Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 757280	(X3) Date Survey Completed 11/04/2025
Name of Provider or Supplier Rely Home Health, Inc.	Street Address, City, State 100 N Brand Blvd Suite 401, Glendale, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
G0000	The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey. Complaint # 2565290 Census: 94 Sample Size: 13 Home Visit: 5 Closed Records: 4 For G572 On 10/31/2025, at 2:16 PM, The Department called an Immediate Jeopardy (IJ, a situation in which the HHA’s noncompliance with one or more Conditions Participation (minimum health and safety standards that healthcare organizations must meet to participate in the Medicare and Medical programs) has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the Director of Patient Care Services (DPCS) for failing to demonstrate a process and provide documented evidence that the facility ensured treatments were documented in the patient medical record and patient home visits were completed according to physician orders as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of 13 sampled patients (Patient 5). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. For G1024 On 11/4/2025 at 12 PM, while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Director of Patient Care Services (DPCS), for failing to demonstrate a process and provide documented evidence that the facility ensured patient records were not willfully falsified, all entries into the patient health record were appropriately authenticated, and staff obtained unique identifiers to access and authenticate protected health information (any health information that can identify an individual that is in possession of or transmitted by a "covered entity" or its business associates that relates to a patient's past, present, or future health). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. The following Condition of Participation were not met: 484.60 Condition of participation: Care planning, coordination of services, and quality of care. 484.110 Condition of participation: Clinical records.
G0536	A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medication reconciliation (the process of creating the most accurate and complete list of a patient's medications and comparing it with the current list in use to avoid medication errors) was completed for one of 13 sampled patients (Patient 2) when: 1. Patient 2’s “Patient Medication List,” from the Home Health Agency (HHA) did not match Patient 2’s “Physician Order Review,” from Patient 2’s assisted living facility. 2. Physical Therapist (PT) 1 did not perform medication reconciliation during Patient 2’s Start of Care (SOC) assessment (a comprehensive, in-person evaluation conducted at the beginning of a home health care episode to determine a patient's health needs and eligibility for services). These failures had the potential to result in Patient 2 taking incorrect or duplicate medications, which could lead to medication interactions (occurs when one medication alters the effects of another medication, food, or dietary supplement in the body) and side effects such as decreased blood pressure and increased risk of bleeding. Findings: 1. During a review of Patient 2’s Patient Profile (admission record), the Patient Profile indicated Patient 2’s SOC date was 10/1/2025, with primary diagnoses of acute pain due to trauma (an unpleasant sensory and emotional experience due to actual or potential tissue damage), wedge compression fracture of the second lumbar vertebra (a break in the second bone of the lower back which results in a wedge shape) and hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart muscle, leading to impaired pumping function). During a review of Patient 2’s “Patient Medication Profile,” for the recertification period from 10/1/2025 to 11/29/2025, the Patient Medication Profile indicated the following medications ordered on 10/1/2025: - Acetaminophen (a medication used to treat pain and reduce fever) 500 milligrams (mg, a unit of measurement), 2 tablets by mouth daily. - Alprazolam (a medication used to treat anxiety) 0.5 mg, 1 tablet by mouth daily. - Amlodipine (a medication used to treat high blood pressure) 5 mg, 1 tablet by mouth daily. - Ibuprofen (a medication used to treat pain and reduce fever) 400 mg, 1 tablet by mouth every 12 hours. During a concurrent interview and record review on 10/28/2025 at 2:44 p.m., with Licensed Vocational Nurse (LVN) 3 from the assisted living facility, Patient 2’s “Physician Order Review,” dated 10/28/2025 was reviewed. The Physician Order Review indicated Nurse Practitioner (NP) 1 ordered the following medications: - Acetaminophen 500 mg, 2 tablets by mouth three times daily, ordered on 2/9/2025. - Alprazolam 0.5 mg, 1 tablet by mouth twice a day, ordered on 8/5/2025. - Amlodipine 2.5 mg, 1 tablet by mouth daily, ordered on 12/11/2024. - Ibuprofen 400 mg, 1 tablet by mouth 3 times a day as needed, ordered on 9/26/2025. LVN 3 stated she is the LVN on duty for Patient 2’s assisted living facility. LVN 3 stated she has never seen the medication list titled “Patient Medication Profile,” from the HHA. LVN 3 stated she did not know why the medication list from the HHA was different from the medication list from the assisted living facility. LVN 3 stated the assisted living facility follows the physician orders listed in the “Physician Order Review.” LVN 3 stated she has never seen anyone from the HHA do medication reconciliation to compare both medication lists. During an interview on 10/30/2025 at 12:01 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation is the responsibility of the HHA. The DPCS stated the medication lists from both the HHA and the assisted living facility should match. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” revised 11/2024, the P&P indicated, “Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” 2. During an interview on 10/29/2025 at 11:41 a.m. with the DPCS, the DPCS stated physical therapists are expected to do medication reconciliation during a patient’s SOC assessment. The DPCS stated physical therapists have the same knowledge and credentials to be able to do medication reconciliation and know what medications are contraindicated. During an interview on 10/29/2025 at 3:15 p.m. with Physical Therapist (PT) 1, PT 1 stated he conducted Patient 2’s SOC assessment. PT 1 stated he did not do medication reconciliation during Patient 2’s SOC assessment and has never seen Patient 2’s medication list. PT 1 stated it was the HHA’s responsibility to assign a nurse to ensure Patient 2’s medication lists matched. PT 1 stated the medication lists from both the HHA and the assisted living facility should match because drug doses and frequencies could differ and lead to confusion within the interdisciplinary team (group of professionals from different disciplines who work together to provide comprehensive and coordinated care for patients). PT 1 stated medication reconciliation should be done for clear communication between the interdisciplinary team and to prevent medication errors for the patient. During an interview on 10/30/2025 at 3:06 p.m. with the DPCS, the DPCS stated it was his responsibility to ensure every patient’s medication reconciliation was completed. The DPCS stated not doing medication reconciliation could result in patients taking the wrong medications, taking duplicate medications, which could lead to medication interactions and side effects such as low blood pressure and increased risk of bleeding. During a review of PT 1’s “Physical Therapist Job Description,” dated 9/1/2022, the Physical Therapist Job Description indicated, the physical therapist “will organize and review a patient’s medications to ensure accuracy, safety, and proper adherence during home visits.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” revised 11/2024, the P&P indicated, “Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, drug classification, date prescribed/discontinued, dose, strength, route, frequency, date and time of administration and any drug or food allergies.”
G0570	Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Care Planning, Coordination, and Quality of Care was met as follows: The HHA failed to ensure the plan of care was implemented for one of 13 sampled patient (Patient 5) when: The HHA license nurses did not have documented evidence the wound care was provided according to physician order as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5) on 10/15/2025, 10/17/2025, and 10/28/2025. The HHA failed to ensure patient home visits were completed according to physician order as indicated on the Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5). Patient 5 who had an order for Skilled nursing visits two times a week for wound care and medication management did not have the skilled nurse visits for the week of 10/19/2025 through 10/25/2025. These failures had the potential to result in Patient 5 to receive inaccurate or inappropriate wound care treatment and the inability to track response to wound care treatment; potentially resulting in Patient 5 experiencing increased pain, delayed wound healing, localized and systemic infections, increased risk for emergency hospitalization, and avoidable traumatic and/or undignified death. (Refer to G572). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.
G0572	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 observation, interview, and record review, the Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed to ensure the plan of care was implemented for one of 13 sampled patient (Patient 5) when: 1.The HHA license nurses did not have documented evidence the wound care was provided according to physician order as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5) on 10/15/2025, 10/17/2025, and 10/28/2025. 2.The HHA failed to ensure patient home visits were completed according to physician order as indicated on the Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5). Patient 5 who had an order for Skilled nursing visits two times a week for wound care and medication management did not have the skilled nurse visits for the week of 10/19/2025 through 10/25/2025. These failures had the potential to result in Patient 5 to receive inaccurate or inappropriate wound care treatment and the inability to track response to wound care treatment; potentially resulting in Patient 5 experiencing increased pain, delayed wound healing, localized and systemic infections, increased risk for emergency hospitalization, and avoidable traumatic and/or undignified death. On 10/31/2025, at 2:16 PM, The Department called an Immediate Jeopardy (IJ, a situation in which the HHA’s noncompliance with one or more Conditions Participation (minimum health and safety standards that healthcare organizations must meet to participate in the Medicare and Medical programs) has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the Director of Patient Care Services (DPCS) for failing to demonstrate a process and provide documented evidence that the facility ensured treatments were documented in the patient medical record and patient home visits were completed according to physician orders as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of 13 sampled patients (Patient 5). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. Findings: 1. During a review of Patient 5’s “Patient Profile” (page of the medical chart containing a summary of basic patient information), undated, the “Patient Profile” indicated Patient 5, was admitted on 10/3/2025, with diagnoses that included pressure ulcer stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) of right buttock, encounter for change or removal of non-surgical wound dressing (medical appointment focused solely on changing or removing a dressing [a pad applied to a wound to promote healing] from a wound that did not originally require surgery), and hypertensive heart disease with heart failure (the heart cannot pump enough blood to the body because high blood pressure has damaged it over time).   During a review of Patient 5’s “Home Health Certification and Plan of Care” for certification period 10/3/2025 through 12/1/2025, the “Home Health Certification and Plan of Care” indicated: Principal diagnosis: pressure ulcer of right buttocks  Orders for Discipline and Treatments: Admit to Home Health Agency skilled nursing services with skilled nursing visit frequency: once for one week and two times per week for three weeks Medications: wound cleanser irrigation spray three times per week “SN [skilled nurse] to instruct/validate patient/caregiver understanding on: disease process, management, and complications related to pressure ulcer of right buttock stage 2; encounter for change or removal of nonsurgical wound dressing [… and] medication regimen (effects, side effects, dosage and frequency), and medication administration.”  Goals/ Rehabilitation Potential/ Discharge Plans/ Referral Plan/ Other notes continued: “Pt [patient]/ PCG [patient caregiver] will be independent with medication management within 3-5 weeks.”  During a review of Patient 5’s “Nursing Progress Note,” dated 10/15/2025, 10/17/2025 and 10/28/2025, authored by Licensed Vocational Nurse (LVN) 1, the Nursing Progress Notes indicated the following:  Under “Homebound Status,” the checkbox next to “Wound Care” was checked.   Under “Integumentary,” “Right Buttock Stage II, Right Thigh Hematoma, Stage 1 Coccyx” was documented.  Under “Wound Type,” the checkbox next to “Decubitus Stage I and II” and “See Wound sheet assessment and treatment,” were checked.  Under “Skilled Teaching/Instructions: To Patient/Caregiver,” the checkbox next to “Skilled observation and assessment” and “S/S [signs and symptoms] of infection: Wound, Teach wound care, Decubitus,” were checked.  During a review of Patient 5’s “Nursing Progress Note,” dated 10/17/2025 and 10/28/2025, authored by LVN 1, the Nursing Progress Notes indicated the following:  Under “Approximate Date and Plan for Next Visit,” “Continue mobility exercises, in place marching, leg extensions, raising from chair using walker, ankle rotation,” was documented.  During a concurrent observation and interview on 10/28/2025 at 10:35 AM, with Physical Therapist Assistant (PTA) 1 and LVN 1, LVN 1 was observed conducting the skilled nurse home visit to Patient 5. LVN 1 stated she was assigned to do Patient 5’s home visits to help the Patient with mobility, exercises, and home safety because Patient 5 had recent falls. PTA 1 stated he would continue providing physical therapy services to Patient 5. LVN 1 stated she would end her visit and let PTA 1 continue providing physical therapy to Patient 5.  LVN 1 stepped out of Patient 5’s room.   During an interview on 10/28/2025 at 10:36 AM with LVN 1, LVN 1 stated she received orders from the HHA to conduct home visits for Patient 5 focused on mobility assistance and exercise education. LVN 1 stated she visited Patient 5 two times a week and during the visits she instructed Patient 5 to walk around the room, march in place, stretch, and perform sit to stand exercises using a walker. LVN 1 stated she did not provide wound care treatment or medication management to Patient 5 during the home visits and stated she did provide skilled nursing services, like wound care and mediation management, to other patients. LVN 1 stated she only provided exercise and exercise education to Patient 5.   During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Nursing Progress Note,” dated 10/15/2025 and 10/17/2025 were reviewed. The Nursing Progress Notes did not indicate documented evidence that wound care treatment was performed during the home visits.  LVN 1 stated she could not recall if wound care was provided to Patient 5 during the home visits and if the wound care treatment was not documented in the progress note, the treatment was not done. LVN 1 stated accurate documentation was important to ensure Patient 5 did not experience potential mistakes in wound assessment and wound care treatment.   During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Nursing Progress Note,” dated 10/28/2025 was reviewed. The Nursing Progress Note did not indicate documented evidence that wound care treatment was performed during the home visit. LVN 1 stated she only provided range of motion teaching and reinforcement during the home visit, and no wound care was provided.  During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Referral Order,” dated 10/2/2025 was reviewed. The Referral Order indicated, “Treatment goal(s): PT [physical therapy] to provide patient with therapeutic exercises for strengthening of BLE [bilateral lower extremity]. Patient to begin ambulating at least 10 feet in room with [minimum assistance]” and “Treatment direction(s) (for SN [skilled nurse] only): n/a [not applicable]”. LVN 1 stated there were no treatment orders specifically for the skilled nurse listed on the Referral Order. LVN 1 stated she understood the referral to mean she was to deliver range-of-motion exercises and reinforcement of exercise education to Patient 5, who had experienced recent falls.    During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Referral Order,” dated 10/2/2025 was reviewed. The Referral Order indicated the following: - Pressure ulcer of right buttock, stage 2 - Ordering HHSN [home health skilled nurse] visits three (3) times a week to assist with monitoring and care. - Monitor skin for worsening PI (pressure injury).   - Saline wound wash 0.9% solution [...] use during wound care twice a week. - Gauze pad 4 by 4 inches (unit of measurement bandage use as directed.  - Mepilex Border Sacrum 9.2 by 9.2 inches bandage use as directed. LVN 1 stated she only monitored the wound and she did not provide wound care treatment to Patient 5 as ordered by the physician.  LVN 1 stated she was expected to provide wound care treatment as ordered. LVN 1 stated if there were any issues that prevented her from providing wound care treatment to Patient 5, she would notify the HHA via text. LVN 1 stated she would not document in Patient 5’s health record when a treatment was not administered as ordered or the reason or the omission. During an interview on 10/30/2025 at 11:52 AM with the DPCS, the DPCS stated treatments must be administered as ordered by the physician to ensure the patient gets better and to prevent possible infection or hospitalizations. The DPCS stated that administering treatments as ordered ensures the Patient’s overall well-being, including the patient’s mental, physical, and psychosocial health. The DPCS stated a patient’s health might become compromised if treatments are not administered as ordered by the Physician, and stated for wound care, if wound care treatment is not provided the wound may become infected and the patient may require hospitalization.   During a review of the facility’s policy and procedure (P&P) titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following:  - “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.”  - “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly”  - “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses.”  During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.”  During a review of the facility’s P&P titled, “Care Planning Process”, dated November 2024, the P&P indicated, “The patient specific clinical plan of care includes measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care and measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to mee the patient’s needs”.   During a review of the facility’s P&P titled, “Missed Visits,” dated November 2024, the P&P indicated, “Purpose: To ensure the missed visits are documented and does not affect the quality of patient care. Missed visit will be communicated to the clinical supervisor and the patient’s physician.”  2. During a review of Patient 5’s “Nursing Progress Note,” dated 10/21/2025 and 10/24/2025, the Nursing Progress Notes did not indicate documented evidence that the skilled nurse home visits were performed.   During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she visited Patient 5 on 10/15/2025, 10/17/2025 and 10/28/2025. LVN 1 stated she did not conduct skilled nurse home visits for Patient 5 on the week of 10/19/2025 through 10/25/2025. LVN 1 stated she informed the HHA she would not be available from 10/22/2025 through 10/26/2025.   During an interview on 10/30/2025 at 11:10 AM with the DPCS, the DPCS stated the nurse assigned to visit Patient 5 on the week of 10/19/2025 through 10/25/2025 was LVN 1. The DPCS stated the facility was not aware that LVN 1 was not available to visit Patient 5 that week. The DPCS stated there were no other nurses assigned to see Patient 5 on the week of 10/19/2025 through 10/25/2025.  During a concurrent interview and record review on 10/31/2025 at 11:30 AM with the DPCS, Patient 5’s “Nursing Progress Note,” dated 10/21/2025 and 10/24/2025 were reviewed. The Nursing progress Notes indicated a blank skilled nurse visit note; the note was unsigned and undated. The DPCS stated either the documentation was not yet uploaded or the visit was not done. The DPCS stated visit notes should be uploaded into the electronic medical record within two days after the home visit, The DPCS stated that if documentation was not uploaded, the HHA intake staff should contact the visiting clinician to verify the visit occurred and remind the visiting clinician to upload the notes. The DPCS stated the HHA should have contacted LVN 1 on 10/23/2025 and 10/26/2025 regarding the missing documentation for the skilled nurse visit scheduled for 10/21/2025 and 10/24/2025.  Documented evidence that LVN 1 was contacted regarding the unsubmitted records was not made available. During an interview on 10/31/2025 at 11:33 AM with the DPCS, the DPCS stated if a scheduled skilled nurse visit was missed, Patient 5 was at risk of experiencing possible wound infection, wound worsening, and possible harm.   During a review of the facility’s P&P titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following:  - “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.”  - “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly”  - “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses”. During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.”  During a review of the facility’s P&P titled, “Care Planning Process,” dated November 2024, the P&P indicated, “The patient specific clinical plan of care includes measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care and measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to mee the patient’s needs”.   During a review of the facility’s P&P titled, “Missed Visits,” dated November 2024, the P&P indicated, “Purpose: To ensure the missed visits are documented and does not affect the quality of patient care. Missed visit will be communicated to the clinical supervisor and the patient’s physician.”
G0610	Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Physical Therapist Assistant (PTA) 2 discussed the plan of care with one of 13 sampled patients (Patient 2) during home visits. This failure had the potential to result in Patient 2 not being informed or involved in their own care. Findings: During an observation on 10/28/2025 at 2:25 p.m., PTA 2 was observed performing physical therapy exercises with Patient 2. PTA 2 did not discuss the plan of care located inside the Home Health Agency (HHA) folder with Patient 2. During an interview on 10/28/2025 at 2:30 p.m. with Patient 2, Patient 2 stated nobody from the HHA has gone over the care plan in the admission folder with her. During an interview on 10/29/2025 at 10:19 a.m. with PTA 2, PTA 2 stated she has never seen Patient 2’s plan of care in the Home Health Agency’s admission folder. PTA 2 stated she has never discussed the plan of care with Patient 2. PTA 2 stated the purpose of a care plan is to provide information on the patient’s condition, the medications they are taking, goals to reach while receiving HHA services, and interventions to reach their goals. PTA 2 stated not discussing the care plan with Patient 2 could result in Patient 2 not knowing if they are progressing towards their goals or not. PTA 2 stated Patient 2 could decline and Patient 2 would not be informed or involved in their own care. During an interview on 10/29/2025 at 3:15 p.m. with Physical Therapist (PT) 1, PT 1 stated he was the PT assigned to Patient 2. PT 1 stated PTA 2 was assigned to do Patient 2’s home visits. PT 1 stated PTA 2 should have been discussing the plan of care with Patient 2. During an interview on 10/30/2025 at 12:01 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated it is the PTA’s responsibility to go over the care plan during each patient visit, so the patient is aware of how they are progressing. The DPCS stated PTAs are expected to physically see the HHA’s admission folder and use the plan of care inside to go over each goal and intervention to educate the patient. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” revised 11/2024, the P&P indicated, “The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible.”
G0728	Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure physical therapy assistants were supervised by a physical therapist for one of 13 sampled patients (Patient 2). This failure had the potential to result in Patient 2 not meeting the mobility goals established in the plan of care by the physical therapist. Findings: During a review of Patient 2’s Patient Profile (admission record), the Patient Profile indicated Patient 2’s SOC date was 10/1/2025, with primary diagnoses of acute pain due to trauma (an unpleasant sensory and emotional experience due to actual or potential tissue damage), wedge compression fracture of the second lumbar vertebra (a break in the second bone of the lower back which results in a wedge shape) and hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart muscle, leading to impaired pumping function). During an interview on 10/28/2025 at 2:25 p.m. with Physical Therapist Assistant (PTA) 2, PTA 2 stated she was PTA assigned to Patient 2 to help perform mobility exercises. PTA 2 stated a physical therapist has never supervised her during patient visits. During an interview on 10/29/2025 at 3:15 p.m. with Physical Therapist (PT) 1, PT 1 stated he was the PT assigned to Patient 2. PT 1 stated he does not do any supervisory visits for PTA 2. PT 1 stated not having supervisory visits could result in Patient 2 not meeting the mobility goals established in the plan of care. PT 1 stated it would be difficult to verify if Patient 2 was progressing or declining in terms of range of motion, balance, transferring, and walking without PTA supervisory visits. During a review of PT 1’s “Physical Therapist Job Description,” dated 9/1/2022, the Physical Therapist Job Description indicated, the physical therapist “Supervises physical therapy assistants according to organization policy and state regulations.”
G1008	Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical records as follows: The Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed: 1. To ensure Licensed Vocational Nurse (LVN) 1 did not willfully falsify (knowingly make a false entry into a patient record) patient records for one of thirteen sampled patients (Patient 5) when LVN 1 copied LVN 2’s visit notes for Patient 5 on 10/15/2025 and 10/17/2025, that indicated wound care was provided to Patient 5 when wound care treatment was not actually provided by LVN 1. 2. To ensure the Outcome and Assessment Information (OASIS, an assessment tool used to collect functional and clinical status data for patients) patient assessment, was authenticated with a signature of the staff who completed the OASIS form and dated for one of thirteen sampled patients (Patient 8). 3. To ensure Occupational Therapist (OT) 1, who was a contracted employee, used a unique identifier that included OT 1’s signature when completing the “Patient Assessment: OASIS (OASIS)” form for one of thirteen sampled patients (Patient 9). These failures affect data accuracy that could result in inappropriate guidance for the development of Patient 5, Patient 8 and Patient 9’s plan of care (POC), compromise patient safety, disrupt continuity of care, poor quality of care that could lead to adverse health outcome (any negative or suboptimal result affecting a person's physical or mental well-being, stemming from various factors including medical care, disease progression, or environmental exposure). (See G01024). The cumulative effect of these practices resulted in the systemic failure of the HHA to deliver statutorily (decided and controlled by law) mandated compliance with the federal regulations for Clinical Records to ensure the clinical records contained accurate and completed clinical information to all patients certified to receive the home health benefits.
G1024	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 observation, interview, and record review, the Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed: 1. To ensure Licensed Vocational Nurse (LVN) 1 did not willfully falsify (knowingly make a false entry into a patient record) patient records for one of thirteen sampled patients (Patient 5) when LVN 1 copied LVN 2’s visit notes for Patient 5 on 10/15/2025 and 10/17/2025, that indicated wound care was provided to Patient 5 when wound care treatment was not actually provided by LVN 1. 2. To ensure the Outcome and Assessment Information (OASIS, an assessment tool used to collect functional and clinical status data for patients) patient assessment, was authenticated with a signature of the staff who completed the OASIS form and dated for one of thirteen sampled patients (Patient 8). 3. To ensure Occupational Therapist (OT) 1, who was a contracted employee, used a unique identifier that included OT 1’s signature when completing the “Patient Assessment: OASIS (OASIS)” form for one of thirteen sampled patients (Patient 9). These failures affect data accuracy that could result in inappropriate guidance for the development of Patient 5, Patient 8 and Patient 9’s plan of care (POC), compromise patient safety, disrupt continuity of care, poor quality of care that could lead to adverse health outcome (any negative or suboptimal result affecting a person's physical or mental well-being, stemming from various factors including medical care, disease progression, or environmental exposure). On 11/4/2025 at 12 PM, while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Director of Patient Care Services (DPCS), for failing to demonstrate a process and provide documented evidence that the facility ensured patient records were not willfully falsified, all entries into the patient health record were appropriately authenticated, and staff obtained unique identifiers to access and authenticate protected health information (any health information that can identify an individual that is in possession of or transmitted by a "covered entity" or its business associates that relates to a patient's past, present, or future health). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. Findings: 1. During a review of Patient 5’s “Patient Profile”, undated, the Patient Profile indicated that Patient 5’s Start of Care (SOC, the initial, in-person visit and assessment conducted by a clinician to establish a patient’s care plan) was on 10/3/2025, with diagnoses that included pressure ulcer stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) of right buttock, encounter for change or removal of non-surgical wound dressing (medical appointment focused solely on changing or removing a dressing [a pad applied to a wound to promote healing] from a wound that did not originally require surgery), and hypertensive heart disease with heart failure (the heart cannot pump enough blood to the body because high blood pressure has damaged it over time). During a concurrent observation and interview on 10/28/2025 at 10:35 AM with Physical Therapist Assistant (PTA) 1, LVN 1 was observed conducting Skilled Nurse (SN) visit to Patient 5. LVN 1 stated she was assigned to do Patient 5’s home visit to help the patient with mobility, exercises, and home safety because Patient 5 had recent falls. PTA 1 stated he would provide physical therapy to Patient 5. LVN 1 stated she would stop her visit and let PTA 1 continue with the visit, LVN 1 then stepped out of Patient 5’s room. During an interview on 10/28/2025 at 10:36 AM with LVN 1, LVN 1 stated she received orders from the HHA to do home visit for Patient 5 to provide help with mobility and exercise education. LVN 1 stated she visited Patient 5 two times a week and during the visits she instructed Patient 5 to walk around the room, march in place, stretch, and sit to stand using a walker. LVN 1 stated she does not provide wound care treatment or medication management when she conducts her visit to Patient 5. LVN 1 stated she only provides exercise and exercise education to Patient 5. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s Skilled Nurse Visit Notes, dated 10/15/2025 and 10/17/2025, were reviewed. The Skilled Nurse Visit Noted indicated the following assessment and treatment for Patient 5: Under homebound status, the box for wound care was checked. Under integumentary (the set of organs that forms the external covering of the body) it indicated “right buttock stage II right thigh hematoma”. Under wound type, the boxes for decubitus (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) stage I (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness), II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) and see wound sheet assessment and treatment were checked. During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she could not recall if wound care was provided to Patient 5 during the home visit and if the wound care treatment was not documented, the treatment was not done. LVN 1 stated the contents of the 10/15/2025 and 10/17/2025 Skilled Nurse Visit Notes were copied from the previous nurse’s (LVN 2) visit notes. LVN 1 stated she intended to go back and uncheck anything she did not do during her home visits with Patient 5. During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she should not copy Patient 5’s assessment information from the documentation of the previous nurse to put on her Skilled Nurse Visit Note. LVN 1 stated she should only document data from her own assessment during her visit with Patient 5. LVN 1 stated not having accurate documentation (copying the Skilled Nurse Visit Notes of LVN 2) could lead to inaccurate assessment. LVN 1 stated accurate documentation was important to ensure Patient 5’s care and wound care treatment were provided. During an interview on 11/3/2025 at 3:16 PM with the DPCS, the DPCS stated that “if a nurse accepts the fact that they copied another nurse’s notes then it is a falsification of records”. During an interview on 11/3/2025 at 3:20 PM with Quality Assurance (QA), the QA stated that “nurses need to make their own assessments, and oversight can happen in a pattern of copying and can fall into patient neglect (failure of a caretaker to supply the patient with the necessary food, clothing, shelter, health care, or supervision; or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient)”. The QA stated, “there could be an opportunity to miss a change of condition” and there was a potential risk for missed adverse medication reactions, change in medication regimen, or changes from a patient’s baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes). During a review of the facility’s policy and procedure (P&P) titled, “Contents of Clinical Record”, dated 11/2024, the P&P indicated: “The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel”. “The following information will be available in the clinical record for patients receiving skilled care: [...] procedures and/or treatments rendered [...] documentation of the assessment data collected, actions and interventions performed, and patient response to care provided.” During a review of the facility’s P&P titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following: “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.” “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly” “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses.” During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.” 2. During a review of Patient 8’s “Patient Profile”, undated, the Patient Profile indicated that Patient 8’s SOC was on 10/8/2025, with a diagnosis of hypertension (HTN, pressure in the blood vessels is high). During a review of Patient 8’s “Patient Assessment: OASIS”, for the certification period of 10/8/2025 to 12/6/2025, it indicated, Patient 8’s primary diagnosis as spondylosis without myelopathy or radiculopathy, lumbar region (a condition where the intervertebral discs in the lower back degenerate, without damage to the spinal cord or nerve roots) and other diagnoses including presence of right artificial shoulder joint, generalized muscle weakness, muscle wasting and atrophy (wasting or shrinkage of a body part or tissue), joint stiffness, and low back pain. During a review of Patient 8’s “Patient Assessment: OASIS”, for the certification period of 10/8/2025 to 12/6/2025, further indicated the following: Discipline of Person Completing the Assessment: PT (Physical Therapy) Care Staff Name: the record indicated the company name (Contracted Company [CC] 2) instead of the name of the clinician who completed the form. Date Assessment Completed: 10/8/2025 This assessment is currently being completed for the following reason: start of care-further visits planned. The signature and date lines were blank under the section “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” During an interview on 11/3/2025 at 2:01 PM with the CC2 Intake Coordinator, the CC 2 Intake Coordinator stated CC2’s staff had access to the form “Patient Assessment: OASIS” through the HHA’s EMR. The CC2 Intake Coordinator stated the form “Patient Assessment: OASIS” must be completed by the clinician performing the initial evaluation and the clinician must sign the assessment.” During a review of the facility’s P&P titled, “Person or Entity Authentication Policy,” undated, the P&P indicated: “The purpose of this policy is to ensure that (name of the HHA) verifies the identity of any person or entity seeking access to electronic protected health information (ePHI). This helps protect patient confidentiality and maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule.” “Each user is assigned a unique user ID to access system containing ePHI” “Shared accounts are strictly prohibited.” During a review of the facility’s P&P titled, “OASIS Data Transmission,” dated November 2025, the P&P indicated: “OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points” “All encoded OASIS data shall accurately reflect the patient’s status at the time the assessment was completed” “Discrepancies identified will be corrected following organization approved processes” “The organization must electronically transmit accurate, complete and encoded OASIS data for each patient...” 3. During a review of Patient 9’s “Patient Profile”, undated, the Patient Profile indicated that Patient 9’s SOC was on 10/11/2025, with a diagnosis of essential primary hypertension (pressure in the blood vessels is high without an identifiable medical cause) and primary osteoarthritis (a joint disease that causes the breakdown of protective tissue that cushions the ends of bones, without an identifiable medical cause) of the left shoulder. During a review of Patient 9’s “Patient Assessment: OASIS”, for the certification period of 10/11/2025 to 12/9/2025, the record indicated, name of the care staff assigned to the patient was documented as the contracted company name (CC1) instead of the actual name of the clinician who performed the initial patient assessment.. The OASIS was not signed by the actual person who performed the initial assessment. During an interview on 10/31/2025 at 3:39 PM with the Director of Patient Care Services (DPCS), the DPCS stated that Occupational Therapy (OT, a therapy service that helps people improve their ability to perform everyday tasks such as dressing, bathing and cooking) can complete an SOC if that is the only service ordered for the patient and that OT had access to complete the OASIS form. The DPCS stated when the OASIS form is completed, it should be signed and dated and when a contracted employee completes the OASIS, the name and signature that appears on the OASIS form would be under the employee’s contracted company and not the individual staff who completed the OASIS. During an interview on 10/31/2025 at 3:51 PM with the DPCS, the DPCS stated the only way to determine who completed the “Patient Assessment: OASIS” was to compare the report against visit notes, and determine which clinician performed a home visit on the same day the “Patient Assessment: OASIS” was dated. During an interview on 11/3/2025 at 12:08 PM with OT 1, OT 1 stated the process when a new patient was assigned to her was that she would receive an intake form and if it were for an SOC, she would complete the “Occupational Therapy-OT OASIS-SOC (the OT SOC notes)” that she would submit to the HHA. During a concurrent interview and record review on 11/3/2025 at 1:50 PM with OT 1, Patient 9’s “OT OASIS-SOC”, dated 10/11/2025, was reviewed. Patient 9’s “OT OASIS-SOC” indicated it was signed by OT 1. OT 1 stated that for SOC’s, she only completes the “OT OASIS-SOC form”. OT 1 stated she was not familiar with the “OASIS” form and that she did not fill out the “OASIS”, form for Patient 9. OT 1 stated when she needed to access HHA’s electronic medical record (EMR, a digital collection of patient’s health information), she signs in using the User ID under (CC 1 of OT 1) and not under her own name. During a concurrent interview and record review on 11/3/2025 at 3:02 PM with Customer Support Representative 2 (CSR 2) of the HHA’s EMR, the “EMR User Activity” report, dated 9/30/2024 to 10/31/2025, for Patient 9 was reviewed. The “EMR User Activity” report indicated Patient 9’s OASIS was accessed on 10/30/2025 at 3:04 PM by “User ID: CC 1”. CSR 2 stated “cannot specify which person signed the OASIS and if it was from the contracted company or the home health agency and that it was the same account because the same credentials were used”. During a review of the facility’s P&P titled, “Person or Entity Authentication Policy,” undated, indicated: “The purpose of this policy is to ensure that (name of the HHA) verifies the identity of any person or entity seeking access to electronic protected health information (ePHI). This helps protect patient confidentiality and maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule.” “Each user is assigned a unique user ID to access system containing ePHI” “Shared accounts are strictly prohibited.” During a review of the facility’s P&P titled, “OASIS Data Transmission,” dated November 2025, the P&P indicated: “OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points” “All encoded OASIS data shall accurately reflect the patient’s status at the time the assessment was completed” “Discrepancies identified will be corrected following organization approved processes” “The organization must electronically transmit accurate, complete and encoded OASIS data for each patient...”