Prudential Home Health Corporation

“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 Emergency Preparedness Plan binder review and staff interview, the Agency failed to ensure that the Agency conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Emergency Preparedness Plan as required. Findings include: 1. The Agency’s Emergency Preparedness Plan binder was reviewed on 01/26/26. The Emergency Preparedness Plan binder included Fire drill testing exercises for the year 2023, 2024 and 2025. The Plan lacked documentation that the Agency activated the Emergency Preparedness Plan for an actual emergency or participated in a full scale/community-based testing exercise, as required. 2. During an interview with the Administrator on 01/28/26 at 2:40 PM, the Administrator confirmed the above findings.”

“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 for the last 12 months and staff interview, the Agency failed to submit 12 of 98 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 01/26/25 to 01/26/26, was reviewed on 01/26/26. The report documented 12 of 98 (12.24%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator, Agency Supervisor and Quality Assurance / Office staff on 01/27/26 at 1:30 PM, the Administrator confirmed the above findings.”

“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 records review and staff interviews, in 4 of 7 (Pts# 1,3,2 and 5) clinical records, the Agency failed to provide services included in the POC. Findings include: 3. Pt. #2 was admitted to Home Health services on 01/03/26 with diagnosis of Cerebral Infarction. The clinical record was reviewed on 01/26/26. The record included a POC for certification period 01/03/26 to 03/03/26. The POC included an order written on 01/03/26 for Physical Therapy (PT) evaluation. The clinical record lacked evidence of PT evaluation. 4. Pt. # 5 was admitted to Home Health services on 12/13/25 with diagnosis of Other specified peripheral vascular diseases. The clinical record was reviewed on 01/26/26. The clinical record included a POC for certification period 12/13/25 to 02/10/26 that required PT frequency of 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 4 weeks. The clinical record lacked PT visits weeks of 12/14/25 and 12/21/25 (weeks 2 and 3) of certification period. 5. Findings of Agency staff not providing services ordered in the PsOC were confirmed during interviews with the Administrator, Nursing Supervisor and Quality Assurance on 01/27/25 between 1:30PM and 3:00PM. 2. Pt. #3 was admitted to Home Health Services on 09/29/2025 with the diagnosis of Heart Failure. The clinical record was reviewed on 01/26/2026. The clinical record included a POC dated 12/10/2025 that included an order for Physical Therapy and Occupational Therapy to evaluate and treat. The record inlcuded a Physical Therapy Evaluation dated 12/17/2025 that ordered PT visits one time a week for six weeks. The clinical record lacked documentation PT visits were conducted the weeks of 12/29/2025 and 01/05/2026. The record also included an Occupational Therapy Evaluation dated 12/16/2025 ordering OT one time a week for six weeks. The record lacked documentation of OT visits for the weeks of 01/12/2026 and 01/19/2026. The PT and OT frequency were not followed as ordered. There were no modification orders to the visit frequencies for PT and OT in the clinical record. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included PsOC for the certification period of 11/11/25 to 01/09/25 that required: “….The skilled nurse will perform weekly weight monitoring and notify the physician for weight gain of 3 lbs in one day and/or 5 lbs in one week…” and a resumption POC for certification period of 01/10/26 to 03/10/26, that required: “….report weight gain of three pounds in a day or five pounds in a week….” The Skilled Nurse visit note dated 01/19/26, lack a weight assessment as ordered. During a home visit conducted with Employee # 4 (Registered Nurse / Date of hire 06/15/15) on 01/26/26 at 1:30 PM, there was no weight assessment, as ordered.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on home visit observation, Agency policy review and staff interview, for 1 of 3 (Pt. #1) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. During a home visit conducted with Employee # 4 (Registered Nurse / Date of hire 06/15/15) on 01/26/26 at 1:30 PM, Employee # 4 was observed to put down nursing bag on the floor next to the kitchen table in Pt. #1’s home without placing a barrier. During an interview with Employee # 4 on 01/26/26 at 2:00 PM, Employee # 4 confirmed that there was no barrier between nursing bag and the floor. 2. The Agency policy titled:” Bag Technique” was reviewed on 01/27/26 and required: “…. Procedure: 1. Spread the poly towel provided on the surface before setting the bag down….” 3. During an interview with the Administrator, Director of Nursing and Quality Assurance/Office Staff on 01/27/26 at 2:40 PM, the Administrator confirmed the above findings.”

“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 and staff interviews, in 3 of 7 (Pts. # 1, 3 and 6) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. 3. Pt # 6 was admitted to Home Health services on 09/29/25 with diagnosis of Chronic combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included a document titled “Advance Beneficary Notice of Non-coverage” signed by the patient on 09/29/25. The document was incomplete, lacked information on what service / items Medicare may not pay. 4. Finding of Agency having incomplete documentation in the clinical records was confirmed during interviews with the Administrator, Director of Nursing and Quality Assurance / Office Staff on 01/27/26 between 1:30 PM and 3:15 PM. 2. Pt. #3 was admitted to home health services on 09/29/2025 with the diagnosis of heart failure. The clinical record was reviewed on 01/26/2026. The clinical record included a form titled: “Vaccination Form”, dated and signed by Pt. #3 and nurse, and included sections for history of vaccination Patient’s response, Referral for Vaccination and Follow up remarks. These sections were incomplete. The clinical record also included the form titled: “Advance Beneficiary Notice of Non-coverage (ABN), signed by Pt. #3 and dated 09/29/2025, the form was incomplete. The section of the form that would include what was not covered was left blank. The clinical record included nursing notes dated 12/01/2025, 12/15/205, 12/29/2025 and 01/09/2026. The nursing notes documented a “Med-A-Port” to the upper right chest with a dressing that was dry and intact. The notes also included documentation the area was open to air. During an interview with the Administrator, Director of Nursing and QA/Office staff on 01/27/2026 at 2:15 PM, it was confirmed the documentation was inaccurate. The IV access could not have a dressing and be open to air at the same time. Findings include: 1. Pt. #1 was admitted to Home Health Services on 11/11/25 with the diagnosis of Chronic Diastolic Congestive Heart Failure. The clinical record was reviewed on 01/26/26. The clinical record included a form titled: “Vaccination Form”, dated and signed by Pt. #1 and nurse, and included sections for history of vaccination, Patient’s response, Referral for Vaccination and Follow up remarks. These sections that were required to be filled up, were left blank/incomplete. The clinical record also included the form titled: “Advance Beneficiary Notice of Non-coverage (ABN), signed by Pt. #1 and dated 11/11/25, lacked complete information on what is not covered, as the form required.”

“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 reviewed, home visit observation and interviews, for 2 of 7 (Pts. # 3 and 7) clinical records reviewed the Agency failed to ensure the plans of care included all pertinent interventions and medications. Findings include: . 1.The clinical record for Pt. #3 was reviewed on 01/26/26. Pt. #3 was admitted to home health on 09/29/2025 with a diagnosis of heart failure. The clinical record included a POC dated 11/28/25 that ordered SN visitis one time a week for nine weeks. The nursing notes dated 12/01/25, 12/15/25, 12/29/25 and 01/05/26 included documentation the nurse assessed the patients IV access/Med-A-Port. The plan of care lacked documented interventions for the Med-A-Port. The record included a Resumption of Care SN note dated 12/22/25. The SN note documented medication reconciled. The note inlcuded an attachment of a hospital discharge dated 12/21/25. The discharge document included a medication list that included...”aspirin 81 mg... atorvastatin 40 mg... clopidogrel 75 mg... ferrous sulfate 325 mg... furosemide 40 mg... letrozole 2.5 mg...” The Resumption of care visit narrative documented “...updated plan of care...” The POC completed on 12/22/25 lacked the above mentioned medications. A home visit was conducted on 01/27/26 at 11:15 AM with Pt. #3. During the home visit the patient confirmed the medication on the hospital medication list were her current medications. 2. The clinical record for Pt. #7 was reviewed on 01/26/26. Pt. #7 was admitted to home health services on 01/25/25 with the diagnoses of hypertension and lower back pain. The POC dated 01/25/25 through 03/25/25 ordered SN visits one time a week for one week, two times a week for two weeks and 1 time a week for six weeks. The SN visit notes dated 01/31, 02/01, 02/05, 02/08, and 02/12 all documented the patient had pain and used medication to reduce pain. The plan of care lacked documentation of medication the patient used for pain. 3. During an interview with the Administrator, the Director of Nuring and the Quality Assurance/Office Staff on 01/27/2026 at 2:15 PM, the above findings were confirmed. The plans of care lacked a complete list of medications and interventions.”