Highlite Home Care, 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 Home Health Agency failed to submit their Comprehensive Emergency Management Plan (CEMP) to the Department of Health (DOH) annually, as required. The findings included: During an interview, on 03/25/25 at 9:44 AM, the Administrator was asked to provide the Home Health Agency’s CEMP and the DOH letter of the CEMP approval. During an interview, on 03/26/25 at 9:25 AM, the Administrator was asked again to provide the Home Health Agency’s CEMP and DOH approval letter. On 03/26/25 at 3:40 PM, during a joint interview with the Administrator and the Director of Nursing (DON), were asked to provide the Home Health Agency’s CEMP and DOH CEMP approval letter. On 03/26/25 at 3:50 PM, during an interview and record review, the Administrator provided a copy of the Home Health Agency’s CEMP and the DOH approval letter; review of the DOH letter documents the Home Health Agency’s CEMP was approved on 01/05/24 and the CEMP “approval” expired on 01/05/25; they were asked for written evidence of submission of the HHA’s CEMP to DOH for revision prior to expiration date on 01/05/25. The DON stated, on 03/26/25 at 3:50 PM, during an interview, that she “did the CEMP;” the Administrator stated he just submitted the (CEMP) plan and provided a copy of the “Florida Health Comprehensive Emergency Management Plan…submission date 03/25/25 11:20 AM; the Administrator added that he received an e-mail that there was a new reporting system. He provided an e-mail addressed to the Administrator of the HHA in ... (another) County dated 02/24/25 that documented, “beginning 02/25/25, the Florida Department of Health’s process for submitting CEMPs will change for the following provider type: Home Health Agencies…”. On 03/26/25 at 3:50 PM, during an interview, the Administrator was shown that their CEMP “expired” in January 2025 and the Administrator stated the “system was down for two months;” the administrator was asked if he contacted anyone at the DOH and he referred back to the e-mail from DOH.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on review of the Home Health Agency’s Policies, record review and interview, the Home Health Agency failed to follow the physicians’ orders for Skilled care frequencies for 1 of 8 sampled patients (Patient #7). The findings included: Review of the Home Health Agency’s policy titled, “Medical Doctor (MD) Order Policy for Home Care” documents, “...documentation and verification: orders must be ...reviewed for completeness and accuracy before implementation...services will be provided according to the physician’s prescribed care plan...” Review of the Home Health Agency’s policy titled, “Utilization of Services Frequencies” documents, “each patient’s amount, duration, and frequency of the visit will be individualized according to specific patient’s needs based on physician’s orders and current Medicare guidelines…” Review of Patient #7’s record documented a “Start of Care” date of 01/24/25. Review of Patient #7’s “Home Health Certification and Plan of Care,” certification period from 01/24/25 to 03/24/25 revealed documentation of physician’s orders for a Skilled Nurse once a week for one week, then twice a week for two weeks, Physical Therapy once a week for one week, then twice a week for two weeks. There was no evidence of documentation that the physician ordered “as needed” Skilled Discipline visits. Review of Patient #7’s Skilled Nurse Notes revealed a Skilled Nurse’s visit three times a week, 01/27/25, 01/29/25 and 01/31/25, rather than two times a week as per the physician’s orders. Review of Patient #7’s Physical Therapy Notes revealed a Physical Therapist’s visits three times a week, 01/27/25, 01/29/25 and 01/31/25 rather than two times a week as per the physician’s orders. On 03/25/25 at 2:49 PM, a side-by-side review and interview was conducted with the Director of Nursing who stated Patient #7’s Plan of Care’s disciplines’ frequencies was her mistake because the physician’s standard is three times a week and the DON stated that reviewing the Plan of Care for accurate disciplines’ frequency was not part of the Quality Assurance review.”