Every finding on record at We Care Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 9/19/25. Standard level deficiencies cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/17/25 at 10:00 AM. The plan lacked documentation of an updated vulnerability risk assessment, utilizing an all-hazards approach since 2022. 2. Finding of the Agency's Emergency Preparedness Plan lacking documentation of a facility and or community risk assessment, was confirmed during an interview with the Administrator on 9/17/25 at 1:45 PM.

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 the review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to have a communication plan that included the required names and contact information. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/17/25 at 10:00 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for current staff members, entities providing service under arrangement and Patients' Physicians. 2. During an interview with the Administrator on 9/17/25 at 1:45 PM the above finding was confirmed.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to provide staff training of Emergency Preparedness Plan. Findings include: 1. The Emergency Preparedness Plan was reviewed on 9/17/25 at 10:00 AM. The plan lacked documentation indicating the Agency provided staff training on the Emergency Preparedness Plan in 2023, 2024, and 2025 as of 9/17/25. 2. During an interview with the Administrator on 9/17/25 at 1:45 PM the above finding was confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to ensure that the Agency conducted / participated in a full-scale Community Based Exercise or any testing to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/17/25 at 10:00AM. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted and participated in any testing exercise or drills since 2022. 2. During an interview with the Administrator on 9/17/25 at 1:45 PM, the above finding was confirmed.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 09/19/25. Standard level deficiencies cited. Abbreviations: - = to x = by q =every x = times wk = week # = number AM = morning > = greater than SN = Skilled Nurse POC = Plan of care SOC = Start of care mg/MG = milligrams PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening snv = skilled nursing visit Pt./ Pts. = Patient/Patients NSS = Normal Sterile Saline MSW = Medical Social Worker PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist SLP = Speech Language Pathology/Pathologist OASIS = Outcome and Assessment Information Set

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 a review of the Error Summary report and staff interview, it was determined in 114 of 335 assessments submitted for the last 12 months, the Agency failed to submit reports timely. Findings include: 1. The Error Summary report for 9/1/24 to 8/31/25, was reviewed on 9/15/25. The report included error # -3330 for 114 of 335 (34.03 %) OASIS reports submitted more than 30 days after the assessment was completed. 2. During an interview with the Owner and Administrator on 9/17/25 at 10:45 AM, the Owner stated the Biller submits the OASIS. During the same interview, the Owner and Administrator were not aware of the Agency’s failure to submit reports in a timely manner.

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 review of the Agency’s Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure Pts. consented for treatment, and/or informed of the services to be provided in writing, and the frequency of visits by each discipline. Findings include: 1. The Pt. admission booklet was reviewed on 9/15/25 at 11:03 AM. The booklet included a page titled “Admission Consent” that included a section with the various services provided by the Agency (SN, PT, OT, SLP, MSW, and home health aide). The RN that conducts the SOC/initial visit is required to complete this section to indicate the services to be provided and visit frequency of each discipline, and obtain the patient's signature to verify consent for treatment. 2. Home visits were conducted on 9/16/25 at 9:50 AM, 10:30 AM, and 1:30 PM. During the home visits, the Pt. admission booklet was observed. The booklet lacked documentation of the services provided, and frequency of each service for: Pt. #1. SOC 4/4/25. Pt. #2. SOC 7/25/25. Pt. #3. SOC 2/12/25. 2. The clinical records were reviewed on 9/16/25 and 9/17/25. The records included an “Admission Consent” form with a section on the form for the RN to document the service(s) to be provided and the visit frequency, and a section for the Pt./caregiver to sign consenting to the services of the Agency. The following patient's records lacked: Pt. #1. SOC 4/4/25. A completed admission consent form signed by the Pt./caregiver. Pt. #2. SOC 7/25/25. Information of the service(s) to be provided by the Agency and the visit frequency on the signed consent. Pt. #3. SOC 2/12/25. Information of the service(s) to be provided by the Agency and the visit frequency on the signed consent. Pt. #4. SOC 11/1/24. Information of the service(s) to be provided by the Agency and the visit frequency on the signed consent. Pt. #5. SOC 7/7/25. Information of the service(s) to be provided by the Agency and the visit frequency on the signed consent. Pt. #6. SOC 5/15/25. Information of the service(s) to be provided by the Agency and the visit frequency on the signed consent. Pt. #7. SOC 3/27/25. A completed admission consent form signed by the Pt./caregiver. 3. During staff interviews with the Owner and Administrator on 9/17/25 at 1:45 PM and 9/18/25 at 10:10 AM, both confirmed the Agency failed to ensure Pts. consented for treatment, and/or were informed of the services to be provided and the frequency of visits by each discipline in writing.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interview and observation during a home visit, review of the complaint log, Pt. admission booklet, and staff interview, in 1 of 3 (Pt. #3) home visits conducted, the Agency failed to document the patient’s complaint. Findings include: 1. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. A home visit was conducted with Employee #1 on 9/16/25 at 9:50 AM. During the home visit, Pt. #3 stated she has bowel incontinence, and the sacral wound dressing must be changed several times a week, but the Agency does not provide enough wound care supplies and she must pay out-of-pocket for some of her supplies. The Pt. provided the supplies that was paid out-of-pocket. Observed wound gel, 4x4 gauze, Alginate wound dressing, bordered gauze with adhesive border, and zinc oxide protective skin cream. Pt. #3 stated she told this complaint the nurse “last week” (9/7/25 to 9/13/25), the nurse took pictures of receipts for the paid wound care supplies and forwarded the complaint to the Agency’s Owner. Employee #1 stated they also forwarded the patient’s complaint to the Agency’s Owner last week. 2. The Agency’s complaint log was reviewed on 9/16/25 at 1:30 PM, the log lacked documentation of the above complaint made by Pt. #3. 3. The Agency’s Pt. admission booklet was reviewed on 9/15/25. The booklet included “Section 3. Patient Rights and Responsibilities… Your Rights… Lodge complaints and ...We must document both the existence and the resolution of the complaint…” 4. During an interview with the Agency’s Owner and the Administrator on 9/16/25 at 1:39 PM, the Owner confirmed that the nurse had reported the patient’s complaint on 9/9/25. The administrative team confirmed the above findings.

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 a review of clinical records, and staff interview, in 2 of 7 (Pts. #1 and 6) clinical records reviewed, the Agency failed to obtain a referral to initiate service or initiate service within 48 hours of receipt of the referral. Findings include: 1. Pt. #1 was admitted for home health services 4/4/25 with a diagnosis of, but not limited to, Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 9/16/25 at 10:30 AM. As of 9/16/25, the Agency lacked a referral to initiate service on 4/4/25. 2. Pt. #6 was admitted to Home Health services on 5/15/25 with the diagnosis of, but not limited to, Unspecified Polyosteoarthritis. The closed clinical record was reviewed on 9/17/25 at 12:45 PM. The closed clinical record included a referral faxed from the Physician’s office to the Agency on 4/8/25 to begin SN and PT services. The SOC was not conducted until 5/15/25. The record lacked a reason for the late SOC. 3. During an interview with the Owner, Administrator, and the Backup Director of Nursing on 9/18/25 at 10:10 AM, the Backup Director of Nursing confirmed the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation and interview during a home visit, clinical record review, and staff interview, in 1 of 7 (Pt.#3) clinical records reviewed, the Agency failed to ensure the POC contained accurate and/or complete interventions. Findings include: 1. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. A home visit was conducted on 9/16/25 at 9:50 AM. During the home visit, the medications were observed, and an interview was conducted with Pt. #3. Observed Gabapentin 300 MG Tablets, the Pt. stated she takes 600 MG (2 Tablets) in the morning and afternoon, 900 MG (3 Tablets) at night; the Pt. stated Aspirin and Ibuprofen were discontinued after she was discharged from the hospital months ago; observed prescription bottle dated 8/29/25 with “Metoprolol ER Succinate 50 MG Tablets Take 1 tablet (50 MG) by mouth 1 time each day”, the Pt. stated this medication was not new and was refilled on 8/29/29; observed the prescription bottle dated 7/11/25 labeled "Hydrocodone/Acetaminophen 10-325 Take 1 Tablet by mouth every 8 hours as needed for pain", Pt. #3 stated she had taken this medication for the past 3 to 4 years. The clinical record was reviewed on 9/16/25 at 7:30 AM. The clinical record included a POC effective 8/11/25 that included the medications Aspirin and Ibuprofen that were stopped; Gabapentin 300 MG oral capsule 600 mg take 2 caps three times a daily oral (inaccurate dosage) and lacked Metoprolol and Hydrocodone/ Acetaminophen. As of 9/16/25, the POC effective 8/11/25 was inaccurate. During the home visit on 9/16/25, observed that Pt. #3 had a Foley catheter. Pt. #3 stated she had the Foley catheter "for a long time". The clinical record included the PsOC for the certification period of 6/12/25 to 8/10/25 and effective 8/11/25, both PsOC lacked instructions for Foley care and maintenance. The Physician orders dated 7/28/25, 8/7/25, 8/21/25, and 9/1/25 required the same instructions for treatment of the sacrum wound, “Cleanse wound with wound cleanser of choice – Pat dry Lightly pack with Medihoney and calcium alginate Ag Secure with bordered gauze”. The POC effective 8/11/25 included three (3) different instructions for treatment of the sacrum wound: 1st instruction - “Medihoney Ca Alginate … Lightly pack wound weekly… sacral wound”. 2nd instruction - Wound Care: “SN to perform wound care by first cleansing area with wound cleanser or NSS… Allow area to dry or pat dry area gently then apply wound gel, cover with 4x4, wrap with kerlix, and then secure with tape. 3rd instruction – SN to perform pressure ulcer care to sacral region q snv. Cleanse/irrigate wound with wound cleanser, pat dry with 4x4, pack the wound with alginate wound care dressings then cover with a silicone foam dressing and secure the perimeter with paper tape…” The POC contained conflicting instructions for treatment of the Stage 3 sacrum pressure ulcer. 2. During an interview with Owner, Administrator, and the Backup Director of Nursing on 9/18/25 at 10:10 AM, the Backup Director of Nursing confirmed the Agency failed to ensure the POC contained accurate and/or complete interventions.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a home visit observation and interview, review of clinical records, and staff interviews, in 2 of 7 (Pt. #2 and 3) clinical records reviewed, the Agency failed to ensure staff provided service as ordered by the Physician. Findings include: 1. Pt. #2 was admitted to home health services on 7/25/25 with diagnosis of Unspecified Dementia. The clinical record was reviewed on 9/16/25 at 11:00AM. The clinical record included a POC for certification period 7/25/25 to 9/22/25. The POC included Durable Medical Equipment – “Walker”. A home visit observation with PT was conducted with Pt #2 on 9/16/25. During the home visit it was observed that patient did not have a walker to assist with ambulation. During an interview with patient's caregiver, the caregiver stated, “we were told we will get a walker ordered on admission, although we have not received a walker”. The clinical record for Pt #2 was reviewed on 9/17/25 at 9:00 AM. The clinical record lacked documentation indicating reason for not providing walker to patient. The Agency failed to follow POC by ensuring the Pt. was provided the listed Durable Medical Equipment. 2. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 9/16/25 at 7:30 AM. The clinical record included the POC for the certification period of 6/12/25 to 8/10/25 that required, “Notify Physician of… Pain Level: greater than (>) 6/10…” The SN visit note dated 7/25/25 included the Pt. rated sacrum pain 7/10 with “grimacing” and “bracing”. The record lacked documentation the SN notified the Physician. On 7/28/25, the wound doctor provided service to the Pt. and wrote wound care orders that included, “Cleanse wound with wound cleanser of choice – Pat dry Lightly pack with Medihoney and calcium alginate Ag Secure with bordered gauze” The SN visit notes dated 8/1/25, 8/8/25, and 8/15/25 lacked documentation the SN applied Medihoney to the sacral wound as ordered by the Physician. The clinical record included the POC effective 8/11/25 that required, “SN Frequency: 1wk9”. As of 9/16/25, the record lacked documentation the SN provided service during the week of 8/24/25 to 8/30/25. 3. The above findings were confirmed during staff interviews on 9/17/25 at 2:45 PM with the Owner, Administrator, and Employee #6, and on 9/18/25 at 10:10 AM with the Owner, Administrator, and the Backup Director of Nursing.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on staff interview, and clinical record review, in 2 of 7 (Pts. #3 and 6) clinical records reviewed, the Agency failed to complete an assessment for Pt. Pneumonia and Influenza vaccines. Findings include: 1. An entrance interview was conducted on 9/15/25 at 9:40 AM with the Owner, Administrator, and the Backup Director of Nursing. During the interview, the Backup Director of Nursing stated, the RN assess the patient’s need for the Influenza (flu) and Pneumonia vaccines during the SOC/initial visit. The information gathered by the RN is documented in an individualized vaccine inquiry form and entered into the patient’s clinical record. 2. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 9/16/25 at 7:30 AM. The record lacked documentation the RN assessed the patient’s need for the Influenza and Pneumonia vaccines during the SOC/initial visit. 3. Pt. #6 was admitted to home health services on 5/15/25 with the diagnosis of, but not limited to, Unspecified Polyosteoarthritis. The closed clinical record was reviewed on 9/17/25 at 12:45 PM. The closed clinical record lacked documentation the RN assessed the patient’s need for the Influenza and Pneumonia vaccines during the SOC/initial visit. 4. During an interview with Owner, Administrator, and the Backup Director of Nursing on 9/18/25 at 10:10 AM, the Backup Director of Nursing confirmed the Agency failed to complete an assessment and determine whether the Pt. required, refused, or had received the Influenza and Pneumonia vaccines.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, in 2 of 7 (Pts. #3 and 7) clinical records reviewed, the Agency failed to ensure the recertification POC was reviewed by the Physician, as evidenced by the signature. 3. Pt. # 7 was admitted to home health services on 03/27/25 with diagnosis of Parkinson’s Disease. The clinical record was reviewed on 9/17/25 at 2:00PM. The clinical record included a POC for certification period 5/26/25 to 7/24/25 that as of 9/17/25 has not been revised and signed by the physician. 4. The above findings were confirmed during interviews on 9/18/25 at 10:10 AM and 11:15 AM with Administrator, back up Director of Nursing and Agency Owner. Findings include: 1. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 9/16/25 at 7:30 AM. The record included the POC effective 8/11/25. As of 9/17/25, the POC lacked the Physician’s signature to indicate the Physician reviewed and approved the POC. 2. During interviews with the Owner and Administrator on 9/17/25 at 1:45 PM, and 9/18/25 at 10:10 AM, the Backup Director of Nursing stated the Agency requires the Physician to review and sign the POC within 30 days of the recertification date. During the same interview, the above findings were confirmed.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview in 1 of 2 (Pt #7) discharge clinical records the Agency failed to notify physician of change in patient condition. Findings include: 1. Pt. # 7 was admitted to home health services on 03/27/25 with diagnosis of Parkinson’s Disease. The clinical record was reviewed on 9/17/25 at 2:00PM. The clinical record included documentation that for certification period 05/26/25 to 07/24/25 the patient was receiving SN, PT and ST services. 2. The Agency’s Incident log report was reviewed on 9/17/25. The log included a document dated 6/3/25 with Pt. #7 name. The document is signed by the SLP. The document describes “Upon arrival, spouse assisting pt s/p fall. Spouse informed that pt was trying to use the bathroom prior to visit and fell while using walker. Paramedics called for assistance to get up into w/c. No injuries/pain noted. Pt did not want to go to ER."”. The clinical record lack documentation indicating that the fall incident was communicated to the physician. 3. During an interview with the Administrator, back up Director of Nursing and Agency Owner on 9/17/25 at 11:15 AM the above finding was confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission booklet, observation during home visits, clinical record reviews, and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt. information regarding the Director of Nursing/Clinical Manager. Findings include: 1. The Pt. admission booklet was reviewed on 9/15/25 at 11:03 AM. The booklet lacked the name and contact information of the Director of Nursing. 2. On 9/16/25 home visits were conducted at 9:50 AM, 10:30 AM, and 1:30 PM. The Pt. admission booklet was observed and lacked the name and information of the Director of Nursing for: Pt. #1. SOC 4/4/25. Pt. #2. SOC 7/25/25. Pt. #3. SOC 2/12/25. 3. The clinical records were reviewed on 9/16/25 and 9/17/25. The following clinical records lacked the name and contact information of the Director of Nursing: Pt. #1. SOC 4/4/25. Pt. #2. SOC 7/25/25. Pt. #3. SOC 2/12/25. Pt. #4. SOC 11/1/24. Pt. #5. SOC 7/7/25. Pt. #6. SOC 5/15/25. Pt. #7. SOC 3/27/25. 4. During an interview with the Owner, Administrator, and the Backup Director of Nursing on 9/18/25 at 10:10 AM, the Backup Director of Nursing confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, in 1 of 2 (Pt. #3) clinical records reviewed where the Pt. received home health aide services, the Agency failed to ensure the RN conduct home health aide supervision every 14 days. Findings include: 1. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 9/16/25 at 7:30 AM. The clinical record included the home health aide visit notes dated 8/11/25 and 8/18/25. The RN supervised the home health aide on 8/6/25, next on 8/25/25 (18 days without Home Health Aide supervision). 2. During an interview with the Owner, Administrator, and the Backup DON on 9/18/25 at 10:10 AM, all confirmed the RN failed to supervise the home health aide every 14 days.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on staff interviews, and letter of designation, the Agency failed to ensure an alternate for the Director of Nursing/Clinical Manager was available during working hours of the Agency. This has the potential to affect all services provided by the Agency. Findings include: 1. On 9/15/25 at 9:40 AM, the entrance interview was conducted with the Owner and Administrator onsite, the Administrator stated the Director of Nursing was on vacation and not available. The Administrator and/or Owner called the Backup Director of Nursing (Employee #7) that participated in the entrance interview remotely via telephone. The Administrator stated the Agency's operation hours are Monday through Friday from 9:00 AM to 5:00 PM with on-call availability after hours. The Backup Administrator stated she would be available for clinical supervision on Monday (9/15/25), Tuesday (9/16/25), and Wednesday (9/17/25) remotely; available onsite on Thursday (9/18/25). On 9/17/25 (1:20 PM), requested to review clinical findings with the Backup Director of Nursing. The Owner and Administrator stated the Backup Director was not available. On 9/17/25 (1:45 PM), a review of some findings was conducted with Employee #6 (field staff RN) who was not designated as an alternate for the Director of Nursing. On 9/17/25 (2:40 PM), asked to continue to review clinical findings with Employee #6, the Administrator stated Employee #6 was not available during the remaining of the evening, survey activities were suspended. On 9/18/25 (10:10 AM) resumed the review of clinical findings with the Backup Director of Nursing. The Agency failed to ensure an alternate for the Director of Nursing/Clinical Manager was available during all working hours of the Agency. 2. During an interview with the Owner, Administrator, and the Backup Director of Nursing on 9/18/25 at 10:10 AM, all confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined that in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. 2. Pt. # 7 was admitted to home health services on 03/27/25 with diagnosis of Parkinson’s Disease. The clinical record was reviewed on 9/17/25 11:00AM. The clinical record included a discharge OASIS assessment and summary dated 9/12/25. The clinical record lacked documentation evidence that a discharge summary was sent to the physician. 3. During a staff interview with the Owner, Administrator, and Backup Director of Nursing on 9/18/25 at 10:10 AM and 11:15 AM, the Backup Director of Nursing confirmed the Agency failed to send a copy of the discharge summary to the patients' Physician. Findings include: 1. Pt. #6 was admitted to home health services on 5/15/25 with the diagnosis of, but not limited to, Unspecified Polyosteoarthritis. The closed clinical record was reviewed on 9/16/25 at 12:45 PM. The closed clinical record contained a discharge summary completed by the SN and dated 9/4/25. The record lacked documentation that a copy of the summary was sent to the Physician. __. During a staff interview with the Owner, Administrator, and Backup Director of Nursing on 9/18/25 at 10:10 AM and 11:15 AM, the Backup Director of Nursing confirmed the Agency failed to send a copy of the discharge summary to the patients' Physician.

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 a review of clinical records, and staff interviews, in 5 of 7 (Pts. #3, 6, 4, 5, and 7) clinical records reviewed, the Agency failed to ensure the clinical records were complete and/or accurate. 3. Pt. #4 was admitted to home health services on 6/24/25 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 9/16/25 12:00 PM. The clinical record included a document titled “Beneficiary Elective Transfer of Home Health Services” signed by the patient on 6/24/25. The document was blank in section indicating date of transfer and name of transferring Agency. 4. Pt. #5 was admitted to home health services on 7/7/25 with diagnosis of Essential Hypertension. The clinical record was reviewed on 9/16/25 10:30AM. The clinical record included a document titled “Beneficiary Elective Transfer of Home Health Services” signed by the patient on 7/7/25. The document was blank in section indicating date of transfer and name of transferring Agency. 5. Pt.#7 was admitted to home health services on 3/27/25 with diagnosis of Parkinson's Disease. The clinical record was reviewed on 9/17/25 1:00 PM. The clinical record included a document titled “Beneficiary Elective Transfer of Home Health Services” signed by the patient on 9/17/25. The document was blank in section indicating date of transfer and name of transferring Agency. 6. During interviews with the Administrator, Agency Owner and Employee #6 on 9/17/25 at 1:45 PM and on 9/18/25 at 10:10 AM, with the Administrator, back up Director of Nursing and Agency Owner findings of incomplete documents in the clinical records were confirmed. Findings include: 1. Pt. #3 was admitted to home health services on 2/12/25 with the diagnosis of, but not limited to, Encounter for Change or Removal of Nonsurgical Wound Dressing, and Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 9/16/25 at 7:30 AM. The record included the “Beneficiary Elected Transfer” form signed by the SN, Pt. and dated 2/12/25. The form required Agency staff to document the current Agency that the Pt. receives services and the effective date, both sections were left blank. The “Notice of Medicare Non-Coverage” form required Agency staff to enter the date that “Services Will End”, this section was left blank. 2. Pt. #6 was admitted to Home Health services on 5/15/25 with the diagnosis of, but not limited to, Unspecified Polyosteoarthritis. The closed clinical record was reviewed on 9/17/25 at 12:45 PM. The closed clinical record included the included the “Beneficiary Elected Transfer” form signed by the SN, Pt. #6 and dated 5/15/25. The form lacked name of the current Home Health Agency and the effective date. The “Notice of Medicare Non-Coverage” form was signed by the Pt. and dated 5/15/25. The form lacked the date “Services Will End”. The SN visit notes dated 7/24/25, 7/29/25, and 8/5/25 contained documentation in one section of the visit notes that the “Pt. denies pain”. In the same visit notes in a different section, the SN documented the Pt. experienced “joint pain”. The SN visit notes included conflicting documentation.

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness Policy/Plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's “...Emergency Preparedness Policy/Plan” was reviewed on 6/7/22 at 12:15 PM. The Plan included, "Effective Date: 2017". As of 6/7/22, the Agency lacked documentation that the Plan was reviewed and revised after 2017. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 1:50 PM, both confirmed the above finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Policy/Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan was based on a risk assessment. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's “...Emergency Preparedness Policy/Plan” dated 2017 was reviewed on 6/7/22 at 12:15 PM, and lacked documentation of a risk assessment. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 1:50 PM, both confirmed the above finding.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Policy/Plan and staff interview, it was determined the Agency failed to review and update the Communication Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's "...Emergency Preparedness Policy/Plan" was reviewed on 6/7/22 at 12:15 PM. The Emergency Preparedness Plan contained a Communication Plan dated "7/2017". As of 6/7/22, the Agency failed to review and revise the Communication Plan every 2 years. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 1:45 PM, both confirmed the above finding.

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness Policy/Plan and staff interview, it was determined the Agency failed to ensure the Communication Plan was complete. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's "...Emergency Preparedness Policy/Plan" dated 2017 was reviewed on 6/7/22 at 12:15 PM. The Plan contained a section titled, "Emergency Calling Tree" which lacked the names and contact information of the direct staff (Administrator, Director of Nursing, RN Supervisor, and the 1-field staff RN); contracted agency, and Pt. #1's Physician. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 1:45 PM, both confirmed the above findings.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: A. Based on review of a clinical record, the Agency's Emergency Preparedness Policy/Plan and staff interview, it was determined the Agency failed to comply with its own policy for sharing Pt. information, in the event of an emergency. This was found in 1 of 1 (Pt. #1) active clinical record reviewed. Findings include: 1. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. The clinical record was reviewed on 6/7/22 at 9:30 AM. The record contained the POC for the certification period for 2/18/22 to 4/17/22, and documentation the RN provided service 2 times a week from 4/19/22 to 5/13/22. As of 6/7/22, the Agency lacked a current POC (effective 4/18/22) describing the wound care and other interventions the RN had provided. The Agency lacked a current POC to share with a different care provider in the event of an emergency or disaster, and the Agency is unable to reach the Pt. to provide the required service and treatment. 2. The Agency's "Emergency Preparedness Policy/Plan" dated 2017 was reviewed on 6/7/22 at 12:15 PM. The Policy required, "1.4 Communications Plan: Emergency...Our Agency Emergency Communication Plan Includes...5. Method of sharing patient medical information with other healthcare providers: to ensure continuity of care. A 485 Binder will be maintained with current patient, current 485 forms..." 3. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 1:45 PM, both confirmed the Agency currently does not have a 485 binder or a current POC for Pt. #1.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: # = number AM = morning PM = evening SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse Pt./ Pts. = Patient/Patients COVID-19 = Corona Virus Disease 2019 CDC = Centers for Disease Control and Prevention

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: A. Based on review of the Agency's Pt. admission folder, clinical record review, observation during a home visit and staff interview, it was determined the Agency failed to inform and provide information regarding the Administrator. This was found in 3 of 3 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 6/6/22 at 2:00 PM, and lacked the name of the Administrator's name and contact information. 2. The following clinical records were reviewed between 6/7/22 at 9:30 AM to 6/8/22 at 11:00 AM, and lacked documentation of the Administrator's name and contact information. Pt. #1. SOC: 10/26/20. Pt. #2. SOC: 8/17/21. Pt. #3. SOC: 8/18/21. 3. On 6/7/22 at 1:00 PM, a home visit was conducted with Employee #1. During the home visit the patient's admission folder was observed, and lacked documentation of the Administrator's name and contact information. 4. During an interview with the Director of Nursing and the RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the Administrator's name and contact information was not provided to the Pts.

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: A. Based on a review of clinical records and staff interview, it was determined that the Agency failed to inform Pts. of the disciplines that will provide care and the frequency of visits. This was found in 3 of 3 (Pts. #1, 2 and 3) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 6/7/22 at 9:30 AM to 6/8/22 at 11:00 AM: Pt. #1 SOC: 10/26/20. Pt. #2 SOC: 8/17/21. Pt. #3 SOC: 8/18/21. The records lacked documentation of the Pt. consenting to the disciplines that would furnish care and the frequency of visits. 2. During an interview with the Director of Nursing and the RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the records lacked documentation of the disciplines that furnished care, and the frequency of visits provided by each discipline.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency's Pt. admission folder, observation during a home visit and staff interview, it was determined the Agency failed to ensure complete information regarding the State Hotline was provided to Pts. This was found in 1 of 1 (Pt. #1) home visit conducted, and has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Agency's Pt. admission folder was reviewed on 6/6/22 at 2:00 PM. The folder lacked an address for which the Pt. may submit a complaint to the State Hotline in writing. 2. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. A home visit was conducted on 6/6/22 at 1:00 PM with Employee #1. During the home visit the patient's admission folder was observed and lacked the address to which the Pt. may file a complaint in writing to the State Complaint Hotline. 3. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the Agency failed to provide Pts. the address (contact information) to file a complaint in writing.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: A. Based on review of the Agency's Pt. admission folder, clinical record review, observation during a home visit and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. This was found in 3 of 3 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 6/6/22 at 2:00 PM, and lacked documentation of the Agency's transfer and discharge policies. 2. The following clinical records were reviewed from 6/7/22 at 9:30 AM to 6/8/22 at 11:00 AM: Pt. #1. SOC 8/2/20. Pt. #2. SOC 9/2/20. Pt. #3. SOC 8/19/20. The records lacked documentation that the Agency provided Pts., information regarding the Agency's policies pertaining to transfer and discharge. 3. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. A home visit was conducted on 6/6/22 at 1:00 PM. During the home visit, the patient's admission folder was observed, and lacked documentation of the Agency's transfer and discharge policies. 4. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the Agency had failed to provide Pts. information regarding the Agency's transfer and discharge policies.

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: A. Based on clinical record review and staff interviews, it was determined the Agency failed to obtain a referral to provide care and/or services. This was found in 3 of 3 (Pts. #2, 3 and 1) clinical records reviewed. 3. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. The clinical record was reviewed on 6/7/22 at 9:30 AM. The record included a consent for treatment signed by the Pt., RN and dated 10/26/20. The record included SN visit notes indicating service was provided since 10/26/22. As of 6/7/22, the record/Agency lacked a referral or Physician order to initiate service for Pt. #1. 4. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the clinical records lacked a referral or Physician order to initiate service. Findings include: 1. Pt. #2. SOC: 8/17/21. Primary Diagnosis: Non-Insulin Dependent Diabetes Mellitus. The clinical record was reviewed on 6/7/22 at 2:30 PM. The record included a consent for treatment signed by the Pt. and dated 8/17/21. The record included documentation SN services were provided since 8/17/21. As of 6/7/22, the record lacked a referral or Physician order to initiate service for Pt. #2. 2. Pt. #3. SOC: 8/18/21. Primary Diagnosis: Non-Insulin Dependent Diabetes Mellitus. The clinical record was reviewed on 6/8/22 at 11:00 AM. The record included a consent for treatment signed by the Pt. and dated 8/18/21. The record included documentation SN services were provided since 8/18/21. As of 6/7/22, the record lacked a referral or Physician order to initiate service for Pt. #3.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure the RN update and revise the comprehensive assessment within the last 5 days of the 60 Day certification period. This was found in 1 of 2 (Pt. #1) clinical records reviewed of Pts. who received care, beyond the initial 60 Day episode. Findings include: 1. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. The clinical record was reviewed on 6/7/22 at 9:30 AM. The record included a POC for the certification period of 2/18/22 to 4/17/22 where SN services were provided 2 to 3 times a week. The RN conducted a recertification comprehensive assessment on 4/22/22 which was 5 days after the certification period ended. The record lacked documentation the SN updated and revised the comprehensive assessment within the last 5 days of the previous 60 day certification period. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 2:00 PM, both confirmed the Agency failed to ensure the RN updated and revised the comprehensive assessment within the last 5 days of the 60 Day certification period.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: A. Based on observation during a home visit, clinical record review and staff interview, it was determined the Agency failed to develop a recertification POC for every 60 days, beginning with the SOC. This was found in 2 of 3 (Pts. #1 and 2) clinical records reviewed. 2. Pt. #2. SOC: 8/17/21. Primary Diagnosis: Non-Insulin Dependent Diabetes Mellitus. The clinical record was reviewed on 6/7/22 at 2:30 PM. The record contained SN visit notes for 1 time a week from 2/20/22 to 3/5/22. As of 6/7/22, the record lacked a POC for Pt. #2 after 2/12/22. 3. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the records/Agency lacked a POC for service and treatment provided, as indicated above for Pts. #1 and 2. Findings include: 1. Pt. #1. SOC 10/26/20. Primary Diagnosis: Hidradenitis. During a home visit on 6/6/22 at 1:00 PM with Employee #1, observed Employee #1 provide wound care to multiple wounds which included: Left center abdomen, left upper abdomen, center chest, left breast, under right breast and the right axilla. Employee #1 cleaned the wounds with normal saline, pat dry with 4 by 4 gauze, applied topical ointments (Clindamycin, Betamethasone and Mupirocin) to the wounds and/or skin before applying dry gauze dressings. The clinical record was reviewed on 6/7/22 at 9:30 AM, and contained the SN visit notes for 2 times a week from 4/19/22 to 5/13/22 which included documentation the SN provided wound care. The most recent POC in the medical record was dated 2/18/22 to 4/17/22. As of 6/7/22, the record lacked a current POC effective 4/18/22.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: A. Based on review of the Agency's Pt. admission packet, clinical record review, observation during a home visit and staff interview, it was determined the Agency failed to inform and provide information regarding the Clinical Manager. This was found in 3 of 3 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 6/6/22 at 2:00 PM, and lacked the name of the Clinical Manager and contact information. 2. The following clinical records were reviewed from 6/7/22 at 9:30 AM to 6/8/22 at 11:00 AM, and lacked documentation of the Clinical Manager's name and contact information. Pt. #1. SOC: 10/26/20. Pt. #2. SOC: 8/17/21. Pt. #3. SOC: 8/18/21. 3. On 6/7/22 at 1:00 PM, a home visit was conducted with Employee #1. During the home visit the patient's admission folder was reviewed, and lacked documentation of the Clinical Manager's name and contact information. 4. During an interview with the Director of Nursing and the RN Supervisor on 6/8/22 from 2:00 PM to 2:45 PM, both confirmed the Clinical Manager's name and contact information was not provided to the Pts.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: A. Based on review of Agency policies and staff interviews, it was determined the Agency failed to develop policies and procedures for tracking the COVID-19 vaccination status of direct care staff as outlined in CDC guidelines. Findings include: 1. The Agency’s COVID-19 policies and procedures were reviewed on 6/7/22 at 1:00 PM. The document lacked policies and procedures that provides guidelines for tracking the vaccination status of Agency staff providing direct care. 2. During an interview with the Director of Nursing and the RN Supervisor on 6/8/22 at 2:30 PM, both confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and Agency policy and staff interview, it was determined the Agency failed to ensure Pts. received services as ordered by the physician, and in accordance with the POC. This was found in 1 of 3 (Pt. #2) clinical record reviewed. Findings include: 1. Pt. #2. SOC: 8/17/21. Primary Diagnosis: Non-Insulin Dependent Diabetes Mellitus. The clinical record was reviewed on 6/7/22 at 2:30 PM. The record included a POC for the certification period of 12/15/21 to 2/12/22 which required to provide skilled services: SN 1 time a week for 9 weeks. The record lacked an SN visit for the weeks of 1/2/22 to 1/8/22, 1/16/22 to 1/22/22, 1/30/22 to 2/5/22 and lacked documentation of why the SN visit was missed. 2. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 2:40 PM, the above findings were confirmed.

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: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #2 and 3) closed/discharged clinical records reviewed. Findings include: 1. Pt. #2. SOC 8/17/21. Principal Diagnosis: Non-Insulin Dependent Diabetes Mellitus. The clinical record was reviewed on 6/7/22 at 2:30 PM. Pt. #2 was discharged from the Agency on 3/1/22. The record lacked documentation the Agency sent a copy of Discharge Summary to the Physician. 2. Pt. #3. SOC 8/18/21. Principal Diagnosis: Bilateral Osteoarthritis. The clinical record was reviewed on 6/8/21 at 11:00 AM. Pt. #3 was discharged from the Agency on 12/12/21. The record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. 3. During an interview with the Director of Nursing and RN Supervisor on 6/8/22 at 2:30 PM, both confirmed the above findings and stated that the discharge summary is to be sent to the Physician.