Home Health Care Solutions, 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 agency failed to maintain an alternate office or command post site to ensure business operations will continue during an actual emergency, which is necessary for supporting the care continuation, in a universe of 10 patients, when staff members provided different information regarding the agency’s Emergency Preparedness Plan for the designated alternate office site during emergency event. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview on February 18, 2026, at 1:40 PM, with Physical Therapy Aid 1 (PTA 1), PTA 1 stated that he was not sure when the agency’s Emergency Preparedness Plan in-services (training) was given. PTA 1 further stated it might have been around October 2025, and he was not sure about the alternate office site in case of an emergency event. During an interview on February 18, 2026, at 2:50 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the last time the agency’s Emergency Preparedness Plan in-service provided to the staff was in October 2025. The DPCS further stated she was not sure where the alternate office site would be during an emergency but guessed it might be outside the agency office parking lot area or at [name of the agency Administrator] other office. During a sequent concurrent interview and record review on February 20, 2026, at 3:30 PM, with the Administrator (Admin), DPCS and Office Manager (OM), the agency’s policy and procedure (P&P) titled, “Emergency Management Plan”, revised January 2018, was reviewed. The P&P indicated, “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. Procedures….7. An alternate site will be designated in the event the office must be evacuated or is not accessible due to the emergency. Any clinical and financial records or blank documentation forms necessary for care during the emergency will be maintained off-site in the event they cannot be retrieved from the office… When an Emergency is Declared: 1. …leadership staff is unable to initiate the PPCP. Additionally, as able, personnel are to report to the office or alternate site if the office building is not accessible… Office Operation. In case of emergency shelter in place… If the original office SIP is compromised, we will meet secondary office location at … (functioning office location) …” The OM stated she is responsible for the agency’s Emergency Preparedness Plan. The OM confirmed that she did not have documentation to show the designated alternate office site/command post had been provided to all staff to maintain essential functions during emergency event. Furthermore, she stated the agency did not follow the policy.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure that the current patient roster contained the required acuity level (a system of classifying patients according to the urgency of their medical needs during an emergency) for each patient and was readily available to support continuity of care during an emergency in accordance with the agency’s policy. This failure had the potential to impact on the agency’s ability to adequately assess and address the needs of the patients to implement immediate intervention during emergencies, compromising the safety and well-being of nine patients at risk. Findings: During a concurrent interview and record review on February 20, 2026, at 4:20 PM, with the Administrator (Admin), Director of Patient Care Services (DPCS) and Office Manager (OM), the agency’s “Emergency Management Plan” (EMP) binder for the period from January 1, 2025, through January 31, 2026, was reviewed. The EMP indicated that a patient roster with required acuity levels was not readily available to ensure adequate support for maintaining continuity of care during an emergency. The OM stated that she was responsible for the agency’s Emergency Preparedness Plan including updating the patient roster. The OM was unable to provide an explanation as to why the patient roster, containing the required acuity levels, was not implemented in accordance with the agency’s policy. During a sequent concurrent interview and record review on February 20, 2026, at 4:30 PM, with the Admin, DPCS and OM, the agency’s policy and procedure (P&P) titled, “Emergency Management Plan”, revised January 2018, was reviewed. The P&P indicated, “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. Procedures…. 12. The agency maintains a hard copy of a current patient list including contact information and categories identified for each patient in the event there is a power failure…”. The OM stated that she was unaware that the patient roster needed to be available and updated as per the agency’s policies and procedures. The DPCS stated that the agency did not follow the policy.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide evidence of completed and ongoing Performance Improvement Projects (PIPs are a concentrated effort on a particular problem in one area of the agency or agency-wide) based on the agency’s quality assessment and performance improvement (QAPI) data collected and analysis of quality indicators from January 1, 2025, to January 31, 2026. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unaddressed and continue for a universe of 10 patients. Findings: A review of the agency QAPI binder for the period of January 1, 2025, to January 31, 2026. There was no documented evidence to show implemented, ongoing, or completed PIPs in response to actual issues identified through data collection and analysis of quality indicators. During an interview on February 20, 2026, at 2:45 PM, with the Director of Patient Care Services (DPCS), the DPCS stated she is the person responsible for the QAPI program. The DPCS further stated that the agency currently has no implemented or ongoing PIPs addressing the actual issues identified through quality indicator data. Furthermore, the DPCS stated she was unfamiliar with how PIPs are selected and implemented to address specific areas for improvement. During a concurrent interview and record review, on February 20, 2026, at 3:00 PM, with the Administrator (Admin) and DPCS, the agency’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, revised January 2018, was reviewed. The P&P indicated, “PURPOSE To develop, implement, evaluate, and maintain an effective, ongoing, (HHA) home health agency-wide, data-driven QAPI program. To systematically evaluate the quality of care rendered to individuals, families, and the community, in order to improve the quality of care provided, and to assure proper utilization of services. POLICY. As we strive for excellence in the provision of care, the organization is committed to the development and implementation of a performance improvement program. The multifaceted program encompasses an ongoing evaluation of structural, process, and measurable outcome criteria. To ensure quality effective, cost effective services (within available resources) to individuals, families, and the community, we subscribe to compliance with both internal and external standards. Procedure…. VII. The QA personnel or designee shall monitor quality of care and prepare reports on activities for review by the Quality Assessment Performance Improvement (QAPI) Committee, supervisory staff and for annual evaluation of the program. All documents and reports must be kept confidential. They are to be made available to State survey agency by request… IX. The QAPI Committee should complete individual Performance Improvement Projects on areas for improvement outside the major QAPI Plan. X. Program assessments and any recommendations for improvement shall be documented and reported in writing at least annually to the Administrative Director and Governing Body.…”. The DPCS stated that the agency should have regularly implemented and maintained ongoing PIPs focused on maintaining or improving patient safety and care quality. The DPCS further stated that the agency did not follow its own 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 interview and record review, the agency failed to ensure patients’ rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to one of three sampled home visit patients (Patient 1). This failure had the potential to limit patient’s ability to lodge a complaint, leading to the ongoing provision of substandard care by the agency. Findings: A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of November 3, 2025, with a certification period (a 60-day episode of care during which a beneficiary receives authorized skilled services) of January 2, 2026, to March 2, 2026. Patient 1 had diagnoses that included hypothyroidism (when the thyroid gland [ a small organ in your neck that makes hormones to help your body work properly] doesn’t make enough thyroid hormones to meet your body’s needs), pain in right arm and epilepsy (a brain disorder that causes seizures [staring spells, uncontrollable shaking, stiff muscles, loss of consciousness, confusion, and unusual sensations]) During a home visit and interview on February 18, 2026, at 12:20 PM, with License Vocational 1 (LVN 1) and in the presence of Patient 1’s care giver, Patient 1’s home clinical record binder was reviewed. There was no documented evidence indicating that the state free home health telephone hotline and supporting information had been provided. LVN 1 confirmed the absence of the state free home health telephone hotline and its supporting information. During an interview on February 18, 2026, at 12:25 PM, with LVN 1 and in the presence of Patient 1 care giver, Patient 1’s caregiver stated that he was not aware of his right to have the state complaint phone number in the home clinical record binder and had only been calling the agency for all needs or concerns. LVN 1 verified that the state phone number was not available in the home clinical record binder to lodge a complaint when needed. During an interview on February 20, 2026, at 2:30 PM, with the Director of Patient Care Services (DPCS), the DCPS stated the admitting nurse should have made sure the home notebook left in the patient’s home included the hot line information at admission, and it should be in the home. The DPCS stated, “I do not know why it is not.” During a concurrent interview and record review on February 20, 2026, at 2:35 PM, with the DPCS, the agency’s policy and procedure (P&P) titled “Rights/Responsibilities”, revised January 2018, was reviewed. The P&P indicated “PURPOSE. To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. POLICY… To assist with fully understanding patient rights and responsibilities, all policies are available to organization personnel, the patient, and his/her representatives as well as other organizations and the interested public. Procedures… P. The right to be advised of state toll-free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about home health agencies…”. The DPCS stated the agency did not follow the policy.”

“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 agency failed to ensure essential documents were provided for one of seven sampled patients (Patient 1), when Patient 1’s home clinical record binder did not contain the current plan of care (POC- a document signed by a doctor, outlines the medical, nursing, and therapy services needed at home, detailing treatments, medications, and personal preferences to ensure continuous care) including the most current Medication Profile (MP-a current list of all medications prescribed for a specific patient). This failure could result in poor care coordination, unmanaged symptoms, and medication errors, putting Patient 1 at risk of unmet health goals and delays in timely medical interventions. Findings: A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of November 3, 2025, with a certification period (a 60-day episode of care during which a beneficiary receives authorized skilled services) of January 2, 2026, to March 2, 2026. Patient 1 had diagnoses that included hypothyroidism (when the thyroid gland [ a small organ in your neck that makes hormones to help your body work properly] doesn’t make enough thyroid hormones to meet your body’s needs), pain in right arm and epilepsy (a brain disorder that causes seizures [staring spells, uncontrollable shaking, stiff muscles, loss of consciousness, confusion, and unusual sensations]) During a home visit and interview on February 18, 2026, at 12:30 PM, with the License Vocational 1 (LVN 1) and in the presence of Patient 1’s care giver, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. LVN 1 confirmed that these essential documents were missing from the home health binder. During an interview on February 20, 2026, at 2:20 PM, with the Director of Patient Care Services DPCS, the DPCS stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current POC, including the most recent MP, and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the DPCS stated that maintaining an up-to-date POC and MP is crucial for effective care coordination, proper medication management, and ensuring the continuity of care. During a concurrent interview and record review on February 20, 2026, at 2:25 PM, with the DPCS, the agency’s policy and procedure (P&P) titled “Care Planning Process”, revised January 2018, was reviewed. The P&P indicated “Purpose. To provide Clinical Direction to clinicians providing direct patients care. POLICY…. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. 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 Agency 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. 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, …”. The DPCS stated the agency did not follow the policy.”