Every finding on record at Synergy Home Care-Capitol Region, Inc.

The entity is in compliance with federal emergency preparedness requirements.

Recertification Survey.

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 observations, interviews, and record reviews, the agency failed to ensure an accurate reconciliation of medication was completed for 1 (Patient #2) of 4 sampled patients reviewed for medication reconciliation during home visits. Findings: Review of Patient #2’s Client Medication Report, provided to the surveyor on 07/08/2026 as Patient #2’s current medication list, revealed, in part, Patient #2 was prescribed Lasix (medication used to remove excess fluid) 20 milligrams (mg), one tablet by mouth daily. Observation of the label on Patient #2’s Lasix medication bottle on 07/08/2026 at 11:00AM revealed Patient #2’s Lasix was prescribed as 20 mg, 0.5 tablet daily by mouth, with a filled date of 05/20/2026. In an interview on 07/08/2026 at 11:00AM, S2Registered Nurse (RN) confirmed Patient #2 was currently prescribed and taking 0.5 of a tablet of Lasix 20mg daily. In an interview on 07/09/2026 at 5:53PM, S1Administrator/Director of Nursing (DON) indicated the skilled nurse did not reconcile the Lasix discrepancy on Patient #2’s Client Medication Report.

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 interview and record reviews, the agency failed to ensure a patient’s physician was alerted to the patient’s change in condition for 1 (Patient #3) of 10 sampled patients reviewed for change in condition requirements. Findings: Review of Patient #3’s Client Coordination Note Report dated 05/26/2026 revealed, in part, Patient #3 was assessed as having adventitious (abnormal) sounds to the bilateral lower lobes (both lower lungs) and bilateral lower extremity pitting edema. Further review revealed Patient #3's skilled nurse attempted to contact Patient #3's physician; however, Patient #3's physician was not contacted and a phone message was left. Further review revealed a fax was sent to Patient #3’s physician’s office. Review of Patient #3’s record revealed no evidence Patient #3’s physician received the message or fax sent to the physician’s office on 05/26/2026. Further review revealed no evidence Patient #3’s physician called the agency back regarding Patient #3’s change in condition. In an interview on 07/09/2026 at 5:57PM, S1Administrator/Director of Nursing (DON) indicated the agency had no evidence the agency or its staff ensured Patient #3’s physician was made aware of Patient #3’s change in condition. S1Administrator/DON further indicated there was no evidence the agency or its staff made any follow-up contact after 05/26/2026 with Patient #3’s physician to ensure the physician had received the message or fax.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the registered nurse measured the patient’s wound weekly to assess for wound healing status for 3 (Patient #1, Patient #6, Patient #10) of 4 sampled patients reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed, in part, the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed the comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information was used to track the progress of wound healing. Patient #1 Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 05/16/2026 to 07/14/2026 revealed, in part, the skilled nurse was to assess the integumentary system (skin) and identify changes every skilled nurse visit. Review of Patient #1’s Wound Record Report revealed, in part, Patient #1 had a left mid-calf partial thickness wound. Further review revealed no wound care measurements were obtained from Patient #1’s admit on 05/16/2026 through 05/28/2026. Review of Patient #1’s Visit Note Report dated 05/16/2026 revealed, in part, Patient #1 had moist cobblestone open areas to the left lower extremity. Review of Patient #1’s Visit Note Report dated 05/22/2026 revealed, in part, Patient #1 had a partial thickness open area to the left mid-calf area with moderate serous drainage. In an interview on 07/09/2026 at 5:51PM, S1Administrator/Director of Nursing (DON) indicated the agency had no evidence wound measurements were obtained for Patient #1’s wound from 05/16/2026 through 05/28/2026. S1Administrator/DON further indicated all wounds were to be assessed and measured by a registered nurse weekly to assess for wound healing. Patient #6 Review of Patient #6’s Home Health Certification and Plan of Care for the certification period of 06/12/2026 to 08/10/2026 revealed, in part, the skilled nurse was to assess the integumentary system and identify changes. Review of Patient #6’s Wound Record Report revealed, in part, Patient #6 had an unstageable (a wound which the depth of the wound cannot be measured) deep tissue injury (a wound characterized by a soften area with a bruised appearance indicating deep tissue damage) of the coccyx (area of the buttock). Further review revealed wound assessments dated 06/08/2026, 06/14/2026, 06/22/2026, 06/28/2026, 07/02/2026, and 07/05/2026 did not include wound measurements. In an interview on 07/09/2026 at 6:10PM, S1Administrator/DON indicated the agency had no evidence wound measurements were obtained for Patient #6’s wound from 06/08/2026 through 07/05/2026. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care for the certification period of 10/28/2025 to 12/26/2025 revealed, in part, the skilled nurse was to assess the integumentary system and identify changes. Review of Patient #10’s Wound Record Report revealed, in part, Patient #10 had a left pretibial (area of the front of the leg just above the ankle) blister. Further review revealed wound assessments dated 11/06/2025 and 11/28/2025 did not include wound measurements. In an interview on 07/09/2026 at 6:24PM, S1Administrator/DON indicated the agency had no evidence wound measurements were obtained for Patient #10’s wound for the week of 11/02/2025 through 11/08/2025 or the week of 11/23/2025 through 11/29/2025, as required.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient’s Outcome and Assessment Information Set) OASIS was accurately documented for skin conditions for 1 (Patient #10) of 13 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, and Patient #13) sampled patients reviewed for accurate assessments. Findings: Review of the National Pressure Injury Advisory Panel’s pressure injury definition revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Review of Patient #10’s Visit Note Repot and RN OASIS Admission dated 02/16/2023 revealed Patient #10 was coded as having one unhealed pressure ulcer at stage 2 (open wound) or higher. Review of Wound Assessment section revealed Patient #10 was assessed as having only one wound which was a wound to the left posterior proximal upper leg (back of left thigh) stage 2. Further review revealed documentation of, in part, during Patient #10’s collapse she experienced a burn causing the skin to blister, and during her hospitalization the blister opened. In an interview on 07/20/2023 at 3:51 p.m., S1Area Director of Operations stated after reviewing Patient #10’s OASIS dated 02/16/2023 and subsequent visits during the certification period of 02/16/2023 to 04/16/2023 revealed Patient #10 never had a pressure ulcer/pressure injury and the wound being assessed and treated was a burn. S1Area Director of Operation stated Patient #10’s OASIS dated 02/16/2023 was inaccurately documented.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure an accurate medication reconciliation was completed during visits for 1 (Patient #4) of 5 (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5) sampled patients which home visit observations were conducted to review accurate medication reconciliation in a total sample of 13. Findings: Review of Patient #4’s Active Inpatient Medication List for hospital admit of 06/15/2023 revealed, in part, Primaquine (anti-malaria medication also used to treat certain types of lung infections) 52.6 milligram (mg) tablet by mouth daily with first dose on 06/11/2023. Further review revealed plan was to complete a 21 day dose of the Primaquine. Review of Patient #4’s Hospital Notes dated 06/28/2023 revealed no documented evidence of Primaquine being listed a medication for Patient #4. Review of Patient #4’s Medicine List dated 07/17/2023 (provided to surveyors as current medication for Patient #4 as of last visit) revealed, in part, Primaquine 26.3 mg take two tablets daily with reason to take as heart transplant. Observation on 07/18/2023 at 10:30 a.m. revealed no Primaquine was available in the home. In an interview on 07/18/2023 at 10:30 a.m., Patient #4 stated he was not taking Primaquine and was unsure when he would have last taken the medication. Observation on 07/18/2023 at 10:30 a.m. revealed S4Physical Therapy Assistant (PTA) contacted Patient #4’s heart transplant team during visit, and also inquired if Patient #4 should still be taking Primaquine due to it was not present in home and the patient stated he was not taking the medication. Patient #4’s transplant team coordinator instructed S4PTA, Patient #4 did not have Primaquine listed on his medication profile with them. Review of Patient #4’s record revealed Patient #4 had nursing visits on 07/06/2023, 07/11/2023, 07/13/2023, and 07/18/2023. In an interview on 07/20/2023 at 3:38 p.m., S1Area Director of Operations stated the agency did not see on the resumption of care paperwork from 06/28/2023 where Patient #4 should have continued to take the Primaquine therefore the therapist and nurse in the home should have clarified the discrepancy with the physician immediately.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to: 1. Ensure a physical therapy (PT) evaluation was completed timely (Patient #1); 2. Ensure the patient received skilled nursing services per physician orders (Patient #10); and 3. Ensure the patient received speech therapy services per physician orders (Patient #11). This deficient practice was identified for 3 (Patient #1, Patient #10, Patient #11) of 13 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, and Patient #13) sampled patients reviewed care and services per physician orders. Findings: 1. Patient #1 Review of Patient #1’s Physician Order dated 06/08/2023 revealed Patient #1 had an order for PT evaluation for mobility device, with a PT frequency of effective 06/11/2023 PT once a week for one week. Review of Patient #1’s Physician Order dated 06/26/2023 revealed Patient #1 had an order for PT evaluation for power chair pending insurance approval, order received originally on 06/08/2023 rolled over into new certification period, with a PT frequency of effective 06/25/2023 PT once a week for one week. Review of Patient #1’s record revealed Patient #1’s PT evaluation was not completed until 06/29/2023. Further review revealed no documented evidence and the provider presented no documented evidence of Patient #1’s physician having been notified of the order not being able to implement per the order. In an interview on 07/20/2023 at 3:49 p.m., S1Area Director of Operations stated the original order was not completed due to insurance authorization was not received, however the agency should have notified the physician the PT evaluation could not be completed to have the order changed and the agency did not. 2. Patient #10 Review of Patient #10’s Physician Order dated 03/09/2023 revealed the skilled nurse was to increase visits to clean left posterior thigh burn with normal saline, apply thera-honey and opti-foam gentle twice a week. Review of Patient #10’s record revealed no skilled nurse visits were conducted the week of 03/12/2023 to 03/18/2023. Further review revealed no documented evidence and the agency presented no documented evidence of the physician had been notified why the visits were not made, or the visits had been made or refused by the patient. In an interview on 07/20/2023 at 3:51 p.m., S1Area Director of Operations stated the skilled nurse visits were not completed the week of 03/12/2023 to 03/18/2023 due to the agency did not have authorization for services from Patient #10’s insurance, however the physician should have been contacted for a new order or the visits should have been completed. 3. Patient #11 Review of Patient #11’s Physician Order dated 12/08/2022 revealed an order to extend Patient #11’s speech therapy beginning week of 12/12/2022 for once a week for one week, then twice a week for three weeks, then once a week for one week to continue to work on dysphagia (difficulty swallowing) and dysarthria (difficulty with speech sounds). Review of Patient #11’s record revealed no speech therapy visits were conducted the week of 12/11/2022 to 12/17/2022. Further review revealed no documented evidence and the agency presented no documented evidence of the physician had been notified why the visits were not made, or the visits had been made or refused by the patient. In an interview on 07/20/2023 at 4:04 p.m., S1Area Director of Operations stated the agency did not have an insurance authorization for Patient #11’s speech therapy for the week of 12/11/2022 to 12/17/2022 and therefore the visits were not made. S1Area Director of Operations further stated the physician should have been contacted for a new order or the visits should have been completed.

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 record review and interview the agency failed to notify the physician when the patient had a vital sign out of parameters for 1 (Patient #1) of 13 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, and Patient #13) sampled patients reviewed physician notification of change. Findings: Review of Patient #1’s Home Health Certification and Plan of Care for certification period of 06/17/2023 to 08/15/2023 revealed, in part, the licensed professional to report vital signs outside of the following established parameters, heart rate of less than 50 beats per minute (bpm). Review of Patient #1’s Visit Note Report dated 07/14/2023 revealed Patient #1 had a heart rate of 46 bpm. Further review revealed no documented evidence and the agency presented no documented evidence of Patient #1’s physician had been notified of Patient #1’s heart rate of 46 bpm until 07/16/2023. In an interview on 07/21/2023 at 3:49 p.m., S1Area Director of Operations stated Patient #1’s nurse should have notified Patient #1’s physician of Patient #1’s heart rate being below parameters the same day, preferably during the visit.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure agency-wide surveillance for the identification and prevention of all infections for 2 (Patient #1 and Patient #5) of 2 (Patient #1 and Patient #5) sampled patients identified as having infections reviewed during the infection control review in a total sample of 13. Findings: Patient #1 Review of Patient #1’s Client Medication Report revealed, in part: -Cefuroxime Axetil (antibiotic used to treat infections) 500 milligrams one tablet by mouth twice a day for a bacterial infection with start date of 02/20/2023; -Levofloxacin (antibiotic used to treat infections) 500mg one tablet by mouth daily for urinary tract infection (UTI) with a start date of 03/08/2023; -Macrobid (antibiotic used to treat infections) 100mg one capsule by mouth twice a day for UTI with start date of 03/28/2023; and -Cephalexin (antibiotic used to treat infections) 500mg one capsule by mouth twice a day for UTI with a start date of 07/07/2023. Patient #5 Review of Patient #5’s Client Medication Report revealed, in part: -Sulfamethoxazole-Trimethoprim (antibiotic used to treat infections) 800mg/160mg one tablet by mouth twice a day for right foot wound infection with a start date of 03/10/2023; -Amoxicillin Potassium Clavulante (antibiotic used to treat infections) 875mg/125mg one tablet by mouth twice a day for wound infection with a start date of 05/02/2023; -Amoxicillin Potassium Clavulante 875mg/125mg one tablet by mouth twice a day for wound infection with a start date of 05/29/2023; -Amoxicillin Potassium Clavulante 875mg/125mg one tablet by mouth twice a day for right plantar foot wound infection with a start date of 06/22/2023; -Vancomycin (antibiotic used to treat infections) 1.25gram/250 milliliters (ml) intravenous (IV-medication administered directly in the vein) solution administer 250ml every 12 hours for osteomyelitis with a start date of 07/03/2023; and -Vancomycin) 750mg/175ml IV solution administer via peripherally inserted central catheter (PICC) over 75 minutes every 12 hours for osteomyelitis with a start date of 07/10/2023. Review of the agency’s Quality Improvement (QI) Event Summary for Infections for 01/01/2023 through 07/20/2023 revealed no documented evidence and the provider presented no documented evidence of the above mentioned infections were identified and reviewed to determine any trends in infections for the agency. In an interview on 07/20/2023 at 1:36 p.m., S2Clinical Manager/Alternate Administrator stated the process for the agency’s infection surveillance was once an infection was identified the staff at the home were to initiate an infection control report with information on the type of infection, signs/symptoms of the infection, and treatment of the infection. S2Clinical Manager/Alternate Administrator stated then the workflow is updated, and the agency will review weekly in case conferences and ensure proper follow-up and resolution of the infection. S2Clinical Manager/Alternate Administrator stated this information was used to look for trends to see if any common staff, similar types of infections, or the need to intervene for any issues. S2Clinical Manager/Alternate Administrator stated the agency was not tracking patients that are admitted with an infection present. S2Clinical Manager/Alternate Administrator confirmed Patient #1 and Patient #5 did not have infection reports completed for the above mentioned infections and therefore the agency did not maintain an effective infection control surveillance program.