Compassion North America Home Health Services Corp

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on personnel file review and staff interview, the agency failed to ensure the home health aides successfully completed competencies in home health aide skills that exceed basic skills, which require a registered nurse, or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 1 of 2 sampled home health aides (Staff D). Failure to ensure home health aides were competent in a skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the undated agency policy titled Requirement for Home Health Aide services a home health aide must be certified consistent the competency evaluation requirements. During an interview on 4/8/26 at 9:26 AM, the Director of Nursing stated when the aide works with a patient who requires a skill that is beyond basic skills, she goes to the home with the aide for competency testing and documents in the supervisory visit. 1.Patient #1 had a start of care date of 3/30/26. Clinical record review revealed the following: a. An undated home health aide care plan directed the aide to provide shaving for the patient. The clinical record identified that Staff D, Home Care Aide (HCA) provided care to the patient. b. Staff D, HCA had a hire date of 9/28/21. Staff D’s personnel file lacked documentation of competency testing completed for shaving. The above findings were reviewed with the Administrator and Director of Nursing.”

“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 home observation visit, patient interview, staff interview, and clinical record review, the agency failed to ensure accurate completion of all components of the Plan of Care (POC), including all medical supplies/equipment for used by the patient for 1 of 1 home visits (Patient #1). Failure to maintain complete and accurate POCs with current orders placed patient at risk to not receive services, supplies, and/or medication according to assessed needs and physician orders. Findings include: In an interview on 4/8/26 at 9:35 AM, the Director of Nursing (DON) reported the home health agency was not a durable medical equipment (DME) provider and has a limited role with DME. The DON reported that all of the patient’s DME was coordinated prior to the patient’s start of care with the home health agency and that the DON did not receive an order from the patient’s doctor for the rotating adjustable bed. The rotating adjustable bed was not something that the DON coordinated which is why the rotating adjustable bed was not included as supplies and equipment on the patient’s POC. In an interview on 4/8/26 at 10:32 AM, the Administrator reported that the agency has limited control over DME, what is medically necessary and what is allowed by a provider. The agency can be on the case and there can be a different DME provider. DME is a completely different process than what the agency is doing, our responsibility is tied with communication with the doctor. The Administrator reported understanding how those supplies are listed on the OASIS (Outcome and Assessment Information Set), it is some type of equipment but the patient’s supplies/equipment does not fall under DME, the OASIS documentation shows that it is actually under there. The supplies that are in the agency’s jurisdiction are listed on the OASIS. Patient#1 had a start of care date of 7/14/22. Clinical record review revealed: a. The POC, dated 2/23/26 to 4/23/26, included a primary diagnosis of malignant neoplasm of ampulla of Vater and included physician orders for medical supplies/equipment used by the patient. The POС included the following medical supplies/equipment used by the patient: wheelchair, sterile gloves, elevated toilet seat, grab bars, exam gloves, tub/shower bench, walker, alcohol pads. The POC identified the patient received 2 skilled nursing visits per week. b. During a home observation visit on 4/6/26 at 2:50 PM with DON, a rotating adjustable bed, medical alert device, lift chair, blood pressure cuff, scale, wheelchair vertical lift, and pneumatic compression pump with wraps for legs were present in the home. The patient reported that the use of the blood pressure cuff, scale, and medical alert device began prior to starting services with this agency, the lift chair was started 3 years ago, the rotating adjustable bed and wheelchair vertical lift were started 2 years ago, and the pneumatic compression pump with wraps for legs was started 1 year ago. The agency failed to include all medical supplies/equipment on the patient’s POC, including rotating adjustable bed, medical alert device, lift chair, blood pressure cuff, scale, wheelchair vertical lift, and pneumatic compression pump with wraps for legs. The above findings were reviewed with the Administrator and DON.”

“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 clinical record review and staff interview, the agency failed to provide services as ordered by the physician for 1 of 2 patients (Patient #1). Failure to ensure staff follow physician orders for treatments provided by agency staff placed patient at risk for inconsistent care/treatment and possible harm. Findings include: Patient #1 had a start of care date of 7/14/22. Clinical record review revealed: a. The Plan of Care, dated 2/23/26 to 4/23/26, included a diagnosis of malignant neoplasm of Vater and included skilled nursing orders for weight management and monitoring, report weight gain greater than 3 pounds (lbs.) in 3 days or 5 lbs. in 7 days to primary care provider (PCP). b. Skilled nursing visit notes, dated 3/16/26, 3/30/26, and 4/3/26 failed to include documentation of the patient’s weight. Agency staff failed to follow physician’s orders to monitor the patient’s weight. The above stated findings were reviewed with Administrator and Director of Nursing.”

“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 clinical record review, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 2 sampled patients receiving home health aide services (Patients #1 and #2). The agency reported 2 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: 2.Patient #1 had a start of care date of 7/14/22. Clinical record review revealed the following: a. The POC, dated 2/23/26 to 4/23/26, included primary diagnosis of malignant neoplasm of ampulla of Vater and physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 2/23/26, by the Director of Nursing (DON) identified the tasks to be performed each visit: change linen, light housekeeping, make bed, back rub, comb hair, complete bath, foot care, oral hygiene-denture care, partial bath/sponge daily, shampoo hair, partial bath/sponge, skin care, nail care, tub, and shower. Universal precautions were to be performed always. c.During a home observation on 4/6/26 at 2:50 PM with the DON, pneumatic compression pump with wraps for legs was present in the home. The patient reported that the pneumatic pump with wraps for legs started 1 year ago and that Staff C, Home Health Aide (HHA), assists with putting the wraps on their legs and taking the wraps off their legs. d. In an interview on 4/7/26 at 1:22 PM, when asked about the pneumatic compression pump with wraps for legs, Staff C, HHA, reported that they have been putting the wraps on the patient and taking the wraps off the patient for 1 year. e.In an interview on 4/8/26 at 9:26 AM, the DON reported that the pneumatic compression pump with wraps for legs was present in the home. The DON reported that they were not aware that Staff C, HHA, was putting the wraps on the patient and taking the wraps off the patient. The HHA failed to report to Registered Nurse (RN) that the patient requested the HHA to perform a task not included on the Aide Care Plan. The above findings were reported to the Administrator and DON. According to the undated policy, titled Requirement for Home Health Aide Services, the aide to provide bathing, dressing, grooming, caring for hair, mail and oral hygiene which are needed to facilitate treatment or to prevent deterioration of the client’s health, changing the bed linens of an incontinent patient, shaving, deodorant application, skin care with lotions and/or powder, foot care, and ear care. During an interview on 4/8/26 at 9:36 AM the Director of Nursing stated staff expected to address and document on all tasks assigned on the home health aide care plan. 1.Patient #2 had a start of care date of 11/17/25. Clinical record review revealed the following: a. The Plan of Care (POC), dated 3/30/26 to 5/28/26, included primary diagnosis of chronic congestive heart failure and physician orders for skilled nurse and home health aide services. b. Undated aide care plan, identified the tasks bath: weight daily, incontinent care daily, assist ambulation with walker each visit, assist transfer each visit, range of motion each visit, assist to reposition every 2 hours, change linen each visit, light housekeeping each visit, make bed each visit, assist to dress each visit, back rub each visit, check pressure areas each visit, comb hair each visit, complete bath 2 times per week, foot care apply lotion , oral hygiene-denture care daily, partial bath/sponge daily, shampoo twice a week, shave twice a week, skin care daily, universal precautions always. c. Aide visit note, dated 4/7/26, completed by Staff D, Home Health Aide, failed to include documentation on the following tasks: assist with ambulation, assist in transfer, turn or position, range of motion, back rub/massage, oral hygiene denture care, check pressure areas, partial bath and shave.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on staff interview, agency policy review, and clinical record review, the agency failed to ensure a registered nurse completed home health aide supervision at least every 14 days for 1 of 1 sampled patients that required Home Health Aide (HHA) supervision every 14 days (Patient #1). The agency reported 2 patients received care provided by a home health aide. Failure to supervise HHA services at last every 14 days increased the risk that patients received unsatisfactory or inappropriate care from HHA. Findings include: According to undated policy titled Service Manual Version 1, Registered Nurses (RN) are required to make supervisory visits twice a month to supervise the services delivered by a Home Health Aide (HHA). Interview on 4/8/26 at 9:26 AM, when asked about Patient #1’s late HHA supervision, Director of Nursing (DON) reported that HHA supervision visits are sometimes late when the patient has appointments occur that the DON is not aware of when scheduling skilled nurse visits. The skilled nurse visit then needs to be rescheduled which can make HHA supervision visits late. Patient #1 had a start of care date of 7/14/22. Clinical record revealed: a.Plan of Care, dated 2/23/26 to 4/23/26, included primary diagnosis of malignant neoplasm of ampulla of Vater and included physician orders for skilled nurse and HHA services. b. Skilled nurse visit note, dated 3/5/26, completed by DON included documentation of HHA supervision. c. Skilled nurse visit note, dated 3/21/26, completed by DON included documentation of HHA supervision, 16 days after the last home health aide supervision, 2 days late per regulation. The agency failed to provide HHA supervision every 14 days. The above findings were reviewed with the Administrator and DON.”