower leg. The clinical record was reviewed on 12/17/25 and included a POC effective 05/10/25. The POC lacked documentation of blood glucose monitoring parameters and lacked the procedure and equipment used for care of infusion line and insertion site.

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 a review of records and staff interviews, it was determined in 2 of 17 (Pts.#12 and 15) clinical records reviewed, the Agency failed to ensure staff administered medications and wound treatment as ordered by a physician. 2. Pt. #15 was admitted for home health services on 05/10/25 with the diagnoses of but not limited to Type 1 Diabetes Mellitus with foot ulcer, non-pressure chronic ulcer other part right lower leg. The clinical record was reviewed on 12/17/25. The clinical record included documentation of the development of 5 new diabetic wounds on 05/14/25: “Wounds…#9, #10, #11, #12, #13”. The SN note dated 05/28/25, 06/06/25 and 06/11/25 included documentation of treatment provided by the SN for the following wounds: #9, #11, #12, #13… “wound care provided…awaiting orders by wound home health…. wound cleansed with wound cleanser, abd pad and kerlix wrap applied…” The record lacked documentation of physician orders prior to providing the wound treatment. 3. During an interview conducted with the Executive Director and Clinical Services Manager on 12/18/25 at 10:00 AM, the above findings were confirmed. 1. Pt. #12 was admitted to home health services on 11/27/25 with the diagnoses of, but not limited to, pneumonia unspecified organism and pressure ulcer of sacral region stage 3. The clinical record was reviewed on 12/17/25. The clinical record included the POC for the certification period of 11/27/25 to 01/25/26. On 12/04/25 the SN documented 7/10 wound pain, and that the Pt. took “Tylenol as prescribed.” The patient’s medication list does not include Tylenol or any other pain medication. The patient was administered a medication that was not prescribed by the physician.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observations and staff interviews, the Agency failed to provide the name and contact information of the Clinical Manager to the Pts. and their families on admission. This was found in 5 of 7 home visits (Pts.# 1, 2, 3, 5, and 7). Findings include: 1. The following patient home visits were conducted with an Agency staff between 12/15/25 and 12/17/25. During the home visits it was observed that the Agency's admission booklet page that includes the name and contact information for the Clinical Manager were blank. Pt. # 1 SOC 12/06/25 - PT visit Pt. # 2 SOC 12/06/25 - PT visit Pt. # 3 SOC 10/24/25 - Aide visit Pt. # 5 SOC 12/04/25 - SN visit Pt. # 7 SOC 06/24/25 - PT visit 2. During an interview with the Executive Director and Clinical Service Manager on 12/18/25 at 11:30 AM, the Executive Director stated and confirmed that staff should write the name and contact information of the Clinical Manager on admission.

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 onsite observations and interviews during a home visit, clinical record review and staff interviews, for 1 of 2 Pts. (Pt.#3) reviewed receiving HHA services, the Agency failed ensure that the written Pt. care instruction was individualized and based on RN assessment of Pt. needs. Findings include: 1. Pt. #3 was admitted for home health services on 10/24/25 with the diagnoses of but not limited to hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, and end stage heart failure. The clinical record was reviewed on 12/17/25 and included the HHA Care Plan. The HHA Care Plan included documentation of all these types of baths: Bathing (tub bathing), Seated shower, and Shower bath. A home visit was conducted for Pt. #3 with E#1 (Home Health Aide) on 12/17/25. During the home visit, it was observed the Pt. had a shower bench in the bathroom and also had a tub with a built-in seat. During an interview with E#1 it was stated that Pt. #3's baths are provided in the shower: Pt. #3 sits on the bench and E#1 assists with the baths because Pt. #3 gets tired and short of breath easily. The Aide Care Plan lacked instruction for the HHA that was based on the need of the Pt. 2. During an interview with the Executive Director and Clinical Service Manager on 12/18/25 at 10:40 AM, the above findings were confirmed.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, for 2 of 2 (Pts. #3 and 11) clinical records reviewed, wherein the Pt. received HHA services, the Agency failed to conduct HHA supervisory visits as required. 2. Pt. #11 was admitted to home health services on 11/13/25 with the diagnoses of, but not limited to, secondary malignant neoplasm of right lung, secondary malignant neoplasm of left lung, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential (primary) hypertension, and unspecified open wound of left breast subsequent encounter. The clinical records were reviewed on 12/17/25. The clinical record included the POC for the certification period of 11/13/25 to 01/11/26. The POC included HHA visits starting 11/16/25: 2wk1, 1wk1, and 2wk6. HHA supervisory visits were not performed by a SN during this certification period and as of 12/18/25, two supervisory visits should have been completed. The Agency failed to ensure HHA supervisory visits were performed every 14 days. 3. During interviews with the Clinical Services Manager and Executive Director on 12/18/25 at 8:50 AM and 9:35 AM, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted for home health services on 10/24/25 with the diagnoses of but not limited to Hypertensive heart and chronic kidney disease with heart failure, Congestive heart failure and End stage heart failure. The clinical record was reviewed on 12/17/25 and included documentation HHA services were provided on 11/06/25, 11/08/25, 11/12/25, 11/19/25 and 11/25/25. The record lacked documentation a supervisory visit was conducted every 14 days as required.