Caretenders

The home health agency failed to advise the patient nor the physician that a discharge for cause was being considered (see G464) and failed to immediately report potential neglect and unsanitary living conditions to Adult Protective Services (see G488).

The home health agency failed to ensure all POCs were individualized to include patient-specific outcomes, goals, and interventions which addressed all patient needs (see G572), failed to include all medications on the POC (see G574),failed to perform wound care only according to physician order…

The agency failed to include strategies for addressing emergencies identified on the risk assessment for 1 of 1 agency.

The agency failed to document attempts to contact emergency officials to perform cooperation and collaboration planning activities for 1 of 1 agency.

The agency failed to ensure the emergency plan included patient specific plans that were complete and legible for 1 of 1 agency emergency plan.

The agency failed to submit 28 OASIS assessments within 30 days of the assessment for 1 of 1 agency.

The home health agency failed to ensure the comprehensive assessment was updated at recertification to include the patient’s current wound status for 1 of 1 record reviewed of a patient with a wound (Patient #6).

The home health agency failed to ensure all POCs were individualized to include patient-specific outcomes, goals, and interventions which addressed all patient needs for 4 of 7 active records reviewed (Patient #1, #2, #6, #7).

The agency failed to ensure employees followed hand hygiene and bag technique procedures to reduce the risk of cross- contamination during 3 of 4 home visit observations (Patients #2, 4, and 5).

The home health agency failed to advise the patient nor the physician that a discharge for cause was being considered for 1 of 1 closed record reviewed of a patient discharged for cause (Patient #9).

The home health agency failed to immediately report potential neglect and unsanitary living conditions to Adult Protective Services (APS) for 1 of 1 record reviewed which evidenced the patient was frequently found appearing disheveled, having a body odor which indicated they had not been bathed…

The RN failed to include all medications on the POC for 1 of 4 home visit observations (Patient #3).

The RN failed to perform wound care only according to physician order, for 1 of 1 active records reviewed which evidenced the patient developed redness from a catheter (Patient #7).

The home health agency failed to notify the physician of a patient fall for 1 of 1 active record reviewed which evidence staff were aware of a patient fall (Patient #3), failed to notify the physician of a positive test result for urinary tract infection (UTI) for 1 of 2 records reviewed which…

The home health agency failed to ensure the revised POC included information from the patient’s updated comprehensive assessment and the patient’s progress towards his/her goals for 4 of 4 active records reviewed of a patient with a recertification POC (Patient #2, #4, #6, #7) Findings include: 2.…

The home health agency failed to coordinate care with all outside entities providing in-home services for 1 of 1 active records reviewed with a SOC in 2026 and which evidenced the patient was receiving PSA services (Patient #4) Findings include: 1.Patient #4’s clinical record indicated a SOC date…

The agency failed to notify patients of the name and contact information of the clinical manager for 4 of 4 home visit observations where the patient's home binder was reviewed (Patients #2, 3, 4, and 5).

The RN failed to conduct a complete assessment during each visit for 1 of 1 home visit observation with an RN (Patient #2) and 1 of 1 active record reviewed of a patient with pressure ulcer wounds (Patient #6).

The RN failed to ensure all documentation was accurate for 1 of 1 home visit observation with an RN (Patient #2) Findings include: 1.During a home visit observation with Patient #2 on 06/18/2026 beginning at 7:37 AM, RN 1 failed to conduct a complete skin assessment to check for wounds or skin…

The agency failed to ensure the administrator was responsible for all day-to-day activities for 1 of 1 agency.

The agency failed to ensure the communication plan included a list of all employees and phone numbers in 1 of 1 agency surveyed, with the potential to affect all patients and employees.

The home health agency failed to ensure that the plan of care (POC) was signed by the provider, per agency policy, for 4 of 12 active clinical records reviewed (Patient # 4, 5, 7, and 8).

The agency failed to provide their patient's, on admission, the contact information for the Area Agency on Aging with the potential to affect all patients for 1 of 1 agency.

The agency failed to investigate a complaint in 1 of 5 complaints regarding medication management, with the potential to affect any patient receiving medication management services.

The agency failed to resolve in 1 of 5 complaints regarding a complaint filed regarding medication management, with the potential to affect all patients receiving medication management services.

The home health agency failed to ensure an initial assessment was completed by a registered nurse [RN] within 48 hours, for 1 of 5 patient records reviewed with a referral for skilled nurse services (Patient #8).

The home health agency failed to ensure all required information was included in the plan of care (POC) for 7 of 14 patient records reviewed (Patient #1, 3, 4, 5, 8, 9, 13).

The home health agency failed to ensure all services and treatments were performed as ordered by the attending physician or other authorized practitioner and all orders for medical care were signed, per provider policy, for 6 of 14 patient records reviewed (Patient #2, 3, 4, 5, 8, and 13).

The home health agency failed to document collaboration with the patient, caregiver and physician regarding discharge and failed to notify the patient at least 15 days prior to discharge for 1 of 4 discharged patient records reviewed (Patient #13).

The home health agency failed to ensure the licensed practical nurse (LPN) reported a wound change to the registered nurse (RN) for 1 of 4 active records reviewed of patients with wounds (Patient #5.) Findings include: 1. Review of LPN job description included but not limited to, “...Continually…

The agency failed to ensure all patients and/or caregivers received written information with the name and contact information of the home health agency’s clinical manager for 1 of 1 agency, with the potential to affect all patients of the agency.

The licensed practical nurse (LPN) failed to adequately assess heart and breath sounds for 1 of 2 LPNs observed during home visits (LPN 1.) Findings include: 1. Review of the LPN job description included but not limited to “Provides high quality clinical services within the scope of practice…” 2.…

The Physical Therapist (PT) failed to supervise the Physical Therapy Assistant (PTA) according to agency policy for 1 of 3 active records reviewed where patient received PT services (Patient #3).

The Clinical Manager failed to ensure coordination between the home health agency and a Personal Service Agency (PSA) for 2 of 2 patients who reported during their home visit observations that they received services from a PSA (Patient #4 and 5).