Northwest Home Health & Rehab

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Operations Plan and Policies, and staff interview, the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Agency’s Emergency Operations Plan and Policies, last revised February 2025, was reviewed on 03/02/26. The Plan included the “Hazard Vulnerability Assessment” (risk assessment), which included potential hazardous events. The Assessment included, “Ice Snow, Flooding, Earthquake, Hurricane, Tornado, Volcano, Severe Thunderstorm, Pandemic/Infectious Disease, Transportation Interruption, and Environment/Altered Air Quality Pollution” as possible events. As of 03/02/26 at 11:30 AM, the Agency’s Emergency Operations Plan and Policies lacked policies and procedures pertaining to “Ice Snow, Flooding, Earthquake, Hurricane, Tornado, Volcano, Severe Thunderstorm, Pandemic/Infectious Disease, Transportation Interruption, and Environment/Altered Air Quality Pollution.” 2. During an interview with the Administrator on 03/02/26 at 11:30 AM, the Administrator confirmed the Agency failed to establish policies and procedures based on the risk assessment.”

“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 review of the Error Summary report and staff interview, it was determined that in 469 of 2249 reports submitted for the last 12 months, the Agency failed to submit the report within 30 days after the assessment was completed resulting in a warning. Findings include: 1. The OASIS Error Summary report for 01/01/25 to 01/27/26 was reviewed on 03/04/26. The report included a warning for the error: 469 of the 2249 assessments were submitted late; 20.85 % of the OASIS reports were submitted more than 30 days after the assessment was completed. 2. During staff interviews with the Administrator and Director of Nursing, on 03/04/26 at 2:30 PM, the above findings were confirmed.”

“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 observations and interviews during a home visit, clinical records reviews and staff interviews, for 6 of 13 (Pts. #8, 9, 5, 6, 11, and 12) clinical records, the Agency failed to ensure that the orders in the POC were followed and the PsOC were signed by the physician as required. 3. Pt. #5 was admitted to home health services on 11/20/25 with diagnoses of Unspecified atrial fibrillation. The clinical record was reviewed on 03/03/26. The clinical record included the POC for the certification period of 01/19/26 to 03/19/26 that required the SN to instruct patient to weight daily in the morning. Notify MD with weight gain of 3 pounds in 24 hours or 5 pounds in 1 week. The SN documented the weight on 01/26/26 as 157 pounds and on 02/04/26 as 164 and on 02/17/26 as 164 pounds and on 02/23/26 as 157 pounds. The SN failed to notify the doctor of the 7 pounds weight gain and 7 pounds weight loss. 4. Pt. #6 was admitted to home health services on 02/13/26 with diagnosis of Metabolic encephalopathy and Type 2 diabetes mellitus with diabetic chronic kidney disease. The clinical record was reviewed on 03/03/26. The record included the POC for the certification period of 02/13/26 to 04/13/26 that required “SN to assess the diabetic status…may obtain blood sugar level via fingerstick as needed….SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy.” The SN visit notes dated 02/13/26, 02/17/26, and 02/25/26 lacked documentation the SN performed the above. 5. Pt. #11 was admitted for home health services on 10/31/25 with the diagnoses of, but not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Long term (current) use of anticoagulants. The clinical record was reviewed on 03/03/25. The clinical record included a POC effective 10/31/25. The Physician signed the POC on “12/2/25.” The Agency failed to ensure the POC was reviewed and signed by the Physician within 30 days of the start of care date. 6. Pt. #12 was admitted for home health services on 03/10/25 with the diagnoses of, but not limited to, Parkinsonism, unspecified and Dementia in other diseases classified elsewhere, unspecified severity, with agitation. The clinical record was reviewed on 03/03/25. The clinical record included a POC effective 03/10/25. The Physician electronically signed the POC on “05/06/2025.” The Agency failed to ensure the POC was reviewed and signed by the Physician within 30 days of the start of care date. 7. During interviews with the Administrator and Director of Nursing on 03/04/25 from 12:30PM to 2:30 PM, the above findings were confirmed. 1. Pt. #8 was admitted to home health services on 11/26/25 with the diagnosis of Polyosteoarthritis. The clinical record was reviewed on 03/02/26. The clinical record included a PT POC for the certification date of 11/26/25 to 01/24/26 which required, “POC 2W4, 2W1.” The clinical record lacked documentation of any PT visits for the week of 01/04/26 to 01/10/26. The clinical record also included a POC effective 01/25/26. As of 03/04/26, the POC lacked the Physician’s signature. 2. Pt. #9 was admitted to home health services on 12/01/25 with the diagnosis of Encounter for other orthopedic aftercare. The clinical record was reviewed on 03/03/26. The clinical record included a POC effective 01/30/26. As of 03/04/26, the POC lacked the Physician’s signature.”

“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 clinical records and staff interviews, it was determined in 2 of 13 (Pts. #2 and 11) clinical records reviewed, the PsOC lacked patient specific interventions. 3. During staff interviews with the Administrator and Director of Nursing on 03/04/26 at 12:30 PM and 2:30 PM the above findings were confirmed. Findings include: 1. Pt. #2 was admitted for home health services on 02/03/26 with the diagnoses of, but not limited to, Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing and Dependence on renal dialysis. The clinical record was reviewed on 03/03/25. The record included the POC for the certification period of 02/03/26 to 04/03/26. On 02/13/26, the SN discharge Summary Section titled “Condition of discharge” stated, “Continuing dialysis MWFs...Fistula left arm has good thrill and bruit heard, dressing in place after dialysis.” The POC lacked the patient’s dialysis orders and care/precautions of their dialysis fistula. 2. Pt. #11 was admitted for home health services on 10/31/25 with the diagnoses of, but not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Long term (current) use of anticoagulants. The clinical record was reviewed on 03/03/25. The record included the POC for the certification period of 10/31/25 to 12/29/25. On 11/25/25, the SN Visit note section “Response to Care/Progress Toward Goals/Plan for Next Visit” stated, “Both the patient and her caregiver...verbalized understanding of the importance of the patient monitoring her INR reading every week and calling it in the Coumadin Clinic...for direction on the SPECIFIC dosage of...Warfarin to take on a daily...” The POC lacked orders and directions for the use of the INR machine, and parameters of the patient’s results.”

“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 clinical record reviews and staff interviews, for 11 of 13 (Pts. 1, 2, 3, 4, 6, 7, 8, 9, 10, 12 and 13) clinical records reviewed, the Agency failed to conduct complete assessments of patients’ Influenza and Pneumonia vaccination status. Findings include: 1.The following clinical records were reviewed from 03/02/26 to 03/04/26: Pt. #1 SOC 10/01/25 lacked Influenza and Pneumonia vaccination assessment. Pt. #2 SOC 02/03/26 lacked Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 01/02/26, lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 12/18/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 02/13/26, lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 10/01/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #8 SOC 11/26/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #9 SOC 12/01/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #10 SOC 01/24/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #12 SOC 03/10/25, lacked Influenza and Pneumonia vaccination assessment. Pt. #13 SOC 04/22/25, lacked Influenza vaccination assessment. The records lacked documentation that the Influenza or Pneumonia vaccination was assessed. 2. During staff interviews with the Administrator and Director of Nursing on 03/04/26 at 12:30 PM, 1:30 PM and 2:30 PM, the above findings were confirmed.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review and staff interview, in 2 of 13 clinical records reviewed (Pts. #11 and 12) , the Agency failed to ensure that concerns/continuity of care are communicated/coordinated within the patient’s healthcare team to ensure Pt. needs were met. 1.Pt. #11 was admitted for home health services on 10/31/25 with the diagnoses of, but not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Long term (current) use of anticoagulants. The clinical record was reviewed on 03/03/25. The clinical record included a POC effective 10/31/25 with the certification period of 10/31/25 to 12/29/25. On 11/26/25, the Pt. was discharged from the Agency and transferred to outpatient therapy. The PT Discharge Summary dated 11/26/25 and the OASIS E-1 Discharge (PT) dated 11/26/25 lacked documentation of the PT coordinating care, or giving report on the patient, when service transferred from home health to outpatient. The Agency failed to ensure coordination between all disciplines of the patient’s healthcare team. 2. Pt. #12 was admitted for home health services on 03/10/25 with the diagnoses of, but not limited to, Parkinsonism, unspecified and Dementia in other diseases classified elsewhere, unspecified severity, with agitation. The clinical record was reviewed on 03/03/25. The clinical record included a POC effective 03/10/25 with the certification period of 03/10/25 to 05/08/25. On 04/17/25 the COTA entered a Missed Visit note stating, “Physician Office Notified: No....Comments Attempted to see patient twice this afternoon while in the building patient sleeping decreased alertness...” The record lacked documentation of the COTA reporting “decreased alertness” to the patient’s Memory Care staff and/or the Agency staff. The Agency failed to ensure coordination between all disciplines of the patient’s healthcare team. 3. During an interview with the Administrator and DON on 03/04/26 at 12:30 PM, the above findings were confirmed.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records and staff interviews, in 2 of 13 clinical records reviewed (Pts. #1 and 8), the Agency failed to ensure the records were complete and current. 2. Pt. # 8 was admitted for home health services on 11/26/25 with a diagnosis of Polysoteoarthritis. The clinical record was reviewed on 03/02/26. The SN Visit note included the following documentation: “Visit Narrative: SN will continue to educate, patient was instructed on strategies that can significantly help to decrease the risk of a fall such as Skid -proof mats or strips in the shower and bathtub, Removal of furniture that can slip away if grabbed accidentally for support, supportive non-slip footwear and not walking in stocking feet. Patients currently use cane while ambulating and states that it helps her with her balance. Patient advised that side effect of most medications taking can cause dizziness so that it can be addressed by MD.” The same verbiage was replicated in the “Visit Narrative” section for all SN Visit notes with the following dates: 01/02/26, 01/09/26, 01/017/26, 02/09/26 and 02/20/26. 3. During interviews conducted with the Administrator and Director of Nursing on 03/04/25 at 12:30 PM and 1:30 PM, it was stated the clinical notes should be accurate and complete. During the same interview, the above findings were confirmed. 1. Pt #1 was admitted for home health services on 10/01/25 with a diagnosis of Type 2 diabetes mellitus with foot ulcer. The clinical record was reviewed on 03/04/26. The record included the certification period of 01/29/26 to 03/29/26, and “Admission/Recert/ROC Communication Coordination” note on 01/27/26, which required the SN to visit the Pt. 3w2, 2w6, 2PRN for issues related to POC or unexpected health declines and the HHA 1w9. The SN performed visits on the following dates and failed to document the assessments associated with the SN visits on 02/09/26, 02/11/26, 02/13/26, 02/16/26, 02/20/26, 02/23/26, 02/27/26, and 03/02/26. The SN failed to document the HHA Supervisory Visit notes on the dates 02/09/26 and 02/23/26. 2. Pt. # 8 was admitted for home health services on 11/26/25 with a diagnosis of Polysoteoarthritis. The clinical record was reviewed on 03/02/26. The SN Visit note included the following documentation: “Visit Narrative: SN will continue to educate, patient was instructed on strategies that can significantly help to decrease the risk of a fall such as Skid -proof mats or strips in the shower and bathtub, Removal of furniture that can slip away if grabbed accidentally for support, supportive non-slip footwear and not walking in stocking feet. Patients currently use cane while ambulating and states that it helps her with her balance. Patient advised that side effect of most medications taking can cause dizziness so that it can be addressed by MD.” The same verbiage was replicated in the “Visit Narrative” section for all SN Visit notes with the following dates: 01/02/26, 01/09/26, 01/017/26, 02/09/26 and 02/20/26. 3. During interviews conducted with the Administrator and Director of Nursing on 03/04/25 at 12:30 PM and 1:30 PM, it was stated the clinical notes should be accurate and complete. During the same interview, the above findings were confirmed.”

“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 a review of clinical records and staff interviews, for 2 of 4 discharged records reviewed (Pts.# 11 and 13), the Agency failed to send the patient’s discharge summary to the primary care care provider within five days of discharge. 2. Pt. #13 was admitted for home health services on 04/22/25 with the diagnosis of Spondylosis without myelopathy or radiculopathy, lumbosacral region. The clinical record was reviewed on 03/04/26. The record included the discharge summary completed by the PT dated 06/05/25. The record lacked documentation that a copy of the summary was sent to the Physician. 3. During staff interviews with the Administrator and Director of Nursing on 03/04/26 at 12:30 PM, and 2:30 PM, the administrative team confirmed the above findings. Findings include: 1. Pt. #11 was admitted for home health services on 10/31/25 with the diagnoses of, but not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and Long term (current) use of anticoagulants. The clinical record was reviewed on 03/03/25. The record included the discharge summary completed by the PT dated 11/26/25. The record lacked documentation that a copy of the summary was sent to the Physician.”