Prime Home Health Services, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined that the Agency failed to review and update its Emergency Preparedness Plan and policies biennially. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 07/21/26 at 1:30 PM. The plan and policies lacked documentation indicating the date they were last reviewed. The Agency was unable to provide documentation of the review date. 2. During an interview conducted with the Administrator/Agency Supervisor/Director of Nursing on 07/22/26 at 2:30 PM, the Administrator stated that the policies and plan are to be reviewed every two years. During the same interview, the finding above was confirmed.”

“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 the review of the Agency’s Emergency Preparedness Plan, policy review, and staff interview, the Agency failed to have a communication plan that included the current names and required contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 07/21/26 at 1:30 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement and Patients’ Physicians. 2. During an interview with the Administrator and Agency Supervisor/Director of Nursing on 07/22/26 at 2:15 PM, the above finding was confirmed.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on clinical records review, Agency’s patient admission folder review and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the name and contact information of the Administrator to Pts. or their families to report complaints/grievances. Findings include: 1. The Agency patient admission folder was reviewed on 07/20/26. The admission folder lacked the Administrator’s name and contact information. 2. The clinical records were reviewed from 07/21/26 to 07/23/26. Pt. #1. SOC 03/17/26. Pt. #2. SOC 05/06/26. Pt. #3. SOC 02/10/26. Pt. #4. SOC. 06/11/26. Pt. #5. SOC 04/10/26. Pt. #6. SOC 01/08/26. Pt. #7. SOC 02/05/25. The clinical records reviewed lacked information identifying the Administrator’s name and contact information was provided to Pts./representatives to report any complaints/grievances. 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 07/22/26 at 1:30 PM, the administrative team confirmed the above finding.”

“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 review of the Agency’s Pt. admission folder, review of the clinical records, observations during home visits, and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4,5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. and/or patients’ representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1. The patient admission folder was reviewed on 05/05/26 and included the form titled, “Consent Information”. The Agency required the SN to complete the Agreement form during the SOC visit. A section on the form labeled “Frequency of Visit:” included five disciplines, SN, PT, OT, ST, HHAide, with a blank line after each 2. The clinical records were reviewed from 07/21/26 to 07/23/26, and included documentation that the following services were provided: Pt. #1. SOC 03/17/26. SN. Pt. #2. SOC 05/06/26. SN and PT. Pt. #3. SOC 02/10/26. SN and PT. Pt. #4. SOC. 06/11/26. SN and PT. Pt. #5. SOC 04/10/26. SN and PT. Pt. #6. SOC 01/08/26. SN and PT. Pt. #7. SOC 02/05/25. SN and PT. The records included the form titled, “Consent Information” completed by the RN, signed by the Pt./patient’s representative, and dated with the SOC date. The “Frequency of visit:” line of the consent was left blank and the records lacked documentation that the Pt. or Pt.’s representative was notified of each discipline providing services and frequency of visits, prior to when Pt. care and services were provided. 3. Home visits were conducted on the following Pts. on 07/21/26: Pt. #1. SOC 03/17/26. Pt. #2. SOC 05/06/26. Pt. #3. SOC 02/10/26. During home visits, the patient’s admission folder was reviewed and lacked discipline and the frequency of the services to be provided. 4. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 07/22/26 at 1:30 PM and 2:30 PM, the administrative team confirmed the above findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record reviews and staff interviews, for 1 of 2 discharged clinical records reviewed (Pt. #6), the Agency failed to ensure physician orders were followed. Findings include: 1. Pt. #6 was admitted to home health services on 01/08/26 with a diagnosis of bilateral primary osteoarthritis of the knees. The clinical record was reviewed on 07/21/26. The physician order dated 01/08/26 included documentation of the frequency of SN visits: 1 time per week for 9 weeks. The record lacked documentation of an SN visit for the week of 02/15/26 to 02/21/26. The record also included a physician order for PT with a frequency of 1 time per week for 9 weeks. The record lacked documentation of PT visits for the weeks of 02/15/26 to 02/21/26, 02/22/26 to 02/28/26, and 03/01/26 to 03/07/26. Additionally, the record included a physician order dated 02/18/26 requiring referral to PT/OT/SN. The record lacked documentation of any OT visits for the entire episode. 2. During an interview with the Administrator and Agency Supervisor/Director of Nursing on 07/22/26, 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 review of the Agency’s Pt. admission folder and staff interviews, in 7 of 7 (Pts #1, 2, 3, 4, 5, 6 and 7) the Agency failed to provide information regarding the Agency Supervisor/Director of Nursing (DON), and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 07/20/26. The folder lacked information identifying the Agency Supervisor’s name and contact information. 2. The clinical records were reviewed from 07/21/26 to 07/23/26. Pt. #1. SOC 03/17/26. Pt. #2. SOC 05/06/26. Pt. #3. SOC 02/10/26. Pt. #4. SOC. 06/11/26. Pt. #5. SOC 04/10/26. Pt. #6. SOC 01/08/26. Pt. #7. SOC 02/05/25. The clinical records reviewed lacked information identifying the Agency Supervisor’s name and contact information. 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 07/022/26 at 1:30 PM, it was indicated the same admission folder is given to all Pts. The administrative staff also confirmed the above findings.”

“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 observations and interviews during a home visit, clinical record reviews, and staff interviews, for 2 of 7 patients (Pts. #1 and #7), the Agency failed to ensure that information in the clinical records was complete and accurate. Findings include: 1. Pt. #1 was admitted for home health services on 03/17/26 with a diagnosis of bilateral primary osteoarthritis of the knee. The clinical record was reviewed on 07/22/26. SN visit notes dated 05/28/26, 06/04/26, 06/11/26, and 06/18/26 included the same documentation under the sections “Interventions,” “Response to care/Progress toward goals/Plan for next visit,” and “Visit Narrative.” The record contained inaccurate and repeated documentation. 2. Pt. #7 was admitted to home health services on 02/05/25 with a diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 07/21/26. Skilled nurse visit notes dated 09/05/25, 09/10/25, 09/12/25, and 09/17/25 included the same documentation under the sections “Interventions,” “Response to care/Progress toward goals/Plan for next visit,” and “Visit Narrative.” The record contained inaccurate and repeated documentation. 3. During an interview with the Administrator and the Agency Supervisor/Director of Nursing on 07/22/26 at 2:00 PM, 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 2 discharged clinical records reviewed (Pts. #6 and #7), the Agency failed to ensure a copy of the discharge summary was sent to the physician. Findings include: 1. Pt. #6 was admitted to home health services on 01/08/26 with a diagnosis of bilateral primary osteoarthritis of the knee. The record included a discharge assessment indicating that Pt. #6 was discharged from the Agency on 03/04/26. As of the clinical record review on 07/22/26, the record lacked documentation that a copy of Pt. #6’s discharge summary was sent to the physician. 2. Pt. #7 was admitted to home health services on 02/05/25 with a diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. The record included a discharge assessment indicating that Pt. #7 was discharged from the Agency on 10/22/25. As of the clinical record review on 07/22/26, the record lacked documentation that a copy of Pt. #7’s discharge summary was sent to the physician. 3. During an interview with the Administrator and the Agency Supervisor/Director of Nursing on 07/22/26 at 2:00 PM, the above findings were confirmed.”