Quality Home Health Agency

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the implementation of an alternate office or command post-site, as required in the agency’s Emergency Preparedness Plan, for continued business operations will continue during an emergency, for two of three staff members (Certified Home Health Aide (CHHA) and License Vocational Nurse (LVN), when the CHHA and LVN were unable to identify the agency’s Emergency Preparedness Plan for the designated alternate office site during emergency event. This failure had the potential to affect the agency’s ability to maintain continuity of operations and could delay the provision of patient care, placing 48 patients at risk, and compromising their safety and quality of care during an emergency event. During an interview on June 3, 2026, at 7:45 AM, with CHHA, the CHHA stated that the agency’s Emergency Preparedness Plan in-services (training) was given 2 weeks ago. The CHHA further stated she was not aware of the alternate office site to be used, in case of an emergency event. During an interview on June 3, 2026, at 9:00 AM, with the LVN, the LVN stated the last time the agency’s Emergency Preparedness Plan in-service was in March 2026. The LVN further stated she was not aware of the alternate office site would be during an emergency. During a sequent concurrent interview and record review on June 5, 2026, at 2:00 PM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), the agency’s policy and procedure (P&P) titled, “Emergency Management Plan,” revised January 2018, was reviewed. The P&P indicated, “PURPOSE . To establish a plan which will allow for continuation of services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records… If there is a disaster at or near the office, such that the office becomes or is inaccessible, members may meet at: [named address and telephone number of the church]. ALTERNATE SITE: [name address and telephone number of two alternate sites]” The Admin stated she is responsible for the agency’s Emergency Preparedness Plan. The Admin stated the agency did not follow the policy.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interviews and record reviews, the agency failed to implement the Emergency Operations Plan when two of three staff members (Certified Home Health Aide (CHHA) and Registered Nurse (RN)), were unable to identify alternate communication methods to be used during emergency events, as required by the agency’s Emergency Preparedness Plan. This failure had the potential to affect the agency’s ability to communicate essential patient needs to implement immediate interventions and maintain continuous care during emergencies with staff and Federal, State, tribal, regional, and local emergency management agencies. This put the safety and well-being of 48 patients at risk during emergency events. During an interview on June 3, 2026, at 7:50 AM, with CHHA, the CHHA stated that the agency’s Emergency Preparedness Plan in-services training was given 2 weeks ago. The CHHA further stated that she was not aware of the alternate communication methods to be used during emergency events and recalled only remembered being instructed to report to the office if she was unable to contact anyone. During an interview on June 3, 2026, at 10:00 AM, with the RN, the RN stated the last time she received the agency’s Emergency Preparedness Plan in-service was in October 2025. The RN further stated that she was not aware of the alternate communication methods for emergency events and recalled only being instructed to report to the office if she was unable to contact anyone. During an interview on June 5, 2026, at 2:10 PM, with the Director of Patient Care Services (DPCS) and Administrator (Admin), the DPCS stated the last Emergency Preparedness Plan in-service training for staff was provided on January 9, 2026. The Admin stated, “After the in-services were conducted, I should have ensured that staff actually implemented the alternate communication methods during emergencies.” During a sequent concurrent interview and record review on June 5, 2026, at 2:15 PM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), the agency’s policy and procedure (P&P) titled, “Emergency Management Plan,” revised January 2018, was reviewed. The P&P indicated, “PURPOSE . To establish a plan which will allow for continuation of services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records… Category. Communication: Zello App – push to talk. Walkie talkie app. Planning. Ensure alternate communication mechanism are available. Walkie Talkie Cobra Micro talk…” The Admin stated she is responsible for the agency’s Emergency Preparedness Plan. The Admin stated the agency did not follow the policy.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure one of three sampled patients (Patient 1) received the required written notice of patient rights during the initial evaluation visit and prior to the initiation of care. This failure had the potential to impede the patient’s ability to understand, exercise, and advocate for their rights while receiving home health services. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of February 16, 2003, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of April 16, 2026, to June 14, 2026. Further review indicated Patient 1 had primary diagnoses that included other developmental disorders of scholastic skills (brain’s inability to receive and process information such as reading, writing, spelling, reasoning, recalling and/or organizing information) and unspecific convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). During a home visit on June 3, 2026, at 7:10 AM with a Certified Home Health Aide (CHHA), Patient 1’s home clinical record folder (a paper folder containing home health agency and Patients medical information) was reviewed. There was not documented evidence that the agency provided the “Patient Rights and Responsibilities” document and its supporting information, written notice. The CHHA confirmed that the “Patient Rights and Responsibilities” document and supporting information were not present in the folder. During an interview on June 3, 2026, at 7:15 AM with Patient 1’s mother, Patient 1’s mother stated the “Patient Rights and Responsibilities” document and its supporting information were not in Patient 1’s clinical record folder or elsewhere in the home. Patient 1’s mother stated she did not know where the document was. Patient 1’s mother further stated, “I remembered signing the consent forms at the time of admission, but that was it”. During an interview on June 5, 2026, at 3:20 PM, with the Director of Patient Care Services (DPCS). The DPCS stated upon admission, the admitting nurse is required to provide and explained the “Patient Rights and Responsibilities” document to patients and their families and ensured it is placed in the home clinical record folder. The DPCS further stated the visiting nurse should verify the document remains in the folder in the patient’s home, during each visit. The DPCS further stated, “I do not know why it is not.” During a concurrent interview and record review on June 5, 2026, at 3:25 PM, with the DPCS, the agency’s policy and procedure (P&P) titled, “Patient Bill of Right,” revised April 2018, was reviewed. The P&P indicated, “Purpose. To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning. Procedure. 1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. 2. The Patient Bill of Rights statement defines the right of the patient to: A. Exercise and understand his or her rights and responsibilities as a patient and not to be subject to discrimination or reprisal for exercising these rights. B. Have his or her property treated with respect, consideration, and recognition of patient dignity and individuality.…”. The DPCS stated the agency did not follow the policy. During a concurrent interview and record review on June 5, 2026, at 3:30 PM, with the DPCS, the agency’s undated P&P titled, “ Patient Rights and Responsibilities,” was reviewed. The P&P indicated,” The following are the rights and responsibilities that you have as a home care patient with our agency. You have the right to review these prior to your admission into home care services. If a patient’s competence is determined to be impaired, the patient’s legal representative (if any), a selected representative, or family member would be able to exercise the following rights. PATIENT RIGHTS, you have the right: To be informed of your rights and responsibilities in advance concerning care and treatment you will receive… 2) To receive services appropriate to your needs and expect the home care organization to provide safe, professional care at the level of intensity needed, without unlawful restriction by reason of age, sex, race, creed, color, national origin, religion or disability …” The DPCS stated the agency did not follow the policy.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patients’ rights were protected for one of three sampled patients (Patient 1), when Patient 1 did not received the required written notice of the state’s free home health hotline, including its contact information, hours of operation and its purpose to receive complaints, as required by state licensing requirements. This failure had the potential to restrict Patients 1’s ability to report a complaint, which could delay the identification and correction of quality-of-care issues. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of February 16, 2003, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of April 16, 2026, to June 14, 2026. Further review indicated Patient 1 had primary diagnoses that included other developmental disorders of scholastic skills (brain’s inability to receive and process information such as reading, writing, spelling, reasoning, recalling and/or organizing information) and unspecific convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). During a home visit on June 3, 2026, at 7:20 AM with a Certified Home Health Aide (CHHA), Patient 1’s home clinical record folder (a paper folder containing home health agency and Patients medical information) was reviewed. There was no documented evidence to show the state free home health telephone hot line and supporting information had been provided. CHHA verified there was no state free home health telephone hot line with supporting information, present in the folder. During an interview on June 3, 2026, at 7:25 AM, with Patient 1’s mother, Patient 1’s mother stated neither the state free home health telephone hotline nor supporting information could be located in Patient 1’s clinical record folder or elsewhere in the house. Patient 1’s mother further stated that she remembered signing Patient 1’s consent forms at the time of admission and receiving Patient 1’s home clinical folder but she was not advised the folder should contain information regarding the state’s free home health hotline. During an interview on June 5, 2026, at 3:35 PM, with the Director of Patient Care Services (DPCS), the DPCS stated upon admission, the admitting nurse is required to explain to the patients and their families the home clinical record folder, left in the patient’s home, included the hotline information and its intended purpose. The DPCS further stated the visiting nurse should verify the document remains in the folder in the patient’s home, during each visit. The DPCS further stated, “I do not know why it is not.” During a concurrent interview and record review on June 5, 2026, at 3:40 PM, with the DPCS, the agency’s policy and procedure (P&P) titled, “Patient Bill of Right” revised April 2018, was reviewed. The P&P indicated, “Purpose. To encourage awareness of patient rights and provide guidelines to assist patients in making decisions regarding care and for active participation in care planning. Procedure…. 2. The Patient Bill of Rights statement defines the right of patient to: …. V. Received in writing, prior to the start of care, the telephone number of the State Home Health Hotline and the ACHC Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or question about the organization…” The DPCS stated the agency did not follow the policy. During a concurrent interview and record review on June 5, 2026, at 3:45 PM, with the DPCS, the agency’s P&P titled, “Patient Rights and Responsibilities” undated, was reviewed. The P&P indicated,” The following are the rights and responsibilities that you have as a home care patient with our agency. You have the right to review these prior to your admission into home care services. If a patient’s competence is determined to be impaired, the patient’s legal representative (if any), a selected representative, or family member would be able to exercise the following rights… COMPLAINTS, you have the right: … 3) To be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies … ” The DPCS stated the agency did not follow the policy.”

“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 agency failed to ensure the Plan of Care (POC- a form where you can summarize a person’s health conditions, specific care needs, and current treatments) including Medication Profile (MP), accurately reflected the current status for two of two sampled patients (Patients 1 and 3) reviewed during home visit, when: Patient 1’s MP listed Xcopri (a medication used to treat seizures) at a strength that did not match the strength of the Xcropi dose currently being administered in the home. Patient 3’s POC documented a gastrostomy tube (G‑tube is a medical device inserted through the abdomen directly into the stomach) feeding rate that differed from the actual feeding rate being administered in the home. These failures had the potential to cause ineffective or unsafe drug therapy, incorrect nutritional delivery, clinical instability, avoidable adverse outcomes, and delays in appropriate POC adjustments, placing Patient 1 and 3 at risk for medication errors, treatment errors, and unmet clinical needs. 1. A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of February 16, 2003, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of April 16, 2026, to June 14, 2026. Further review indicated Patient 1 had primary diagnoses that included other developmental disorders of scholastic skills (brain’s inability to receive and process information such as reading, writing, spelling, reasoning, recalling and/or organizing information) and unspecific convulsions (also known as seizure - rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). During a home visit on June 3, 2026, at 7:25 AM, with Certified Home Health Aide (CHHA), in the presence of Patient 1’s mother, Patient 1’s actual medications, which were available in the home, were compared with Patient 1’s most current MP. During a continued concurrent observation and interview on June 3, 2026, at 7:30 AM, with CHHA, CHHA and Patient 1’s mother inspected the medication bubble pack card (a presorted pouches that organized pills by day and time) of Xcopri 200 mg (milligrams-a unit of measure), take 1 tablet by mouth every evening. CHHA and Patient 1’s mother reviewed Patient 1’s MP and confirmed the order on Patient 1’s MP indicated, “Xcopri 150 mg tablet administered by mouth once daily.” Patient 1’s mother stated that she has been giving Xcopri 200 mg daily to her son (Patient 1), since May 2026, and his doctor was aware of it. 2. A review of Patient 3’s face sheet, indicated a start of care date of October 1, 2004, with a certification period from April 9, 2026, to June 7, 2026. Patient 3 had diagnoses which included postsurgical malabsorption (a condition where the body cannot properly absorb nutrients, vitamins, and minerals after surgery on the digestive system [stomach and intestines]). During a home visit on June 3, 2026, at 9:30 AM, with Registered Nurse (RN), in the presence of Patient 3’s brother, an observation of Patient 3’s actual medications and treatments available in the home, were compared with Patient 3’s most current POC. During a concurrent observation and record review on June 3, 2026, at 9:45 AM with the RN, Patient 3’s G tube feeding pump (a medical device used to deliver nutrition formula) was observed. The feeding bag contained [name of the formula] 1.0 formula with a total volume of 600 cc, and the pump was infusing at 65 mL/hr (milliliter/hour - a unit of measure). Patient 3’s POC under Nutrition was reviewed, indicated an order for “ [name of the formula] 1.0 cal [calorie is unit of energy] liquid, 35 mL/hr.” During an interview on June 3, 2026, at 9:50 AM, with the RN. The RN stated, “the order had been changed to 65 mL/hr at least for a couple of months” and the updated order had been communicated to the office. The RN stated she was unsure why the POC had not been updated to reflect the current feeding rate. During a concurrent record review and interview on June 5, 2026, at 1:30 PM, with the Director of Patient Care Services (DPCS), Patient 1’s MP and Patient 3’s POC were reviewed. The DPCS acknowledged the discrepancies in Patient 1’s medication strength and Patient 3’s G‑tube feeding rate. The DPCS stated, it was the Case Manager’s responsibility to update POC and MP when there’s new or changed orders and nurses should review and update this documents during home visits. A review of agency’s policy and procedure (P&P) titled “Care Planning Process,” revised April 2018, indicated, “PURPOSE. To provide clinical direction to the clinicians providing direct patient care. POLICY. A written plan of care will be initiated… The plan of care will be reviewed more frequently than every 60 days when a patient elects a transfer to another home health organization, a significant change occurs in the patient’s condition… PROCEDURE. 1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. A Case Manager will be assigned to coordinate all activities involved in the patient’s care… 17. The organization shall provide the patient and caregiver with a copy of written instructions outlining: A. Visit schedule, including the day of the week, frequency of visits by personnel and personnel acting on behalf of the organization. B. Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization 1. Instructions will be written in a plain language the patient can understand and that does not use medical abbreviations. C. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization, including therapy services. D. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs…” During a concurrent record review and interview on June 5, 2026, at 1:45 PM, the DPCS reviewed the agency’s P&P titled “Medication Profile,” revised April 2018, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. …” The DPCS stated the agency did not follow the policy.”