Physicians Preferred Home Health Care, Inc.

“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 meets the requirements. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/09/25. The Emergency Preparedness Plan lacked the current Agency staff Names and contact information. 2. The above finding, regarding the lack of updated communication plan was confirmed during an interview with the DON on 12/10/25 at 11:15 AM.”

“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, the Agency failed to conduct a full - scale exercise to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/09/25. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted any full-scale exercise or implemented the Emergency Preparedness since 2022. 2. During an interview with the DON on 12/10/25 at 11:30 AM, the DON confirmed that the Agency has no documentation supporting the Agency conducted a full – scale testing of the Emergency Preparedness.”

“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 interviews, in 4 of 7 (Pts. # 2, 3, 5 and 7) clinical records reviewed, the Agency failed to ensure that the Pt. / representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The following clinical records were reviewed from 12/08/25 to 12/09/25. The clinical records included a consent and verification of receipt of information/ admission agreement form by the Agency, and lacked documentation of the proposed service(s) and visit frequencies to be provided: Pt. #2 SOC: 12/05/24. Pt. #3 SOC: 07/21/25. Pt. #5 SOC: 08/25/25. Pt. #7 SOC: 07/02/25. 2. During an interview with the Director of Nursing and Office Manager on 12/10/25 at 1:30 PM, the DON confirmed the above findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical records review and staff interview, in 3 of 7 (Pts # 1, 4 and 3) the Agency failed to ensure the initial SOC assessment was conducted within 48 hours of the referral date. 3. Pt.# 3 was admitted to Home Health Services on 07/21/25 with the Diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney disease or Unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 12/09/25. The record included a Physician referral for home health services dated 07/03/25. The record included the initial SOC assessment, dated 07/21/25 (18 days after the referral date). The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 12/10/25, the record lacked documentation the Agency initiated service within the required time frame. 4. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the DON confirmed the above findings. Findings include: 1. Pt. # 1 was admitted to Home Health Services on 06/23/25 with Diagnosis of Essential primary Hypertension. The clinical record was reviewed on 12/09/25. The record included a referral for homecare with request indication for SOC 06/16/25. Pt#1 initial SOC assessment was completed 06/23/25. 7 days after the referral, no documentation was found in the clinical record indicating reason for delay in SOC assessment. 2. Pt. #4 was admitted to Home Health Services on 07/29/24 with Diagnosis of Permanent Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The clinical record was reviewed on 12/09/25. The record included a referral for homecare dated 07/24/24. Pt#4 initial SOC assessment was completed 07/29/24. 5 days after the referral, no documentation was found in the clinical record indicating reason for delay in SOC assessment”

“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 review and staff interviews, the Agency failed to ensure that, in 3 of 7 (Pts. # 2, 3 and 5) clinical records reviewed, the Plans of Care (PsOC) included Pt. specific interventions. Findings include: 1. Pt. #2 was admitted to Home Health Services on 12/05/24 with the Diagnosis of Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 12/08/25. The PsOC effective 10/01/25 to 11/29/25 and 11/30/25 to 01/28/26, required: “....Skilled Nurse to assess and instruct patient/ caregiver on signs and symptoms requiring notification of healthcare provider:….significant weight gain….” The POC lacked Pt. specific weight parameters to report to healthcare provider. 2. Pt.# 3 was admitted to Home Health Services on 07/21/25 with the Diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney disease or Unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 12/09/25. The PsOC effective 09/19/25 to 11/17/25 and 11/18/25 to 01/16/26, included that Pt. is on “Novolin N insulin” for Type 2 Diabetes Mellitus but lacked Pt. specific interventions related to blood sugar parameters and monitoring. 3. Pt. #5 was admitted to Home Health Services on 08/25/25 with the Diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/08/25. The PsOC effective 08/25/25 to 10/23/25 and 10/24/25 to 12/22/25, “....Skilled Nurse to assess and instruct patient/ caregiver on signs and symptoms requiring notification of healthcare provider:….significant weight gain….” The POC lacked Pt. specific weight parameters to report to healthcare provider. 4. During an interview with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM, the DON confirmed the above findings.”

“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: Based on clinical records review, Agency policy review and staff interviews, in 4 of 7 (Pts. #1, 3, 4 and 7) clinical records reviewed, the Agency failed to ensure that Pts. were assessed for Pneumonia vaccination status. Findings include: 1. The following clinical records were reviewed from 12/08/25 to 12/10/25. The records lacked documentation of the pneumonia vaccination assessment: Pt. #1 SOC 06/23/25. Pt. #3 SOC 07/21/25. Pt. #4 SOC 07/29/24. Pt. #7 SOC 07/02/25. 2. The Agency policy titled “Vaccinations” was reviewed on 12/09/25. The Policy required: “…. Pneumococcal pneumonia vaccination….(Agency) will administer or arrange for the administration of a pneumococcal vaccination to each patient age 65 or over who has not received this immunization prior to or upon service initiation unless medically contraindicated or refused by the patient….1. Arranging for vaccination includes referring patients to their supervising or primary physician, referral to local health department….3. Documentation shall include…. a. The assessment of need of the vaccination…b. Date of offer or referral…. c. indications/contraindications…. d. Patient education…e. Patient response, including refusal…. f. Arrangements made…. g. Follow-up activities…..” 3. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the DON confirmed the above findings.”

“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 interview, in 3 of 7 (Pts # 4, 6 and 7) clinical records the Agency failed to complete and send a transfer / discharge summary to the Physician. 3. Pt. #7 was admitted to Home Health Services on 07/02/25 with the Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 12/08/25. The clinical record included a discharge summary dated 10/29/25. The clinical record lacked evidence that the discharge summary was complete and sent to the physician. 4. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #4 was admitted to Home Health Services on 07/29/24 with Diagnosis of Permanent Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The record included a transfer summary dated 11/21/25. The clinical record lacked evidence that the transfer summary was complete and sent to the physician. 2. 2. Pt. #6 was admitted to Home Health Services on 12/16/24 with Diagnosis of Spondylosis without myelopathy. The clinical record was reviewed on 12/09/25. The record included a discharge summary dated 12/02/25. The clinical record lacked evidence that the discharge summary was complete and sent to the physician.”