USA Home Health, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing [a specialized level of medical care provided to patients who require assistance with daily activities and medical treatments] and other therapeutic service to a patient at home), failed to ensure that all staff are trained in emergency preparedness and conduct the emergency drill annually. This failure had the potential to affect the staff’s immediate response to emergency procedures to be carried out during an emergency/disaster situation. Findings: During a review of the HHA’s emergency preparedness plan, on 9/11/2026 at 9:30 a.m., the HHA did not have documented evidence that all staff were trained in an Emergency Preparedness/Disaster Drill. During a concurrent interview and record review, on 9/11/2026 at 10:35 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed HHA’s Emergency Preparedness Plan binder. The DPCS stated the HHA conducts emergency drills annually but could not provide documented evidence that all field staff attended the disaster drill training. The DPCS stated regular training ensures staff remain confident and better prepared in case of an emergency or disaster to protect public health. During a review of the agency’s undated policy and procedure (P&P) titled, “Emergency Management Policy”, the P&P indicated that the agency will have an identified plan in place to ensure the safety and well-being of clients and employees during periods of an emergency or disaster that disrupts agency services. All staff members will be oriented to the emergency preparedness plan and their associated responsibilities. Reviews will be held at least annually.”

“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 interview and record review, the home health agency (HHA, an organization that delivers skilled nursing [a specialized level of medical care provided to patients who require assistance with daily activities and medical treatments] and other therapeutic service to a patient at home), failed to ensure pain interventions and reassessment of pain were carried out in accordance with the plan of care (POC - a document that serves as a comprehensive, physician-signed plan detailing the necessary skilled home health services for patients, that includes diagnoses, orders, medications, treatments, and goals), for one of 7 sampled patients (Patient 2). This deficient practice may had a potential for inadequate pain management, potentially impacting Patient 2’s overall quality of life. Findings: During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/18/2028, with a diagnosis which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), hemiplegia (one-sided muscle paralysis or weakness) following cerebral infarction (also called a stroke, occurs as a result of disrupted blood flow to the brain), and bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee. During a review of Patient 2’s Home Health Certification and POC form for the certification period starting from 8/18/2026 to 10/16/2026, the Home Health Certification and POC form indicated the skilled nurse (or SN, provides advanced medical care, often requiring specialized training and certifications) frequency of visits to twice a week visits for 2 weeks and then once a week for 7 weeks, to perform vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]), to assess and monitor for signs and symptoms of complications related to diabetes, to assess and monitor for medications effectiveness, and to perform on every visit pain assessment using pain scale 0-10 (0 = no pain; 10 = unbearable pain), implement pain relief measures, and evaluate its effectiveness. During a review of Patient 2’s clinical record titled SN Visit Note, dated 8/21/2026, the SN Visit Note indicated Patient 2 had aching pain 5/10 on her knees, upper back and bilateral hands. There was no documented evidence that specific pain intervention was performed, and pain reassessment was conducted after an intervention was done. During a concurrent interview and record review, on 9/11/2026 at 10:35 a.m. with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s SN Visit note dated 8/21/2026. The DPCS stated that if a patient verbalizes pain during a visit, the skilled nurse should first offer pain medications and/or implement non-pharmacologic (treatments or therapies that manage health conditions and improve well-being without using medication) interventions such as repositioning, massage, or applying a cold compress. The DPCS stated untreated pain can lead to patient’s physical decline and worsening health status. The DPCS stated and acknowledged the findings. During a review of the agency’s undated policy and procedure (P&P) titled, “Plan of Care”, the P&P indicated an individualized plan of care signed by the physician shall be required for each client receiving home health and personal care services. The Plan of care shall be completed in full to include: a. All pertinent diagnosis(es), principle and secondary, including dates of onset b. Mental status c. Type, frequency, and duration of all visits/services d. Specific procedures and modalities for therapy services e. Diagnostic tests, including laboratory and x-rays f. Surgical procedure(s) g. Prognosis, Rehabilitation potential h. Functional limitations and precautions i. Activities permitted or restrictions j. Specific dietary or nutritional requirements or restrictions k. Medications, treatments, and procedures l. Medical supplies and equipment required During a review of the agency’s undated P&P titled “Pain Assessment/Management”, the P&P indicated that pain is assessed on every home visit and documented on a pain or symptom flowsheet. The follow-up assessments will address effectiveness of the pain management program and identify if there is a need for referral for additional or alternative therapy. Assessment of presence of pain and treatment/response will be incorporated into all agency assessment/reassessment tools.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard 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 therapeutic services to a patient at home), failed to provide a copy of the plan of care (POC - a document that serves as a comprehensive, physician-signed plan detailing the necessary skilled home health services for patients, that includes diagnoses, orders, medications, treatments, and goals), to three of 7 sampled patients (Patient 2, Patient 3, and Patient 4). This failure might result in the patients and their family members/caregivers not being able to be active participants in their care. a. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/18/2028, with a diagnosis which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), hemiplegia (one-sided muscle paralysis or weakness) following cerebral infarction (also called a stroke, occurs as a result of disrupted blood flow to the brain), and bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee. During a review of Patient 2’s Home Health Certification and POC form for the certification period starting from 8/18/2026 to 10/16/2026, the Home Health Certification and POC form indicated the skilled nurse (or SN, provides advanced medical care, often requiring specialized training and certifications) frequency of visits to twice a week visits for 2 weeks and then once a week for 7 weeks, to perform vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]), to assess and monitor for signs and symptoms of complications related to diabetes, to assess and monitor for medications effectiveness, and to perform on every visit pain assessment using pain scale 0-10 (0 = no pain; 10 = unbearable pain), implement pain relief measures, and evaluate its effectiveness. During a joint home visit, on 9/9/2026 at 11:00 a.m., at Patient 2’s residence with the licensed vocational nurse (LVN 1), Patient 2 was observed sitting on a sofa, awake, alert, oriented to person, place and time, accompanied by a caregiver (CG 1). During a review of the HHA’s folder located at the Patient 2’s home with LVN 1, LVN 1 stated and confirmed there was no copy of the current POC at the patient’s home. LVN 1 further stated that the agency does not provide a copy of the POC at the patient’s home. b. During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 4/27/2026, with a diagnosis that includes other idiopathic peripheral autonomic neuropathy (a condition that occurs when the nerves that control involuntary body functions become damaged), muscle spasms of calf, and essential hypertension (high blood pressure). During a review of Patient 3’s Home Health Certification and POC for the certification period starting from 8/25/2026 to 10/23/2026, the POC included an order for the skilled nurse to visit the patient twice a week for 1 week and then once a week for 8 weeks, to perform on every visits vital signs, pain assessment, assess and monitor for signs and symptoms of bradycardia (low heart rate), and to assess and monitor for medications effectiveness, possible side effects (an undesirable secondary effect that occurs in addition to the intended therapeutic effect of a drug or medication) and duplications. During a joint home visit, on 9/10/2026 at 1:35 p.m., at Patient 3’s residence with the Director of Patient Care Designee (DPCSD), Patient 3 was observed sitting in a chair, awake, alert, oriented to person, place and time, accompanied by a family member. During a review of the HHA’s folder located at the Patient 3’s home with the DPCSD, DPCSD stated and confirmed there was no copy of the current POC at the patient’s home. c. During a review of Patient 4’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 of 8/19/2026 to 10/17/2026, the POC indicated the HHA admitted Patient 4 on 8/19/2026 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that Patient 4 was to receive 2 (two) Skilled Nurse (SN, a licensed nurse) visits per week for 2 weeks, then 1 SN visit per week for 7 weeks. During a joint home visit on 9/9/2026 at 11 a.m., with Registered Nurse 1 (RN 1) at Patient 4’s residence, observed Patient 4 alert and oriented to person, place, and time (aware of who they are, where they are located, and the current date or time). During the joint home visit, the surveyor and RN 1 reviewed the content of Patient 4’s home health folder. There was no copy of the plan of care in Patient 4’s home health folder. During an interview with RN 1 on 9/9/2026 at 12:03 p.m., RN 1 stated that the HHA did not provide patients with copy of the POC. RN 1 stated the HHA only provided the POC copy to the nurses. When RN 1 was asked how the patient would be able to learn about their plan of care, interventions, and goals without the POC, RN 1 stated that he explained the purpose of visit and what the goals were for the patient. RN 1 stated that if the patient wanted to request additional goals, he would report it to the HHA’s Case Manager or DPCS. During an interview with the DPCS on 9/10/2026 at 2:42 p.m., the DPCS stated the HHA did not provide a copy of the POC to the patients or their family/caregivers. The DPCS stated that most of the HHA’s patients were Spanish-speaking, therefore they would not understand what was written in the POC, since the POC was written in English. The DPCS stated the nurse would explain what was written in the POC to the patients in Spanish. During a review of the HHA’s undated policy and procedure (P&P), titled “Plan of Care,” the P&P indicated an individualized plan of care signed by a physician shall be required for each client receiving home health and personal care services. The client, therapist, and other agency personnel shall participate in developing the plan of care. The client shall be informed of any changes in the plan of care. During a review of the HHA’s undated P & P, titled “Home Care Bill of Rights/Grievance Procedure,” the P & P indicated that the clients should be informed verbally and in writing, or by other means understood by the clients, of their right to make informed decisions regarding their care.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on observation and interview, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide education on contaminated sharps disposal for one of 7 sampled patients (Patient 4). This failure had the potential to expose patient and/or caregiver to sharps injury and infection caused by blood-borne pathogens. Findings: During a review of Patient 4’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 of 8/19/2026 to 10/17/2026, the POC indicated the HHA admitted Patient 4 on 8/19/2026 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that Patient 4 was to receive 2 (two) Skilled Nurse (SN, a licensed nurse) visits per week for 2 weeks, then 1 SN visit per week for 7 weeks. The POC indicated the visiting nurse was responsible for teaching the patient and/or the caregiver about proper skin care, diabetic health care, hygiene practices, and infection control measures. The POC also indicated the SN was responsible for teaching the patient about safe disposal of sharps and to validate the patient’s knowledge on safe disposal of sharps. During a joint home visit on 9/9/2026 at 11 a.m. with Registered Nurse 1 (RN 1) at Patient 4’s residence, observed Patient 4 alert and oriented to person, place, and time (aware of who they are, where they are located, and the current date or time). During the joint home visit, the surveyor observed Patient 4’s diabetic supplies that included a glucometer (a portable device that measures the amount of glucose in a person’s blood), disposable lancets (sharp, pointed medical instruments used to make small punctures or incisions, commonly for blood sampling), and blood glucose strips (disposable diagnostic tool to use with a glucometer to check blood glucose level). Patient 4 stated that she checked her blood glucose level every morning before breakfast. Patient 4 reported that her blood sugar level that morning was 116 mg/dl (milligrams per deciliter, a unit measurement). When Patient 4 was asked if she had a sharps container (a puncture-resistant, leak-proof container designed to safely hold used needles, syringes, and lancets) at home, Patient 4 stated that she did not. When Patient 4 was asked where she would dispose of the used lancet after she checked her blood sugar, Patient 4 stated she would put the used lancet in a small plastic bag before putting in in the trash can. Patient 4 stated she did not know she was supposed to use a sharps container to dispose of the used lancets. During an interview with RN 1 on 9/9/2026 at 12:03 p.m., RN 1 stated that he was not aware that Patient 4 did not have a sharps container. RN 1 also stated that he did not know that Patient 4 had been disposing of the used lancets in the trash can. RN 1 stated that disposing the used lancets in the trash can instead of the sharps container put the patient at risk for injury and spread of infection. During an interview with the Director of Patient Care Services (DPCS) on 9/10/2026 at 2:42 p.m., the DPCS stated that disposal of the used lancets in the trash might cause injury and carry the risk of infection. The DPCS stated, “It can spread infection, somebody can pick it up and reuse it, it can cause injury.” During a review of the HHA’s undated policy and procedure (P & P), titled “Handling and Storage of Waste,” the P & P indicated the following: a. All used sharps will be placed into a puncture-resistant, leak proof impervious container immediately after use. b. Sharps are to be disposed of in an approved: puncture-resistant container with an international biohazard symbol labeled as “biohazardous” or “infectious medical waste.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient’s personal residence), failed to ensure the patient’s clinical records included complete and accurate assessment, including assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders, for three of 7 sampled patients (Patient 2, Patient 4, and Patient 5). This failure resulted in incomplete patient’s medical records that could have caused delayed or missed care and compromised continuity of care. Findings: During an interview with the Administrator Designee (ADMD), on 9/8/2026 at 2:36 p.m., the ADMD stated the HHA was currently using both electronic and paper-based charting to maintain the patients’ clinical records. The ADMD stated that OASIS (Outcome and Assessment Information Set, a standardized assessment tool required by the Centers for Medicare & Medicaid Services [CMS] that measures a patient’s functional abilities, clinical condition, and service needs), assessments and 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), were available on the Electronic Health Record (EHR, a computer‑ and telecommunication‑based system designed to store, manage, and share patient health information), while Skilled Nursing Notes, Communication Notes, Medication Profile, and some Physician Orders were paper-based only and kept in each patient’s physical chart. a. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care date (SOC) of 8/18/2028, with a diagnosis which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), hemiplegia (one-sided muscle paralysis or weakness) following cerebral infarction (also called a stroke, occurs as a result of disrupted blood flow to the brain), and bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee. During a review of Patient 2’s Home Health Certification and POC form for the certification period starting from 8/18/2026 to 10/16/2026, the Home Health Certification and POC form indicated the skilled nurse (or SN, provides advanced medical care, often requiring specialized training and certifications) frequency of visits to twice a week visits for 2 weeks and then once a week for 7 weeks, to perform vital signs (essential measurements that indicate a person’s basic physiological status, which includes body temperature, pulse rate [the number of times the heart beats per minute], respiratory rate [the number of breaths taken per minute], and blood pressure [the force of blood against the artery walls]), to assess and monitor for signs and symptoms of complications related to diabetes, to assess and monitor for medications effectiveness, and to perform on every visit pain assessment using pain scale 0-10 (0 = no pain; 10 = unbearable pain), implement pain relief measures, and evaluate its effectiveness. During a concurrent interview and record review with the ADMD on 9/8/2026 at 2:45 p.m., the ADMD reviewed Patient 2’s physical chart and confirmed that no Skilled Nursing Notes had been submitted for Patient 2 since the SOC. The ADMD further stated there was a delay by the assigned nurse in submitting the visit notes. b. During a review of Patient 4’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 of 8/19/2026 to 10/17/2026, the POC indicated the HHA admitted Patient 4 on 8/19/2026 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that Patient 4 was to receive 2 (two) Skilled Nurse (SN, a licensed nurse) visits per week for 2 weeks, the 1 SN visit per week for 7 weeks. During a review of Patient 4’s clinical records on 9/8/2026, there was 1 (one) Skilled Nursing Note documented. The Skilled Nursing Note was dated 8/24/2026. c. During a review of Patient 5’s POC for the certification period of 8/20/2026 to 10/18/2026, the POC indicated the HHA admitted Patient 5 on 8/20/2026 with a primary diagnosis of hypertensive heart disease without heart failure (a condition where long-term high blood pressure causes structural and functional changes in the heart). The POC indicated that Patient 5 was to receive 1 (one) SN visit per week for 1 week, then 2 (two) SN visits per week for 2 weeks, then 1 (one) SN visit per week for 6 weeks. During a review of Patient 5’s clinical records on 9/8/2026, there were no Skilled Nursing Notes documented for Patient 5. During a concurrent interview and record review with the ADMD on 9/8/2026 at 3:17 p.m., the ADMD confirmed that Registered Nurse 1 (RN 1), who was the visiting nurse for Patient 4 and Patient 5, had only submitted one SN Visit Note for Patient 4 and had not submitted any SN Visit Notes for Patient 5. During a phone interview with RN 1 on 9/10/2026 at 12:26 p.m., RN 1 stated that he was the visiting nurse for Patient 4 and Patient 5. RN 1 stated that he would usually submit the SN Visit Notes within the week of the visit. RN 1 stated that visited Patient 4 on 8/24/2026, 8/27/2026, 9/2/2026, and 9/8/2026. RN 1 stated the HHA’s timeframe for Visit Notes submission was 5 days or a week. RN 1 stated that was late in submitting the SN Visit Notes for Patient 4 and Patient 5. RN 1 stated that it was important to submit SN Visit Notes timely so that all the discipline would be informed about the patient’s condition, so that necessary treatment was not delayed. During an interview with the Director of Patient Care Services (DPCS) on 9/10/2026 at 2:42 p.m., the DPCS stated that the timeframe to submit SN Visit Notes was 7 to 10 working days after the visit was made. The DPCS stated that it was important to submit the notes timely so that the doctor knew s about the patient’s condition. During a review of the HHA’s undated policy and procedure (P & P), titled “Clinical Documentation/Submission of Notes,” the P & P indicated that documentation of services ordered on the plan of care would be completed the day service was rendered and incorporated into the clinical record within seven (7) days after the care had been provided.”