Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 757737	(X3) Date Survey Completed 03/19/2026
Name of Provider or Supplier Alaunus Home Health, Inc	Street Address, City, State 110 S Rosemead Blvd. Suite R4, Pasadena, 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 conducted from 3/16/2026 to 3/19/2026. Complaint intake number: 2742600 Active patients: 43 Sampled patients: 7 Home visits: 3 Closed Record reviews: 2 The following Conditions of Participation was not met: 484.60 Care Planning, Coordination of Services, and Quality of Care.
G0520	5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to complete initial comprehensive assessments for four of seven sampled patients (Patient 1, Patient 2, Patient 3, and Patient 5). This failure had the potential to result in delayed patient care, decline in functional, physical health and lack of communications between interdisciplinary team for Patient 1, Patient 2, Patient 3, and Patient 5. d. During a record review of Patient 5’s medical record form titled “Patient Profile” undated, indicated a start of care date of 11/21/2025 with a primary diagnosis of pressure ulcer of sacral region, stage 2 (a partial-thickness loss of skin over the tailbone/sacrum, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister). During a concurrent interview and record review on 3/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, a senior healthcare leader responsible for overseeing clinical operations, ensuring regulatory compliance, and maintaining high standards of patient care), Patient 5’s “Home Health Certification and Plan of Care” (POC), for recertification periods (60-day timeframe during which a Medicare beneficiary receives ordered home health services under a certified plan of care) 1/20/2026 to 3/20/2026 was reviewed. Patient 5’s POC did not indicate an initial wound assessment (a comprehensive, objective, and documented evaluation of a patient's wound, performed by a licensed clinician to establish a baseline for healing, determine etiology, and guide the treatment plan) The DPCS stated there is no initial wound assessment for Patient 5 to indicate the wound’s location, size (length, width, depth), color, tunneling, pain, and signs of infection, odor, type, tissue type in the wound bed, amount/type of exudate (drainage), and the condition of the peri wound (around the wound) skin. DPCS stated without the initial wound assessment, there is increased risk of infection and pain. During a review of the facility’s policy and procedure titled, “Availability of Services, Policy No. 2-001.1”, dated November 2017, indicated, “Additional discipline initial assessments will be provided within five (5) business days of the start of care or date of the physician’s (or other authorized licensed independent practitioner’s) order.” During a review of the facility’s policy and procedure titled, “Initial and Comprehensive Assessment, Policy No. 4-018.1,” dated November 2017, indicated, “4. During the initial and comprehensive patient assessment, all baseline data to be used measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s clinical record, including at least the following information…B. A physical assessment, including…skin breakdown…” a. During a review of Patient 1’s “Home Health Certification and Plan of Care,” (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone). During an interview on 3/18/2026 at 11:23 a.m. with Registered Nurse 2 (RN 2), RN 2 stated the RN Initial Evaluation Visit for Patient 1 dated 1/21/2026 was blank. RN 2 stated she conducted the initial assessment visit for Patient 1. RN 2 stated she only completes the OASIS (Outcome and Assessment Information Set) Start of Care (a mandatory, comprehensive initial assessment for Medicare/Medicaid home health patients, setting the baseline for care, patient outcomes, and reimbursement) assessment for newly admitted patients. RN 2 stated she was not aware she had to document a separate initial comprehensive assessment for newly admitted patients. RN 2 stated it was important to document an initial comprehensive assessment to establish a baseline for patient care and identify any needs that can be addressed. During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s “RN Initial Evaluation Visit” dated 1/21/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs. b. During a review of Patient 2’s POC for the certification period from 1/15/2026 to 3/15/2026, the POC indicated Patient 2 was admitted to the HHA on 1/15/2026 with a primary diagnosis of pressure ulcer of the right heel (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the right heel). During an interview on 3/18/2026 at 11:34 a.m. with RN 1, RN 1 stated the RN Initial Evaluation Visit for Patient 2 dated 1/15/2026 was blank. RN 1 stated she conducted the initial assessment visit for Patient 2. RN 1 stated she only completes the OASIS Start of Care assessment when admitting patients to the HHA. RN 2 stated it was important to document an initial comprehensive assessment to provide detailed information about a patient to the DPCS and interdisciplinary team. During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the DPCS, Patient 2’s “RN Initial Evaluation Visit” dated 1/15/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs. c. During a review of Patient 3’s POC for the certification period from 1/16/2026 to 3/16/2026, the POC indicated Patient 3 was admitted to the HHA on 1/6/2026 with a primary diagnosis of stage 1 pressure ulcer of the sacral region (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the tailbone). During an interview on 3/18/2026 at 11:34 a.m. with RN 1, RN 1 stated the RN Initial Evaluation Visit for Patient 3 dated 1/16/2026 was blank. RN 1 stated she conducted the initial assessment visit for Patient 3. RN 1 stated she only completes the OASIS Start of Care assessment when admitting patients to the HHA. RN 2 stated it was important to document an initial comprehensive assessment to provide detailed information about a patient to the DPCS and interdisciplinary team. During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the DPCS, Patient 3’s “RN Initial Evaluation Visit” dated 1/16/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs. During a review of the facility’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment,” revised 11/2017, the P&P indicated, “A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.” d. e.
G0528	Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure to complete wound assessments and timely for three of seven sampled patients (Patient 1, Patient 5, and Patient 6). This failure had the potential to place Patient 1, Patient 5, and Patient 6 at risk for complications of wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization. a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone). During a joint home visit on 3/17/2026 at 10:20 a.m. in Patient 1’s residence, with Licensed Vocational Nurse 3 (LVN 3), Patient 1 was observed lying in bed watching television. Patient 1 was observed with a sacral wound dressed with a foam dressing. Patient 1 stated he did not want LVN 3 to remove the foam dressing and assess the sacral wound. During an interview on 3/17/2026 at 11:04 a.m. with LVN 3, LVN 3 stated she was the visiting nurse for Patient 1. LVN 3 stated she changes Patient 1’s wound dressing once a week. LVN 3 stated her process for changing Patient 1’s wound was to cleanse with saline and pat dry, apply collagen powder (a wound dressing used to accelerate healing in chronic and acute wounds), xeroform (a sterile gauze designed to create a moist, antimicrobial environment for healing wounds), Calmoseptine (a moisture barrier designed to treat and prevent skin irritations), and cover with a foam dressing. LVN 3 stated she follows the Wound Specialist Nurse Practitioner (WSNP) order from 1/26/2026. During an interview on 3/17/2026 at 1:26 p.m. with LVN 3, LVN 3 stated she does not assess Patient 1’s sacral wound when she visits Patient 1 because it is the WSNP’s responsibility. LVN 3 stated she does not take Patient 1’s wound measurements or assess for signs of infection, including odor, color, drainage. LVN 3 stated she does not document any wound assessments for Patient 1 in the electronic medical record. During a concurrent interview and record review on 3/17/2026 at 3:20 p.m. with the WSNP, Patient 1’s “Wound Specialist Progress Note,” dated 3/9/2026 was reviewed. The Wound Specialist Progress Note indicated the treatment plan for Patient 1’s sacral wound was to cleanse the sacral wound with normal saline rinse at each dressing change and pat dry, apply MediHoney (a medical-grade, sterilized Manuka honey used to treat wounds and burns by maintaining a moist environment, reducing infection risk, and aiding debridement) to areas of slough (stringy necrotic tissue that covers the wound bed), apply collagen powder evenly to the wound bed, cover the wound with calcium alginate (a highly absorbent, biodegradable dressing used to treat moderate to heavily exudating wounds) and foam pad, and apply Calmoseptine to the peri wound (area of skin surrounding a wound). The WSNP stated she wrote the order for the wound treatment process. The WSNP stated LVN 3 should have been following her most recent order from 3/9/2026, not from 1/26/2026. The WSNP stated she expected LVN 3 to follow each treatment step to change Patient 1’s wound dressing. The WSNP stated LVN 3 should not have used xeroform when treating Patient 1’s wound, and that MediHoney should be applied before collagen powder. During an interview on 3/17/2026 at 3:41 p.m. with the WSNP, the WSNP stated she visits Patient 1 weekly to assess and treat Patient 1’s sacral wound. The WSNP stated LVN 3 should have been assessing Patient 1’s sacral wound during each visit and notify her (WSNP) if there were any changes in the wound. The WSNP stated it was LVN 3’s responsibility to assess Patient 1’s wound measurements, color, odor, peri wound, and drainage. The WSNP stated LVN 3’s lack of assessment could have resulted in Patient 1’s wound becoming infected, which could lead to delayed wound healing. During an interview on 3/18/2026 at 2:27 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated LVN 3 should have followed the most recent orders written by WSNP. The DPCS stated not following wound treatment order as written could result in Patient 1’s wound worsening. The DPCS stated it was also LVN 3’s responsibility to assess Patient 1’s sacral wound during each visit, including wound size and measurement, pain level, drainage, odor, color, and signs of infection. The DPCS stated not assessing Patient 1’s wound could have resulted in the wound developing an infection, which could lead to hospitalization. During an interview on 3/18/2026 at 2:45 p.m., the DPCS stated the HHA does not have a policy for wound assessments. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” revised 11/2017, the P&P indicated, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.” b. During a record review of Patient 5’s “Patient Profile,” undated, indicated start of care date 11/21/2025 with primary diagnosis of pressure ulcer of sacral region, stage 2 (a partial-thickness loss of skin over the tailbone/sacrum, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister). During a concurrent observation and interview on 3/17/2026 at 10:15 am with Registered Nurse (RN, a nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 1 and Patient 5 in Patient 5’s room, Patient 5’s sacral region was faintly discolored, intact with light pressure, and showed no signs of skin breakdown. RN 1 stated the pressure ulcer appears to have healed. Patient 5 stated that the pressure ulcer healed about 2 weeks ago. During a concurrent interview and record review on 3/172026 at 12:00 pm with RN 1, Patient 5’s “Nursing Progress Notes” (legal, chronological records within a patient's medical chart that detail the patient’s clinical status, nursing assessments, interventions, and their response to care) dated 3/10/2026, 3/3/2026, 2/24/2026, 2/10/2026, 1/24/2026, 1/10/2026, and 12/1/2025 were reviewed. All seven “Nursing Progress Notes” indicated, “Sacral region: SN cleared the wound with normal saline, patted dry, closed sacrum bordered dressing. PRESSURE ULCER of SACRAL REGION, STAGE 2.” RN 1 stated, these are not my nursing notes, Patient 5’s pressure ulcer appears to have healed, and these nursing notes are inconsistent with Patient 5’s current physical condition. During an interview on 3/18/26 at 1:04 pm with LVN 2, LVN 2 stated Patient 5’s sacral wound healed at the end of February, no more care was provided after it healed, and LVN 2 cannot comment on why LVN 2’s "Nursing Progress Notes" for Patient 5 indicate that Patient 5 received wound care after the wound healed. LVN 2 stated LVN 2 called the office and let Intake know that the wound was healed. During a concurrent interview and record review on 1/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, senior nursing leadership role responsible for overseeing clinical staff, quality assurance, and patient care standards), Patient 5’s “Nursing Progress Notes” dated 3/10/2026, 3/3/2026, 2/24/2026, 2/10/2026, 1/24/2026, 1/10/2026, and 12/1/2025 were reviewed. All seven “Nursing Progress Notes “indicated, “Sacral region: SN cleared the wound with normal saline, patted dry, closed sacrum bordered dressing. PRESSURE ULCER of SACRAL REGION, STAGE 2.” DPCS stated this would indicate falsification of records and lead to unnecessary treatment for Patient 5. During a concurrent interview and record review on 1/18/2026 at 1:47 pm with DPCS, the facility’s policy and procedure (P&P) titled, “Reassessments/Recertification Policy No. 4-020.1,” revised November 2017 was reviewed. The P&P indicated, “4. Each patient will be reassessed … when A. There is a significant change in the patient’s condition…” The DPCS stated Patient 5's condition changed, but the LVN 2 did not update and falsified Patient 5's medical records when “Nursing Progress Notes” indicated treatment for a healed wound. DPCS stated falsifying medical records could lead to unnecessary treatment. c. During a record review of Patient 6’s “Patient Profile,” undated, indicated start of care date 12/20/2025 with primary diagnosis of pressure ulcer of sacral region, unstageable (a full-thickness wound over the tailbone where dead tissue covers the wound base). During a concurrent interview and record review on 3/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, a senior healthcare leader responsible for overseeing clinical operations, ensuring regulatory compliance, and maintaining high standards of patient care), Patient 6’s "Nursing Progress Notes" dated 2/1/2026, 1/31/2026, 1/28/2026, and 1/25/2026 were reviewed. DPCS stated Patient 6's "Nursing Progress Notes" do not contain wound assessments, and the Skilled Nurse (SN, a licensed professional nurse who provides high-level medical care, such as wound management) is responsible for assessing the patients’ wounds during every patient visit by including, but not limiting to, wound size, pain level, drainage, color, signs of infection. The DPCS stated there is no wound care or wound assessment policy. The DPCS stated not assessing Patient 6’s wound could have resulted in a wound infection and hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process, Policy No. 4-001.1,” revised November 2017, the P&P indicated, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.”
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 observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate, and current medication profiles for three of seven sampled patients (Patient 1, Patient 4, and Patient 5). This failure had the potential to place Patient 1, Patient 4, and Patient 5 at risk for medication errors and adverse drug reactions. b. During a record review of Patient 4’s “Patient Profile” (a comprehensive, centralized record containing a person’s demographic data, medical history, medications, allergies, and sometimes lifestyle factors (e.g., occupation, preferences) to support personalized care and improve treatment adherence), undated, “Patient Profile” indicated Patient 4’s start of care was 12/10/2025 with primary diagnosis of Type 2 diabetes mellitus without complications (a diagnosis for individuals with high blood sugar (diabetes) who have not yet developed chronic complications, such as nerve damage, kidney disease, or eye disease). During a concurrent interview and record review on 3/17/2026 at 10:30 am with RN 1, Patient 4’s Ararat Gardens’ “Order Summary Report” (a concise, organized record of all medical orders), dated 3/17/2026, was reviewed. The Order Summary Report indicated these are some of the medications Patient 4 was currently prescribed: Carbidopa-Levodopa Oral Tablet 25-100 MG Give 2.5 tablet by mouth four times a day for Parkinson's DiseaseVitamin D3 Oral Capsule 1.25 MG (50000 UT) Give 1 capsule by mouth one time a day every Sat for Supplement on Saturdays for osteoporosis and muscle weaknessRN 1 stated, ALF's “Order Summary Report” lists Patient 4’s current medications. During an interview on 3/17/26 at 12:30 pm, with Patient 4 in Patient 4’s room, Patient 4 stated he took the meds he was given and didn’t know which medications did what. During a concurrent interview and record review on 3/17/2026 at 1:10 with RN 1, Patient 4’s HHA's “Patient Medication Profile” (a comprehensive, updated record of a patient's prescription drugs, over-the-counter medications, supplements, allergies, and health conditions, often maintained in electronic health records), for recertification period (60-day timeframe during which a Medicare beneficiary receives ordered home health services under a certified plan of care) 2/8/2026 to 4/8/2026, indicated these were some of the medications Patient 4 was prescribed: Carbidopa ER 25 mg-levodopa 100 mg tablet, extended release take 2.5 tablets orally, twice daily for Parkinsons DiseaseVitamin D2 1,250 mcg (50,000 unit) capsule take 1 capsule orally, every Saturday, for osteoporosis and muscle weaknessRN 1 stated, Alaunus Home Health’s “Patient Medication Profile” lists Patient 4’s current medications. During a concurrent interview and record review on 3/17/2026 at 1:10 pm, with RN 1 at Patient 4’s residence, RN 1 reconciled Patient 4’s ALF's “Order Summary Report” with HHA's “Patient Medication Profile”. RN 1 stated the following medication discrepancies for Patient 4: ALF listed Carbidopa-Levodopa administered “four times a day” while HHA indicated Carbidopa-Levodopa administered “twice daily”ALF listed vitamin “D3” while HHA indicated vitamin “D2”RN 1 stated it appears the medication reconciliation (the formal process of creating the most accurate, up-to-date list of a patient's medications and comparing it against physician orders to prevent errors like omissions, duplications, or dosage mistakes) was not performed, she will let the physician and Alaunus Home Health know of these discrepancies and fix the problem. RN 1 stated these discrepancies could weaken Patient 4’s bones, increase Patient 4’s risk for falls, and cause confusion, agitation, and hallucination. During an interview on 3/18/2026 at 12:20 pm with Director of Patient Care Services (DPCS, a senior healthcare leader responsible for overseeing clinical operations, ensuring regulatory compliance, and maintaining high standards of patient care), the DPCS stated it appears LVN 2 did not complete Patient 4’s medication reconciliation, LVN 2 did not contact the DPCS regarding any discrepancies with medication reconciliation, the DPCS will look for the physician’s orders for these medication discrepancies, and LVN 2 should complete medication reconciliations at every patient visit. Discrepancies with medication reconciliations could lead to medication error or the patient receiving the wrong dose or the wrong medication. During an interview on 3/18/2026 at 1:04 pm with LVN 2, LVN 2 stated medication reconciliations are performed during every patient visit, and Patient 4 had no medication discrepancies. LVN 2 stated a patient could become toxic from receiving double the prescribed dose of Carbidopa-Levodopa and was not aware of any harm to the patient if the patient received vitamin D3, instead of the prescribed vitamin D2. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile, Policy No. 4-024.1,” dated November 2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record.” c. During a record review of Patient 5’s “Patient Profile” undated, “Patient Profile” indicated start of care was 11/21/2025 with primary diagnosis of pressure ulcer of sacral region, stage 2 (a partial-thickness loss of skin over the tailbone/sacrum, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister). During a concurrent interview and record review on 3/17/2026 at 10:30 am with RN 1, Patient 5’s ALF's “Order Summary Report,” dated 3/17/2026, was reviewed. The “Order Summary Report” indicated these are some of the medications Patient 5 was currently prescribed: Aspirin Oral Capsule 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CHF with an order status of “On-Hold” to reduce risk for heart attacks and strokesCholecalciferol Oral Capsule (Cholecalciferol) Give 50 mcg by mouth one time a day for SUPPLEMENT with an order status of “On-Hold” for healthy bones and musclesCyanocobalamin Oral Tablet (Cyanocobalamin) Give 1000 mcg by mouth one time a day for Supplement with an order status of “On-Hold” to reduce risk of anemiaPreserVision AREDS 2 Oral Capsule (Multiple vitamins w/ Minerals) Give 1 capsule by mouth two times a day for MACULAR DEGENERATION with an order status of “On-Hold” to slow progression of macular degenerationPriolia Subcutaneous Solution Prefilled Syringe (Denosumab) Inject 1 ml subcutaneously one time only for OSTEOPOROSIS for 168 daysRN 1 stated, ALF's “Order Summary Report” lists Patient 5’s current medications. During an interview on 3/17/26 at 11:14 am, with Patient 5 in Patient 5’s room, Patient 5 stated she took whatever meds she was given. During a concurrent interview and record review on 3/17/2026 at 12:00 with RN 1, Patient 5’s HHA's “Patient Medication Profile” for recertification period 1/20/2026 to 3/20/2026, indicated these were some of the medications Patient 4 was prescribed: Aspirin 81 mg tablet, delayed release take 1 tablet orally, once dailyCholecalciferol (vitamin D3) 50 mcg (2,000 unit) capsule take one capsule orally, once dailyCyanocobalamin (vit B-12) 1,000 mcg tablet take one tablet orally, once dailyPreserVision AREDS 2 Oral Capsule (Multiple vitamins with minerals) Take 1 capsule orally, twice dailyPriolia 60 mg/ml subcutaneous syringe Inject 1 ml subcutaneously, once daily every Monday until 5/24/2026. Injection performed by LVNRN 1 stated, HHA's “Patient Medication Profile” lists Patient 5’s current medications. During a concurrent interview and record review on 3/17/2026 at 12:00 pm, with RN 1 at Patient 5’s residence, RN 1 reconciled Patient 5’s ALF's “Order Summary Report” with HHA's “Patient Medication Profile”. RN 1 stated the following medication discrepancies for Patient 5: ALF listed Aspirin “On-Hold” while HHA indicated Aspirin administered “once daily”ALF listed Cholecalciferol “On-Hold” while HHA indicated Cholecalciferol “once daily”ALF listed Cyanocobalamin “On-Hold” while HHA indicated “once daily”ALF listed PreserVision AREDS 2 “On-Hold” while HHA indicated “twice daily”ALF listed Priolia Subcutaneous Solution Prefilled Syringe (Denosumab) Inject 1 ml subcutaneously “one time only” for OSTEOPOROSIS while HHA indicated “once daily every Monday until 5/24/2026”RN 1 stated it appears the medication reconciliation was not performed; she will let the physician and HHA know of the discrepancies and fix the problem. RN 1 stated these discrepancies could lead to stroke, weakened immune system and falls. During an interview on 3/18/2026 at 12:20 pm with DPCS, the DPCS stated it appears LVN 2 did not complete Patient 5’s medication reconciliation, LVN 2 did not contact the DPCS regarding any discrepancies with medication reconciliation, the DPCS will look for the physician’s orders for these medication discrepancies, and LVN 2 should complete medication reconciliations at every patient visit. Discrepancies with medication reconciliations could lead to medication error or the patient receiving the wrong dose or the wrong medication. During an interview on 3/18/2026 at 1:04 pm with LVN 2, LVN 2 stated medication reconciliations are performed during every patient visit, and Patient 5 had no medication discrepancies. LVN 2 stated if a patient did not receive Aspirin, Cholecalciferol, Cyanocobalamin, AREDS 2 or Priolia, they could experience a stroke, weakened immune system, anemia, poor eyesight, and falls. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile, Policy No. 4-024.1,” dated November 2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record.” a. During a review of Patient 1’s “Home Health Certification and Plan of Care,” (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone). During a joint home visit on 3/17/2026 at 10:20 a.m. in Patient 1’s residence, with Licensed Vocational Nurse 3 (LVN 3), Patient 1 was observed lying in bed watching television. During a review of Patient 1’s current medications on 3/17/2026 at 11:20 a.m. with LVN 3, the following medications were available at Patient 1’s residence but not listed in Patient 1’s medication profile or POC provided by the HHA: - Simethicone (a medication used to relieve symptoms of excess gas, such as painful pressure, bloating, and fullness) 500 milligrams (mg, a unit of measurement) - Calcium carbonate (a medication used to relieve heartburn, acid indigestion, and upset stomach) 1000 mg During an interview on 3/17/2026 at 11:24 a.m. with LVN 3, LVN 3 stated she was the visiting nurse for Patient 1. LVN 3 stated simethicone and calcium carbonate were medications that should have been included in Patient 1’s medication profile. LVN 3 stated she did not thoroughly complete medication reconciliation (a process of comparing the physician ordered medication to all the medications the patient is taking) during past visits. During an interview on 3/18/2026 at 2:38 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation should be completed by the visiting nurses during every visit. The DPCS stated completing medication reconciliation at each visit is important to ensure medications are being taken as prescribed, the medication profile remains current and accurate, and potential medication interactions are identified. The DPCS stated not doing medication reconciliation at each visit could result in medications being administered incorrectly. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” revised 11/2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” b. c.
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 observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to participate in federally funded healthcare programs) for Care Planning, Coordination of Services and Quality of Care as follows: The HHA failed to ensure the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) was individualized that addressed the treatment needs for three of seven sampled patients (Patient 1, Patient 5, and Patient 6). This failure resulted in Patient 1, Patient 5, and Patient 6 receiving home health services without a detailed, patient specific plan of care that included management of their medical conditions and/or diagnosis that could lead to declination of health condition and hospitalization of the patients. (Refer to G574) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Care Planning, Coordination, and Quality of Care to ensure the highest quality of care were being provided to patients certified to receive home health care and services.
G0574	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 interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure to have an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that including wound treatment orders for three of seven sampled patients (Patient 1, Patient 5, and Patient 6). This failure had the potential to result in delayed care, poor communication between interdisciplinary team (IDT, a group of professionals from different fields working collaboratively toward a shared goal to provide patient-centered care) members regarding patient care and failure to re-assess patient's condition that could lead to declination of health condition and hospitalization for Patient 1, Patient 5, and Patient 6. a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone). During a review of Patient 1's Progress Note, dated 1/26/2026, the Progress Note indicated a wound treatment order, "Cleanse the sacral wound with normal saline rinse at each dressing change and pat dry. Apply collagen powder (topical dressing) evenly to the wound bed to support granulation tissue (new, highly vascular connective tissue) formation. Cover the wound with calcium alginate (a natural gel-forming dressing) and foam pad. Apply Calmoseptine (an ointment as moisture barrier) to the peri wound (around wound) skin to protect against moisture-associated skin damage related to incontinence (inability to control the release of urine or feces). Change dressing every other day, or sooner if soiled, saturated, or dislodged." During a concurrent interview and record review on 3/18/2026 at 2:01 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s POC for the certification period from 1/21/2026 to 3/21/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 1’s wound treatment order in Patient 1’s POC. The DPCS stated the wound treatment order should be included in Patient 1’s POC so IDT members would know the actionable steps for Patient 1’s needs for wound care ensuring consistent quality care. The DPCS stated that not having an individualized POC for the patient with wounds could result in nurses not providing needed care and interventions to the patient, which could lead to delayed wound healing and decline of patient health conditions. b. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 1/20/2026 to 3/20/2026, the POC indicated Patient 5 was admitted to the HHA on 11/21/2025 with a primary diagnosis of stage 2 pressure ulcer of the sacral region (a partial-thickness loss of skin over the tailbone, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister). During a concurrent interview and record review on 3/18/2026 at 3:08 p.m. with the DPCS, Patient 5’s POC for the certification period from 1/20/2026 to 3/21/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 5’s wound treatment order in Patient 5’s POC. The DPCS stated the wound treatment order should be included in Patient 5’s POC to provide guidance, communicate and track progress among IDT members to improve patient outcomes. c. During a review of Patient 6’s Home Health Certification and Plan of Care (POC) for the certification period from 12/20/2025 to 2/17/2026, the POC indicated Patient 6 was admitted to the HHA on 12/20/2025 with a primary diagnosis of pressure ulcer of the sacral region. During a review of Patient 6's Progress Note, dated 1/7/2026, the Progress Note indicated a wound treatment order, "Cleanse the wound with normal saline. apply collagen powder and then thin layer of santyl (an ointment for wound) to the wound bed and lightly pack with iodoform (topical wound disinfectant) gauze to promote drainage and prevent dead space. Cover with calcium alginate, followed by covering with abd (a highly absorbent, multi-layered, sterile pad) dressing applied for additional protection and exudate management. Secure with paper tape. Dressing to be changed every 48 hours or sooner if saturated." During a concurrent interview and record review on 3/19/2026 at 12:09 p.m. with the DPCS, Patient 6’s POC for the certification period from 12/20/2025 to 2/17/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 6’s wound treatment order in Patient 6’s POC. The DPCS stated the wound treatment order should be documented in Patient 6’s POC to ensure all caregivers provide consistent care. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process”, dated 11/2017, the P&P indicated that based on the assessment and conclusions, the plan of care will include, but will not be limited to, patient specific interventions and education, specific services and treatments to be provided, and type, frequency, and duration of above actions.
G0716	Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure clinical visit notes were completed for two of seven sampled patients (Patient 2 and Patient 3). This failure had the potential to result in delayed or inappropriate treatment and lack of coordination between the interdisciplinary team for Patient 2 and Patient 3. a. During a review of Patient 2’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/15/2026 to 3/15/2026, the POC indicated Patient 2 was admitted to the HHA on 1/15/2026 with a primary diagnosis of pressure ulcer of the right heel (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the right heel). During an interview on 3/18/2026 at 12:08 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the Nursing Progress Notes for Patient 2 dated 1/19/2026, 1/23/2026, 2/2/2026, and 2/9/2026 were blank. LVN 3 stated she has not yet completed charting her visits for Patient 2. LVN 3 stated it was important to document visit notes in the patient’s electronic health record timely so the interdisciplinary group can see how the patient is progressing. During a concurrent interview and record review on 3/18/2026 at 2:34 p.m. with the Director of Patient Care Services (DPCS), Patient 2’s “Nursing Progress Notes,” dated 1/19/2026, 1/23/2026, 2/2/2026, and 2/9/2026, authored by LVN 3, were reviewed. The Nursing Progress Notes were blank. The DPCS stated the visit notes were blank. The DPCS stated nurses are expected to document their visits in the patient’s electronic health record within seven days. The DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician. b. During a review of Patient 3’s POC for the certification period from 1/16/2026 to 3/16/2026, the POC indicated Patient 3 was admitted to the HHA on 1/6/2026 with a primary diagnosis of stage 1 pressure ulcer of the sacral region (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the tailbone). During an interview on 3/18/2026 at 12:10 p.m. with LVN 3, LVN 3 stated the Nursing Progress Notes for Patient 3 dated 1/20/2026, 1/27/2026, 2/3/2026, 2/10/2026, 2/25/2026, 3/4/2026, and 3/10/2026 were blank. LVN 3 stated she has not yet completed charting her visits for Patient 3. LVN 3 stated it was important to document visit notes in the patient’s electronic health record timely so the interdisciplinary group can see how the patient is progressing. During a concurrent interview and record review on 3/18/2026 at 2:36 p.m. with the DPCS, Patient 3’s “Nursing Progress Notes,” dated 1/20/2026, 1/27/2026, 2/3/2026, 2/10/2026, 2/25/2026, 3/4/2026, and 3/10/2026, authored by LVN 3, were reviewed. The Nursing Progress Notes were blank. The DPCS stated the visit notes were blank. The DPCS stated nurses are expected to document their visits in the patient’s electronic health record within seven days. The DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection”, revised 11/2017, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.”