Star Light Home Health

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation 484.105, Organization and Administration of Services, was out of compliance. A total of 11 personnel records were reviewed for compliance with the Condition and Standards for Organization and Administration of Services. Record review revealed a systemic failure in the agency’s organization and administration of services to ensure the development and implementation of personnel qualifications and policies. Survey findings showed the agency failed to develop and implement a consistent administrative process to evaluate employee suitability, mitigate identified risks, and protect patients when concerns regarding employee misconduct, criminal history, or adverse licensing actions were identified and before employees provided or continued providing direct patient care. The state agency (SA) determined this failure posed an immediate potential risk to the health, safety, and welfare of patients served by the agency and on 6/26/26 at 9:00 a.m, the agency was advised these failures created a situation of Immediate Jeopardy. The agency administrator was advised to develop a plan to immediately address the circumstances of the Immediate Jeopardy. The agency submitted a plan to remove the Immediate Jeopardy on 6/26/26 at 3:13 p.m. These failures had the potential to affect all agency personnel and all patients served by the home health agency. G952 - Based on record review and interview, the agency failed to develop and implement policies to ensure the home health agency employed qualified personnel. Specifically, the agency failed to establish and implement policies and procedures to evaluate employee suitability, assess potential risks to patients, document leadership’s decision-making, and implement protective measures when concerns regarding employee misconduct, criminal history, or adverse licensing actions were identified (Employee #2, #4, #8).”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) included all information pertinent to patient care. Specifically, the agency failed to ensure all services were identified in the POC; failed to ensure documentation of delineation of services in the POC; and failed to ensure the POC included information regarding who was responsible to administer medications, monitor the medication supply, and ensure the timely delivery of medications for 1 of 5 sample patients (Patient # 5). Findings include: The clinical record for Patient #5 was reviewed on 6/23/26. Plan of care orders for the certification period dated 2/12/26 to 4/12/26 revealed a start of care date of 2/12/26; diagnoses included pressure ulcer of the sacral region, acute kidney failure, and spinal stenosis. Plan of care orders included skilled nursing once per week for medication management and wound care and physical therapy twice per week for gait and balance training. a) The agency failed to ensure the plan of care identified all services provided to Patient #5. Review of an incident report in the clinical record revealed a personal care worker provided care to Patient #5. However, review of the POC did not reveal documentation of the personal care worker’s involvement in Patient #5’s care. Further review of the incident report revealed a personal care worker who provided care to Patient #5 was involved in a medication error on 4/4/26 in which Patient #5 took twice the ordered daily dose of losartan 50 mg, used for high blood pressure. The patient took a total of 100 mg losartan when both a personal care worker and the son of Patient #5 separately reminded Patient #5 to take the medication. During an interview on 6/24/26 at 9:39 a.m., when asked how nursing staff knew what tasks the personal care workers performed for Patient #5, the director of nursing (DON) stated if the nursing staff needed information, then the nursing staff needed to call the supervisor or care coordinator in charge of the unskilled staff the agency employed as personal care workers. During a follow-up interview on 6/24/26 at 10:27 a.m., the DON acknowledged the plan of care did not include information regarding the involvement of unskilled personal care workers, how services were coordinated, who was to give medication reminders, or who was to administer medications. b) The agency failed to ensure delineation of services, between skilled home health services and unskilled personal care services, was documented in the POC for Patient #5. Review of the clinical record revealed a log of notes documented by unskilled personal care workers who provided care for Patient #5. Personal care workers documented “meds given” to Patient #5 on 2/17/26, 2/21/26, and 2/26/26. During an interview on 6/24/26 at 10:33 a.m., the director of nursing (DON) stated she believed the notes meant a reminder to take medications was given by the unskilled personal care workers, and she stated she believed the documentation was worded poorly or improperly. She acknowledged medication administration is outside the scope of practice for unskilled personal care workers. The DON further acknowledged the plan of care did not delineate the services provided by skilled versus unskilled staff. c) The agency failed to ensure the POC for Patient #5 included who was responsible to administer medications, monitor the medication supply, and ensure the timely delivery of medications. Review of the clinical record revealed a physician order for losartan 50 mg for high blood pressure, dated 3/16/26. A skilled nursing note, dated 3/17/26, documented the losartan prescription was on back order from the pharmacy. A skilled nursing note, dated 3/20/26, documented Patient #5 could not start taking the ordered losartan because no one from Patient #5’s family was able to pick up the medication from the pharmacy. Further review of the clinical record revealed Patient #5 started taking losartan 50 mg on 3/24/26. Review of the POC did not reveal documentation regarding who was responsible for administering medications, monitoring the medication supply, or ensuring the timely delivery of medications. During an interview on 6/24/26 at 10:14 a.m., the director of nursing (DON) stated Patient #5 lived a long distance from the pharmacy. The DON also stated the family of Patient #5 had hired an individual, who was not employed by the agency, to drive from Patient #5’s home to the pharmacy to pick up medications. The DON further stated, in the case of the losartan prescription, several days passed before the individual was able to make the drive. The DON acknowledged there was no documentation, in the clinical record or in the POC for Patient #5, regarding who would administer medications, how the medication supply was to be monitored, who would order refills, or who was responsible for the delivery of medications.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement policies to ensure the home health agency employed qualified personnel. Specifically, the agency failed to establish and implement policies and procedures to evaluate employee suitability, assess potential risks to patients, document leadership’s decision-making, and implement protective measures when concerns regarding employee misconduct, criminal history, or adverse licensing actions were identified (Employee #2, #4, #8). Survey findings showed the agency failed to develop and implement a consistent administrative process to evaluate employee suitability, mitigate identified risks, and protect patients when concerns regarding employee misconduct, criminal history, or adverse licensing actions were identified and before employees provided or continued providing direct patient care. The state agency (SA) determined this failure posed an immediate potential risk to the health, safety, and welfare of patients served by the agency and on 6/26/26 at 9:00 a.m, the agency was advised these failures created a situation of Immediate Jeopardy. The agency administrator was advised to develop a plan to immediately address the circumstances of the Immediate Jeopardy. The agency submitted a plan to remove the Immediate Jeopardy on 6/26/26 at 3:13 p.m. Findings include: 1. On 6/23/26, a review of the personnel record for Employee #4, a physical therapist, revealed a hire date of 9/7/21. a) The agency failed to evaluate employee suitability, assess potential risks to patients, document leadership’s decision-making, and implement protective measures when the agency became aware of concerns regarding Employee #4’s alleged misconduct. Review of the personnel record revealed Employee #4 was hired following a background check with no identified arrests or convictions. A repeat background check completed on 5/13/26 identified an arrest on 5/9/25 involving alleged sexual misconduct. Further review revealed Employee #4 continued providing unsupervised direct patient care without documented restrictions, increased supervision, reassignment, or other interim protective measures. During an interview on 6/23/26 at 10:30 a.m., the alternate administrator stated the agency became aware of the arrest in May 2025 when Employee #4 notified the agency administrator. The alternate administrator stated the agency did not investigate the allegation, conduct a risk assessment, document leadership’s evaluation of the employee’s continued suitability to provide direct patient care, or implement measures to protect patients. The alternate administrator stated she thought the agency did not need to implement interim protective measures because Employee #4 had only been arrested and had not yet been to trial or convicted. 2. On 6/23/26, a review of the personnel record for Employee #2, a care coordinator, revealed a hire date of 12/5/24. a) The agency failed to document an evaluation of employee suitability, assess potential risks to patients, document leadership’s decision-making, or implement protective measures when notified of the revocation of Employee #2’s certified nurse aide certificate. Review of the personnel record revealed a Department of Regulatory Agencies (DORA) verification completed on the hire date identified a certified nurse aide certificate revocation, dated 4/3/23, for misappropriation of patient or facility property. The personnel file contained a written explanation from Employee #2 regarding the revocation, but did not contain documentation of the agency’s decision-making process to evaluate Employee #2’s suitability for providing patient care. During an interview on 6/23/26 at 10:30 a.m., the alternate administrator stated although agency leadership reviewed the revoked certified nurse aide certificate before hiring Employee #2, the agency did not conduct or document an individualized risk assessment, document leadership’s determination Employee #2 could safely provide direct patient care, document the rationale supporting the hiring decision, or document whether protective measures or monitoring were necessary. Additionally, the alternate administrator stated Employee #2 did not provide patient care in the care coordinator position. During an interview on 6/25/26 at 10:38 a.m., Employee #2 stated she was assigned to the agency’s on-call schedule and could provide unskilled personal care services when staffing coverage was needed. In a follow-up email, Employee #2 confirmed she had provided care to 15 patients since her date of hire. 3. On 6/23/26, a review of the personnel record for Employee #8, a personal care worker, revealed a hire date of 2/14/25. a) The agency failed to evaluate employee suitability, assess potential risks to patients, document leadership’s decision-making, and implement protective measures when Employee #8’s background report identified criminal convictions. Review of the personnel record revealed a preemployment background report identified convictions involving possession of a controlled substance, assault, forgery, and identity theft. During an interview on 6/23/26 at 2:32 p.m., the alternate administrator stated agency leadership reviewed the criminal history before hiring Employee #8. However, the alternate administrator stated the agency did not conduct or document an individualized risk assessment, document leadership’s determination Employee #8 could safely provide direct patient care, document the rationale supporting the hiring decision, or document whether protective measures or monitoring were necessary before assigning the employee to provide patient care. 4. During the same interview on 6/23/26 at 2:32 p.m., the alternate administrator stated the agency had tried to find or gather policies to address questions regarding background reports for employees. The alternate administrator stated policies the agency had gathered only partially addressed personnel qualifications. Additionally, the alternate administrator acknowledged the agency had no written policies, procedures, or standardized administrative process for evaluating allegations of personnel misconduct involving current employees, evaluating criminal histories or adverse licensing actions found upon or after the start of employment, documenting leadership’s review and decision-making, implementing protective measures when risks to patients were identified, or monitoring employees following identified concerns.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and record reviews, the agency failed to participate in a full-scale community based emergency preparedness exercise at least every two years. Findings include: 1. Review of the agencies emergency preparedness documents on 9/4/25 revealed the agency had completed a series of emergency drills in 2023 and 2024, however there was no documentation of a full-scale exercise in 2023, 2024 or 2025. During an interview on 9/4/25 at 11:40 a.m., the administrator, and alternate administrator stated the agency had done drills, but had not done a full-scale exercise in the last few years. The administrator stated the agency would need to do a full scale exercise, and would reach out to the community and join their full scale exercises.”