Compassionate Professional Home Care, Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined, in the last 12 months, the Agency failed to submit 9 of 151 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 2/1/24 to 2/25/25 was reviewed on 3/19/25 at 9:30 AM. The report included error # -3330 for 9 of 151 late submissions and 5.96 % of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 at 4:00 PM, it was confirmed that the error occurred.”

“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 clinical record review and staff interviews, it was determined in 2 of 7 (Pts. #2 and 3) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician/health practitioner and as indicated in the POC. 2. Pt. #3 was admitted for home health services on 10/15/24 with the diagnosis of Hypothyroidism, Unspecified. The clinical record was reviewed on 3/19/25. The clinical record included the referral for home health services dated 10/11/24. The referral contained the health practitioner’s order, “…Plan… 4. Nurse to update medications list and call our office to reconcile meds list at every visit…” The weekly SN visit notes from 1/16/25 to 2/11/25 and 2/13/25 to 3/13/25 lacked documentation the SN contacted the health practitioner’s office with an update/review of Pt. #3’s medications. 3. Pt. #4 was admitted for home health services on 3/3/25 with the diagnoses of Non-Pressure Chronic Ulcer of Skin of other Sites with Unspecified Severity, and Type 2 Diabetes Mellitus with Other Diabetic Kidney Complication. The clinical record was reviewed on 3/18/25. The clinical record included the POC effective 3/3/25 that required; “…SN to… assess the patient’s type 2 diabetes… by monitoring blood glucose levels…” The SN visit note dated 3/12/25 lacked documentation the SN assessed the patient’s blood glucose level. 4. During staff interviews with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 from 2:00 PM to 4:30 PM, the RN/Alternate Secretary confirmed the Agency failed to ensure care and/or services were provided according to the POC and/or health practitioner orders. Findings include: 1. Pt. # 2 was admitted to home health services on 1/24/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The POC effective 1/24/25 required, “SN to perform medication review each skilled visit and reconcile medications as indicated…” A home visit was conducted with Employee #2 (RN) on 3/18/25. Pt. #2 provided the bottles of all the medications that were currently taken, and the medications were reviewed. The medications “Amlodipine Besylate and Furosemide” which were written on the POC were not present at the time of the review. Employee #2 did not conduct a medication reconciliation during the home visit.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on a review of clinical record, Agency policy, and staff interviews, it was determined in 5 of 7 (Pts. #1, 3, 4, 2, and 5) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. 4. Pt. #2 was admitted to home health services on 1/24/25 with a diagnosis of Diabetes Mellitus with Diabetic Neuropathy, Unspecified. The clinical record was reviewed on 3/18/25. The clinical records contained the form titled, Financial Liability signed and dated by the Pt. on 1/24/25 but lacked entries on the area “Payment Source/Costs.” The form titled, “Home Health Advance Beneficiary Notice” was signed and dated by the Pt. on 1/24/25 but the rest of the form were not filled out. The form “Beneficiary-Elected Transfer” was also signed by the Pt. and lacked entries of the name and contact information of the previous Agency. 5. Pt. #5 was admitted to home health services on 12/20/24 with a diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 3/18/25. The clinical records contained the form titled, “Notice of Medicare Non-Coverage” which was signed by the Pt. on 12/20/24, but the areas containing “Patient Number and the Effective Date of Coverage your current home health services will end” were left blank. The form “Beneficiary-Elected Transfer” was also signed by the Pt. and lacked entries of the name and contact information of the previous Agency. 6. The Agency policy titled, “Patient Chart Documentation” was reviewed on 3/20/25 and required, “…review of patient charts shall be undertaken on a regular basis to ensure accuracy and completeness…” 7. During interviews conducted on 3/19/25 from 2:00 PM to 4:00 PM with the RN/Alternate Secretary and Assistant Administrator/Office Manager, it was confirmed that the clinical record should be accurate and complete. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for home health services on 10/9/24 with the diagnoses of Unspecified Anemia and Acute on Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/18/25. The clinical record included the form titled “Notice of Medicare Non-Coverage” completed by the SN and dated 10/9/24. The form lacked the effective date that home health coverage will end, as required by the Agency’s form. The “Beneficiary Elected Transfer” form was completed by the SN and dated 10/9/24. The form lacked the name and contact information of the previous home health agency, date and time of notification to the previous home health agency, as required by the Agency’s form. The “Home Health Advance Beneficiary Notice” form was completed by the SN and dated 10/9/24. The form lacked documentation to indicate whether Medicare will not or will no longer pay for the “SN” service, and the patient’s option to either refuse the service, or pay for the SN service received, as required by the Agency’s form. 2. Pt. #3 was admitted for home health services on 10/15/24 with the diagnosis of Hypothyroidism, Unspecified. The clinical record was reviewed on 3/19/25. The clinical record included the “Home Health Advance Beneficiary Notice” form completed by the SN and dated 10/15/24. The form lacked documentation to indicate whether Medicare will not or will no longer pay for the “SN” service, and the patient’s option to either refuse the service, or pay for the SN service received. The form titled “Notice of Medicare Non-Coverage” completed by the SN and dated 10/15/24. The form lacked the effective date that home health coverage will end, as required by the Agency’s form. 3. Pt. #4 was admitted for home health services on 3/3/25 with the diagnoses of Non-Pressure Chronic Ulcer of Skin of other Sites with Unspecified Severity, and Type 2 Diabetes Mellitus with Other Diabetic Kidney Complication. The clinical record was reviewed on 3/18/25. The clinical record included the “Beneficiary Elected Transfer” form completed by the SN and dated 3/3/25. The form lacked the name and contact information of the previous home health agency, date and time of notification to the previous home health agency. The “Home Health Advance Beneficiary Notice” form completed by the SN and dated 3/3/25 lacked documentation indicating whether Medicare will not or will no longer provide “SN” service, and the patient’s option to either refuse the service, or pay for the SN service received.”

“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 observation during home visits, clinical record reviews, Pt. admission folder review, and staff interviews, it was determined in 6 of 7 (Pts. #1, 2, 3, 4, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./patient’s representative was informed of the services to be provided in writing, and the frequency of visits provided by each discipline. Findings include: 1. Home visits were conducted on the following Pts. on 3/18/25 and 3/19/25: Pt. #1. SOC 10/9/24. Pt. #2. SOC 1/24/25. Pt. #3. SOC 10/15/24. During the home visits, the Pt. admission folders were observed and lacked documentation of the services provided, and frequency of each service. 2. The clinical records were reviewed from 3/18/25 to 3/19/25. The records included a form titled “Financial Responsibility” completed by the RN and contained the section, “Anticipated Services and frequency or Number of…” The SN was required to indicate the service to be provided, and the frequency or number of visits for each service. This section was left blank in the following clinical records: Pt. #1. SOC 10/9/24. Lacked SN service and the visit frequency. Pt. #2. SOC 1/24/25. Lacked SN service and the visit frequency. Pt. #3. SOC 10/15/24. Lacked SN service and the visit frequency. Pt. #4. SOC 3/3/25. Lacked SN service and the visit frequency. Pt. #6. SOC 4/10/24. Lacked SN and Physical Therapy services and the visit frequency. Pt. #7. SOC 10/11/23. Lacked SN, Physical Therapy, and Occupational Therapy services and the visit frequencies. 3. The Pt. admission folder was reviewed on 3/17/25. The folder included a booklet that contained consent forms which included a section for the SN to enter the service(s) to be provided and frequency of each service. During an interview with the Office Manager and RN/Alternate Secretary on 3/19/25 at 2:00 PM, the Alternate Secretary/RN stated the Agency recently received the booklets, as of 3/19/25 the Agency had not began using the booklets. 4. During staff interviews with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 at 2:00 PM, the RN/Alternate Secretary confirmed the Agency failed to ensure the Pt./patient’s representative was informed of the services to be provided in writing, and the frequency of visits provided by each discipline.”

“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 observation and interviews during a home visit, clinical record review, Agency policy review, and staff interviews, it was determined for 1 of 7 (Pt. #1) clinical record reviewed, the Agency failed to ensure PsOC were accurate and include all the requirements. Findings include: 1. Pt. #1 was admitted for home health services on 10/9/24 with the diagnoses of Unspecified Anemia and Acute on Chronic Systolic (Congestive) Heart Failure. A home visit was conducted on 3/18/25 with Employee #1. During the home visit, the patient’s medications were observed, and interviews were conducted with the patient’s primary caregiver. The primary caregiver stated the Physician discontinued “Cyproheptadine a long time ago, around Thanksgiving… Entresto was stopped by the doctor in December (2024) or January (2025) … The doctor stopped “Ferrous Sulfate” about 6 months ago… Furosemide was stopped and changed to Torsemide, and he (the doctor) doubled the Torsemide in January (2025) … Isosorbide was stopped last summer (2024), Metoprolol and Midodrine was stopped in November (2024) after being in the hospital … she does not use Sulfadiazine anymore, the wound on her toe healed in January (2025).” The clinical record was reviewed on 3/18/25. The clinical record included the PsOC for the certification periods of 12/8/24 to 2/5/25 and effective 2/6/25 which contained the medications: Cyproheptadine, Entresto, Ferrous Sulfate, Furosemide, Isosorbide Mononitrate ER, Metoprolol Succinate ER, Midodrine, and Silver Sulfadiazine. The PsOC effective 12/8/24 and 2/6/25 were inaccurate. The SN visit note dated 2/5/25 included the patient’s weight as 165 pounds. The SN visit note dated 2/13/25 included the patient’s weight as 154 pounds, this was an 11-pound weight loss within 8 days. The PsOC for the certification period of 12/8/24 to 2/5/25 and effective 2/6/25 lacked weight parameters to notify the Physician for excess weight loss or gain. 2. The Agency policy titled; “Patient Weight Monitoring” was reviewed on 3/20/25 at 10:45 AM. The policy required, “… The attending physician should be notified immediately of any weight gain/loss of 2 pounds per day or 5 pounds per week.” 3. During a staff interview with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 at 2:00 PM, the RN/Alternate Secretary confirmed Pt. #1’s PsOC included inaccurate medications and lacked weight parameters.”

“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 a review of clinical records, Agency policy and staff interviews, it was determined in 2 of 7 (Pts. #1 and 4) clinical records reviewed, the Agency failed to ensure the SN provide wound care according to Physician orders. Findings include: 1. Pt. #1 was admitted for home health services on 10/9/24 with the diagnoses of Unspecified Anemia and Acute on Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/18/25. The clinical record included the SN visit notes dated 1/15/25, 1/22/25, and 1/29/25 that contained documentation the SN cleaned the surgical right toe wound with “sterile saline… applied a thin layer of antibiotic ointment… sterile dressing.” As of 3/18/25, the record lacked a Physician order for the wound care provided from 1/15/25 to 1/29/25. 2. Pt. #4 was admitted for home health services on 3/3/25 with diagnoses of Non-Pressure Chronic Ulcer of Skin of other Sites with Unspecified Severity, and Type 2 Diabetes Mellitus with Other Diabetic Kidney Complication. The clinical record was reviewed on 3/18/25. The clinical record included the SN visit notes dated 3/3/25 and 3/12/25 that contained documentation the SN provided wound care to the right foot, left leg, and right ankle wounds with “Dakin’s solution, betamethasone ointment applied, covered with non-stick dressing, gauze.” As of 3/18/25, the record lacked a Physician order for the wound care provided on 3/3/25 and 3/12/25. 3. During a staff interview with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 at 2:00 PM, the RN/Alternate Secretary confirmed the Agency failed ensure that wound care provided was according to Physician orders.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on review of clinical records, policy review and staff interviews, it was determined that for 5 of 7 (Pts. #1, 2, 4, 6 and 7) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines. Findings include: 1. The clinical records were reviewed on 3/18/25 and 3/19/25. Each clinical record contained a form titled, “Immunization and Consent Forms.” Pt. #1. SOC 10/9/24. The form lacked Influenza inquiry. Pt. #2. SOC 1/24/25. The form lacked Influenza and Pneumonia inquiry. Pt. #4. SOC 3/3/25. The form lacked Influenza and Pneumonia inquiry. Pt. #6. SOC 4/10/24. The form lacked Influenza and Pneumonia inquiry. Pt. #7. SOC 10/11/23. The form lacked Influenza and Pneumonia inquiry. 2. The policy titled, “Influenza/ Pneumonia Vaccination” was reviewed on 3/18/25 and required: “Procedure: 01. All patients will be routinely assessed for receipt of vaccination, including flu and pneumonia during the initial assessment…03. After securing the patient’s/authorized person’s signature in the consent form, an immunization assessment form shall be filled up to include the following: a. Assessment of Influenza Status, b. Assessment of Contraindication to Influenza Immunization, c. Assessment of Pneumococcal Immunization Status, d. Assessment of Contraindication to Pneumococcal Immunization… 04. Declination of vaccine/immunization shall be recorded/documented in the immunization declination form and mailed to the attending physician for signature before being filed in the patient’s chart…” 3. During staff interviews with the Alternate Administrator and RN/Alternate Secretary on 3/19/25 at 2:00 PM, it was stated that during the SOC, the patient’s Influenza and Pneumococcal Pneumonia vaccination status is assessed, and this information should be contained in the clinical record. During the same interview, the above findings were confirmed.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Director of Nursing. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 3/17/25. The folder lacked the name and information of the Director of Nursing. 2. The following home visits were conducted on 3/18/25 and 3/19/25: Pt. #1. SOC 10/9/24. Pt. #2. SOC 1/24/25. Pt. #3. SOC 10/15/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Director of Nursing. 3. The following clinical records were reviewed from 3/18/25 to 3/19/25: Pt. #1. SOC 10/9/24. Pt. #2. SOC 1/24/25. Pt. #3. SOC 10/15/24. Pt. #4. SOC 3/3/25. Pt. #5. SOC 12/30/24. Pt. #6. SOC 4/10/24. Pt. #7. SOC 10/11/23. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact information of the Director of Nursing. 4. During staff interviews conducted with the Assistant Administrator/Office Manager, and RN/Alternate Secretary on 3/19/25 at 2:00 PM, both confirmed the Agency failed to provide the Pt./patient’s representative written information regarding the Director of Nursing.”

“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 review of clinical records and staff interview, it was determined in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. Findings include: 1. Pt. #6 was admitted to home health services on 4/10/24 with the diagnosis of Peripheral Vascular Disease. The clinical record was reviewed on 3/19/25. The record included a Discharge comprehensive assessment dated 10/6/24, indicating that Pt. #6 was discharged from the Agency. As of 3/19/25, the record lacked documentation that a copy of the Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home health services on 10/11/23 with the diagnosis of Bilateral Primary Osteoarthritis of the Knee. The clinical record was reviewed on 3/19/25. The record included a Discharge comprehensive assessment dated 4/8/24, indicating that Pt. #7 was discharged from the Agency. As of 3/19/25, the record lacked documentation that a copy of the Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Assistant Administrator/Office Manager and RN/Alternate Secretary on 3/19/25 at 4:00 PM, the above findings were confirmed.”