Every finding on record at Tak Progressive Health Services Inc

An onsite recertification survey was conducted at TAK-Progressive Health Services Inc., located at 100 Everett Ave, Unit 3A, Chelsea MA. 02150 on 1/20/2026, 1/21/2026 and 1/22/2026 to determine compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with the Condition of Participation for Emergency Preparedness. Deficiencies were cited.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on document review and interview, the (Home Health Agency) failed to develop, implement and maintain an Emergency Preparedness (EP) Program/Plan that met the regulatory requirement 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies, Condition of Participation. Findings include: Specifically, the HHA: - Failed to ensure the Center specific Emergency Preparedness (EP) plan was developed, implemented and maintained. Please refer to E-0004. -Failed to develop and implement policies and procedures that align with the identified hazards within the facility's risk assessment and the facility's overall Emergency Preparedness (EP) plan that was reviewed and updated at least every 2 years Please refer to E-0013. -Failed to develop a Center specific Emergency Preparedness (EP) plan that included a Communication Plan that included names and contact information of the staff currently employed by the agency. Please refer to E-0030 - Failed to conduct exercises to test the Emergency Preparedness (EP) plan at least annually (emergency drill; tabletop exercise; or actual emergency event). Please refer to E-0039.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on document review and interview the agency failed to develop, implement and maintain an Emergency Preparedness (EP) plan that must be reviewed and updated at least every 2 years. Findings include: An emergency plan is one part of a facility's Emergency Preparedness plan. The plan provides the framework, which includes conducting facility-based and community-based risk assessments that will assist a facility in addressing the needs of their patient populations, along with identifying the continuity of business operations which will provide support during an actual emergency. The plan must be reviewed and updated at least every 2 years. Review of the documents provided to the surveyor indicated a risk assessment that was completed 3/2025. Upon further review of the documents, there was not a comprehensive, facility-based Emergency Preparedness (EP) Plan as required. During an interview on 1/22/26 at 4:30 P.M. the Director of Nursing said there was no formalized plan associated with the risk assessment that was done 3/2025. He said the documents that he provided to the surveyor was all he had related to the EP Plan.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on document review and interview the agency failed to develop and implement policies and procedures that align with the identified hazards within the facility's risk assessment and the facility's overall Emergency Preparedness (EP) plan. Findings include: Review of the documents provided to the surveyor for the agency's EP Plan indicated that a risk assessment was completed in 3/2025. Further review of the documents provided indicated that the agency did not develop policies and procedures that align with the identified hazards within the agency's risk assessment. During an interview on 1/22/26 at 4:30 P.M., the Director of Nursing said that he had provided all the documentation for the EP plan, and it did not include any policies and procedures that addressed the identified hazards identified within the agency's risk assessment. The surveyor requested any additional documentation that the agency could provide that could not be located at the time of exit conference. The EP Plan policies and procedures were again requested on 1/23/26 at 2:47 P.M, 1/26/26 at 1:06 P.M, and 1/27 at 2:10 P.M. with no additional documentation provided to the surveyor.

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 document review and interview, the agency failed to ensure the communication plan included names and contact information of the staff currently employed by the agency. Findings include: Review of the agency's Emergency Preparedness (EP) Plan documentation provided to surveyors included a list of staff with their contact information. Upon further review, it indicated that the list of staff with the contact information was incorrect. The list included staff who no longer worked for the agency and the list did not include all the current staff working at the agency. The staff list of contact information was not updated to reflect the current staff working at the Agency. During an interview on 1/22/26 at 2:45 P.M., the Director of Nursing said that the list was not current and needed to be updated but had not done so. He said he did not have a current, revised, staff contact list that would be used during an emergency.

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: The agency failed to conduct exercises to test the Emergency Preparedness (EP) plan at least annually (emergency drill; tabletop exercise; or actual emergency event). Findings Include: Review of the EP documents provided to the surveyor by the agency indicated that the last drill was conducted 4/2021. There were no other emergency drills, tabletop exercises or actual emergency events within the documents provided to the surveyor. During an interview on 1/22/26 at 4:30 P.M., the Director of Nursing said that the drill conducted 4/2021 was the most recent drill and no other drill, tabletop exercise or actual emergency event had been completed as required.

An onsite recertification survey was conducted at TAK-Progressive Health Services Inc, located at 100 Everett Avenue, Unit 3A, Chelsea, MA 02150, on 1/20/26, 1/21/26, and 1/22/26 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. 484.65 Condition of Participation: Quality assessment and performance improvement (QAPI) was not met. Please refer to G0658 and G0660. 484.75 Condition of participation: Skilled professional services was not met. Please refer to G0710, G0718, G0726, and G0728. 484.80 Condition of participation: Home health aide services was not met. Please refer to G0770 and G0808. 484.105 Condition of Participation: Organization and administration of services was not met. Please refer to G0952 and G0958. Deficiencies were cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review, policy review and interview, the agency failed to: Complete and electronically transmit an Outcome and Assessment Information Set (OASIS-mandatory assessment tool to measure patient outcomes and quality of care) assessment within 30 days for one Patient (#5), out of a total sample of 7 patients, andTrack, correct, and resolve Home Health Agency (HHA) Error (-3330) Summary by Agency reports regarding compliance with encoding and transmitting OASIS data to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the assessment. 2. Review of the HHA (Home Health Agency) Error (-3330) Summary by Agency report (identifies compliance issues with transmission requirements for late OASIS submissions) indicated the agency had 13 assessments with error out of 56 assessments processed to equal 23.21%. The -3330 error indicated the assessments were not submitted within 30 days as required. During an interview on 1/22/26 at 11:48 A.M. with the owner and Administrator, the Administrator said he was also the agency's DON and oversees monitoring of the agency’s HHA error summary reports but said he hadn’t pulled the report recently. He said, however, the agency had a 0% error rate. The Administrator showed the surveyor a report dated January 2025 where the agency had a 24% error rate and a May 2025 report where the error rate had increased to 47%. No other reports were located and provided to the surveyor upon request. The Administrator and owner said they were not aware of the current error percentage rate but said OASIS assessments should have been submitted within 30 days as required. Findings include: Review of the agency's policy titled, Initial Assessment/Comprehensive Assessments, dated as revised 5/2024, included but was not limited to the following: *Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes. *The agency's comprehensive assessment includes the use of the Outcome and Assessment Information Set (OASIS) items for all patients except patients under the age of 18, patients receiving maternity services, patients receiving only housekeeping or chore services, patients receiving personal care services until further notice and patients for whom Medicare or Medicaid insurance is not billed. *Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient's needs, but no later than 5 calendar days after the start of care. Review of the agency's policy titled, Oasis Assessment Reference Sheet, dated as revised 5/2024, indicated but was not limited to the following: *Reason for Assessment (RFA) Description: Start of Care (SOC)-further visits planned *Assessment Completed: Within 5 calendar days after the SOC date (SOC=Day 0) *Submission Timing: Transmission required within 30 calendar days of completing assessment 1.Patient #5 was admitted to the agency in January 2024 with the diagnoses of bi-polar disorder, requiring skilled services. Review of the Physician Order, dated 1/7/24 indicated the following: Skilled Nursing (SN): 1 time daily 7 days per week for 9 weeks. Review of the clinical record indicated a SN visit was completed on 1/7/24 as physician ordered. Further review of the clinical record failed to include a completed and transmitted OASIS. During an interview on 1/22/26 at 2:06 P.M., the Director of Nurses (DON) said he was unable to locate a completed and transmitted OASIS for start of care for Patient #5. The DON said the agency failed to complete and transmit an OASIS within 30 days as required.

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 policy review and interview, the agency failed to ensure the patient and the patient’s legal representative (if any) were provided with the following information during the initial evaluation visits, in advance of furnishing care to the patient: contact information for the home health agency administrator, including the administrator’s name, business address and business phone number in order to receive complaints. Findings include: Review of the agency policy titled Patient Bill of Rights, revised 11/2021, included the following: *The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. *The Patient Bill of Rights statement defines the right of the patient to: voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must be subjected to discrimination or reprisal for doing so. Review of the Patient Information Booklet included an informational sheet titled "Complaints and Grievances" which included, but was not limited to the following: *You may report a complaint or grievance at any time without reprisal or disruption of services. *The patient may also contact the Accreditation Commission for Health Care (ACHC) or the State of Massachusetts Department of Health at any time to file a complaint if the agency fails to resolve the complaint to your satisfaction without fear of reprisal or disruption in services. Additional review of the informational sheet included incorrect identification of the listed administrator, incorrect information for the accreditation agency and incorrect information for the Department of Health. During an interview on 1/22/26 at 1:26 P.M., the Administrator reviewed the informational sheet and said the administrator name listed on the sheet was incorrect. The Administrator also said the agency was currently not certified through the ACHC and was unaware the contact information provided for the Department of Health was incorrect. The Administrator said this was the informational sheet which was provided to new patients and the information provided was incorrect.

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 record review, policy review and interview, the agency failed to ensure 2 patients (#1and #5) had the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, out of a total sample of 7 patients. Findings include: Review of the agency policy titled, "Informed Consent/Refusal of Treatment" dated as last revised 11/2021, included, but was not limited to the following: *To obtain written consent for care during the admission process and to communicate the organization's process for informing patients and family/caregivers regarding services as well as involving patients in the care/service planning process. *Upon admission and throughout the course of care/services, the patient and family/caregiver will be: -Given information, in an understandable language, to make informed decisions regarding the care/service being provided. -Encouraged to participate in the care/service planning process, including planning for transfer, referral and discharge. -Allowed to refuse all or part of his/her care/services to the extent permitted by law, the expected consequences of such action must be explained. -During the admission visit, the patient or authorized representative will sign the organization's written consent for care/services. *During the admission visit and follow-up visits, the patient and family/caregiver will be given information (verbally and/or in writing) that describes: -The services and/or disciplines anticipated to be involved in the care/service of the patient 1.Patient #1 was admitted to the agency in January 2025 with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease, requiring skilled services. Review of the physician ordered Plan of Care (POC) for certification period 1/13/25 through 3/13/25 indicated the following: Skilled Nursing (SN): 3 visits daily for 60 days. Review of the clinical record indicated SN visits were completed 3 times daily as physician ordered. Further review of the clinical record failed to include any consent for services and care provided. During an interview on 1/22/26 at 1:50 P.M., the Director of Nurses (DON) said he was unable to locate and provide any signed consents for the care provided to Patient #1. 2. Patient #5 was admitted to the agency in January 2024 with a diagnosis of bi-polar disorder, requiring skilled services. Review of the Physician Order, dated 1/7/24 indicated the following: SN: 1 time daily 7 days per week for 9 weeks. Review of the clinical record indicated SN visits were completed daily as physician ordered. Further review of the clinical record failed to include any consents for services and care provided. During an interview on 1/22/26 at 2:06 P.M., the DON said he was unable to locate and provide any signed consents for the care provided to Patient #5. The DON said all consents for treatment needed to be completed before initiation of any provided services.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure the comprehensive assessment was completed in a timely manner, consistent with patient's immediate needs, but no later than 5 calendar days after the start of care for one patient (#5), out of a total sample of 7 patients. Findings include: Review of the agency's policy titled, Initial Assessment/Comprehensive Assessments, dated as revised 5/2024, included but was not limited to the following: *Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes. *The comprehensive assessment will identify the patient's need for home care and meet patient's need for: medical, rehabilitative, nursing, social and discharge planning. *The agency's comprehensive assessment includes the use of the Outcome and Assessment Information Set (OASIS-mandatory assessment tool to measure patient outcomes and quality of care) items for all patients except patients under the age of 18, patients receiving maternity services, patients receiving only housekeeping or chore services, patients receiving personal care services until further notice and patients for whom Medicare or Medicaid insurance is not billed. *A registered nurse, physical therapist or speech language pathologist must conduct the initial assessment visit with 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. *Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient's needs, but no later than 5 calendar days after the start of care. Patient #5 was admitted to the agency in January 2024 with a diagnosis of bi-polar disorder, requiring skilled services. Review of the Physician Order, dated 1/7/24 indicated the following: Skilled Nursing (SN): 1 time daily 7 days per week for 9 weeks. Review of the clinical record indicated the SN visits were initiated on 1/7/24 as physician ordered. Further review of the clinical record failed to include an initial comprehensive assessment for start of care on 1/7/24 as required. During an interview on 1/22/26 at 2:08 P.M., the Director of Nurses (DON) said he was unable to locate an initial comprehensive assessment. The DON said Patient #5 should have had an initial comprehensive assessment completed within 5 days of start of care but did not.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated the last five days of every 60 days beginning with the start of care date for one patient (#6), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled Reassessment/Comprehensive Assessments, revised May 2024, indicated but was not limited to the following: *The comprehensive assessment (including OASIS data elements) must be updated and revised as frequently as the patient’s condition warrants due to a major improvement or decline in health status. *Minimally, the comprehensive assessment must be updated and revised, for recertification, the last 5 days of every 60 days, e.g., days 56-60 of the current period. Patient #6 was admitted to the agency in July 2025 with a diagnosis of anxiety disorder, requiring skilled services. Review of the clinical record indicated a physician ordered Plan of Care (POC) for certification period 11/16/25 through 1/14/26. Patient #6 remained on service into a subsequent certification period beginning 1/15/26. Further review of the clinical record indicated an Outcome and Assessment Information Set (OASIS-tool used to collect data on patient outcomes and quality of care) Recertification assessment for Patient #6, dated 1/12/26. The assessment was incomplete. A comprehensive assessment (including OASIS data elements) to reflect the patient’s current health status was not updated or revised in the last 5 days of every 60 days by a skilled nurse until discharged as required. During an interview on 1/21/26 at 2:25 P.M., the Director of Nursing, after reviewing Patient #6’s clinical record, said an updated comprehensive assessment was not completed within the required timeframe.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure an individualized plan of care was established and signed timely by the physician which identified patient-specific measurable outcomes for 1 patient (#5), out of a total sample of 7 patients. Findings include: Review of the agency policy titled Care Plan Process, dated as revised 11/2021, included but was not limited to the following: *To provide clinical direction to the clinicians providing direct care. *A written plan of care will be initialed within 5 days of start of care and updated at least 60 days or as patient's condition warrants. *Individualized Plan of Care: the patient-specific clinical plan includes: -Start of care date and certification period. -All patient care orders including verbal orders. -Measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. -Orders for patient-specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including amount/frequency/duration. -Frequency and duration of visits. Patient #5 was admitted to the agency in January 2024 with a diagnosis of bi-polar disorder, requiring skilled services. Review of the clinical record included a Physician Order, dated 1/7/24, which indicated the following: -Skilled Nursing (SN): 1 time daily 7 days per week for 9 weeks. Further review of the clinical record failed to include a Home Health Certification and Plan of Care for services provided as of 1/7/24 to Patient #5. During an interview on 1/22/26 at 2:08P.M., the Director of Nurses reviewed the clinical record with the surveyor and said he was unable to locate a Home Health Certification and Plan of Care for services provided to Patient #5 as of 1/7/24.

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 record review and interview, the agency failed to ensure the Plan of Care (POC) included all the required elements for one Patient (#2), out of a total sample of 7 patients. Findings include: Review of the facility’s policy titled Plan of Care – CMS #485 and Physicians Orders, revised May 2024, included but was not limited to the following: *Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. *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. Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). Review of the physician ordered Plan of Care (POC) for certification periods 8/20/25 through 10/18/25 and 10/19/25 through 12/17/25, indicated the following: *Home Health Aide (HHA) visits 4 times a week, times 3 hours, for 60 days Further review of the POCs failed to indicate patient-specific HHA interventions and education; measurable outcomes and goals as identified by the agency and the patient. During an interview on 1/22/26 at 10:43 A.M., the Director of Nursing, after reviewing Patient #2’s clinical record, said the care plans did not reflect measurable goals or outcomes for home health aide services as required.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure all patient care orders, including verbal orders, were recorded in the plan of care for three patients (#7, #3 and #4) out of a total sample of 7 patients. 2. Patient # 3 was admitted to the agency in September 2025 with a diagnosis of pressure ulcer of the coccyx, Stage IV (severe, full-thickness wound with exposed muscle, tendon, or bone). a. Review of the physician ordered POC for certification period 9/17/25 through 11/15/25 indicated the following daily wound care orders: - Wash the area with Normal Saline (NS), pat dry. - Apply Santyl (a debriding agent) ointment to wound. - Cover with a border dressing. Review of the physician ordered POC for certification period 11/16/25 through 1/14/26 indicated the following daily wound care orders: - Wash the wound with Vash (solution that cleanses, debrides, and promotes wound healing) and keep the dressing/gauze wet with Vash for three minutes inside the wound then remove. - Cut an 1/8 inch slit in the middle of the 4 x 4 Hydro-Fera blue (sterile non-cytotoxic, antibacterial foam dressing to manage bioburden and promote healing in moderate-to heavy draining wounds) fold and pack inside the wound wet with Vash, fold and pack inside the wound wet with Vash. -Apply Zetuvit (a sterile absorbent dressing for covering wounds and ensuring mechanical protection for upholstering and cushioning) 4 x 4 dressing. On 1/21/26 at 9:45 A.M., Nurse #2 was observed by the surveyor doing the above wound care but used Aquacel (Calcium Alginate Dressing used to treat moderate to heavily exudating wounds) for wound care instead of the Hydro-Fera blue. The wound care completed by Nurse #2 did not reflect current physician orders for the use of Hydro-Fera blue. Nurse #2 said that she was notified by the wound clinic (didn’t indicate the date) to change the treatment to the Aquacel but forgot to transcribe/enter the new wound care treatment order. She said the patient goes to the wound clinic every two weeks and that they are responsible for all the wound care treatments changes. Clinical record review indicated that there was no skilled nurse documentation of an order for the change in the wound care. There was no documentation in the clinical record with any changes in wound care, i.e., starting the Hydro-Fera blue and discontinuing the Santyl, discontinuing the Hydro-Fera blue and starting the Aquacel, and the Santyl ointment was still present on the subsequent recertifications indicating it was to be applied to the wound daily, even though it was no longer in use. Further, there was no documentation that the patient was being followed by the wound care clinic as Nurse #2 had indicated. During an interview on 1/22/26 at 4:20 P.M., the DON said that any change to the patients POC during the certification period should have an order (verbal/telephone) indicating the change so that the information would be correct when the recertification was due. The information that the patient was being followed by a wound clinic with visits every two weeks should have been on the POC and was not. He further said that the POC should be reviewed, revised and accurate to reflect the current patient status and was not. (b) Review of the physician ordered POC for certification periods 9/17/25 through 11/15/25 and 11/16/25 through 1/14/26, indicated the following: -Medical Social Worker (MSW) to assess psychosocial issues that impact health care. MSW to establish a plan as discussed with Case Manager and approved by physician. -Physical Therapy (PT) to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT to assess rehabilitation potential and determine the need for gait training, safety precautions, pain management, strengthening/conditioning exercise balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. Review of the clinical record indicated no documented evidence that Patient #3 had been seen by either PT or an MSW for an assessment or evaluation as ordered by the physician. During an interview on 1/22/26 at 4:20 P.M., the DON said that because the patient had declined the above services, there should be documentation of the declination, and then the above orders should have been edited/removed so that the subsequent recertifications were accurate and reflected the current POC and did not. He said the orders continued to populate on the physician ordered POC. 3. Patient # 4 was admitted to the agency September 2025 with diagnosis including Cerebral Infarct and mild cognitive impairment. Review of the physician ordered POC for certification periods 9/19/25 through 11/17/25 and 11/18/25 through 1/16/26, indicated the following: -PT to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT to assess rehabilitation potential and determine the need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. -Occupational Therapy (OT) to assess functional status, home environment to eliminate structural barrier and improve safety, need for home modifications to promote functional independence. OT to assess rehabilitation, potential and determine the need for Activity of Daily Living (ADL) training, safety precautions, pain management, strengthening/conditioning exercise. OT to establish a home exercise program and plan of care as approved by physician. Review of the clinical record indicated no documented evidence that Patient #4 had been seen by either PT or OT for an assessment or evaluation as ordered by the physician. During an interview on 1/22/26 at 4:20 P.M., the DON said that because the patient had declined the above services, there should be documentation of the declination, and then the above orders should have been edited/removed so that the subsequent recertifications were accurate and reflected the current POC and did not. He said the orders continued to populate on the physician ordered POC. Findings include: Review of the agency policy titled Care Plan Process, dated as revised 11/2021, included but was not limited to the following: *To provide clinical direction to the clinicians providing direct care. *A written plan of care will be initialed within 5 days of start of care and updated at least 60 days or as patient's condition warrants. *Individualized Plan of Care: the patient-specific clinical plan includes: -Start of care date and certification period. -All patient care orders including verbal orders. -Measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. -Orders for patient-specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including amount/frequency/duration. -Frequency and duration of visits. 1.Patient #7 was admitted to the agency in June 2025 with diagnoses of type 2 diabetes mellitus with hyperglycemia and required skilled home care services. Review of the physician ordered Plan of Care (POC) for certification period 10/5/25 through 12/3/25 indicated the following: *Home Health Aide (HHA) visits 4 hours daily 7 times per week for 60 days. Review of the physician ordered POC for certification period 12/4/25 through 2/1/26 failed to include physician orders for continued HHA visits, Further review of the clinical record indicated HHA visits for the certification period beginning 12/4/25 were provided 12/4/25 through 1/20/26. During an interview on 1/22/26 at 2:30 P.M., the Director of Nurses (DON) said the physician orders for HHA visits were not carried over to the next certification period and care cannot be provided without physician orders.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to meet the Condition of Quality Assessment/Performance Improvement: Findings include: 1. The HHA failed to conduct performance improvement projects to reflect the scope, complexity, and past performance of the HHA's services and operations. Refer to G0658. 2. The HHA failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained and that HHA-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness. Refer to G0660.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to conduct annual performance improvement projects to reflect the scope, complexity, and past performance of the HHA's services and operations. Findings include: Review of the Quality Assessment and Performance Improvement (QAPI) Plan and Program, revised May 2024, indicated but was not limited to the following: *The Agency program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. *The Agency will use this data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. *The Agency’s performance improvement activities will: -Focus on high risk, high volume and problem-prone areas. -Consider incidence, prevalence and severity of problems in those areas. -Lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of patients. *Performance improvement activities must track adverse patient events and, after implementing these actions, must measure its success and track performance to ensure that improvements are sustained. *Data collection will include established priorities for improvement. Organizational functions with major processes of the Agency include: -Environment of Care: (Patient Safety) -Emergency Management: (Emergency Operations Plan, Evaluation of Plan) -Human Resources: (Staff Competencies/Clinical Skills, Staff Supervision, Staff Education) -Infection Prevention and Control: (Infection Control Policies, Standard Precautions) -Information Management: (Informed Consent Policy) -Leadership: (Role in QAPI, Operational Components/Responsibilities) -Provision of Care: (Initial Assessment/Timeframe, Comprehensive Assessment, Reassessment, Care Planning, Discharge and Transfer Process, Physician’s Orders, Standards of Practice) -Record of Care, Treatment and Services: (Clinical record components, Authentication of Entries, Record Audits, Timeliness and Retention) -Rights and Responsibilities of the Individual: (Informed Consent) *The QAPI Committee is responsible for taking the appropriate action. Aggregate measures of performance for each process will be compared to pre-established performance expectations to determine if additional evaluation is required. Review of the agency’s QAPI book on 1/22/26 at 10:19 A.M., provided by the Administrator/Director of Nursing (DON), did not indicate documented evidence of annual performance improvement plans PIP(s) completed in 2025 to reflect the scope, complexity, and past performance of the HHA’s services and operations as well as the reasons for conducting the project(s) and the measurable progress achieved. Throughout the survey period from 1/20/26 through 1/22/26, the survey team identified concerns including, but not limited to, emergency preparedness, employment criteria, staff competencies, staff supervision, infection control, informed consent, leadership responsibilities, initial and comprehensive assessments, care planning, discharge and transfer process, coordination with physicians, clinical record components, and authentication of entries. During the QAPI meeting on 1/21/26 at 4:35 P.M., with the owner/Governing Body (GB) and Administrator, the Administrator said he could not locate any documented evidence of PIPs since 2024 and said the agency did not meet the annual requirement. The GB and Administrator said they should have known but had not identified or addressed any of the surveyor’s concerns and had not initiated any projects for them.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on document review, policy review, and staff interviews, the agency failed to ensure its Governing Body (GB) assumed full responsibility to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, and maintained and that Home Health Agency (HHA) -wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety and were evaluated for effectiveness. Findings include: Review of the Quality Assessment and Performance Improvement (QAPI) Plan and Program, revised May 2024, indicated but was not limited to the following: *The Agency will establish an ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program. *The Governing Body (GB) is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented and maintained. *The Agency program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. *The Agency will use this data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. *Data collection will include established priorities for improvement. Organizational functions with major processes of the Agency include: -Environment of Care: (Patient Safety) -Emergency Management: (Emergency Operations Plan, Evaluation of Plan) -Human Resources: (Staff Competencies/Clinical Skills, Staff Supervision, Staff Education) -Infection Prevention and Control: (Infection Control Policies, Standard Precautions) -Information Management: (Informed Consent Policy) -Leadership: (Role in QAPI, Operational Components/Responsibilities) -Provision of Care: (Initial Assessment/Timeframe, Comprehensive Assessment, Reassessment, Care Planning, Discharge and Transfer Process, Physician’s Orders, Standards of Practice) -Record of Care, Treatment and Services: (Clinical record components, Authentication of Entries, Record Audits, Timeliness and Retention) -Rights and Responsibilities of the Individual: (Informed Consent) *The QAPI Committee is responsible for taking the appropriate action. Aggregate measures of performance for each process will be compared to pre-established performance expectations to determine if additional evaluation is required. *The QAPI committee will meet on a regular basis and will report findings to the Administrator/Director of Clinical Services, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI committee to staff, including contract staff. Review of the agency’s QAPI book on 1/22/26 at 10:19 A.M., provided by the Administrator, did not indicate documented evidence of annual performance improvement plans PIP(s) completed in 2025 to reflect the scope, complexity, and past performance of the HHA’s services and operations as well as the reasons for conducting the project(s) and the measurable progress achieved. The book indicated quarterly meeting minutes on 7/20/24, 10/5/24, and 1/18/25 signed by the Administrator who said he was also the Director of Nursing. There was no documentation of other attendees. Throughout the survey period from 1/20/26 through 1/22/26, the survey team identified concerns including, but not limited to, emergency preparedness, employment criteria, staff competencies, staff supervision, infection control, informed consent, leadership responsibilities, initial and comprehensive assessments, care planning, discharge and transfer process, coordination with physicians, clinical record components, and authentication of entries. During the QAPI meeting on 1/21/26 at 4:35 P.M., with the GB (owner) and Administrator, the Administrator said the QAPI committee meets quarterly and includes himself, the GB, and nurses which are all required to be present. The surveyor reviewed the meeting minutes with the owner and Administrator who said he could not provide documentation of lists of attendees for the 7/20/24, 10/5/24, or 1/18/25 meetings. The Administrator said he could not locate any documented evidence of PIPs since 2024 and said the agency did not meet the annual requirement. The owner and Administrator said they should have known but had not identified or addressed any of the surveyor’s concerns and had not initiated any projects for them. The GB said he did not ensure an ongoing QAPI and patient safety program that was defined, implemented, and maintained as required.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to follow standards of practice for infection control for one patient (#3) during the surveyor observation of Nurse #2 providing wound care. Findings Include: On 1/21/26 at 9:45 A.M., during a home visit, the surveyor observed Nurse #2 providing wound care for Patient #3. Patient #3 had a Stage IV (severe, full-thickness wound with exposed muscle, tendon, or bone) pressure ulcer of the coccyx. Nurse #2 washed the wound with the prescribed wound wash and gauze pads four times and “tossed ”the soiled gauze each time into an unlined, uncovered trash barrel located several feet from Patient #3's bed. The soiled gauze pads were not disposed of properly or properly contained. During an interview on 1/21/26 at 10:15 A.M., Nurse #2 said she should have used the plastic bag provided by the agency to dispose of the used wound supplies but did not. During an interview on 1/22/26 at 4:45 P.M., the Director of Nurses said Nurse #2 should have used the plastic bags supplied by the agency and should have not discarded the used/dirty dressing materials in Patient #3's uncovered, unlined trash barrel.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review, patient and staff interviews, the Home Health Agency (HHA) failed to meet the Condition of Participation related to Skilled Professional Services. Findings include: 1.The HHA failed to ensure that the physician’s ordered plan of care was followed. Please refer to G0710. 2.The HHA failed to communicate with the physician when services were not provided as ordered. Please refer to G0718. 3. The HHA failed to ensure that nursing services were provided under the supervision of a registered nurse. Please refer to G0726. 4. The HHA failed to ensure rehabilitative therapy services were provided under the supervision of an occupational therapist or physical therapist. Please refer to G0728.

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 record review and interview, the agency failed to ensure that the physician ordered plan of care was followed for three patients (#2, #3 and #4), out of 7 sampled patients. 2. Patient #3 was admitted to the agency in September 2025 with diagnosis of Pressure Ulcer of the coccyx, Stage IV (severe, full-thickness wound extending to muscle, tendon, or bone). Review of the physician ordered POC for certification periods 9/17/25 through 11/15/25 and 11/16/25 through 1/14/26, indicated the following: -Medical Social Worker (MSW) to assess psychosocial issues that impact health care. MSW to establish a plan as discussed with Case Manager and approved by physician. -Physical Therapy (PT) to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT to assess rehabilitation potential and determine the need for gait training, safety precautions, pain management, strengthening/conditioning exercise balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. Review of the clinical record indicated no documented evidence that Patient #3 had been seen by either PT or a MSW for an assessment or evaluation as ordered by the physician. During an interview on 1/22/26 at 3:57 P.M., the DON said the PT and MSW assessments/evaluations were not completed per the physician’s orders, but that the patient had refused the above services. There was no documentation of the patient’s refusal in the clinical record. 3. Patient # 4 was admitted to the agency in September 2025 with diagnoses including cerebral infarct and mild cognitive impairment. Review of the physician ordered POC for certification periods 9/19/25 through 11/17/25 and 11/18/25 through 1/16/26, indicated the following: -PT to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT to assess rehabilitation potential and determine the need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination and transfers. PT to establish a home exercise program and plan of care as approved by physician. -OT to assess functional status, home environment to eliminate structural barrier and improve safety, need for home modifications to promote functional independence. OT to assess rehabilitation, potential and determine the need for ADL training, safety precautions, pain management, strengthening/conditioning exercise. OT to establish a home exercise program and plan of care as approved by physician. During an interview on 1/22/26 at 3:57 P.M., the DON said the PT and OT assessments/evaluations were not completed per the physician’s orders, but that the patient had refused the above services. There was no documentation of the patient’s refusal in the clinical record. Findings include: Review of the facility’s policy titled Skilled Professional Services, revised May 2024, indicated but was not limited to the following: *Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, occupational therapy, physician and medical social work services. *Skilled professionals must assume responsibility for, but not be restricted to the following: -Providing services that are ordered by the physician as indicated in the plan of care. 1.Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). Review of the physician ordered Plan of Care (POC) for certification periods 8/20/25 through 10/18/25 and 10/19/25 through 12/17/25, indicated the following: *Occupational Therapy (OT): assess and treat; assess functional status, home environment to eliminate structural barriers and improve safety, need for home modifications to promote functional independence. OT to assess rehabilitation potential and determine need for Activities of Daily Living (ADL) training, safety precautions, pain management, strengthening, conditioning exercise. OT to establish a home exercise program and plan of care as approved by the physician. Review of the clinical record indicated no documented evidence that an OT evaluation had been completed as ordered by the physician. During an interview on 1/21/26 at 2:57 P.M., the Director of Nursing (DON) said the OT evaluation was not completed per physician’s orders, but the patient had refused. The DON was unable to provide documentation of the patient’s refusal to receive OT services upon request.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to communicate with the physician when services were not provided as ordered for 3 patients (#7, #6 and #4), out of a total sample of 7 patients. 3. Patient #4 was admitted to the agency in September 2025 with diagnose of cerebral infarction and mild cognitive impairment requiring skilled services. Review of the physician ordered POC for certification period 11/18/25 through 1/16/26 indicated the following: -SN visits 1 time daily for 60 days and 3 as needed visits (prn) for acute changes in medical condition. Review of the clinical record during the week of 12/28/25 and week of 1/4/26 indicated a SN did not provide visits 1/2/26, 1/3/26, 1/4/26, 1/5/26 ,1/6/26 and 1/7/26. Further review of the clinical record contained no documentation that the physician had been notified of the missed SN visits 1/2/26 through1/7/26. During an interview on 1/22/26 at 4:00 P.M., the DON said there was no further documentation in the clinical record that the physician had been notified of the missed SN visits 1/2/26 through 1/7/26 as required. 2. Patient #6 was admitted to the agency in July 2025 with a diagnosis of anxiety disorder, requiring skilled services. Review of the physician ordered POC for certification period 11/16/25 through 1/14/26 indicated the following: -SN visits twice a week for 60 days and 3 visits as needed. Review of the clinical record during the week of 12/14/25 to 12/20/25 indicated a LPN missed visit note, dated 12/18/25. Further review of the clinical record contained no documentation that the physician had been notified of the missed visit. During an interview on 1/21/26 at 2:25 P.M., the DON, after reviewing the clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed LPN visit, as required. Findings include: Review of the agency policy titled Reporting to Physician, dated 11/2021, indicated, but was not limited to the following: *Clinicians will establish and maintain ongoing communication with the physician (or other authorized licensed independent practitioner) to ensure safe and appropriate care for the patient. *The patient's physician (or other authorized licensed independent practitioner) will be contacted the same day when any of the following occur: -When there is a problem implementing the plan of care. -When a visit is missed for any reason. *All conferences or attempts to communicate with physician will be documented in the clinical record. Documentation of the physician notification will include: -Date and time contacted. -Patient name. -Name of physician notified or his/her representative. -Reason for notification. -Physician's response. -Action taken or orders obtained. -Professional's signature and title. *Documentation of attempted physician notification will include: -Date and time. -Patient name. -Name of physician attempting to notify. -Reason for notification. -Name of person taking message. 1.Patient #7 was admitted to the agency in June 2025 with a diagnosis of type 2 diabetes mellitus with hyperglycemia and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 12/4/25 through 2/1/26 indicated the following: -Skilled Nurse (SN) frequency: 1 time weekly for 60 days and 3 visits as needed (PRN) for medical complications. Review of the clinical record during the week of 12/21/25 to 12/27/25 indicated a Licensed Practical Nurse (LPN) missed visit note, dated 12/25/25. During an interview on 1/21/16 at 2:26 P.M., the Director of Nurses (DON), after reviewing the clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed LPN visit, as required.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure nursing services were provided under the supervision of a registered nurse (RN) for 3 patients (#7, #2 and #4), out of total sample of 7 patients, who received nursing services from a licensed practical nurse (LPN). 3. Patient #4 was admitted to the agency in September 2025 with diagnosis of Cerebral Infarction and mild cognitive impairment requiring skilled services. Review of the physician ordered POC for certification period 11/18/25 through 1/16/26, and 1/17/26 through 3/17/26 indicated the following: -SN visits 1 x daily x 60 days and 3 PRN visits for acute changes in medical condition. Review of the clinical record indicated the LPN did the majority of the visits 12/1/25 through 12/31/25 and 1/8/26 through 1/21/26. There was no documentation in the clinical record that LPN supervisory visits were completed by a registered nurse as required. During an interview on 1/22/26 at 4:10 P.M., the DON said the LPN supervisory visits were not completed every 30 days as required. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected) and required skilled home care services. Review of the physician ordered POC for certification periods 10/19/25 through 12/17/25 indicated the following: *SN visits 5 times a week for 60 days. Patient #2 remained on service into a subsequent certification period beginning 12/18/25, however, there was no physician ordered POC. Review of the clinical record indicated LPN visits were completed on 10/28/25, 11/4/25, 11/11/25, 11/25/25,12/9/25, 12/17/25, and 12/18/25. There was no documentation in the clinical record that LPN supervisory visits were completed by a registered nurse as required. During an interview on 1/21/26 at 2:57 P.M., the DON said LPN supervisory visits were not completed every 30 days as required. Findings include: Review of the agency's policy titled, Nursing Services, dated as revised 5/2024, included but was not limited to the following: *Nursing care will be provided in accordance with the patient's plan of care, under the supervision of a registered nurse. *Professional nursing services will be provided by a registered nurse (RN) and include: -Supervising the Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) and paraprofessionals providing service. -The LPN/LVN will be supervised by the RN as required by applicable state rules and regulations. 1.Patient #7 was admitted to the agency in June 2025 with a diagnosis of type 2 diabetes mellitus with hyperglycemia and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 10/5/25 through 12/3/25 indicated the following: -Skilled Nursing (SN) frequency: 1 time weekly for 60 days and 3 visits as needed (PRN) for medical complications. Review of the physician ordered POC for certification period 12/4/25 through 2/1/26 indicated the following: -SN frequency: 1 time weekly for 60 days and 3 visits PRN for medical complications. Review of the clinical record for dates of services between 11/23/25 through 1/21/26 indicated LPN visits were conducted on 11/28/25, 12/4/25, 12/11/25, 12/19/25, 12/31/25, 1/8/26, 1/15/26 and 1/21/26. Further review of these dates of service failed to include any documented RN supervisory visits. During an interview on 1/21/26 at 2:26 P.M., the Director of Nurses (DON) and surveyor reviewed the clinical record for the dates of services between 11/23/25 through 1/21/26. The DON said LPN supervision should be provided by an RN every 30 days and the LPN supervision was not provided as required.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure rehabilitation therapy services were provided under the supervision of a physical therapist (PT) for one patient (#2), out of a total sample of 7 patients. Findings include: Review of the agency’s policy titled Rehabilitation Services, revised 2024, indicated but was not limited to the following: *Each patient referred for rehabilitation services will receive in-depth functional evaluations and assessments by a qualified therapist (PT, SLP (speech language pathology), and/or OT (Occupational Therapy)) before treatment and education are initiated. *Services provided by a physical or occupational therapist include: -Supervising therapy assistants and home health aides as appropriate *Therapy Assistant (PTA, COTA) duties, under the direction of a PT or OT as appropriate, include: -Performing services planned, delegated and supervised by the therapist Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). Review of the physician ordered Plan of Care (POC) for certification periods 8/20/25 through 10/18/25 and 10/19/25 through 12/17/25, indicated the following: *Physical Therapy (PT): assess and treat; to assess functional status, home environment to eliminate structural barriers and improve safety and functional independence. PT to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercises, balance/coordination and transfer. PT to establish a home exercise program and plan of care as approved by the physician. Review of the clinical record indicated Physical Therapy Assistant (PTA) visits were completed on 9/18/25, 9/23/25, 9/26/25, 10/1/25, 10/3/25, 10/8/25, and 10/10/25, and 11/7/25. There was no documentation in the clinical record that PTA supervisory visits were completed by a skilled therapy professional for the assistant’s respective therapy type as required. During an interview on 1/21/26 at 2:57 P.M., the Director of Nursing said PTA supervisory visits were not completed every 30 days as required.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on interview and record reviews, the Home Health Agency (HHA) failed to meet the Condition of Participation related to Home Health Aide services. Findings include: 1. The HHA failed to ensure home health aides did not perform any task for which he or she was evaluated as unsatisfactory. Please refer to G770. 2. The HHA failed to ensure the supervision of home health aides. Please refer to G0808.

Unsatisfactory competency evaluation CFR(s): 484.80(c)(4) A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as "unsatisfactory," and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an "unsatisfactory" rating in more than one of the required areas. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to ensure home health aide (HHA) staff did not perform any skill/task in which he/she was evaluated as unsatisfactory without successfully completing a subsequent evaluation for one home health aide (HHA #1) out of a total sample of 3 HHA personnel files reviewed. Findings include: Review of the agency’s policy entitled Inservice Education, revised May 2024, indicated but was not limited to the following: *Policy: Regularly scheduled and appropriate in-service programs will be made available for all employees. *Purpose: To ensure the continuing education of all Agency personnel. *The employee will be responsible for attending in-service programs and maintain compliance with in-service requirements for his/her position. *HHA in-service training may be furnished during care to patients. The agency maintains documentation that demonstrates that each HHA has met the requirements. HHA #1 was hired 8/21/25. Review of the Annual On-Site Competency Assessment, dated 12/22/25, indicated HHA #1 was not competent in home care record documentation and needed improvement. The Director of Nursing (DON) was documented as the observer during the on-site competency assessment of HHA #1. The section “If needs improvement, explain” was blank. Review of a total sample of 7 patient records indicated HHA #1 completed home care record documentation for one (Patient #7) of 7 patients on 12/23/25, 12/24/25, 12/25/25, 12/29/25, 12/30/25, 1/1/26, 1/5/26, 1/6/26, 1/7/26, 1/8/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/20/26, and 1/21/26, without documentation that he/she had successfully completed a subsequent evaluation for that task. During an interview on 1/22/26 at 1:41 P.M., the DON, after reviewing the personnel file, said if HHAs are not satisfactory for a skills review task, then they should not be performing that task until they are deemed competent. He said HHA #1 had not been re-evaluated prior to performing the home care record documentation task as required.

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 record review, policy review and interview, the agency failed to complete a supervisory assessment of the Home Health Aide (HHA) services being provided no less frequently than 14 days for 2 patients (#7 and #2), out of two patients receiving HHA services out of a total sample of 7 patients. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). Review of the physician ordered POC for certification period 10/19/25 through 12/17/25, indicated the following: *HHA visits 4 times a week, times 3 hours, for 60 days. Patient #2 remained on service into a subsequent certification period beginning 12/18/25 receiving HHA services, however, there was no physician ordered POC. Review of the clinical record indicated HHA visits were completed on 10/27/25, 10/28/25, 10/29/25, 10/30/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/10/25, 11/11/25, 11/18/25, 11/19/25, 11/20/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, 12/21/25, 12/22/25, and 12/23/25. There was no documentation in the clinical record that HHA supervisory assessments of the aide services being provided were completed by a registered nurse or other appropriate skilled professional as required. During an interview on 1/21/26 at 2:57 P.M., the DON, after reviewing Patient #2’s clinical record, said HHA supervisory visits were not being completed every 14 days as required. Findings include: Review of the agency's policy titled Home Health Aide Plan of Care, dated as revised 11/2021, indicated but was not limited to the following: *The registered nurse (RN) or other appropriate clinician who is familiar with the patient, the patient's plan of care and the written patient care instructions will complete a supervisory assessment of the home health aide no less frequently than every 14 days to ensure care is provided according to plan. The home aide does not need to be present during the supervisory assessment. 1.Patient #7 was admitted to the agency in June 2025 with diagnoses of type 2 diabetes mellitus with hyperglycemia and required skilled home care services. Review of the physician ordered Plan of Care (POC) for certification period 10/5/25 through 12/3/25 indicated the following: *Home Health Aide (HHA) visits 4 hours daily 7 times per week for 60 days Patient #7 remained on services into the subsequent certification period beginning 12/4/25 receiving HHA services, however, there was no physician ordered POC. Review of the clinical record indicated HHA visits were completed on 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, 11/30/25, 21/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, 12/30/25, 1/3/26, 14/26, 1/5/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26 and 1/21/26. Further review of the clinical record failed to include any documentation that HHA supervisory assessments of the aide services being provided were completed by a registered nurse (RN) or other appropriate skilled professional as required. During an interview on 1/22/26 at 2:26 P.M., the Director of Nursing (DON), after reviewing Patient #7's clinical record, said HHA supervisory visits were not completed every 14 days as required.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record reviews, the Home Health Agency (HHA) failed to meet the Condition of Participation related to Organization and Administration of Services. Findings include: 1. The agency failed to ensure that a Criminal Offender Record Information (CORI) was completed prior to hire for 2 out of 5 employees reviewed and a Nurse Aide Registry background check was completed prior to hire for 5 of of 5 employees reviewed. Please refer to G952. 2. The HHA failed to ensure one or more qualified individuals provided oversight of all patient care services and personnel. Please refer to G0958

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that a Criminal Offender Record Information (CORI) and/or Nurse Aide Registry background check for 5 out of 5 staff (Licensed Practical Nurse (LPN) #1, Administrator, Home Health Aide (HHA) #1, HHA #2, and HHA #3) was conducted prior to hire, as required. Findings include: 5. HHA #3 was hired on 8/6/25. Review of the employee file indicated a CORI was generated on 9/15/25 with Response Summary, however HHA#3 provided direct care to a patient during an Initial On-Site Competency Home Health Aide visit on 8/6/25, prior to the CORI report being generated. Further review of the employee file failed to indicate a Nurse Aide registry check was conducted. During an interview on 1/22/26 at 8:25 A.M., the Director of Nursing (DON) said he could not provide documentation that any of the Nurse Aide registry background checks were completed for 5 out of 5 staff reviewed. He said they should be done upon hire and before patient care is provided but it was not done as required. The DON further said CORI checks are also required to be completed upon hire and before direct patient care is provided. Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry Section: 105CMR 155.010 (G)(3) included the following: -Each facility, home health agency, homemaker agency and hospice program shall adopt and implement preventive administrative, management and personnel policies and practices, including, but not limited to, the following: (1) careful interviewing of employee applicants; (2) close examination of applicant references prior to hiring; (3) in accordance with applicable federal and state laws, obtaining all available criminal offender record information from the criminal history systems board on an applicant under final consideration for a position that involves the provision of direct personal care or treatment to patients or residents. (4) cooperation with other facilities, Review of the 105 CMR 155.000: Patient and Resident Abuse Prevention, Reporting, Investigation, Penalties and Registry Section: 105CMR 155.010 (E)(3) included the following: -All home health agencies, homemaker agencies, and hospice programs shall contact the Registry prior to hiring an individual who will provide direct care to patients or have access to patients or their property to ascertain if there is any sanction, finding or adjudicated finding of patient or resident abuse, neglect, mistreatment, or misappropriation of patient or resident property against the prospective employee. 1. LPN #1 was hired 6/9/25. Review of the employee file failed to indicate that a Nurse Aide registry check was conducted. 2. Administrator/Director of Nursing (DON) was hired on 8/15/15. Review of the employee file failed to indicate that a Nurse Aide registry check was conducted. 3. Home Health Aide (HHA) #1 was hired on 8/21/25. Review of the employee file indicated that a CORI was generated on 9/12/25 with Response Summary. Review of HHA #1's Initial On-Site Competency Checklist, dated 8/21/25, indicated HHA #1 provided direct care to the patient and prior to the CORI report being generated. Further review of the file failed to indicate that a Nurse Aide registry check was conducted. 4. HHA #2 was hired on 5/15/25. Review of the employee file failed to indicate that a Nurse Aide registry check was conducted. Only an application request was provided to the surveyor.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure a qualified individual provided oversight of all patient care services and personnel. Findings include: During the entrance conference interview conducted with the Program Coordinator/Owner and Administrator on 1/20/26 at 10:37 A.M., the Administrator said he was also the Director of Nursing (DON). He said the Clinical Manager (CM) was not a Registered Nurse (RN) but a Licensed Practical Nurse (LPN #1) who was hired within the past year. He said he and LPN #1 shared the responsibility of oversight of all patient care services and personnel. Review of the signed Job Description for the Director of Clinical Services/Clinical Manager, signed and dated by the Administrator/DON in March 2018 indicated the following: *The Director of Clinical Services/Clinical Manager is a Registered Nurse (RN) who has graduated from an accredited school of nursing and is currently licensed to practice in the state(s) where currently practicing. If an RN, the Director of Clinical Services/Clinical Manager is available at all times during operating hours (or appoints a similarly qualified alternate) and participates in all activities relevant to professional services furnished, including the development of qualifications and assignment of personnel. *Qualifications: -Ability to supervise, guide and develop skills and performance of service personnel. -Ability to assist in evaluating personnel per Agency policy. -Participates in establishing the functions and qualifications for each service position, and coordinates patient care and referrals. -Assures ongoing assessment of patient/family needs and implementation of interdisciplinary team plan of care. -Assures physician approval of plans for continuity of care. -Accepts responsibility for regular attendance and punctuality and fulfills job requirements without regard to time involved. -Oversees Agency’s ongoing Quality Assessment and Performance Improvement (QAPI) program. -Plans and supervises the Agency. -Assures that patient’s plans of care are developed, implemented and updated. -Is normally available at all times during and after operating hours; may designate a qualified temporary replacement if he/she will not be available. -Ensures compliance with federal, state, accrediting bodies, local and Agency policies in all patient care aspects of the Agency. -Makes patient and personnel assignments. *Working Environment: Works indoors in the home health office. *Workers Supervised: Entire home health patient care staff. During an interview on 1/20/26 at 1:29 P.M., the Administrator/DON said he worked part-time, being present at the office two to three times a week and working from home the other days. He said he was the Administrator and DON prior to LPN #1’s appointment as a DON in June 2025. He said because he only worked part-time, the agency hired LPN #1 as a CM to offset his responsibilities as a DON. He said LPN #1 worked part-time as well and was present in the office once a week and provided visits to patients in the home. The Administrator/DON said he and the CM were readily available when needed but neither worked in the office daily during the agency’s hours of operation Monday through Friday. Review of the Letter of Appointment of Assistant Administrator/QA, signed and dated by LPN #1 on 6/9/25, indicated acknowledgement of the role as a “Director of Nursing”, not as an Assistant Administrator, QA nurse, or Clinical Manager. LPN #1 was not a RN, rendering him/her unqualified in the role as a DON or CM. During an interview on 1/21/26 at 4:35 P.M., with the Program Coordinator/Owner and Administrator/DON during Quality Assurance and Performance Improvement (QAPI), the Administrator/DON said he is supposed to be providing all the clinical supervision, not LPN #1 as previously stated. He said he is responsible for both roles as an Administrator and DON but only works part-time because of the low census. He said the agency is trying to hire more people to help. The Administrator/DON further said he should have been overseeing/coordinating all patient care and clinical oversight but was not. On 1/22/26 at 11:46 A.M. and 4:18 P.M., the surveyor left a voicemail for a return call from LPN #1. During a telephonic interview on 1/27/26 at 12:10 P.M., LPN #1 said she was not a CM, DON, or Assistant Director of Nursing (ADON) and performed only as a Quality Assurance (QA) nurse and Assistant Administrator to which she was appointed. She said she was not aware she signed the letter accepting appointment as a DON and not Assistant Administrator/QA but said she had a copy of the correct acknowledgement at home and would email it to the surveyor (was not received). She said she is an LPN and does not provide any clinical management or oversight of staff or patient care as the Administrator/DON had indicated. LPN #1 said the agency is not understanding the difference between a QA nurse and a CM as those are two different roles. She said she observes home visits by clinicians only in a QA nurse role and does not supervise or provide any care.

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 record review and interview, the agency failed to ensure that a completed transfer summary was sent to the primary care physician or other health care professional responsible for providing care and services to the patient within 2 days of becoming aware of the unplanned transfer for two patients (#2 and #3), out of a total sample of 7 patients. Findings include: 2. Patient #3 was admitted to the agency September 2025 with diagnosis of Pressure Ulcer of the coccyx, Stage IV (full-thickness tissue loss with exposed fascia, muscle, tendon, or bone). Review of the clinical record indicated Patient #3 was transferred to the Emergency Room (ER) on 9/20/25 and returned home on 9/24/26. The Home Health Transfer Summary indicated that it was completed on 9/27/25 at 11:35 A.M. and had not been sent to the receiving facility or to the physician. It had been completed 7 days after Patient #3 had been sent to the ER and had already returned home. During an interview on 1/22/26 at 4:05 P.M., the DON said that the receiving facility and the physician should have been notified of the transfer and that the Home Health Transfer Summary was late and should have been completed within 24-48 hours of the event. Review of the agency’s policy entitled Transfer Summary, revised November 2021, indicated but was not limited to the following: *Within 48 hours of transfer, the clinician will complete a transfer summary. *All necessary medical information pertaining to the patient’s current condition and treatment, post-discharge goals of care and treatment preferences will be sent to the receiving facility of health care practitioner. *Within 48 hours of transfer, the clinical records clerk will send a copy of the transfer summary or clinical record to the receiving provider. *All communication with the receiving provider, physician (or other authorized licensed independent practitioner), and patient will be documented in the clinical record. 1. Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). a. Review of the clinical record indicated an Outcome and Assessment Information Set (OASIS) Transfer (mandatory clinical assessment conducted by home health agencies when a Medicare/Medicaid patient is admitted to an inpatient facility (e.g., hospital)), dated 8/29/25, which indicated the patient was transferred to the hospital for uncontrolled pain. The patient’s resumption of care (date of the first visit following the inpatient stay) was 9/4/24. Further review of the clinical record did not indicate documentation that a copy of the transfer summary was sent to the inpatient receiving facility or the physician. b. Review of the clinical record indicated an OASIS Transfer, dated 10/13/25, which indicated the patient was transferred to the hospital after reports of the patient having lots of pain and a decline in mental status. The patient’s resumption of care was 10/18/25. Further review of the clinical record did not indicate documentation that a copy of the transfer summary was sent to the inpatient receiving facility or the physician. c. Review of the clinical record indicated an OASIS Transfer, dated 11/12/25, which indicated the patient was transferred to the hospital for being found at home not responding well to questions. The patient’s resumption of care was 11/17/25. Further review of the clinical record did not indicate documentation that a copy of the transfer summary was sent to the inpatient receiving facility or the physician. During an interview on 1/21/26 at 2:57 P.M., the Director of Nursing (DON) said, after reviewing the clinical record, that the transfer summaries dated 8/29/25, 10/13/25, and 11/12/25 were not sent to the receiving facility or physician within two days as required.

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 record review and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 2 patients (#2 and #6), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled Completion and Timely Submission of Clinical Notes, undated, indicated but was not limited to the following: *The purpose of this policy is to ensure accurate, complete, and timely documentation of all patient care services and the prompt submission of clinical notes to the home health agency office in compliance with federal, state, payer, and agency requirements. *This policy applies to all clinical staff, including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Therapists, Social Workers, and contracted clinical staff, others. *All patient care documentation must be completed on the same day services are rendered and submitted to the agency office within required timeframes. Timely documentation supports patient safety, continuity of care, regulatory compliance, quality assurance, and billing. *Clinical notes must be accurate, legible, complete, signed, dated, and timed. Documentation must reflect services provided, support medical necessity, and comply with CMS, state, and payer guidelines. *All visit notes must be completed and submitted within 24-48 hours of the visit. 1. Patient #2 was admitted to the agency in August 2025 with a diagnosis of paraplegia and acute pyelonephritis (type of urinary tract infection where one or both kidneys become infected). Review of the physician ordered Plan of Care (POC) for certification period 10/19/25 through 12/17/25, indicated the following: *Home Health Aide (HHA) visits 4 times a week times 3 hours for 60 days Review of the clinical record indicated the 11/20/25, 11/24/25, 12/8/25, and 12/9/25 HHA visit notes were not completed and submitted within 24-48 hours of the visit. During an interview on 1/21/26 at 2:57 P.M., the Director of Nursing (DON) and Human Resources Director, after reviewing the clinical record, provided documentation the HHA visits were conducted but said the visit notes had not been completed and submitted within the required timeframe. 2. Patient #6 was admitted to the agency in July 2025 with a diagnosis of anxiety disorder, requiring skilled services. Review of the physician ordered POC for certification period 11/16/25 through 1/14/26 indicated the following: -Skilled Nurse (SN) visits 2 times a week for 60 days and 3 visits as needed. Review of the clinical record indicated the 12/16/25 LPN visit note was not completed and submitted within 24-48 hours of the visit. During an interview on 1/21/26 at 2:25 P.M., the DON, after reviewing the clinical record, said the LPN visit documentation was not completed within 72 hours as required.