All About Healthcare, Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan, Agency Policy and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. . Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 3/31/25 at 2:30 PM. The plan lacked documentation of a Hazard Vulnerability Assessment for 2023 and 2024. 2. The policy (Revised February 2021), “Agency Facility Based and Community-Based Risk Assessment Policy” was reviewed on 4/1/25 and required, “Policy: The Agency will perform, a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan…Procedure: Hazard Vulnerability Analysis (HVA) will be conducted and evaluated biennially…” 3. During an interview with the Agency Supervisor on 4/1/25 at 3:30 PM, the above finding was confirmed.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Program and Plan, Policy and staff interview, it was determined the Agency failed to ensure the Agency conducted the required individual and/or community exercises every 2 years to ensure the effectiveness of the Emergency Preparedness Plan. This has the potential to affect all patients receiving home health services. . Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 4/1/25. The Plan lacked documentation that full-scale community or individual exercises were conducted by the Agency for 2023 and 2024. 2. The Policy titled, “Testing Program for Emergency Operations Plan EOP)” which was revised February 2021, was reviewed on 4/1/25. The Policy requires, “The Agency will ensure that the Emergency Operations Plan (EOP) is functional through testing and evaluation. Two tests will occur every two years, which may either be one community-based full exercise, if available or an individual facility-based exercise every other year and in the opposite years. ...” 3. During an interview with the Agency Supervisor and Nurse on 4/1/25 at 3:10 PM, it was confirmed the Agency failed to meet the testing requirements of the Agency’s Emergency Plan.”

“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 591 of 1243 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. . Findings include: 1. The Error Summary report for 3/1/24 to 3/26/25, was reviewed on 3/31/25 at 9:30 AM. The report included error # -3330 for 591 of 1243 late submissions, 47.55 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Agency Supervisor and the QA RN on 4/2/25 at 11:00 AM, 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 a review of clinical records and staff interviews, it was determined in 3 of 7 (Pts. # 4, 5, and 6) clinical records reviewed, the Pt. care was not provided as ordered in the POC. 2. Pt. #5 was admitted to home health services on 2/4/25 with the diagnoses of but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy and Acute in Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/31/25. The record included a POC effective 2/4/25 which required, “Orders and Treatments: SN 1 week 9.” The clinical record included documentation of 2 SN visits for the following weeks: 2/4/25 to 2/8/25, 2/9/25 to 2/15/25, 2/16/25 to 2/22/25 and 2/23/25 to 3/1/25. The SN failed to follow the visit frequency as required. The same POC also required, “Instruct caregiver to weigh patient daily and record, SN to report to doctor’s office for weight gain > 2 lb./day or > 5 lb./week…” The record lacked documentation of weight monitoring. 3. Pt. #6 was admitted to home health services on 3/20/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The POC for the certification period of 3/20/24 to 5/18/24 required, “Orders and Treatment: PT: Evaluation and Treatment.” The record lacked documentation of a PT evaluation or visit. 4. The Policy dated February 2021 titled, “Plan of Care – CMS #485 and Physician/Practitioners Orders” was reviewed on 4/1/25 and required, “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources… Procedures: 20. Care and services provided will be provided according to physician/practitioner orders. Orders are current and updated…25. All clinical services are implemented only in accordance with a Plan of Care established by a physician/practitioner’s written order… 30. If the Agency misses a visit or treatment or services as required by the plan of care…then the Agency must notify the responsible physician/practitioner of such missed treatment or service…” 5. An interview was conducted with the Agency Supervisor and QA RN on 4/1/25 from 10:15 AM to 11:45 AM. During the interview, it was stated that the POC should be followed. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25 and 4/2/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks and notify the physician if weight greater than 5 pounds per week or less than 2 pounds per day. The SN assessed the weight on 12/5/24 as 170 pounds and on 1/30/25 as 183 pounds. The SN failed to notify the physician of the weight assessment not being done weekly and SN missed visits on 2/6/25, 2/13/25 and 3/6/25, and PT missed visits on 2/6/25, 2/13/25 and 3/4/25.”

“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 records, Agency policy, and staff interview, it was determined that for 3 of 7 (Pts. #1, 2, and 3) clinical record reviewed, the Agency failed to ensure forms and records were complete and accurate. Findings include: 1. The following clinical records were reviewed on 3/31/25 to 4/2/25. The following records contained the form “Notice of Medicare Non-Coverage” and included the statement “The Effective Date of Your Current Home Health Services Will End”: Pt. #1. SOC: 2/18/25 – “The Effective Date Coverage of Your Current Home Health Services Will End 4/18/25.” Pt. #2. SOC: 1/18/25 - “The Effective Date Coverage of Your Current Home Health Services Will End 3/18/25… 5/17/25.” Pt. #3. SOC: 2/15/25 – “The Effective Date Coverage of Your Current Home Health Services Will End 4/15/25.” The above-mentioned forms were signed by the Pt. or Pt. representative at the SOC. The forms were inaccurate. 2. The Agency policy titled, “Medial Record Entries and Authentication” was reviewed on 4/2/25 and required, “All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed.” 3. During an interview with the Agency Supervisor on 4/2/25 at 3:30 PM, it was stated that the form “Notice of Medicare Non-Coverage” is to be filled out once the Agency has determined the effective date Medicare will not pay for the services, and not to be automatically filled out by Agency staff at the SOC.”

“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 record review and staff interview, it was determined that 2 of 7 (Pts. #7 and 4) clinical records reviewed, the Agency failed to ensure that the PsOC include Pt. specific information. 2. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25 and 4/2/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks. The POC lacked the orders for the AV Graft/Fistula site care management. 3. The above findings were confirmed, during the interview with the Agency Supervisor and QA RN, on 4/2/25 between 9:30 AM and 11:45 AM. Findings include: 1. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25 at 10:00 AM. The clinical record included the comprehensive assessment dated 9/3/24. The POC included “(T)exas catheter” in the list of DME. The POC lacked Pt. specific instructions related to Texas catheter/condom catheter care: cleansing/hygiene, frequency of changing catheter, monitoring for skin breakdown, ensuring proper fit, and Pt./family education. The Pt. has a diagnosis of Benign Prostatic Hyperplasia and is on the following medications: Furosemide, Oxybutynin, Tamsulosin, and Finasteride. The POC dated 9/3/24 lacked: interventions related to the use of diuretics and genitourinary system medications, interventions related to urinary output/monitoring, and SN follow-up with the Physician regarding the lack of these interventions on the POC.”

“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 Pt./family/staff interviews during home visit, observation, clinical record review, policy review, and staff interview, it was determined that 3 of 7 (Pts. #1, 7, and 5) clinical records reviewed, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. 3. Pt. #5 was admitted for home health services on 2/4/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 3/31/25. The MSW assessment note dated 2/10/25 included the documentation, “Interventions/Linkages/Recommendations: Pt. to be evaluated by IDOA (Illinois Department of Aging) within 2-4 weeks for Homemaker Services to address ADL needs, reduces risk of hospitalization…” The clinical record lacked documentation of coordination between the Pt., the Agency and IDOA related to the referral for Homemaker services made by the MSW. During an interview with the Agency Supervisor and Quality Assurance RN on 4/1/25 at 11:00 AM, the Agency Supervisor stated that the Agency had no documentation of the follow up and information related to the referral for homemaker services. 4. The Agency policy titled, “Coordination of Patient Care” was reviewed on 4/2/25, and required, “1. The Agency must: Coordinate care delivery to meet the patient’s needs, involve the patient, representative (if any), caregiver, as appropriate, in the coordination of activities...2. The Director of Clinical Services provides oversight of all patient care services includes...coordinating patient care, coordinating referrals, ensuring that patient needs are continually assessed...6. Staff provides the physician/practitioner with patient information on an ongoing basis regarding current condition and changes in condition, outcomes of care and services… 8. Care will be coordinated with other involved external organizations… e.g. community agencies, staff will: share relevant information to facilitate appropriate continuity and care coordination…” 5. During an interview with the Agency Supervisor and Quality Assurance RN on 4/1/25 from 9:30 AM to 11:15 AM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit on 3/31/25, the Pt., the patient’s wife, and PT stated that he does not have a bedside commode and the Pt. is having bowel movements in a large bucket with his wife’s assistance. No bedside commode was visualized in the apartment. The clinical record was reviewed on 4/1/25. The comprehensive assessment dated 2/18/25 included bedside commode as DME. The clinical record lacked documentation of care coordination between the PT and Agency requesting for a bedside commode. SN documented constipation in each SN Visit note and the Pt. is ordered a daily osmotic laxative plus medications with the side effect of constipation. The clinical record lacked communication to the Physician to report chronic constipation despite daily laxative use and lacked Pt./family education regarding constipation prevention. 2. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25. The clinical record included the certification period dates 9/3/24. SN documented constipation in the SN Visit notes from 1/3/25 to 2/7/25. The Pt. is ordered a twice daily stool softener, an as needed laxative suppository, and is on medications with the side effect of constipation. The clinical record lacked communication to the Physician to report chronic constipation despite stool softener and laxative use, and lacked Pt. education regarding constipation prevention.”

“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 home visit, family interview, clinical record review, Agency policy review, and staff interview, it was determined that 5 of 7 (Pts. #1, 7, 3, 2, and 4) clinical records reviewed, the Agency failed to ensure that the clinical record was accurate. 4. Pt. #2 was admitted to home health services on 1/18/25 with the diagnosis of Other Hypertension. The clinical record was reviewed on 4/1/25. The clinical record included a POC dated 1/18/25. The record also included “Discharge Instructions” form completed by the RN at the SOC on 1/18/25 and signed by Pt. #4 at that time. The form was incomplete and lacked documentation of patient’s status, treatments, and services. 5. Pt. #4 was admitted to home health services on 12/5/24 with the diagnosis of Hypertensive Chronic Kidney Disease With Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 4/1/25. The clinical record included a POC dated 12/5/24, that required SN to assess the patient 1 time a week for 9 weeks. The record included the following dates: 1/16/25, 1/23/25, 2/6/25, 2/13/25, 2/20/25, 2/27/25, 3/6/25, 3/11/25, that lacked documentation of the Skilled Nurse visit notes as of 4/1/25. =6. The Policy “Nurse Documentation Submission and Verification of Visit Forms” (Revised January 2024) was reviewed on 4/3/25 and documents under: Policy Statement: “All nursing documentation, including visit notes, assessments, and verification of visit forms, must be completed accurately, and submitted on time. Submission must occur within one week of visit, and failure to submit within this period will result in non-payment for services rendered.” 9. During an interview with the Agency Supervisor on 4/2/25 between 9:30 AM and 11:45 AM., the Agency Supervisor stated, “we know the nurse made the visits, but the notes have not been completed.” During the same interview, it was confirmed Pt. assessments were incomplete, and not placed in the clinical record as required by the Agency. On 4/2/25 at 3:30 PM, The Agency Supervisor and QA RN stated, “Agency staff are completing all the forms upon admission at the SOC”. 3. Pt. #3 was admitted to home health services on 2/15/25 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 unspecified Chronic Kidney Disease. The clinical record was reviewed on 4/1/25. The SN notes dated 3/15/25, 3/22/25 and 3/29/25 recorded Pt. #3’s weight of 257 lbs. for all of the above-mentioned notes. A home visit was conducted with the Agency Supervisor on 4/1/25. During the home visit, Pt. #3 weight was recorded at 210 lbs. During the home visit, Pt. #3 was asked when the last time the nurse recorded his weight to which Pt. #3 replied, “it hasn’t been taken for more than a month…” The clinical record included documentation that Pt. #3 is alert and oriented to person, time, place and orientation. The Admission Booklet containing the RN’s documentation of vital signs did not include a record of the patient’s weight. The weight recorded on the clinical record is inaccurate. The clinical record also included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #3 on 2/15/25 (SOC). The form was incomplete and lacked documentation of patient’s current status, treatments and services. 7. The Agency policy, “Consent for Treatment and Services” was reviewed on 4/2/25 and required, “Consent for treatment and services will be completed upon admission.” 8. The Agency policy, “Discharge Criteria and Planning” was reviewed on 4/2/25 and required, “7. Patient will receive verbal or written discharge instructions two weeks prior to the end of the certification period...” Findings include: 1.Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit on 3/31/25, there was no bedside commode observed and wife stated that a bedside commode has not bee provided since the SOC. The clinical record was reviewed on 4/1/25. The comprehensive assessment dated 2/18/25 and the Aide Care Plan dated 2/21/25 included bedside commode as DME to be included in the patient’s care. The clinical record is inaccurate. The POC lists three different high glucose perimeters for when to notify the physician: :Insulin Lispro...400 and above=6 Units and call MD,” “Fasting blood sugar greater than...200,” and “Random blood sugar greater than...250.” The POC has conflicting documentation. The Pt. “Admission Consent” was not in the chart and was not located in the agency upon initial request. The clinical record included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #1’s wife on 2/18/25 (SOC). The form was incomplete and lacked documentation of patient’s current status, treatments, and services. 2. Pt. #7 was admitted for home health services on 9/3/24 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting The Left Non-Dominant Side and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. The clinical record was reviewed on 4/1/25. The clinical record included the form “Discharge Instructions” which was completed by the RN and signed by Pt. #7 on 9/3/24 (SOC). The form was incomplete and lacked documentation of patient’s current status, treatments, and services.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observations and interviews during home visits, clinical record review, Agency policy review, and staff interviews, it was determined in 2 of 3 (Pts. #1 and 3) home visits conducted, the Agency failed to ensure the clinical record included accurate medication records. 2. Pt. #3 was admitted to home health services on 2/15/25 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 unspecified Chronic Kidney Disease. A home visit was conducted on 4/1/25 with the Agency Supervisor. During the home visit, Pt. #3 presented the medication, “Breo Ellipta inhaler” and stated that “these are current inhalers that was prescribed by the doctor…” The clinical record was reviewed on 4/1/25. The clinical record included “Medication Profile” for 2/15/25 to 4/15/25, but it did not list the above-mentioned medication. The medication profile was not updated. 3. The Agency policy “Medication Reconciliation” which was revised February 2021, was reviewed on 4/2/25. The policy required, “2. Medications ordered while the patient is receiving will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication.” 3. During an interview with the Agency Supervisor on 4/2/25 from 9:30 AM to 11:15 AM, it was stated that the clinical records should contain all the patient’s medications. During the same interview, the above findings were confirmed. Findings include: 1.Pt. #1 was admitted for home health services on 2/18/25 with the diagnoses of, but not limited to, Type 2 Diabetes Mellitus With Foot Ulcer and Long Term (Current) Use Of Insulin. During the home visit, the Agency’s Current Medication list dated 2/18/25 was compared to the medications the patient’s wife is administering to the Pt. The patient’s wife stated she administers the following medications differently than as stated on the Agency’s Current Medication list: Seroquel, Metolazone (she does not know what this medication is and does not administer it), Insulin Lantus, Insulin Lispro (she does not know what sliding scale insulin dosing is and does not consistently check his blood glucose), Potassium Chloride, and Divalproex. Record review of the Agency’s policy titled, “Medication Profile,” revised March 2018, showed direction for the Agency staff to add all new or changed medications to the medication list every home visit and as new orders are received. The Agency failed to follow this policy.”