Care Solutions, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the Emergency Preparedness binder and staff interview, the Agency failed to include names and contact information of entities providing services under arrangements and an updated names and contact information for current staff in the Emergency Preparedness communication plan. Findings included: 1.The Emergency Preparedness binder was reviewed on 03/31/26. The binder lacked documentation of the name and contact information for entities providing services under arrangements and lacked an updated/current staff list with contact information. 2.During an interview with the Administrator, Assistant Administrator, and Director of Nursing on 04/01/26 at 2:00 PM, the 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 a review of clinical records and staff interviews, for 2 of 7 (Pts. #5 and 6) clinical records, the Agency failed to ensure that the physician orders were followed. 2. Pt. #6 was admitted to home health services on 01/09/26 with the diagnosis of Hemiplegia following Cerebral Infarction. The clinical record was reviewed on 03/31/26. The POC for the period review of 01/09/26 to 03/09/26 required, “ST evaluation and SN frequency 2wk9.” The clinical record review lacked documentation of any ST evaluation and a missed SN visit during the week of 01/18/26 and one during the week of 02/01/26 with 2 missed SN visits for the week of 02/08/26. 3. During an interview with the Administrator, Assistant Administrator, and Director of Nursing on 04/01/26 at 2 PM, the Administrator, Assistant Administrator, and Director of Nursing confirmed the above findings. Findings include: 1. Pt. #5 was admitted to home health services on 01/07/26 with the with the diagnoses of but not limited to Periprosthetic fracture around an internal prosthetic right hip joint, subsequent encounter and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/31/26. The POC effective 03/08/26 required, “Referrals: SN/PT/OT.” The clinical record lacked documentation of any Occupational Therapy (OT) visits.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on patient clinical record review, Agency’s Admission Folder review, and staff interview, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide written documentation of the Agency’s Transfer and Discharge policies to Pts. and/or their representatives on admission. Findings included: 1.The Admission Folder was reviewed on 03/30/26. The Folder lacked documentation of the Agency’s Transfer and Discharge policies. 2.The following Pt. clinical records were reviewed from 03/30/26 to 04/01/26. The clinical records lacked documentation that the Pts. and/or their representatives were notified of the Agency’s Transfer and Discharge policies. Pt. # 1 SOC 03/20/26 Pt. # 2 SOC 03/12/26 Pt. # 3 SOC 02/22/26 Pt. # 4 SOC 02/11/26 Pt. # 5 SOC 01/07/26 Pt. # 6 SOC 01/09/26 Pt. #7 SOC 09/14/26 3.During an interview with the Administrator, Assistant Administrator, and Director of Nursing on 04/01/26 at 2:00 PM, the above findings were confirmed.”

“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 a review of clinical records, review of the Agency’s “Patient Bill of Rights” and staff interview, for 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7) the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline prior to providing care and services. Findings Include: 1. The following clinical records were reviewed from 03/30/26 at 2:30 PM to 03/31/26 at 2:00 PM: Pt. #1. SOC:03/02/26. Pt. received SN and PT services. Pt. #2. SOC:03/12/26. Pt. received SN and PT services. Pt. #3. SOC:02/22/26. Pt. received SN, PT and HHA services. Pt. #4. SOC:02/11/26. Pt. received SN and PT services. Pt. #5. SOC:01/07/26. Pt. received SN and PT services. Pt. #6. SOC:01/09/26. Pt. received SN, PT and ST services Pt. #7. SOC:09/04/26. Pt. received SN and PT services. The records lacked documentation that at the SOC, the Pt./patient’s representative participated, or was notified of each discipline’s frequency of visits, prior to providing Pt. care and services. 2. The Agency document, “Patient Bill of Rights” was reviewed on 03/30/26 at 2:00 PM, and includes the documentation, “…All Patients receiving services from (Agency) or their family possess basic rights and responsibilities. This include: the right to: Be fully informed in advance about the care to be furnished and of any changes, including the disciplines and frequency of visits…” 3. During interviews conducted with the Administrator, Assistant Administrator and Director of Nursing on 04/01/26 at 1:15 PM to 3:00 PM, the above findings were confirmed.”

“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 during a home visit, clinical record review and staff interviews, for 2 of 7 Pts. (Pts. #3 and 5), the Agency failed to ensure that the plans of care included all the requirements. Findings include: 1. Pt. #3 was admitted to home health services on 02/22/26 with the diagnoses of but not limited to Encounter for surgical aftercare following surgery on the digestive system and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/31/26. A home visit on 03/18/26 was conducted with the RN/Administrator. During the home visit, it was observed that Pt. #3 had a continuous glucose meter (CGM) on the right upper arm. The RN/Administrator stated that blood glucose is monitored through readings from the CGM. The POC effective 02/22/26 lacked documentation of the frequency of changing the CGM and the supplies used for its care and maintenance. The POC also lacked documentation of the parameters for the results of the glucose meter to be reported to the physician. 2. Pt. #5 was admitted to home health services on 01/07/26 with the diagnoses of but not limited to Periprosthetic fracture around an internal prosthetic right hip joint, subsequent encounter and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 03/31/26. The POC effective 03/08/26 lacked documentation of the parameters of the results of blood glucose monitoring to be reported to the physician. 3. During an interview with the Administrator, Assistant Administrator and the Director of Nursing on 04/01/26 at 1:15 PM, the above finding was confirmed.”

“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 records review, Agency Policy review and staff interviews. In 5 of 7 (Pts # 1, 3, 4, 5 and 6) the Agency failed to assess patients’ flu and pneumonia vaccination status on admission according to Agency policy. Findings include: 1. The following clinical records were reviewed from 03/30/26 to 04/01/26. The clinical records did not include a complete flu and pneumonia vaccination status assessment according to Agency policy. The clinical records lacked the dates Pts. received vaccinations and if any arrangements were made by the Agency to offer vaccine to patients. Pt # 3 SOC 02/22/26 Pt # 4 SOC 02/11/26 Pt # 5 SOC 01/07/26 Pt # 6 SOC 01/09/26. 2. The Agency policy titled “Influenza and Pneumonia Vaccine” was reviewed on 04/01/26. The policy required “ Procedure...Starting November 30 until February of the next year all patients who are on service as well as new admits will be offered influenza and pneumonia vaccine or will be encourage to make arrangement with their attending physician or local pharmacy according to their choice........Upon admission assessment of patient’s vaccination status, it should indicate in the influenza-pneumonia vaccination assessment form and OASIS the dates these vaccinations where given if patient and caregiver can still remember. If by any chance that they could not recall dates. Admitting discipline shall document that patient forgot the dates of administration in both the consent and the OASIS.” 3. During interviews with the Administrator, Assistant Administrator, and the Director of Nursing on 04/01/26 from 1:15 PM to 2:30 PM, the above findings were confirmed.”