Quality Home Health Care, LLC

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on clinical records review, Agency policy and document review, and staff interviews, the Agency failed to complete the complaint/grievance process and failed to inform patients of services and frequency of services provided in writing prior to SOC, This has the potential to affect all patients receiving services. Findings include: In 1 of 7 clinical records reviewed, the Agency failed to ensure the complaint/grievance was resolved and followed-up. (G432)In 3 of 7 clinical records reviewed, the Agency failed to ensure Pts. and/or Pt. representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. (434) The cumulative effect of these practices resulted in the Agency’s inability to protect patients by following through and resolving complaints, and to allow patients to make informed decisions involving their care.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on clinical record review, observation and interview during the home visit, Agency policy review and staff interview, it was determined the Agency failed to coordinate care to meet patient needs, failed to follow and obtain physican orders, and failed to include all necessary requirements in the PsOC. This has the potential to affect all Pts receiving services. Findings include: . 1. In 3 of 7 clinical records reviewed, the Agency failed to ensure PsOC were accurate and included all requirements (G574). 2. In 3 of 7 clinical records reviewed, the Agency failed to ensure physician orders were obtained or followed (G580). 3. In 1 of 7 clinical records reviewed, the Agency failed to coordinate among health care providers/staff to meet patient needs (G606). 4. In 7 of 7 clinical records reviewed, the Agency failed to provide name and contact information of Agency Supervisor (Director of Nursing) to patients (G622). The cumulative effect of these systemic practices resulted in Agency’s inability to provide and coordinate care effectively to ensure Pts. received care and services needed and ordered in the PsOC.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on clinical records review, Agency policy and document review, and staff interviews, for 1 of 7 clinical records reviewed (Pt. #6), the Agency failed to ensure that the complaint/grievance was resolved and followed-up. Findings include: 1. Pt. #6 was admitted to home health services on 05/05/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The complaint log was reviewed and included documentation of a complaint regarding Pt. #6. The clinical record was reviewed on 05/27/26. The clinical record included a communication note dated 7/15/25 with the following documentation: “Pt. was received in soiled condition and inside very hot room. Per SIL (family caregiver) he closes the door because she doesn’t want the entire house to smell bad. Patient was received with feces on his hands, feces on his bed, floor and walls. Cockroaches were visible. Patient stated he wanted the bedroom door open, SIL refused. SN let SIL know the room was brutally hot and there needed to be some airflow. A window opened; however, the patient was still confined to the bedroom in unsanitary conditions…” The Agency’s grievance form was reviewed on 05/26/26, and included the following resolution, “(Agency) contacted the Department of Aging on 07/17/25 and spoke to (staff) who handles negligence complaints and a social worker visited the patient within 72 hours.” The SN and HHA notes were reviewed on 05/27/26 and aside from the Agency reporting the complaint to Department of Aging, there was no documentation of any other steps the Agency staff took in response to the complaint. The record lacked documentation the physician, Pt., caregivers and agency staff were informed of the investigation and the actions taken to investigate the complaint. The clinical record lacked documentation the Agency followed up with the Department of Aging their action/response and the outcome of the response. 2. The Agency policy titled, “Client/Family Complaint/Grievance Policy” was reviewed on 05/28/26 and required, “The Agency must:…4. Grievances will be addressed by the department director or his/her designee and response made to the complainant within seven calendar days of receipt…all persons with a grievance will receive notice of the investigator’s review, which will include the name of the contact person, steps taken to investigate the grievance, the result of the process and the date of completion. Grievances are considered completed when an approved response has been mailed to the client.” 3. An interview was conducted with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM. The Director of Nursing stated that the follow-up was done by the intake coordinator but not documented in the clinical record and was not reported to the physician. The Director of Nursing stated that attempts were made to call Pt. #6 and caregiver to discuss the resolution but were unsuccessful. There was no documentation presented to verify attempts to contact patient or caregiver. During the same interview, the above findings were confirmed.”

“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 review of the Agency’s Pt. admission folder, clinical records, and staff interviews, in 3 of 7 (Pts. #1, 3, and 7) clinical records reviewed, the Agency failed to ensure Pts. and or patients’ representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1. The patient’s admission folder was reviewed on 05/27/26 and included the form titled, “Admission Consent”. The Agency requires the SN to complete the Admission form during the SOC visit. The form includes a section for identifying the disciplines to provide services and the frequency of their visits. 2. The following clinical records were reviewed from 05/27/26 to 05/28/26: Pt. #1. SOC 05/06/26 Pt. #3. SOC 01/06/26 Pt. #7. SOC 11/14/25 The records included the form titled, “Admission Consent” completed by the RN, signed by the Pt./patient’s representative, and dated with the SOC date. The records lacked documentation that the Pt. or Pt.’s representative was notified of each discipline providing services and frequency of visits, prior to providing Pt. care and services. 3. During an interview with the Administrator and Director of Nursing on 05/28/26 at 3:00 PM, the administrative team confirmed the above findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation during a home visit, clinical record reviews and staff interviews, for 1 of 7 clinical records reviewed (Pt. #1), the Agency failed to ensure the comprehensive assessment accurately reflects the patient’s functional status. Findings include: 1. A home visit was conducted with the HHA on 05/26/26. During the home visit, the HHA assisted Pt. #1 with transfers and ambulation. Pt. #1 was observed to be able to sit at the edge of the bed, sit on the wheelchair, toilet and shower chair, transfer from the bed to wheelchair, wheelchair to toilet and ambulate from the toilet to the shower chair. The hospital therapy notes dated 05/12/26 also included documentation Pt. #1 was able to sit with supervision and/or stand-by assistance and was able to stand up for 45 second. The clinical record was reviewed on 05/27/26. The comprehensive assessment dated 05/15/26 was completed by the RN after Pt. #1 was discharged from an in-patient facility. The assessment included the following documentation: (M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair): 6 - Unable to participate effectively in bathing and is bathed totally by another person; (M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode: 4 - Is totally dependent in toileting; (M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast: 5 - Bedfast, unable to transfer and is unable to turn and position self; Ambulation/Locomotion (M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces: 6 - Bedfast, unable to ambulate or be up in a chair. The Comprehensive assessment does not accurately reflect the patient’s current functional status. 2. The Agency policy titled, “Comprehensive client assessment” was reviewed on 05/28/26 and required, “A thorough, well-organized, comprehensive and accurate assessment, consistent with the client’s immediate needs will be completed…in a timely manner.” 3. During an interview with the Administrator and Director of Nursing on 05/28/26, the above findings 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 observation during a home visit, clinical records review and staff interviews, for 3 of 7 Pts. (Pts. #1, 6 and 7), the Agency failed to ensure that the PsOC included all requirements. Findings include: 1. Pt. #1 was admitted to home health services on 05/06/26 with the diagnosis of Type 2 Diabetes Mellitus with foot ulcer. During a home visit conducted with the Home Health Aide on 05/26/26, the following were observed: Pt. #1 was using bilateral offloading boots, had foam dressing on the sacral area, and dressings on the left foot and right toe. The clinical record was reviewed on 05/27/26. The record included a physician note dated 05/02/26 that prior to the SOC, Pt. #1 was identified to have a sacral ulcer and had the offloading boot. The POC effective 05/06/26 lacked documentation of the use and frequency of the offloading boot and lacked documentation of the sacral area pressure ulcer wound, description and its treatment. The POC also lacked documentation of the description of the wounds on the left foot and right toe area, and their corresponding wound treatments. 2. Pt. #6 was admitted to home health services on 05/05/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 05/27/26. The SN notes with the following dates 08/07/25, 08/21/25, 09/11/25 and 10/09/25 included documentation Pt. #6 had an indwelling catheter. The POC for the certification period of 09/02/25 to 10/31/25 lacked documentation of the equipment/supplies used for indwelling catheter care and maintenance. 3. Pt. #7 was admitted to home health services on 11/14/25 with the diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 05/27/26. The initial comprehensive assessment dated 11/14/25 included documentation Pt. #7 had an indwelling catheter. The POC for the certification period of 11/14/25 to 01/12/26 lacked documentation of the equipment/supplies used for indwelling catheter care and maintenance. 4. During an interview with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM, the above findings were confirmed.”

“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 clinical records reviews, Agency policy review and staff interviews, for 3 of 7 clinical records reviewed (Pts. #1, 3 and 6), the Agency failed to ensure physician orders were obtained or followed. Findings include: 1. Pt. #1 was admitted to home health services on 05/06/26 with the diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The clinical record was reviewed on 05/27/26 and included a physician order dated 05/12/26 for “additional home health services needed Occupational Therapy…Eval(uation) and Treat(ment).” The record lacked documentation that any Occupational Therapy visits were provided. The record also included a physician order dated 05/17/26 for SN services to be provided 2 to 3 times a week and PRN. The record documented one visit during the week of 05/17/26 and lacked any additional nursing visits for that week, as ordered. 2. Pt. #3 was admitted to home health services on 01/06/26 with the diagnosis of Emphysema. The clinical record was reviewed on 05/28/26 and included a physician order and POC dated 01/06/26 documenting the patient refused Physical Therapy services. The record included a PT Care Plan dated 01/13/26, and PT visits. The record lacked documentation of a physician order for Physical Therapy during this certification period. 3. Pt. #6 was admitted to home health services on 05/05/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 05/28/26 and included a POC for the certification period of 09/02/25 to 10/31/25 which required, “SN to change (indwelling) catheter every 30 days”. The SN visit notes included the following documentation: SN note dated 08/07/25: “Genitourinary, Indwelling/foley catheter date of last catheter change 05/23/25” ; SN note dated 10/09/25: “Genitourinary, Indwelling/foley catheter date of last catheter change 05/23/25.” The indwelling catheter was not changed every 30 days as ordered. The POC also required, “SN Frequency 1W9.” The record lacked documentation of an SN visit for the weeks of 09/14/25 to 09/20/25, 09/28/25 to 10/04/25 and 10/12/25 to 10/18/25. 4. The Agency policy titled “Clinical Documentation” was reviewed on 05/28/26 and required, “6) services not provided as ordered and the reason for the missed visits will be documented and reported to the physician/allowed non-physical practitioner.” 5. During an interview with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM and 3:00 PM, the above findings were confirmed.”

“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, document review and staff interviews, for 1 of 7 clinical records reviewed (Pt. #6) the Agency failed to coordinate among health care providers to address patient needs and assure factors that could affect patient safety were addressed. Findings include: 1. Pt. #6 was admitted to home health services on 05/05/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 05/27/26. The clinical record included a communication note dated 7/15/25 that included the following documentation: “Pt. was received in soiled condition and inside very hot room. Per SIL (family caregiver) he closes the door because she doesn’t want the entire house to smell bad. Patient was received with feces on his hands, feces on his bed, floor and walls. Cockroaches were visible. Patient stated he wanted the bedroom door open, SIL refused. SN let SIL know the room was brutally hot and there needed to be some airflow. A window opened; however, the patient was still confined to the bedroom in unsanitary conditions…” A grievance form was reviewed on 05/26/26, and included the following resolution, “(Agency) contacted the Department of Aging on 07/17/25 and spoke to (staff) who handles negligence complaints and a social worker visited the patient within 72 hours.” All SN and HHA notes were reviewed following the the communication note on 7/15/25 through patients discharge on 10/30/25. The notes lacked documentation of the incident, Pt. status, or resolution after the grievance was reported. The clinical record lacked coordination with the Agency administrative staff, the physician, HHA and SN related to the investigation of grievance, pt. status, and resolution. 2. An interview was conducted with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM. The Director of Nursing stated that follow-up was done by the intake coordinator but not documented in the clinical record and was not discussed with the physician or other staff. The Director of Nursing also stated that the Agency’s MSW was not sent to assess the patient. During the same interview, the above findings were confirmed.”

“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 interviews, 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 Pt. admission folder was reviewed on 05/27/26. The 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 05/26/26 to 05/28/26. Pt. #1 SOC 05/06/26 Pt. #2 SOC 03/18/26 Pt. #3 SOC 01/06/26 Pt. #4 SOC 04/25/26 Pt. #5 SOC 03/31/26 Pt. #6 SOC 05/5/26 Pt. #7 SOC 11/14/25 The clinical records reviewed lacked information identifying the Agency Supervisor’s (Director of Nursing) name and contact information. 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/28/26 at 3:00 PM, the administrative team confirmed the above findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation and interviews during a home visit, clinical records review, and staff interview, it was determined for 2 of 3 (Pt. #1 and 4) clinical records reviewed, wherein the Pt. received HHA services, the Agency failed to ensure the HHA followed the plan directed on the Aide Care Plan. Findings include: 1. Pt. #1 was admitted to home health services on 05/06/26 with the diagnosis of Type 2 Diabetes Mellitus with foot ulcer. During a home visit conducted on 05/26/26: the HHA took both offloading boots off, wrapped the left foot with a plastic bag, Pt. #1 sat on the edge of the hospital bed, assisted Pt. to stand up and transferred Pt. from the bed to the wheelchair, then from the wheelchair to the toilet, and then assisted Pt. to walk 5 feet from the toilet to sit on a shower chair and then proceeded to provide a shower. Pt. was observed to sit on the shower chair during the entire shower and was transferred to the wheelchair, assisted with dressing and transferred back to the bed. An interview with the HHA was conducted during the visit. The HHA stated that this was the first HHA visit with Pt. and the care provided is based on the instruction given by the nurse. The clinical record was reviewed on 05/27/26 and included the “HH (Home Health) Aide Care Plan” completed by the Director of Nursing and dated 05/15/26. The Plan included the documentation, “Activities permitted: Bed bound (unable to sit in a chair), Wheelchair.” The Plan also required to provide the following personal care every visit: “Bed Bath” but did not indicate instructions for the offloading boots, transfers and ambulation. The personal care provided by the Home Health Aide at the home visit was not in accordance with the Aide Care Plan. During an interview with the Director of Nursing on 05/28/26, it was stated that the Director of Nursing completes the Aide Care Plan, and it is based on the assessment of the RN. 2. Pt. #4 was admitted to home health services on 04/25/26 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 05/27/26. The record included the “HH Aide Care Plan” completed by the Director of Nursing and dated 04/25/26. The plan details required: “Weight - every visit.” The Home Health Aide notes dated 04/28/26, 05/05/26, 05/12/26 and 05/19/26 lacked documentation that Pt. #4’s weight was obtained every visit. 3. During an interview with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM, the above findings were confirmed.”

“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 a review of clinical records and staff interviews, for 2 of 3 (Pts. #4 and 6) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure that Home Health Aide supervisory visits were conducted every 14 days. Findings include: 1. Pt. #4 was admitted to home health services on 04/25/26 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 05/27/26 and included documentation Home Health Aide services were provided on 04/28/26, 05/05/26, 05/12/26 and 05/19/26. The record lacked documentation that a supervisory visit was conducted every 14 days. 2. Pt. #6 was admitted to home health services on 05/05/26 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 05/28/26 and included documentation Home Health Aide services were provided from 09/03/25 through 10/29/25. The clinical records included Home Health Aide supervisory visits on 09/15/25 and 10/21/25. The record lacked documentation that supervisory visits were conducted every 14 days as required. 3. During the entrance interview conducted with the Administrator and Director of Nursing on 05/26/26, it was stated that the Agency conducts Home Health Aide supervisory visits every 30 days. 4. During an interview with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM, the above findings were confirmed.”

“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 review of clinical records and staff interview, for 2 of 2 discharged clinical records reviewed (Pts. #6 and 7) the Agency failed to ensure a copy of the discharge summary was sent to the physician. Findings include: 1. Pt. #6 was admitted to home health services on 05/05/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The record included a discharge assessment, indicating that Pt. #6 was discharged from the Agency on 10/30/25. As of the clinical record review on 05/28/26, the record lacked documentation a copy of Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home health services on 11/14/25 with the diagnosis of Chronic Obstructive Pulmonary Disease. The record included a discharge order dated 12/22/25. As of the clinical record review on 05/28/26, the record lacked documentation a copy of Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Administrator and Director of Nursing on 05/28/26 at 11:00 AM, the above findings were confirmed.”