Every finding on record at Vcp Home Health Care Agency Inc

Purpose of the visit: Recertification and relicensure survey. Entrance conference date was 02/09/2026. The census was 194: 5 Licensed and Certified, 0 Licensed Home Health, and 189 Personal Assistance Services patients. The agency was in compliance with the emergency preparedness conditions of participation for home health agencies.

Purpose of the visit: Recertification and relicensure survey. Entrance conference date was 02/09/2026. The census was 194: 5 Licensed and Certified, 0 Licensed Home Health, and 189 Personal Assistance Services patients. Abbreviations: CMS – Centers for Medicare and Medicaid Services OASIS – Outcome and assessment and information set POC- plan of care HHA- Home Health Agency CVA- Cerebral Vascular Accident

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 and interview, the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by agencies to collect comprehensive data on patient clinical, functional and service needs) 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 for 4 (Identifiers 4,5,6, and 7) of 7 records reviewed. This failure meant the agency’s quality of care and services cannot be compared to other agencies, and the agency’s reimbursement can be affected. Review of Patient 4’s record revealed a start of care OASIS assessment was completed 11/11/2025 and a recertification assessment completed on 01/10/2026 which were not transmitted to CMS within 30 days of completing the assessments. Review of Patient 5’s record revealed a start of care OASIS assessment was completed 01/27/2025 and a discharge OASIS assessment completed on 03/27/2025 which were not transmitted to CMS within 30 days of completing the assessments. Review of Patient 6’s record revealed a start of care OASIS assessment was completed 06/10/2025, recertification assessments were completed on 08/08/2026, 10/07/25, and 12/05/25 which were not transmitted to CMS within 30 days of completing the assessments. Review of Patient 7’s record revealed a start of care OASIS assessment was completed 05/30/2025, recertification assessments were completed on 07/28/2026, 09/26/25, and a discharge OASIS on 11/25/25 which were not transmitted to CMS within 30 days of completing the assessments. Record review indicated all the OASIS assessments detailed above were signed by the Alternate Director of Nurses and had not been transmitted to CMS on the date of the survey exit. An interview was conducted with the Alternate Director of Nurses on 02/11/2026 at 12:27 PM. The surveyor asked about the completed OASIS and why they were not transmitted as required within 30 days. The Alternate Director of Nurses stated she had completed the OASIS, and she did not transmit the assessments for all skilled clients, and the surveyor would need to speak with the billing coordinator to determine which OASIS assessments were submitted to CMS. The Alternate Director of Nurses stated she did not know about the new requirements effective 01/01/2025 for OASIS assessments to be transmitted to CMS for all payers. The Alternate Director of Nurses stated she had discussed with QA the changes after the surveyor discussed with the Alternate Director of Nurses, and the “agency needed to update their policies to get compliant” (with the Medicare regulations) that required submission of all OASIS assessments from all payers for skilled care patients. The Alternate Director of Nurses stated the Billing Coordinator can tell you which patients the agency had transmitted OASIS assessments for. The Alternate Director of Nurses stated, “We were only transmitting (patient OASIS assessments) for traditional Medicare.” The agency had not transmitted Medicare Advantage and Medicaid patient OASIS assessments. An interview was conducted with Billing Coordinator A on 02/11/2026 at 1:00 PM. The surveyor asked if she was responsible for encoding and transmitting OASIS assessment data to CMS. Billing Coordinator A stated: “Yes. I am responsible for the transmissions.” The Billing Coordinator A stated: “I download and export” the completed OASIS assessments. The surveyor asked what patients the agency was transmitting to CMS. Billing Coordinator A stated: “only traditional Medicare (payers).” The surveyor reviewed patient Identifiers 1-7 and asked if each patient’s assessments were transmitted to CMS. Billing Coordinator A stated she had not transmitted the OASIS assessments for patient identifiers 4,5,6, and 7. Billing Coordinator A stated: “my understanding was only (traditional) Medicare patients were transmitted.” The surveyor asked about the skilled Medicaid and Medicare Advantage clients. Billing Coordinator A stated they had not transmitted the Medicaid and Medicare Advantage patients’ OASIS assessments. The surveyor asked how the failure affected the patients and the agency. Billing Coordinator A stated: “reimbursement” for the agency. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4PM. The surveyor shared the findings regarding the lack of OASIS assessment transmissions. The surveyor asked why the agency was not completing the OASIS transmissions for all skilled patients within the 30-day timeframe. The Alternate Administrator stated: “I will take responsibility for it (the failed practice). The staff needs more education.” The Alternate Administrator stated the effect of the deficient practice for the agency was a reduction in reimbursement. Review of Agency policy titled: “8.10 Timelines” with a revision date of 01/29/2020 read in part: The Agency will ensure timely provision of service and services to meet the client’s needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information… Encoding and locking OASIS data for the state will be completed within (7) days of completion of the Comprehensive Assessment. Completed, encoded and locked OASIS data will be transmitted within thirty (30) days of the M0090 date…

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area where the patients resided: Center for Independent Living (iii) Protection and Advocacy Agency, Aging and Disability Resource Center; and (v) Quality Improvement Organization for 3 (Identifier 1,2, and 3) of 3 patients who completed home visits with the surveyor during the survey. This failure meant clients lacked information to ensure access to services as needed and to request an expedited review of changes in services provided by the agency. Review of the sample admission information requested on 02/10/2026 revealed no list of the required Federally-funded and state-funded entities that included the names, addresses, and telephone numbers of the Center for Independent Living (iii) Protection and Advocacy Agency, Aging and Disability Resource Center; and (v) Quality Improvement Organization that served the areas where the patients resided for 3 (Identifier 1,2, and 3) of 3 patients who completed home visits with the surveyor. Observation of the home folder provided by the agency for the patient Identifier 1 on 02/10/2026 at 1:30 PM revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers of the Center for Independent Living (iii) Protection and Advocacy Agency, Aging and Disability Resource Center; and (v) Quality Improvement. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Identifier #1 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Patient 1 stated they wished their services would continue and that they were told services would end next week. Record review of the patient record for Identifier 1 revealed a start of care date of 11/20/2025, certification period of 11/20/2025 to 01/18/2026, and orders for nursing and physical therapy services for the primary diagnosis of Multiple Myeloma having not achieved remission (a cancer of the plasma cells). Observation of the home folder provided by the agency for the patient Identifier 2 on 02/10/2026 at 11:15 AM revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers of the Center for Independent Living (iii) Protection and Advocacy Agency, Aging and Disability Resource Center; and (v) Quality Improvement. The surveyor asked if the patient or family member had removed any of the documents in the home folder provided by the agency and Identifier 2 and the family member stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Record review of the patient record for Identifier 2 revealed a start of care date of 12/30/2025, certification period of 12/30/2025 to 02/27/2026, and orders for nursing, physical therapy, and home health aide services with primary diagnoses of Hypertension, (high blood pressure), Urinary Tract Infection (bacterial infection of the bladder or tube that transports urine out of the body), Chronic Obstructive Pulmonary Disease ( Lung disease that restricts airflow and makes it hard to breath), Unsteadiness of Feet (gait imbalance), Legal Blindness (high level of visual impairment), and History of Falling (multiple falls within a short period of time), and muscle weakness (decreased muscle strength). Observation of the home folder provided by the agency for the patient Identifier #3 on 02/10/2026 at noon revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers of the Center for Independent Living (iii) Protection and Advocacy Agency, Aging and Disability Resource Center; and (v) Quality Improvement. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Identifier #3 stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. Record review of the patient record for Identifier 3 revealed a start of care date of 02/06/2026, certification of 02/06/2026 to 04/04/2026, and orders for nursing and physical therapy with primary diagnoses of Hypertension, (high blood pressure), Bilateral Osteoarthritis of Knees (joint disease of both knees causing pain stiffness and reduced mobility), Diabetes Mellitus with Neuropathy (blood sugar metabolism disorder affecting peripheral nerves), and post Kidney Transplant status (clinical, functional and immune function state after replacement of a kidney), and muscle weakness (decreased muscle strength). An interview was conducted with the Alternate Supervising Nurse on 02/11/2026 at 12:37 PM. The surveyor reviewed the findings from the home visits and reviewed the sample admission file that found no list of the required resources. The Alternate Supervising Nurse stated the information was “not there and they don’t have it.” The surveyor asked why the information was not provided. The Alternate Supervising Nurse stated “it (the resource list) wasn’t updated.” The surveyor asked who was responsible for updating this information. The Alternate Supervising Nurse stated the agency used a consultant and the agency needed to get the updated policies and forms for the admission packets. The surveyor asked about the outcome for the patients. The Alternate Supervising Nurse stated: they wouldn’t have the information. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4:10PM. The surveyor shared the findings regarding home visits and review of the home folder information. The surveyor asked about the agency policy and why the information was not available for the patients. The Alternate Administrator stated the information should be in the patient homes and admission packet. Review of Agency policy titled: “3.1 Patient Bill of Rights and Responsibilities” dated 01/29/2020 read in part: The patient and representative, if any, have the right to be informed of the patient’s rights in a language and manner the individual can understand. The Agency must protect and promote the exercise of these rights. … The Agency must provide the patient and the patient’s representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: …To be advised of the names, addresses, and telephone numbers of pertinent, federally funded and State-funded, State and local consumer information, consumer protection, and advocacy agencies…

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, a registered nurse failed to conduct an initial assessment visit to determine the immediate care and support needs of 1 (Identifier 4) of 5 active records reviewed. The initial assessment visit was not held within 48 hours of referral on 10/31/2025 and was not conducted until 11/11/2025 (a 10-day delay in the start of care). This failure delayed care for the patient and subjected the patient to poor health outcomes. Review of Identifier 4’s clinical record revealed a referral signed and dated 10/31/2025 by the physician which ordered the home health agency to admit to services for skilled nursing, physical and speech therapies. The order had a fax stamp date of 11/05/2025 at 4:42 PM. Review of Identifier 4’s initial assessment revealed the Alternate Director of Nurses conducted the initial assessment visit on 11/11/2025. Review of Patient 4 record revealed a Plan of Care dated 11/11/2025 to 01/09/2026 which was not signed by the physician. The POC listed diagnoses of Hypertension (high blood pressure), Hemiplegia Post CVA (paralysis or severe weakness of one side of the body after a stroke), Epileptic Seizures (transient, involuntary alterations in behavior, sensation, or consciousness caused by abnormal electrical activity in the brain), Dysphagia (difficulty swallowing), Major Depressive Disorder (mental health condition characterized by persistent sadness, low energy, and loss of interest in activities), Presence of a Gastrostomy Tube (a tube placed through the abdomen into the stomach for long term nutrition, hydration, and medication), Muscle Weakness (lack of muscle strength), Abnormal Gait (any deviation from a normal walking pattern), and Intellectual and Developmental Disability (chronic conditions manifesting in children that impair physical, learning, language, or behavioral areas that typically last a lifetime). Services ordered included nursing twice a week for 9 weeks, physical and speech therapy evaluations. Review of the patient record found no documentation to explain the delay in the initial assessment. An interview was attempted on 02/11/26 at 10am with the family member of the Patient Identifier 4. The surveyor’s call was not returned by the end of the survey. An interview was conducted with the Alternate Director of Nurses on 02/11/2026 at 12:27 PM. The surveyor reviewed the findings of the delayed initial assessment for patient Identifier 4. The Alternate Director of Nurses stated, she didn’t see any written explanation for the delay in the initial assessment and stated: “I will check on it.” On 02/11/2026 At 12:45AM the Alternate Director of Nurses stated the Patient Identifier 4 “fell through the cracks.” I can’t explain it. It should have been done. We had a new phone system and fax system, and it fell through the cracks. The surveyor asked about the outcome for the patient of the delayed initial assessment. The Alternate Director of Nurses stated: “The patient care could be interrupted.” The surveyor asked about the policy for initial assessments. The Alternate Director of Nurses stated the policy was to conduct the initial assessment 24-48 hours after the referral. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4PM. The surveyor shared the findings regarding the 10-day delay in initial assessment for Patient Identifier 4. The surveyor asked when the agency would be expected to conduct the initial assessment. The Alternate Administrator stated within 48 to 72 hours after receipt of the referral. The surveyor asked who was responsible. The Alternate Administrator stated he took responsibility for it (the failed practice). The Alternate Administrator stated the agency had a problem with the new phone and fax system and that caused the delay. The Alternate Administrator stated the effect of the deficient practice for the patient was a delay in starting care for the patient. Review of Agency policy titled: “8.10 Timelines” with a revision date of 01/29/2020 read in part: The Agency will ensure timely provision of service and services to meet the client’s needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information… The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of referral, or within 48 hours of the client’s return home, or on the physician-ordered start of service date…”

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 record review and interview the agency failed to ensure each patient received the home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, and which were 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 for 2 (Identifier 4 and 5) of 7 patient records reviewed. This failure meant the patients care was at risk and services were provided without physician oversight. Review of Patient 4 record revealed a start of care OASIS assessment was completed 11/11/2025 and a Plan of Care dated 11/11/2025 to 01/09/2026 which was not signed by the physician. The POC listed diagnoses of Hypertension (high blood pressure), Hemiplegia Post CVA (paralysis or severe weakness of one side of the body after a stroke), Epileptic Seizures (transient, involuntary alterations in behavior, sensation, or consciousness caused by abnormal electrical activity in the brain), Dysphagia (difficulty swallowing), Major Depressive Disorder (mental health condition characterized by persistent sadness, low energy, and loss of interest in activities), Presence of a Gastrostomy Tube (a tube placed through the abdomen into the stomach for long term nutrition, hydration, and medication), Muscle Weakness (lack of muscle strength), Abnormal Gait (any deviation from a normal walking pattern), and Intellectual and Developmental Disability (chronic conditions manifesting in children that impair physical, learning, language, or behavioral areas that typically last a lifetime). Services ordered included nursing twice a week for 9 weeks, physical and speech therapy evaluations. Review of Patient 5’s record revealed a start of care OASIS assessment was completed 01/27/2025 and a Plan of Care dated 01/27/2025 to 3/27/2025 which was not signed by the physician. The POC listed diagnoses of Lumbago with Sciatica (a combination of lower back pain and shooting and burning pain that radiates down one or both legs due to compression of the sciatic nerve), Muscle Spasm (sudden involuntary and painful contractions of one or more muscles), Embolism (blocked blood vessel caused by a clot), Hypertension (high blood pressure), Heart Failure (heart muscles not pumping like they should), Major Depressive Disorder (mental health condition characterized by persistent sadness, low energy, and loss of interest in activities), and General Anxiety Disorder (a mental health condition defined by excessive, uncontrollable and persistent worry about daily events). Services ordered included nursing visits once per week for 9 weeks and a physical therapy evaluation. An interview was conducted with the Alternate Director of Nurses on 02/11/2026 at 12:27 PM. The surveyor asked about the lack of physician signatures on patient Identifier 4 and 5’s plans of care. The Alternate Director of Nurses stated she had “hounded” Patient 4’s doctor and “didn’t know why the POC was not signed.” The Alternate Director of Nurses stated Patient 5 was from Hospital AA and they had to call one number to request signed orders, and the agency had not been able to get the POC signed. The surveyor asked about the agency’s policy for signed orders. The Alternate Director of Nurses stated they had to be signed within 60 days. The surveyor asked about the effect on the patients. The Alternate Director of Nurses stated this could affect the care of the patients. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4 PM. The surveyor shared the findings regarding the lack of signed plans of care for patients 4 and 5. The surveyor asked what the expectation and policy was for physician signatures on the plans of care. The Alternate Administrator stated: “The POC expectation (for physician signatures) is within 30 days.” Review of Agency policy titled: “5.6 Orders for Care” dated 01/29/2020 read in part The Agency will obtain orders and provide care in accordance with physician’s orders … which are established prior to initiating patient care and reviewed/revised by the physician… every 60 days and as needed … Physician … signatures are obtained on 485’s (plans of care) and supplemental verbal orders within 30 days…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure that 3 (Identifier 1,2, and 3) of three patients were provided written instruction of the visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This failure meant patients lacked information to ensure knowledge of services as directed on their plans of care. Review of the sample admission information requested on 02/10/2026 revealed no schedule information or document to be provided to patients. Observation of the home folder provided by the agency for the Patient Identifier 1 on 02/10/2026 at 1:30 PM revealed no visit schedule. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency and Identifier #1 stated they had not removed anything. The surveyor asked if the patient had been provided with a visit schedule including the frequency of visits by the agency staff and the contracted physical therapist. Patient 1 stated they had not been provided with a visit schedule. Record review of the patient record for Identifier 1 revealed a start of care date of 11/20/2025, certification of 11/20/2025 to 01/18/2026, and orders for nursing visits twice a week for eight weeks and physical therapy services once a week for two weeks, then twice a week for three weeks, then twice a week for 2 weeks for the primary diagnosis of Multiple Myeloma having not achieved remission (a cancer of the plasma cells), muscle weakness (decreased muscle strength), Diabetes Mellitus with Neuropathy (blood sugar metabolism disorder affecting peripheral nerves), and post Stem Cell Transplant status (clinical and functional state after replacement of a stem cells.) Observation of the home folder provided by the agency for the patient Identifier 2 on 02/10/2026 at 11:15 AM revealed no visit schedule. The surveyor asked if the patient or family member had removed any of the documents in the home folder provided by the agency and Identifier 2 and the family member stated they had not removed anything. The surveyor asked if the patient and or family member had been provided with a visit schedule including the frequency of visits by the agency staff and the contracted physical therapists. The patient and the family member stated they had not been provided with a visit schedule. Record review of the patient record for Identifier 2 revealed a start of care date of 12/30/2025, certification of 12/30/2025 to 02/27/2026, and orders for nursing twice a week for 8 weeks, home health aide services once a week for three hours, and physical therapy twice a week for 4 weeks with primary diagnoses of Hypertension, (high blood pressure), Urinary Tract Infection (bacterial infection of the bladder or tube that transports urine out of the body), Chronic Obstructive Pulmonary Disease ( Lung disease that restricts airflow and makes it hard to breath), Unsteadiness of Feet (gait imbalance), Legal Blindness (high level of visual impairment), and History of Falling (multiple falls within a short period of time), and muscle weakness (decreased muscle strength). Observation of the home folder provided by the agency for the patient Identifier 3 on 02/10/2026 at noon revealed no visit schedule. The surveyor asked if the patient had removed any of the documents in the home folder provided by the agency. The patient Identifier 3 stated they had not removed anything. Patient Identifier 3 stated they had not been provided with a visit schedule including the frequency of visits by the agency staff and the contracted physical therapist. Record review of the patient record for Identifier 3 revealed a start of care date of 02/06/2026, certification of 02/06/2026 to 04/04/2026, and orders for nursing once a week for nine weeks and physical therapy to evaluate and treat with primary diagnoses of Hypertension, (high blood pressure), Bilateral Osteoarthritis of Knees (joint disease of both knees causing pain stiffness and reduced mobility), Diabetes Mellitus with Neuropathy (blood sugar metabolism disorder affecting peripheral nerves), post Kidney Transplant status (clinical, functional and immune function state after replacement of a kidney), and muscle weakness (decreased muscle strength). An interview was conducted with the Alternate Supervising Nurse on 02/11/2026 at 12:37 PM. The surveyor reviewed the findings from the home visits and reviewed the sample admission file that also found no schedule document. The Alternate Supervising Nurse stated they didn’t provide a written schedule. The surveyor asked why the information was not provided. The Alternate Supervising Nurse stated they didn’t know they needed to. The surveyor asked who was responsible for updating this information. The Alternate Supervising Nurse stated the agency used a consultant and the agency needed to get the updated policies and forms for the admission packets. The surveyor asked about the outcome for the patients. The Alternate Supervising Nurse stated: they wouldn’t have the information. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4:10PM. The surveyor shared the findings regarding home visits and review of the home folder information. The surveyor asked about the agency policy and why the agency was not providing a visit schedule to the patients. The Alternate Administrator stated the information should be in the patient homes and admission packet. Review of Agency policy titled: “3.1 Patient Bill of Rights and Responsibilities” dated 01/29/2020 read in part: The patient and representative, if any, have the right to be informed of the patient’s rights in a language and manner the individual can understand. The Agency must protect and promote the exercise of these rights. … The Agency must provide the patient and the patient’s representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: …to be informed in advance about the care to be furnished based on the comprehensive assessment, the disciplines that will furnish the care … to include frequency of proposed / frequency of visits …To receive information about the individual(s) providing your care, treatment, or services…”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce their written policy that specified the agency's client care practices for the start of care for 1 (Identifier 4) of 5 active records reviewed. The start of care visit was not held within 48 hours of referral on 10/31/2025 and was not conducted until 11/11/2025 (a 10- day delay in the start of care). This failure delayed care for the client and subjected the client to potential poor health outcomes. Review of Agency policy titled: “8.10 Timelines” with a revision date of 01/29/2020 read in part: The Agency will ensure timely provision of service and services to meet the client’s needs in compliance with all federal and state laws and regulations. Agency will also establish timely parameters for all client record information… The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the client’s return home, or on the physician-ordered start of service date…” Review of Identifier 4’s clinical record revealed a referral signed and dated 10/31/2025 by the physician which ordered the home health agency to admit to services for skilled nursing, physical and speech therapies. The order had a fax stamp date of 11/05/2025 at 4:42 PM. Review of Identifier 4’s start of care assessment revealed the Alternate Director of Nurses conducted the initial assessment visit on 11/11/2025. Review of Identifier 4’s record revealed a Plan of Care dated 11/11/2025 to 01/09/2026 which was not signed by the physician. The POC listed diagnoses of Hypertension (high blood pressure), Hemiplegia Post CVA (paralysis or severe weakness of one side of the body after a stroke), Epileptic Seizures (transient, involuntary alterations in behavior, sensation, or consciousness caused by abnormal electrical activity in the brain), Dysphagia (difficulty swallowing), Major Depressive Disorder (mental health condition characterized by persistent sadness, low energy, and loss of interest in activities), Presence of a Gastrostomy Tube (a tube placed through the abdomen into the stomach for long term nutrition, hydration, and medication), Muscle Weakness (lack of muscle strength), Abnormal Gait (any deviation from a normal walking pattern), and Intellectual and Developmental Disability (chronic conditions manifesting in children that impair physical, learning, language, or behavioral areas that typically last a lifetime). Services ordered included nursing twice a week for 9 weeks, physical and speech therapy evaluations. Review of the client record found no documentation to explain the delay in the start of care. An interview was attempted on 02.11.25 at 10am with the family member of the client Identifier 4. The surveyor’s call was not returned by the end of the survey. An interview was conducted with the Alternate Supervising Nurse on 02/11/2026 at 12:27 PM. The surveyor reviewed the findings of the delayed start of care for Identifier #4. The Alternate Supervising Nurse stated: she didn’t see any written explanation for the delay in the initial assessment and start of care and stated: “I will check on it.” On 02/11/2026 At 12:45AM the Alternate Supervising Nurse stated Identifier 4 “fell through the cracks. I can’t explain it. It should have been done. We had a new phone system and fax system, and it fell through the cracks.” The surveyor asked about the outcome for the client of the delayed initial assessment and start of care. The Alternate Supervising Nurse stated: “The patient care could be interrupted.” The surveyor asked about the policy for initial assessments for the start of care. The Alternate Supervising Nurse stated the policy was to conduct the initial assessment 24-48 hours after the referral. An interview was conducted with the Alternate Administrator on 02/11/2026 at 4PM. The surveyor shared the findings regarding the delay in initial assessment for Identifier 4. The surveyor asked when the agency would be expected to conduct the initial assessment. The Alternate Administrator stated within 48 to 72 hours after receipt of the referral. The surveyor asked who was responsible for the 11 day delay in the start of care for Identifier 4. The Alternate Administrator stated he took responsibility for it (the failed practice). The Alternate Administrator stated the agency had a problem with the new phone and fax system and that caused the delay. The Alternate Administrator stated the effect of the deficient practice for the patient was a delay in starting care for the patient.