Sacred Heart Home Health, Inc.

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan, and staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 2025 was reviewed on 5/6/25. The Plan included the “Agency-Based and Community-Based Risk Assessment Hazard Vulnerability Analysis” (risk assessment), which contained potential hazardous events. The Assessment was last reviewed and updated on 1/17/25. The Assessment tool contained; “Snow/Blizzard, Tornado, Hostage Situation, Workplace Violence, Explosion, Biological, Nuclear, Trauma, Medical or Infectious, Multiple Staff Illness, Flood: Internal, Flood: External, Drought, Transportation Failure, Fuel Shortage (Gas), Supply/Equip Shortage, Building Damage, and Civil Disturbance” as possible events. The Emergency Preparedness Plan lacked policies and procedures pertaining to “Snow/Blizzard, Tornado, Hostage Situation, Workplace Violence, Explosion, Biological, Nuclear, Trauma, Medical or Infectious, Multiple Staff Illness, Flood: Internal, Flood: External, Drought, Transportation Failure, Fuel Shortage (Gas), Supply/Equip Shortage, Building Damage, and Civil Disturbance.” 2. During an interview with the Clinical Manager on 5/7/25 at 11:00 AM, the findings were confirmed.”

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 2025 was reviewed on 5/6/25. The Plan lacked documentation that the Agency conducted or participated in any table-top drill based on the Agency’s policies and procedures, full-scale exercise, facility-based exercise, or activated the Agency’s Emergency Preparedness in 2022, 2023, 2024 and 2025 (as of 5/6/25). 2. During an interview with the Clinical Manager on 5/7/25 at 11:00 AM, the above findings were confirmed.”

“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 Error Summary report and staff interview, it was determined in 21 of 117 assessments submitted for the last 12 months, the Agency failed to submit all reports timely, resulting in a warning. Findings include: 1. The Error Summary report for 5/1/24 to 5/1/25, was reviewed on 5/6/25. The report included error # -3330: 21 (17.95%) of the 117 submissions were submitted more than 30 days after the assessments were completed. 2. During an interview with the Clinical Manager on 5/8/25 at 9:30 AM, the above findings were confirmed.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record review, and staff interview, it was determined in 1 of 2 (Pt. #6) clinical records reviewed, wherein Home Health Aide services are provided, the Agency failed to ensure the RN provide written instructions to the Home Health Aide. Findings include: 1. Pt. #6 was admitted for home health services on 5/22/24 with a diagnosis of, but not limited to, Subsequent Encounter for Closed Fracture with Routine Healing Fracture of Unspecified Part of Neck of Femur. The clinical record was reviewed on 5/7/25. The clinical record included the Home Health Aide visit notes for 2 times a week from 5/28/24 to 6/28/24 indicating care was provided. As of 5/7/25, the record lacked a Home Health Aide Care Plan for the Home Health Aide to follow for providing Pt. care. 2. During an interview with the Clinical Manager, and QA on 5/7/25 at 1:18 PM, the Clinical Manager stated the RN is required to complete a Home Health Aide Care Plan, a form that contains specific Pt. care instructions to the Home Health Aide for providing personal care. During the same interview, the Clinical Manager 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 a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 5/6/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 5/7/25: Pt. #1. SOC 4/4/25. Pt. #2. SOC 5/1/25. Pt. #3. SOC 4/23/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Administrator. 3. The following clinical records were reviewed from 5/6/25 to 5/7/25: Pt. #1. SOC 4/4/25. Pt. #2. SOC 5/1/25. Pt. #3. SOC 4/23/25. Pt. #4. SOC 9/19/24. Pt. #5. SOC 1/11/25. Pt. #6. SOC 5/22/24. Pt. #7. SOC 4/17/23. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During an interview with the Clinical Manager on 5/7/25 at 11:00 AM, the above finding were confirmed.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, it was determined that in 6 of 7 (Pts. #1, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the State’s hot line contact information for home health inquiries and to lodge grievances. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 5/6/25. The folder lacked the the State’s home health telephone hot line, contact information, and business hours to file a grievance. 2. The following home visits were conducted on 5/7/25: Pt. #1. SOC 4/4/25. Pt. #3. SOC 4/23/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the State’s hot line. Interviews were conducted with the Pt./patient’s representative, they were not aware of the State hot line. 3. The following clinical records were reviewed from 5/6/25 to 5/7/25: Pt. #1. SOC 4/4/25. Pt. #3. SOC 4/23/25. Pt. #4. SOC 9/19/24. Pt. #5. SOC 1/11/25. Pt. #6. SOC 5/22/24. Pt. #7. SOC 4/17/23. The clinical records lacked documentation that the Pt./patient’s representative was provided the contact information of the State’s hotline to file a complaint or grievance. 4. During an interview with the Clinical Manager on 5/7/25 at 11:00 AM, the above finding 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 clinical record reviews, observation and interview during home visit, and staff interviews, it was determined that in 2 of 7 (Pts. #1 and 3) Pts. reviewed, the Agency failed to ensure the POC contained specific interventions related to Pt.’s diagnoses and medications. 2. Pt #3 was admitted for home health services on 4/23/25 with the diagnoses of, but not limited to, Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side, Type 2 Diabetes Mellitus With Diabetic Neuropathy Unspecified, and Long Term (Current) Use Of Insulin. A home visit was conducted on 5/7/25 with E#1. During the home visit, the medications were observed and an interview was conducted with the Pt. The medication Ozempic was observed, the box was dated 4/24/25. The Pt. confirmed the medication was started “about a month ago.” The clinical record was reviewed on 5/7/25. The record included a narrative note and Medication List handwritten by the APN, dated 4/21/25, the Medication List contained “Ozempic q wk.” The Agency’s Medication Profile form was reviewed and lacked Ozempic. The POC for the certification period of 4/23/25-6/21/25 contained an intervention for the “SN to perform medication review each skilled nursing visit and reconcile medications as indicated.” As of 5/7/25, the POC lacked the medication Ozempic. During the same home visit, the Pt. reported a wound on his second toe on his left foot and that wound care has not been performed. The Provider note on 4/21/25 contained documentation of “(L) foot ulcer (with) open wound...(L) foot open sore...order placed for wound care nurse.” The POC lacked Physician orders for wound care. The POC was incomplete. 3. During interviews with the Clinical Manager on 5/7/25 at 11:00 AM and 5/8/25 at 9:20 AM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for home health services on 4/4/25 with a diagnosis of Chronic Atrial Fibrillation, unspecified. The clinical record was reviewed on 5/7/25. The record contained a POC effective 4/4/25 to 6/2/25, included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar….Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not indicated for Pt. #1’s diagnosis.”

“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 the clinical record review and staff interviews, it was determined in 2 of 7 (Pts. # 2 and 7) clinical records reviewed, the Agency failed to ensure that services provided were ordered by the physician. Findings include: 1. Pt. #2 was admitted for home health services on 5/1/25 with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 5/6/25 and 5/7/25. The record contained an OT evaluation dated 5/3/25. As of 5/8/25, the record lacked an order for an OT evaluation. 2. Pt. #7 was admitted for home health services on 4/17/23 with a diagnosis of, but not limited to, Acute Diastolic (Congestive) Heart Failure. The closed clinical record was reviewed on 5/7/25. The clinical record included the Medical Social Work Note for an Initial Evaluation dated 4/24/23. The POC for the certification period of 4/17/23 to 6/15/23 lacked a Physician order for the Medical Social Work Initial Evaluation. As of 5/7/25, the record lacked an update to the POC requiring a Medical Social Work Evaluation. 3. During interviews with the Clinical Manager, and QA on 5/7/25 at 1:18 PM and 5/8/25 at 9:20 AM, the Clinical Manager confirmed the Agency failed to ensure services provided were ordered by the Physician or indicated in the POC.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review, Agency policy review, and staff interview, it was determined in 1 of 1 (Pt. #7) clinical record reviewed, wherein Medical Social Worker service was provided, the Agency failed to ensure there was coordination of care between care providers to ensure Pt. needs were met. Findings include: 1. Pt. #7 was admitted for home health services on 4/17/23 with a diagnosis of, but not limited to, Acute Diastolic (Congestive) Heart Failure. The closed clinical record was reviewed on 5/7/25. The clinical record included the Medical Social Work Note for an Initial Evaluation dated on 4/24/23. The Initial Evaluation contained, “Mswa to contact agency to request CNA for bathing.” The record lacked documentation that the Mswa contacted the Agency and/or the Physician to obtain a Physician’s order for the CNA. 2. The Agency policy titled; “Coordination of Patient Care” was reviewed on 5/8/25. The policy required, “…1. The Agency must… Coordinate care delivery to meet the patient’s needs… 2. The Director of Clinical Services provides oversight of all patient care services. Oversight includes: Coordinating patient care… 6. Staff provides the physician with patient information on an ongoing basis regarding…” 3. During interviews with the Clinical Manager, and QA on 5/7/25 at 1:18 PM, the Clinical Manager confirmed the Agency failed ensure care was coordinated between care providers to assure Pt. needs were met.”

“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 a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Clinical Manager. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 5/6/25. The folder lacked the Clinical Manager’s name, address, and phone number. 2. The following home visits were conducted on 5/7/25: Pt. #1. SOC 4/4/25. Pt. #2. SOC 5/1/25. Pt. #3. SOC 4/23/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Clinical Manager. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Clinical Manager. 3. The following clinical records were reviewed from 5/6/25 to 5/7/25: Pt. #1. SOC 4/4/25. Pt. #2. SOC 5/1/25. Pt. #3. SOC 4/23/25. Pt. #4. SOC 9/19/24. Pt. #5. SOC 1/11/25. Pt. #6. SOC 5/22/24. Pt. #7. SOC 4/17/23. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Clinical Manager. 4. During an interview with the Clinical Manager on 5/7/25 at 11:00 AM, it was confirmed the Agency failed to provide the Pt./patient’s representative with the Clinical Manager’s name and contact information.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on clinical record review and staff interview, it was determined in 1 of 2 (Pt. #6) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #6 was admitted for home health services on 5/22/24 with a diagnosis of, but not limited to, Subsequent Encounter for Closed Fracture with Routine Healing Fracture of Unspecified Part of Neck of Femur. The clinical record was reviewed on 5/7/25. The clinical record included the Home Health Aide visit notes for 2 times a week from 5/28/24 to 6/28/24. As of 5/7/25, the record lacked documentation of Home Health Aide supervision by the RN from 5/28/24 to 6/28/24. 2. During the entrance interview conducted on 5/6/25 at 9:34 AM, the Clinical Manager stated the RN is responsible for Home Health Aide supervision every 14 days. 3. During an interview with the Clinical Manager, and QA on 5/7/25 at 1:18 PM, the Clinical Manager confirmed the RN failed to conduct any Home Health Aide supervision between 5/28/24 to 6/28/24.”