After Care Home Health, Inc.

“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 review of Agency’s Emergency Preparedness Plan, review of In-service binder and Staff interview, the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and In-service binders for the years 2023, 2024 and 2025 were reviewed on 09/04/25. The Agency’s Emergency Preparedness Plan and In-service binders lacked documentation that the Agency conducted Emergency Preparedness training. 2. During an interview with the Administrator, Alternate Director of Nursing and Office Manager on 09/04/25 at 11:00 AM, 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 Error Summary report and staff interview, it was determined, in the last 12 months, the Agency failed to submit 200 of 260 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 08/01/24 to 07/31/25 was reviewed on 09/02/25 at 11:30 AM. The report included error # -3330 for 200 of 260 late submissions and 76.92 % of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Administrator, Office Manager and Alternate Director of Nursing on 09/04/25 at 12:00 PM, it was confirmed that the error occurred. .”

“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, the Agency failed to ensure that the staff provided service as ordered in the POC for 3 of 7 (Pts. #1, 3 and 6 ) clinical records reviewed. 3. Pt. #1 was admitted to the Home Health Services on 01/01/25 with the diagnosis of Acute Cystitis without Hematuria and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 09/03/25. The clinical record which included the POC effective 06/30/25, required, “Orders for Discipline and Treatment…SN to Notify Physician if vital sign parameter out of range: Fasting Blood Sugar: greater than > 200 mg/dl less than 70 mg/dl. Random Blood Sugar greater than > 270 mg/dl and less than The Skilled Nursing Visit notes lacked documentation of blood glucose results for the following dates: 07/29/25, 08/15/25, 08/19/25 and 08/26/25. 4. During interviews with the Administrator, Office Manager and Alternate Director of Nursing on 09/04/25 from 11:00 AM to 1:00 PM, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to Home Health Services on 07/30/25 with the diagnosis of Hypertensive Heart disease with Heart Failure. The clinical record was reviewed on 09/03/25. The POC effective 07/30/25 to 09/27/25, required: “ SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular status….” The SN visit notes dated 08/06/25, 08/12/25 and 08/20/25, lacked weight assessments. The Alternate Director of Nursing, stated and confirmed that weight assessments are part of assessing the cardiovascular function. 2. Pt. #6 was admitted to Home Health Services on 02/21/25 with the diagnosis of Encounter for Surgical Aftercare following Surgery on Digestive system and Type 2 Diabetes with non-proliferative Retinopathy without Macular Edema. The POC effective 02/21/25 to 04/21/25, required: “Orders for Discipline and Treatment:….Fasting Blood Sugar….Random Blood Sugar….” The SN assessments dated 02/21/25 and 04/04/25, lacked Blood sugar assessments, as ordered.”

“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 a review of clinical records, observation and interview during home visit and staff interviews, the Agency failed to ensure the PsOC included Pt. specific interventions for 4 of 7 (Pts. #1, 2, 3 and 4) clinical records reviewed. 3. Pt. #1 was admitted to the Home Health Services on 01/01/25 with the diagnosis of Acute Cystitis without Hematuria and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 09/03/25 and included a POC effective 6/30/25. During a home visit conducted with a Physical Therapist on 09/03/25, it was observed that the Pt. has a continuous glucose monitoring device on the right forearm. The POC lacked documentation of the use of the continuous glucose monitoring device and the supplies and procedure needed for its care. 4. Pt. #2 was admitted to the Home Health Services on 06/27/25 with the diagnosis of Fusion of Spine, Lumbar Region, Mild Intermittent Asthma, Low back pain, and Spinal Stenosis. During a home visit conducted with a Physical Therapist on 09/04/25, it was observed that Pt. #2 was complaining of pain during the therapy session. During the home visit, the Pt. stated that Pt. was still having pain, and that Pt. had some difficulty of breathing due to asthma and the medication was recent re-started. The clinical record was reviewed on 09/04/25 and included the POC effective 06/27/25. The POC lacked documentation of individualized interventions addressing pain and pertinent diagnosis affecting Physical Therapy treatment. 5. During interviews conducted with the Administrator, Office Manager and Alternate Administrator on 09/04/25 from 11:00 AM to 1:00 PM, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to Home Health Services on 07/30/25 with the diagnosis of Hypertensive Heart disease with Heart Failure. The clinical record was reviewed on 09/03/25. The POC effective 07/30/25 to 09/27/25 and included: “Orders for Discipline and Treatment:….Fasting Blood Sugar…Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not pertinent to Pt. #3’s diagnosis. 2. Pt. #4 was admitted to Home Health Services on 07/14/25 with the diagnosis of Alcoholic Cirrhosis of Liver without Ascites. The clinical record was reviewed on 09/03/25. The POC effective 07/14/25 to 09/11/25 and included: “Orders for Discipline and Treatment:….Fasting Blood Sugar…Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not pertinent to Pt. #4’s diagnosis.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Findings include: 1. The following clinical records were reviewed on 09/03/25 and 09/04/25. The records lacked documentation of the influenza and/or pneumonia vaccination assessment: Pt. # 1. SOC 01/01/25 lacked Influenza and Pneumonia vaccination assessment Pt. # 3. SOC 07/30/25 lacked Pneumonia vaccination assessment Pt. # 4. SOC 07/14/25 lacked Pneumonia vaccination assessment Pt. #6. SOC 02/21/25 lacked Pneumonia vaccination assessment 2. The policy titled: Home Health Agency (HHA) Vaccine Policy Requirements was reviewed on 09/04/25 and required: “….4. Patient Policy…Assess vaccination status during initial assessment….Offer influenza vaccine annually and pneumococcal vaccine per CDC guidelines. Document vaccine administration or declination, including reasons, in the medical record. 3. During interviews with the Administrator, Alternate Director of Nursing and Office Manager on 09/04/25 from 11:00 AM to 1:00 PM, 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 a review of the Agency’s Pt. admission folder and Staff interview, the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. This has the potential to affect all patients admitted. Findings include: 1. The Agency Pt. admission folder was reviewed on 09/02/25. The folder lacked documentation identifying the current Clinical Manager’s name and their contact information. 2. The following home visits were conducted from 09/03/25 to 09/04/25: Pt. #1. SOC 01/01/25. Pt. #2. SOC 06/27/25. Pt. #3. SOC 07/30/25. During the home visits, the Pt. admission folders were observed and lacked the Clinical Manager, their address and phone number. 3. During an interview with the Administrator, Office Manager and Alternate Director of Nursing on 09/04/25 at 12:30 PM, it was confirmed this was the admission folder used for all admissions and that the folder lacked contact information for the current Clinical Manager. .”

“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 interview, the Agency failed to ensure a transfer/ discharge summary was sent to receiving facility and/or Physician for 2 of 2 (Pts. #6 and 7) discharged records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 02/21/25 with the diagnosis of Encounter for Surgical Aftercare following Surgery on Digestive system and Type 2 Diabetes with non-proliferative Retinopathy without Macular Edema. The clinical record was reviewed on 09/03/25. The record included a Discharge assessment and summary dated 04/04/25 and lacked documentation that the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 06/30/25 with the diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 09/04/25. The record included a Transfer Discharge assessment and summary dated 08/14/25 and lacked documentation that the transfer discharge summary was sent to the transferring facility. 3. During an interview with the Administrator, Alternate Director of Nursing and Office Manager on 09/04/25 at 11:00 AM, the Administrative staff confirmed the above findings.”