Integrated Home Healthcare Services, Corp

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on a review of Agency’s Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to conduct and document Staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 04/10/25 and lacked documentation that the Agency conducted Emergency Preparedness training since 2022. 2. During an interview with the Administrator and Agency Supervisor/ Clinical Manager on 04/10/25 at 1:30 PM, the Administrative Staff 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 the review of the Agency’s Error Summary report and Staff interview, it was determined in 42 of 243 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 04/01/24 thru 03/26/25, was reviewed on 04/08/25 at 11:30 AM. The report included 17.28% of the OASIS reports not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Agency Supervisor/Clinical Manager, on 04/09/25 between 11:30 AM and 12:00 PM.”

“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, it was determined that in 3 of 7 (Pts. #1, 5 and 3) clinical records reviewed, the Agency failed to ensure the notes entered into the clinical record were completely signed and authenticated. 3. Pt. #3 was admitted to Home Health Services on 01/17/25 with the diagnosis of “Unsp Trochan Fx L Femur Subs for Clos Fx w Routn Heal”. The clinical record was reviewed on 04/08/25. The clinical record contained a communication note dated 02/03/25, that lacked the clinician signature and title. 4.The above findings were confirmed, during the interview with the Agency Supervisor/Clinical Manager, on 04/09/25 between 11:30 AM and 2:00 PM and on 04/10/25 at 9:45 AM - 11:00 AM. Findings include: 1. Pt. #1 was admitted to Home Health Services on 06/29/23 with the diagnosis of Malignant Neoplasm of Upper Lobe, Right Bronchus or lung. The clinical record was reviewed on 04/08/25. The clinical record included SN visit notes dated 04/01/25 and 04/07/25, lacked the name and signature of the SN providing the care. The clinical record included HHA visit notes dated 02/10/25, 02/13/25, 02/17/25, 02/20/25, 02/24/25, 02/27/25, 03/03/25, 03/06/25, 03/10/25, 03/13/25, 03/17/25, 03/20/25, 03/24/25, 03/27/25, 03/31/25 and 04/03/25, that lacked the name and signature of the HHA providing the care. 2. Pt. 5 was admitted to Home Health Services on 11/07/24 with the diagnosis of Encounter for Surgical Aftercare following Surgery on Genitourinary system. The clinical record was reviewed on 04/09/25. The clinical record included an SN note dated 04/04/25 that lacked the name and signature of the SN providing the care.”

“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 the clinical records reviewed and Staff interview, it was determined in 3 of 7 (Pts. #2, 3, 4) clinical records reviewed, the PsOC lacked the frequency orders in the plan of care. Findings include: 1. Pt. #2 was admitted to Home Health Services on 02/08/24 with the diagnosis of “Unspecified Dementia, severe without beh/pysh/mood/anx”. The clinical record was reviewed on 04/08/25. The clinical record contained a POC dated 02/08/25 that required the PT to assess the patient. The POC lacked the frequency for the PT services, provided by the Agency 1 time a week from 03/05/25 thru 04/02/25. 2. Pt. #3 was admitted to Home Health Services on 01/17/25 with the diagnosis of “Unsp Trochan Fx L Femur Subs for Clos Fx w Routn Heal”. The clinical record was reviewed on 04/08/25. The clinical record contained a POC dated 01/17/25. The POC orders lacked the frequency for the PT services, provided by the Agency 2 times a week, from 01/19/25 thru 02/03/25. 3. Pt. #4 was admitted to Home Health Services on 02/25/25 with the diagnosis of Pulmonary Nocardiosis. The clinical record was reviewed on 04/08/25. The clinical record contained a POC dated 02/25/25 that required the PT and OT to assess the patient. The POC lacked the frequency for both the PT and OT services, provided by the Agency 2 times a week from 03/06/25 thru 03/31/25. 4. The above findings were confirmed, during the interview with the Agency Supervisor/Clinical Manager, on 04/09/25 between 11:30 AM and 2:00 PM and on 04/10/25 at 9:45 AM - 11:00 AM.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 2 of 2 (Pts. #1 and 2) of clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure that Aide provided services, as ordered by the Physician, and included in the POC. 2. Pt. #2 was admitted to Home Health Services on 02/08/24 with the diagnosis of “Unspecified Dementia, severe without beh/pysh/mood/anx”. The clinical record was reviewed on 04/08/25. The Aide provided services 2 times a week from 02/04/25 thru 04/01/25. The clinical record lacked documentation of the Aide services on the POC dated 02/02/25 -04/02/25. 3. The above findings were confirmed, during the interview with the Agency Supervisor/Clinical Manager, on 04/09/25 between 11:30 AM and 2:00 PM and on 04/10/25 at 9:45 AM - 11:00 AM. Findings include: 1. Pt. #1 was admitted to Home Health Services on 06/29/23 with the diagnosis of Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung. The clinical record was reviewed on 04/08/25. The clinical record included a POC for the certification period of 02/18/25 to 04/18/25, that lacked orders for Home Health Aide services. The Home Health Aide notes dated 02/20/25, 02/24/25, 02/27/25, 03/03/25, 03/06/25, 03/10/25, 03/13/25, 03/17/25, 03/20/25, 03/24/25, 03/27/25, 03/31/25 and 04/03/25, indicated the Home Health Aides services were provided without a Physician order.”

“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 the clinical record review and Staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) clinical records reviewed, the Agency failed to ensure a completed discharge summary was sent to the physician. 2. Pt. #7 was admitted to Home Health Services on 11/02/24 with the diagnosis of Hemiplegia following Cerebral Infarction affecting Right Dominant Side. The clinical record was reviewed on 04/08/25. The discharge assessment and discharge summary, dated 11/05/24, indicated Pt. #7 was discharged from the Agency. The record lacked documentation that the discharge summary was sent to the Physician. 3. During interviews with the Agency Supervisor/Clinical Manager on 04/09/25 at 10:30 AM and on 04/10/25 at 9:45 AM, the Agency Supervisor/ Clinical Manager confirmed the above findings. Findings include: 1. Pt. #6 was admitted to Home Health Services on 03/24/25 with the diagnosis of Malignant Neoplasm of Colon, Unspecified. The clinical record was reviewed on 04/08/25. The clinical record lacked documentation that the discharge summary dated 03/25/25 was sent to the physician.”