Nationwide Healthcare Services, Inc.

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview the provider failed to maintain current emergency plans for 6 of 8 sampled patients (Patients# 1, 4, 5, 8, 9, and 10). Findings Include: The provider’s Emergency Preparedness Policy & Procedures, undated, documents the policy, “Our Agency will establish and maintain an Emergency Preparedness Plan that complies with Federal and State laws” and under procedure, “The plan will address patient populations that include what services our Agency can provide in an emergency and continuity of operations during an emergency” and “The plan will have a procedure for determining how services will be provided when there is an interruption in services due to an emergency. Which will include that our Agency will notify state and local officials of any on-duty staff or patients they are unable to contact.” The policy does not address maintaining current emergency plans on individual patients. Review of the record reveals Patient #1 started care on 05/27/13 and has a Home Health Aide during the day 7 days a week. Patient #1’s Home Health Aide Care Plan with RN signatures on 09/25/24, 11/23/24 and 01/22/25, documents the Home Health Aide assists her with bathing, personal care, hair care, shampoo, oral care, and preparing meals. Review of the providers prioritized list titled Patients Who Need Continued Services During An Emergency reveals it does not include the name of Patient #1. Patient #1’s Emergency/Disaster Plan For Home Health Care Patients, found in Patient #1’s clinical record is dated 05/10/13 and documents in the event of a hurricane they would stay at home, a family member would help with medications, and for type of transportation, “N/A.” No documentation was found of a more recent emergency plan or verification of the plan since 2013. Patient #4’s Home Health Plan Of Care & Certification documents they started care on 12/10/14, have a stomach tube for feeding, have a tracheostomy (tube in the throat by which to breathe) and depend on a ventilator (machine to breathe for them) at night but does not document an Emergency/Disaster plan. Review of the provider’s prioritized list titled Patients Who Need Continued Services During An Emergency reveals Patient #4’s name is on the list with no additional information about whether this patient is registered with a special needs shelter, would need to be transferred, receives skilled care, and how services would continue, but written in large letters across the columns underneath these headings are the words “See attached.” Patient #4’s Emergency/Disaster Plan For Home Health Care Patients, dated 12/10/14 and found in the same binder, documents their emergency classification level is “D1” (high risk) and in the event of a hurricane or other natural disaster they would go to a shelter/hospital and initials consistent with those of an area hospital, but does not include the type of transportation since they need a ventilator, wheelchair, and suction machine and gives no indication that the patient has current arrangements since this is dated 2014 and registration usually must be completed annually. Patient #5’s Home Health Plan Of Care & Certification started care on 08/01/17, has a tracheostomy; requires oxygen, suction machine and a nebulizer as well as nursing services 8 hours a night daily. Review of the provider’s prioritized list titled Patients Who Need Continued Services During An Emergency reveals Patient #5’s name is on the list with no additional information and the words “See attached.” Patient #5’s Emergency/Disaster Plan For Home Health Care Patients, dated 06/01/17 and found in the same binder, documents their emergency classification level is “D3” (low risk) and indicates 3 plans in the event of a hurricane or other natural disaster: “Stay at home,” “Stay with family” but no address or phone number of where they would stay, and “go to a hospital, if medically necessary” but no name of a hospital and no indication of the type of transportation they would need or that they need suction equipment. Review of the record reveals Patient #8 is a child who started care on 01/06/25 and is not included in the provider’s prioritized list titled Patients Who Need Continued Services During An Emergency and has no information in the binder that contains this list. Patient #8’s Emergency/Disaster Plan for Home Health Patients, dated 12/29/24, documents they receive non-skilled services, their emergency classification level is D3, and they would stay home with a family member in the event of an emergency. Review of the record reveals Patient #9 is a child who started care on 02/01/19 and is not included in the provider’s prioritized list titled Patients Who Need Continued Services During An Emergency and has no information in the binder that contains this list. Patient #9’s Emergency/Disaster Plan for Home Health Patients, dated 01/30/19, documents they receive non-skilled services and their emergency classification level is D3, but is unclear where they would go in the event of an emergency since a diagonal line is drawn between “go to shelter” and “go to hospital” and there are no names or addresses for either destination. Furthermore, Patient #9’s Emergency/Disaster Plan indicates they would be driven by family to a destination but names the same family member who would be staying home with Patient #8. Review of Patient #9’s clinical record reveals no evidence of an updated Emergency/Disaster Plan since 01/30/19 to reconcile where Patients# 8 and 9 would stay, with whom, and how they would be transported. Review of the record reveals Patient #10 started care on 08/07/18, is younger than 10 years old, is fed through a tube in the stomach by use of a feeding pump and requires nursing care 16 hours a day Monday through Friday and 24 hours a day on Saturday and Sunday. Review of the provider’s prioritized list titled Patients Who Need Continued Services During An Emergency reveals only Patient #10’s name is on the list with no additional information about whether this patient is registered with a special needs shelter, would need to be transferred, receives skilled care, and how services would continue, but written in large letters across the columns underneath these headings are the words “See attached.” Review of Patient #10’s Emergency/Disaster Plan for Home Health Patients, dated 08/02/18 and kept in the same binder reveals it documents the patient’s name, partial name of a family member without a phone number and a street address with no city or zip code, but no other areas of the emergency plan are completed and it does not include any equipment or supplies he would need if they had to evacuate, no emergency classification (priority) code, whether the patient has skilled or unskilled services, any special needs, whether he is registered with a special needs shelter, the family’s plan for him in the event of an emergency, how he can be transported, or who to notify in case of emergency, such as phone numbers to his parents. Patient #10’s Home Health Plan Of Care & Certification, found in the same binder, for the certification period of 01/02/25 to 03/02/25 also does not document an Emergency/Disaster plan, emergency classification (priority) code, equipment or supplies he would need if they had to evacuate, how he can be transported, or whether he is registered with a special needs shelter. During interview on 03/20/25 at 4:55 PM the Clinical Manager confirmed the patients without emergency plans; asked if unskilled patients need to be prioritized and in the list because he thought this only applied to skilled patients; and stated they call every patient every year before hurricane seasons ask them about their emergency plans and again in the days before an expected hurricane comes through, but they don’t document it anywhere.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview the provider failed to ensure the Home Health Aide followed the Aide Care Plan for 1 of 2 sampled patients (Patient# 1). Findings Include: Review of the record reveals Patient #1 started care on 05/27/13 and has a Home Health Aide during the day 7 days a week. Patient #1’s Home Health Aide Care Plan with RN signatures on 09/25/24, 11/23/24 and 01/22/25, documents activities assigned to be completed with every visit include tub/shower, personal care, assist with dressing, hair care, shampoo, oral care, make meals, wash clothes, and light housekeeping. Patient #1’s weekly Home Health Aide Activity Notes (HHAANs) from 09/30/24 to 12/23/24, 01/03/25 to 01/12/25, and 01/20/25 to 03/09/25 document the aide did not assist her with dressing on any days. Further review of the HHAANs reveal numerous documented discrepancies from the Aide Care Plan as follows. For the week of 09/30/24 to 10/06/24 Patient #1 received hair care and oral care on Monday, Wednesday, Friday, and Sunday, was shampooed only on Monday, and her clothes were washed Tuesday, Thursday, and Saturday although all tasks were assigned daily and the aide worked 7 days. For the week of 10/07/24 to 10/13/24 the aide worked 7 days and Patient #1 received hair care and her clothes were washed on Monday, Wednesday, Friday and Sunday (4 of the 7 days these tasks were care planned); and shampoos only on Tuesday and Thursday (2 of 7 days shampoos were care planned). For the week of 10/14/24 to 10/20/24 the aide worked 7 days and Patient #1 received hair care and her clothes were washed on Monday, Wednesday, Friday, and Sunday; and she had no shampoo that week. For the week of 10/21/24 to 10/27/24 the aide worked 7 days and Patient #1 received hair care on Tuesday, Thursday, and Saturday; and she had shampoos and her clothes were washed on Monday, Wednesday, Friday, and Sunday. For the week of 10/28/24 to 11/03/24, the aide worked 7 days and Patient #1 received hair care and her clothes were washed only on Monday, Wednesday, Friday, and Sunday; she had no shampoos that week; and she received skin care on Tuesday, Thursday, and Saturday although that was not on her care plan. For the week of 11/04/24 to 11/10/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; did not get a shampoo that week; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 11/11/24 to 11/17/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos on Tuesday, Thursday, and Saturday; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 11/18/24 to 11/24/24 the aide worked 7 days and Patient #1 did not get a tub/shower, personal care, meal preparation, or light housekeeping on Saturday; and her clothes were washed only on Monday, Wednesday, Friday and Sunday. For the week of 11/25/24 to 12/01/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos on Tuesday, Thursday, and Saturday; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 12/02/24 to 12/08/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos on Tuesday, Thursday, and Saturday; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 12/09/24 to 12/15/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos Tuesday, Thursday, and Saturday: and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 12/16/24 to 12/23/24 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos Tuesday, Thursday, and Saturday; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 12/23/24 to 12/29/24 the aide worked on 12/23/24 and Patient #1 received nail care that day although that was not care planned. For the week of 12/30/24 to 01/05/25 Patient #1 received a shampoo only on 01/04/25 (Saturday) and her clothes were washed on Friday and Sunday, although the aide worked 01/03/25 to 01/05/25. For the week of 01/06/25 to 01/12/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; shampoos Monday, Wednesday, and Friday; and skin care on Sunday although this was not care planned. For the week of 01/20/25 to 01/26/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; did not get a shampoo that week; and her clothes were washed Tuesday, Thursday, and Saturday. For the week of 01/27/25 to 02/02/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday, did not get a shampoo again that week; and her clothes were washed Monday, Tuesday, Thursday, and Saturday, and Sunday. For the week of 02/03/25 to 02/09/25 the aide worked 7 days and Patient #1 received shampoos on Monday, Wednesday, Friday, and Sunday; and her clothes were washed Monday, Wednesday, Friday, and Sunday. For the week of 02/10/25 to 02/16/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; but no shampoo that week. For the week of 02/17/25 to 02/23/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; no shampoo that week; and skin care on Tuesday, Thursday, and Saturday although that was not in the care plan. For the week of 02/24/25 to 03/02/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; no shampoo that week; and her clothes were washed Monday, Wednesday, Friday, and Saturday. For the week of 03/03/25 to 03/09/25 the aide worked 7 days and Patient #1 received hair care Monday, Wednesday, Friday, and Sunday; no shampoo that week; and her clothes were washed Monday, Wednesday, Friday, and Sunday. During interview on 03/20/2025 at 3:30 PM, the Clinical Manager acknowledged the findings and confirmed the aide should follow the Aide Care Plan.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on record review and interview the Registered Nurse failed to adequately supervise the Home Health Aide to ensure they followed the Aide Care Plan for 1 of 2 sampled patients (Patient# 1). Findings Include: Review of the record reveals Patient #1 started care on 05/27/13 and has a Home Health Aide during the day 7 days a week. Patient #1’s Home Health Aide Care Plan with RN signatures on 09/25/24, 11/23/24 and 01/22/25, documents activities assigned to be completed with every visit include tub/shower, personal care, assist with dressing, hair care, shampoo, oral care, make meals, wash clothes, and light housekeeping. Patient #1’s weekly Home Health Aide Activity Notes (HHAANs) from 09/30/24 to 12/23/24, 01/03/25 to 01/12/25, and 01/20/25 to 03/09/25 document numerous discrepancies from the Aide Care Plan as summarized below. (Cross refer to H2007.) The Home Health Aide, Staff B usually worked with Patient #1 during the day 7 days a week but did not assist Patient #1 with dressing on any days she worked between 09/30/24 and 03/09/25. Patient #1 frequently received shampoos one to 4 times a week rather than daily as care planned, including lapses between shampoos from 9/30/24 to 10/08/24, 10/10/24 to 10/22/24, 10/26/24 to 11/12/24, 01/20/25 to 02/03/25, and 02/09/25 to at least 03/09/25. Patient #1’s clothes were usually washed 3 to 4 times weekly instead of daily, hair care was often completed 3 or 4 times a week, including on weeks that she did not get a shampoo Patient #1’s Supervisory Visit of Staff B by an RN dated 10/15/24 documents for “Follows and implements the client care plan,” checkmarks in 2 columns for both “meets requirements” and “does not meet requirements” and the comment “Family is satisfied with the agency & nurse services no complaint” and no further explanation or intervention. Patient #1’s Supervisory Visit of Staff B by an RN dated 12/16/24 documents for “Follows and implements the client care plan,” a checkmark in the column for “meets requirements” and the comment “Family is ok with the HHA and mother services no complaint,” that the aide assignment was reviewed, and the aide assignment was not changed. Patient #1’s Supervisory Visit of Staff B by an RN dated 01/18/25 documents for “Follows and implements the client care plan,” a checkmark in the column for “meets requirements” and the comment “Family and aide is satisfied with the agency services no complaint reported.” The RN failed to identify and address that the aide was not following the Aide Care Plan. During interview on 03/20/2025 at 3:30 PM, the Clinical Manager acknowledged the findings and confirmed the aide should follow the Aide Care Plan and checking this is part of the RN’s Supervisory Visit.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on interview and record review, the provider failed to ensure the plan of care was implemented for 3 of 5 sampled patients (Patients# 2, 4, and 5). Findings Include: 1) Review of the record reveals Patient #2 is a pediatric patient who started care on 07/09/18 and has a feeding tube, uses a bipap machine (which pushes pressurized air into the lungs) to assist with breathing, and has orders for nursing care 24 hours a day. Patient #2’s Home Health Plan of Care and Certification for the certification period of 02/02/25 until 04/02/25 includes an order for “tobramycin [an antibiotic] 40 mg/ml [milligrams per milliliter] injection use 2ml [2 milliliters] by nebulizer [medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask] Q [every] 12hrs [12 hours] alternate 28 days on, 28 days off.” During a home visit on 03/18/25 beginning at 1:30 PM, Patient #2’s family member reported Patient #2 gets tobramycin by nebulizer for four weeks, then is off of it for four weeks, and this cycle continues since June 2024 with four weeks on and four weeks off because he is very susceptible to lung infections; that Patient #2 is currently off tobramycin and he could not remember when he last had it; and that Patient #2 was recently hospitalized for 43 days with pneumonia which was his longest hospitalization and the sickest he has ever been before he returned home on 02/15/25. During the home visit on 03/18/25 beginning at 1:30 PM, Patient #2’s Licensed Practical Nurse (LPN) Staff A reported Patient #2’s nurses work in 12 hour shifts around the clock and administer his medications; that Patient #2 is not currently on tobramycin; confirmed Patient #2 is currently between tobramycin cycles but was unable to report when the last cycle ended or next cycle would begin; and showed Patient #2’s Medication Administration Record for the current week which did not include documentation of tobramycin or when it should be restarted. Further review of the record reveals Patient #2’s Home Health Plan of Care and Certifications for the certification periods of 06/07/24 to 08/05/24, 08/06/24 to 10/04/24, 10/05/24 to 12/03/24, and 12/04/24 to 02/01/25 each document “tobramycin 40 mg/ml [milligrams per milliliter] injection use 2ml [2 milliliters] by nebulizer Q [every] 12hrs [12 hours] alternate 28 days on, 28 days off.” Further review of the record reveals no documentation of orders to discontinue tobramycin but that tobramycin 40 mg/mL injection was also included in hospital discharge instructions from 02/15/25 with the directions “Use 2 mL by nebulizer every 12 hours for 28 days. Alternate 28 days on, 28 days off.” Review of Patient #2’s Medication Administration Records since 06/03/24 (excluding 01/03/25 to 02/15/25 due to hospitalization and excluding 02/16/25 which was not in the record for unknown reason) reveals he was given tobramycin from 06/19/24 until 07/16/24, after which is the handwritten word “completed” even though the MAR directs to “alternate 28 days on, 28 days off as instructed in the prescription;” no documentation of attempt to keep track of 28 days until it should be started again; and no further administration of tobramycin before the home visit on 03/18/25, approximately 8 months later. Patient #2’s hospital Pediatric Critical Care Discharge Summary documents he was admitted on 01/03/25 with respiratory failure and a chest X-ray that was “concerning for pneumonia,” was intubated (had a tube inserted in his throat by which a machine breathed for him) from 01/03/25 until 01/24/25, that his sputum from admission grew the bacteria Pseudomonas aeruginosa, Stenotrophomonas and Klebsiella, and he was discharged on 02/15/25 During telephonic interview on 03/19/25 at 1:54 PM, Staff A stated the last time tobramycin was administered to Patient #2 was “probably last year” but she can’t recall when it was; that the doctor “may have stopped it” but she was not sure; stated once the 28 days of tobramycin was completed the order should have been stopped; and after the order was reviewed with her was unable to explain why they did not restart the tobramycin after 28 days off as ordered. During telephonic interview with Patient #2’s Pulmonologist’s Registered Nurse, RN Z on 03/20/25 at 2:36 PM, RN Z stated she checked with the Pulmonologist who confirmed he does in fact want Patient #2 on tobramycin as prescribed, alternating 28 days on and 28 days off; that she is contacting the home health agency and patient’s mother to request this medication be resumed as prescribed; and that it should have been continued and resumed when he went home per hospital discharge orders. Further review of Home Health Plans of Care and Certifications for the certification periods of 06/07/24 to 08/05/24, 08/06/24 to 10/04/24, 10/05/24 to 12/03/24, 12/04/24 to 02/01/25, and 02/02/25 to 04/02/25 reveals each documents to “change Gtube [gastric/stomach tube] extension weekly (day)” and “change O2 [oxygen] tubing and humidifier canister weekly (night) and “Acetaminophen 160mg/5ml suspension 451.2mg total (14.1mls) by per GT [g-tube] route Q 6hrs [every 6 hours]. However, reviews of weekly MARs for 06/03/24 to 03/16/25 reveals a weekly entry to “change Gtube extension weekly (day)” with no documentation that this was ever done on any week in this time period of greater than 8 months; a weekly entry to “change O2 tubing and humidifier canister weekly (night)” but these were only documented as changed on 07/22/24, 08/08/24, 09/18/24, 10/14/24, 10/30/24, 11/18/24, 12/09/24, 02/26/25, and 03/04/25 rather than weekly as ordered; and that acetaminophen was only given one time each on 01/02/25, 12/13/24, and 11/26/24 without evidence of rationale for why it was not followed and without evidence of contacting the physician to clarify or change the order. During telephone interview on 3/19/25 at 1:54 PM, Staff A stated the G-tube extension and oxygen tubing and canister get changed if they get soiled or she comes in and “sees it needs to be done” and that she documents in the MAR each time she does this; she confirmed these were not scheduled on a particular day of the week to ensure this is done weekly as ordered but stated, “it probably should be.” Patient #2’s order dated 02/15/25 and electronically signed by the Nurse Practitioner documents, “Please resume home feeds: Peptamen Jr. 1.5 @ 70 ml/hr (165 ml formula + 70 ml water [total: 235 ml] (runs for ~3.5 hours), then 100 ml of water @ 70 ml/hr (which runs over ~1.5 hrs) (total of 5 cycles per day).” Original brackets and parentheses. However Patient #2’s MARs from 02/16/25 to 03/16/25 document “Peptamen Jr 1.5 run 20hrs/day 165ml formula with 70 ml of H2O [water] =235ml/65ml/hr” at 9 AM only and does not include to alternate the formula administrations with 100 milliliters of water at 70 ml/hr for five cycles a day. During the home visit with interview on 3/18/25 at 1:30 PM, Staff A showed the printed Nurse Practitioner’s order for tube feedings dated 2/15/25 and reported she mixes 165 ml of Peptamen Jr 1.5 with 70 ml water and keeps this running on the pump at 70 ml/hr, stopping it only during his respiratory treatments and mixing a new batch when it runs out, and that this runs for a total of 20 hours a day. Staff A did not report alternating the formula mixture with water as ordered. 2) Review of the record reveals Patient #4 started care on 12/10/14, has a tracheostomy and depends on a ventilator for breathing at night. Patient #4’s Home Health Plan of Care & Certifications (HHPOCC) for the certification periods of 12/17/24 to 02/14/25 and 02/15/25 to 04/15/25 both document the order for “Pulmozyme 1mg/ml via neb (nebulizer) Q (every) other month.” Review of Patient #4’s weekly MARs for 12/02/24 to 03/16/25 reveal a weekly entry for Pulmozyme 1mg/ml via neb every other month and a designated time of 4:00 PM although no day is marked for scheduled administration and includes no documentation that Pulmozyme was ever administered between 12/2/24 and 3/16/25, no rationale for not giving the medication, and no evidence of contacting the physician for clarification since the usual administration frequency of Pulmozyme is daily or twice daily and not every other month. 3) Review of the record reveals Patient #5 started care on 08/01/17. Patient #5’s Home Health Plan of Care & Certifications (HHPOCC) for the certification period of 02/20/25 to 04/20/25 documents an order for “Hydroxyzine HCl 25mg tabs give 1 tab PO [by mouth] at bedtime.” Patient #5’s weekly MARs for 02/03/25 to 03/09/25 document “Hydroxyzine HCl 25mg tabs give 1 tab PO at bedtime” is to be given “PRN” (as needed) instead of scheduled as ordered and it was not administered between these dates. During interview on 03/19/25 at 3:30 PM the Clinical Manager reported he makes and prints out the MARs but expects the nurses providing care to keep track of weekly and monthly tasks and medication orders and Patient #2’s tobramycin schedule in order to follow the plan of care.”