Home Health Connect, 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 Agency’s Emergency Preparedness Plan review and staff interview, Agency failed to update the Emergency Preparedness risk assessment every 2 years. Findings include: 1. The Agency’s Emergency Preparedness binder was reviewed on 07/07/26. The Emergency Preparedness Plan included a risk assessment with no date. No other documents were found in the binder indicating when the Agency updated the Agency risk assessment. 2. During an interview with the Administrator on 07/09/26 at 10:30 AM, the Administrator stated and confirmed that the Agency has not updated the risk assessment since 2022.”

“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 Agency’s Emergency Preparedness Plan review and staff interview, the Agency failed to have a communication plan that includes contact information of the current staff and vendors. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 07/07/26, the Emergency Preparedness Plan lacked a communication plan, that included the contact information of the current Agency staff. 2. During an interview with the Administrator on 07/09/26 at 10:30 AM, the Administrator confirmed that the Emergency Plan lacked a communication plan that includes the current Agency staff and vendors.”

“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 269 of 133 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 07/07/25 to 07/07/26, was reviewed on 07/07/26. The report documented 133 of 269 (49.44 %) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 07/09/26 at 10:45 AM, the Administrator confirmed the above findings.”

“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 Agency’s admission folder review and staff interview, Agency failed to include the Administrator contact information, in order to receive complaints from patients. Findings include: 1. On 07/07/26 the Administrator provided the Agency’s patient copy admission folder for review. The admission folder was reviewed on 07/07/26. The admission folder did not include the name and contact information of the Administrator. 2. During an interview with the Administrator on 07/10/26 at 10:45 AM, the Administrator stated and confirmed the admission folder provided for review is the same version provided for patients during admission. During the same interview the Administrator confirmed the admission folders given to patients do not include the Administrator contact information.”

“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 clinical records review and staff interview, in 4 of 7 (Pts. # 1, 2, 3, and 7) clinical records reviewed, the Agency failed to ensure Pts./representatives were informed in writing of the services provided and the frequency of visits. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 07/06/26 and included a “Patient Service Agreement” which had a section for: “Frequency of Visit Verification” the following clinical records were reviewed from 07/06/26 to 07/08/26 and “Frequency of Visit Verification” section on the admission consents lacked documentation of the services/disciplines and proposed visit frequencies. Pt #1 SOC 06/04/26 Pt #2 SOC 05/14/26 Pt #3 SOC 05/14/26 Pt #7 SOC 01/20/26 2. During staff interviews with the Administrator and alternate Director of Nursing on 07/08/26 at 11:30 AM, the administrative staff confirmed the above findings.”

“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, clinical record reviews, and staff interview, in 7 of 7 (Pts. 1 -7) clinical records reviewed, the Agency failed to provide the name and contact information of the Agency Supervisor (Director of Nursing) to Pts. or their families / representatives on admission. Findings include: 1. The Agency patient admission folder was reviewed on 07/06/26. The admission folder lacked information identifying the Agency Supervisor’s (Director of Nursing) name and contact information. 2. The clinical records of the following Pts. were reviewed from 07/07/26 to 07/08/26. Pt #1 SOC 06/04/2026 Pt #2 SOC 05/14/2026 Pt #3 SOC 05/14/2026 Pt #4 SOC 05/14/2026 Pt #5 SOC 06/22/2026 Pt #6 SOC 01/09/2026 Pt. #7 SOC 01/20/2026 The clinical records reviewed lacked information identifying the Agency Supervisor’s (Director of Nursing) name and contact information. 2. The above finding was confirmed during an interview with the Administrator, and alternate Director of Nursing on 07/08/26 at 11:00 AM.”

“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 clinical records review and staff interviews in 2 of 2 (Pts #6 and 7) discharge records, the Agency failed to send a discharge summary to the physician. Findings include: 1. Pt# 6 was admitted to home health services on 01/09/26 with Diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 07/08/26. The clinical record included a SN discharge summary dated 05/07/26. The clinical record lacked evidence that the discharge summary was sent to the physician within 5 days after patient was discharged. 2. Pt# 7 was admitted to home health services on 01/20/26 with Diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation. The clinical record was reviewed on 07/08/26. The clinical record included a SN discharge summary dated 05/19/26. The clinical record lacked evidence that the discharge summary was sent to the physician within 5 days after patient was discharged. 3. During an interview with the Administrator and alternate Director of Nursing on 07/09/26 at 10:45 AM, the above findings were confirmed.”