Customcare Home Health Services Inc.

“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) failed to ensure the plans of care were implemented and/or reviewed and signed by a physician every 60 days for four out of eight sampled patients (Patient 1, Patient 5, Patient 6, and Patient 8). This failure had the potential to prevent patients from receiving accurate and needed home health treatments and services. 4. A review of Patient 6’s clinical records indicated Patient 6 had a start of care date with the HHA on 11/18/25 and had diagnoses that included atrioventricular block, first degree (heart’s electrical signal travels more slowly than usual). A review of Patient 6’s plan of care titled, “Home Health Certification and Plan of Care,” dated 11/18/2025 to 1/16/26, had no physician’s signature or date signed. During a concurrent interview and record review on 6/16/26 at 2:15 p.m. with the ADMD, Patient 6’s clinical records were reviewed. The ADMD confirmed Patient 6’s plan of care was not signed by a physician, and the expectation was for the plan of care to be signed by a physician. 5. A review of Patient 8’s clinical records indicated Patient 8 had a start of care date with the HHA on 5/23/23 and had diagnoses that included cellulitis (serious skin infection) of left lower limb. A review of Patient 8’s plan of care titled, “Home Health Certification and Plan of Care,” dated 2/9/26 to 4/9/26 and 4/10/26 to 6/8/26, had no physician’s signatures and date signed. During a concurrent interview and record review on 6/17/26 at 1:50 p.m. with the ADMD, Patient 8’s clinical records were reviewed. The ADMD confirmed Patient 8’s plan of cares, dated 2/9/26 to 4/9/26 and 4/10/26 to 6/8/26, were not signed by a physician, and the expectation was for the plan of cares to be signed by a physician. During a review of the agency’s Policy and Procedure (P&P) titled, “CARE PLANNING PROCESS,” revised 11/2020, the P&P indicated, “A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as the patient’s condition warrants…” During a review of the facility’s P&P titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE,” revised 4/2017, the P&P indicated, “A physician will direct the care of every home health care patient admitted for service…The attending physician will sign the plan of care/treatment within 30 days of the start of care…The attending physician’s recertification will be obtained in intervals at least every 60 days when the patient’s plan of care is reviewed, the patient recertified, and more often, if warranted.” Findings: 3. A review of Patient 5’s clinical records indicated Patient 5 had a SOC date with the HHA on 4/28/25 and had diagnosis’ that include diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), plantar foot wound (a wound on the bottom of the foot), chronic osteomyelitis (a persistent, progressive bone infection), atrial fibrillation (heart arrhythmia), and chronic kidney disease (CKD- kidneys are damaged and lose their ability to filter blood properly). A review of Patient 5’s most updated POC dated 12/22/25, indicated, “Skilled Nurse (SN) ...: One SN visit a week for one week, and two SN visits a week for seven weeks, starting 12/24/25...” A review of Patient 5’s schedule of SN visits for week four, five and six, indicated Patient 5 had one SN visit during week four and no SN visits for weeks five and six. During a concurrent interview and record review on 6/17/26 at 12:32 p.m. with the ADMD, Patient 5’s clinical record was reviewed. The ADMD confirmed one missed visit for week 4 and no visits for weeks 5 and 6 and no documentation for the missed visits. The ADMD stated, “we are supposed to follow the POC.” A review of the agency’s policy and procedure titled, “MISSED VISITS”, revised 10/2015, indicated, “... A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record...1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit.” Findings: 1. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 4/4/26 and had diagnoses that included atherosclerosis of native arteries (hardening of arteries from plaque building up gradually causing slowed or blocked blood flow and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of Patient 1’s clinical records titled, “SOC [Start of Care] ORDER”, dated 4/2/26, indicated, “...OT VISIT FREQUENCY TO START THE WEEK OF 4/05/2026...” A review of Patient 1’s clinical records did not indicate Patient 1 had an OT visit and/or evaluation. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the Administrator Designee (ADMD), Patient 1’s clinical records were reviewed. The ADMD confirmed that Patient 1 had an order for OT which should have started the week of 4/5/26. The ADMD further confirmed that there was no visit conducted by an occupational therapist for Patient 1. The ADM stated the physician’s order should have been followed, and an occupational therapist should have visited the week of 4/5/26. The ADMD stated there would be a risk for Patient 1 to not receive his occupational therapy needs if the OT never went to visit. A review of the agency’s policy and procedure (P&P) titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE”, revised 4/2017, indicated, “A physician will direct the care of every home health care patient admitted for services. The attending physician will certify the medical, skilled, rehabilitative, and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare...The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the Home Health Agency (HHA) failed to ensure that infection control practices were maintained for one out of eight sampled patients (Patient 1), when Skilled Nurse (SN) 1 did not utilize the bag technique for managing clinical supplies during a home health visit. This failure had the potential to spread germs and cause infection for both the patient and staff. A review of Patient 1’s clinical records indicated Patient 1 had a start of care (SOC) date with the HHA on 9/15/21 and had diagnosis’ that included hemiplegia (partial or total paralysis of one side of the body), gastronomy tube (a soft, tube inserted directly through the abdomen into the stomach). During an observation on 6/16/26 at 9:58 a.m. of SN 1 during a home health visit, SN 1 placed the supply bag on the floor, and the assessment equipment case on the bedside table without cleaning the surface area or using a protective barrier. SN 1 returned the assessment equipment to the case without sanitizing. SN 1 did not hand sanitize before or after handling bag supplies/equipment. During an interview on 6/16/26 at 10:33 a.m. with SN 1, SN 1 stated he forgot to put the assessment supplies on a clean surface and confirmed he did not clean the equipment before returning to the case and did not hand sanitize before or after using the assessment equipment. SN 1 stated the purpose of sanitizing is to prevent infection. During an interview on 6/17/26 at 12:32 p.m. with Administrator Designee (ADMD), the ADMD stated SN 1 should have placed equipment and supply bag on a cleaned surface and sanitized the equipment before returning them to the case to prevent infection. A review of the agency’s policy and procedure (P&P) titled, “bag technique,” revised 10/2015, indicated. “…1. The bag will be placed on a clean surface… 3. After hand washing, the supplies and /or equipment needed for the visit will be removed from the bag… 5. … reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag.””

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to obtain signed written notice of patient rights and responsibilities for one out of eight sampled patients (Patient 6). This failure had the potential for Patient 6 and/or their representatives to not be informed and/or exercise their right to participate in their plan of care. A review of Patient 6’s clinical records indicated Patient 6 had a start of care date with the HHA on 11/18/25 and had diagnoses that included atrioventricular block, first degree (heart’s electrical signal travels more slowly than usual). A review of Patient 6’s clinical records revealed that Patient 6’s health record did not contain a signed written notice of patient rights and responsibilities. During a concurrent interview and record review on 6/16/26 at 2:15 p.m. with the Administrator Designee (ADMD), Patient 6’s clinical records were reviewed. The ADMD confirmed Patient 6’s signed written notice of patient rights and responsibilities were not in his clinical record and the expectation was for them to be there. During a review of the agency’s Policy and Procedure (P&P) titled, “CONTENTS OF CLINICAL RECORD,” revised 11/2020, the P&P indicated, “A clinical record will be maintained for each patient receiving care...The following information will be available in the clinical record for patients receiving skilled care...H. Documentation that a list of patient rights have been made available to each patient, patient’s representative or family…” During a review of the facility’s P&P titled, “PATIENT BILL OF RIGHTS,” revised 4/2018, the P&P indicated, “The Patient will be requested to sign the Patient Bill of Rights form. The original form will be kept in the patient’s clinical record.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to obtain signed informed consent for two out of eight sampled patients (Patient 1 and Patient 6) before collection of personal medical information and before provision of planned treatment and/or services. This failure had the potential for Patient 1, Patient 6, and/or their representatives to not be informed and/or exercise their right to consent or refuse the collection of their personal medical information and/or the planned treatment and/or services. 2. A review of Patient 6’s clinical records indicated Patient 6 had a start of care date with the HHA on 11/18/25 and had diagnoses that included atrioventricular block, first degree (heart’s electrical signal travels more slowly than usual). A review of Patient 6’s clinical records revealed that Patient 6’s health record did not contain a signed consent for treatment from Patient 6. During a concurrent interview and record review on 6/16/26 at 2:15 p.m. with the ADMD, Patient 6’s clinical records were reviewed. The ADMD confirmed Patient 6’s consents for treatment were not in his clinical record and the expectation was for the consents to be there. During a review of the agency’s Policy and Procedure (P&P) titled, “CONTENTS OF CLINICAL RECORD,” revised 11/2020, the P&P indicated, “A clinical record will be maintained for each patient receiving care...The following information will be available in the clinical record for patients receiving skilled care...G. Treatment consent or service authorization forms...” Findings: 1. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 4/4/26 and had diagnoses that included atherosclerosis of native arteries (hardening of arteries from plaque building up gradually causing slowed or blocked blood flow and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of Patient 1’s clinical records revealed that Patient 1’s health record did not contain a signed consent for treatment from Patient 1. Patient 1’s signed consent for treatment was requested from the Administrator Designee (ADMD) on 6/15/26 at 2:11 p.m. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the ADMD, Patient 1’s clinical records were reviewed. The ADMD confirmed that she could not locate Patient 1’s signed consent for treatment. The ADMD stated it was their practice to always obtain the patient’s or their representative’s consent for treatment before performing assessment and providing treatments to patients.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to update the comprehensive assessment on the last 5 days of the 60-day episode, beginning with the start-of-care date on two out of eight sampled patients (Patient 1 and Patient 4). This failure had the potential for Patient 1 and Patient 4 to not have an updated and current assessment necessary for delivery of needed care. Findings: 1. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 4/4/26 and had diagnoses that included atherosclerosis of native arteries (hardening of arteries from plaque building up gradually causing slowed or blocked blood flow and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of Patient 1’s clinical records did not indicate a recertification visit (a comprehensive assessment done to update the original comprehensive assessment) was conducted on the last 5 days of Patient 1’s 4/4/26 to 6/2/26 certification period. A review of Patient 1’s clinical records indicated a resumption of care visit (a visit done to resume care within the certification period) was conducted on 6/10/26. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the Administrator Designee (ADMD), Patient 1’s clinical records were reviewed. The ADMD confirmed that there was no recertification visit conducted for Patient 1 in the 4/4/26 to 6/2/26 certification period. The ADMD also confirmed that there was a resumption of care visit conducted for Patient 1 on 6/10/26 which was out of the 4/4/26 to 6/2/26 certification period. The ADMD stated there should have been a recertification visit conducted for Patient 1 on the last 5 days of the 60-day certification period to update the current comprehensive assessment. 2. A review of Patient 4’s clinical records indicated Patient 4 had a start of care date with the HHA on 12/10/25 and had diagnoses that included encounter for circulatory system surgery aftercare (a care provided after a surgery that involves the circulatory system), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Patient 4’s clinical records did not indicate a recertification visit was conducted on the last 5 days of Patient 4’s 2/8/26 to 4/8/26 certification period. A review of Patient 4’s clinical records indicated a recertification visit was conducted on 4/19/26. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the ADMD, Patient 4’s clinical records were reviewed. The ADMD confirmed that there was no recertification visit conducted for Patient 4 in the 2/8/26 to 4/8/26 certification period. The ADMD also confirmed that there was a recertification visit conducted for Patient 4 on 4/19/26 which was out of the 2/8/26 to 4/8/26 certification period. The ADMD stated she does not know what happened to the visits but there should have been a recertification visit conducted for Patient 4 on the last 5 days of the 60-day certification period to update the current comprehensive assessment. A review of the agency’s policy and procedure (P&P) titled, “REASSESSMENT/RECERTIFCATION”, revised 4/2017, indicated, “The comprehensive assessment must be updated and revised every 60 days beginning with the start of care...2. For each new episode of care, a comprehensive assessment will be completed no earlier than five (5) days before and no later than one (1) day before the calendar day on which the new episode of care will begin.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the individualized plan of care were reviewed and revised by the physician or allowed practitioner once every 60 days, beginning with the start of care date for two out of eight sampled patients (Patients 1 and Patient 4). This failure had the potential for Patients 1 and Patient 4 to receive treatments that were not reviewed and approved by a physician. Findings: 1. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 4/4/26 and had diagnoses that included atherosclerosis of native arteries (hardening of arteries from plaque building up gradually causing slowed or blocked blood flow and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). A review of Patient 1’s clinical records indicated Patient 1 had an initial plan of care dated 4/4/26 which was not signed by the physician. A review of Patient 1’s clinical records indicated Patient 1 had a plan of care dated 6/10/26 which was more than 60 days from the initial plan of care. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the Administrator Designee (ADMD), Patient 1’s clinical records were reviewed. The ADMD confirmed that Patient 1’s plan of care dated 4/4/26 has not been signed by a physician. The ADMD further confirmed that Patient 1’s plan of care was not reviewed and revised by the physician every 60 days. The ADMD stated that patient’s plan of care should be updated and then would be sent to the doctor to review and sign every 60 days. 2. A review of Patient 4’s clinical records indicated Patient 4 had a start of care date with the HHA on 12/10/25 and had diagnoses that included encounter for circulatory system surgery aftercare (a care provided after a surgery that involves the circulatory system), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Patient 4’s clinical records indicated Patient 4’s plans of care dated 12/10/25, 2/7/26, 4/926, and 6/8/26 were all not reviewed and signed by a physician. During a concurrent interview and record review on 6/16/26 at 1:55 p.m. with the ADMD, Patient 4’s clinical records were reviewed. The ADMD confirmed that Patient 4’s plans of care dated 12/10/25, 2/7/26, 4/926, and 6/8/26 were all not reviewed and signed by a physician. The ADMD stated that patients’ plan of care should be reviewed and signed by the doctor every 60 days. A review of the agency’s policy and procedure (P&P) titled, “CARE PLANNING PROCESS”, revised 11/2020, indicated, “A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as patient’s condition warrants.””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure a discharge summary was sent to the primary care practitioner (PCP) within five business days of their discharge from the agency for one out of eight sampled patients (Patient 6). This failure had the potential for Patient 6 not to receive continuous treatment and care after their discharge from the agency. A review of Patient 6’s clinical records indicated Patient 6 had a start of care date with the HHA on 11/18/25 and had diagnoses that included atrioventricular block, first degree (heart’s electrical signal travels more slowly than usual). A review of Patient 6’s discharge document titled, “OASIS -E1 Discharge,” dated 1/16/26, indicated, Patient 6 was discharged from the agency on 1/16/26. During a concurrent interview and record review on 6/16/26 at 2:15 p.m. with the Administrator Designee (ADMD), Patient 6’s clinical records were reviewed. The ADMD confirmed Patient 6 was discharged from their agency on 1/16/26. The ADMD further stated she was unable to locate a record of the discharge summary being sent to the PCP. During a review of the agency’s Policy and Procedure (P&P) titled, “CONTENTS OF CLINICAL RECORD,” revised 11/2020, the P&P indicated, “A clinical record will be maintained for each patient receiving care...The following information will be available in the clinical record for patients receiving skilled care...DD. Transfer/discharge summaries and other summary reports sent to the physician, as required by law and regulation and organization policy…” During a review of the facility’s P&P titled, “DISCHARGE SUMMARY,” revised 4/2020, the P&P indicated, “A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.””