Adoration Home Health

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to identify a process for coordination and collaboration with emergency preparedness officials for 1 of 1 agency surveyed. 1. The agency policy, “Emergency Preparedness,” last reviewed 02/09/2025, indicated the emergency plan should “4. Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness …” officials. 2. The undated agency emergency operations plan stated, “Coordination of planning and response with other healthcare organizations, public health, and local emergency management are emphasized in the plan.” The plan continued, “… In the event of a community wide emergency, the agency’s incident command structure will be integrated into and be consistent with the community command structure.” The plan continued, “This organization will coordinate fully with the Hamilton County Emergency Management Agency ….” During an interview on 01/20/2026 beginning at 05:05 PM, the Area Vice President of Operations indicated they had no documentation of any coordination or collaboration with emergency management officials.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the Governing Body failed to appoint a qualified Administrator for 1 of 1 agency surveyed. 1. During the entrance conference on 01/20/2026 beginning at 10:09 AM, the agency identified the Administrator, Clinical Manager, and alternates. Surveyor requested documentation of communication with the Indiana Department of Health regarding the change in administrator and alternate and clinical manager and alternate. 2. A review of the Internet Quality Improvement and Evaluation System identified Person 1 as the Administrator and Clinical Manager effective 08/12/2025, and Corporate Person 10 as the Alternate Administrator effective 02/01/2025. 3. Review of an agency email chain provided to this surveyor by the Corporate Human Resource Manager on 02/21/2026, with a start date of 01/09/2026. On 01/09/2026 the Corporate Home Health Regulatory Specialist indicated, “I need to get the Appointment of Administrator form approved by the governing body.” On 01/20/2026 at 09:58 AM, the Corporate Home Health Regulatory Specialist wrote “I have not had the Governing Body ‘appoint’ [Administrative Employee 1] as the Administrator and acknowledge [Administrative Employee 2 as the alternate yet ….” The email chain continued 01/20/2026 at 11:52 AM with the Corporate Home Health Regulatory Specialist writing, “I have revised the date in the attached form that [Administrative Employee 1] and [Administrative Employee 2] need to sign. I’ll have [Corporate Employee 10 ] fix the Appointment of Administrator, which [Corporate Employee 10] has been unable to get approved ….” 4. On 01/20/2026 at 12:45 PM, surveyors requested documentation of the appointment of the Administrator, Clinical Manager, and Alternates by the Governing Body. The agency did not provide evidence of the Governing Body appointment of the Administrator, Clinical Supervisor, and Alternates.”

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to review and update the EP plan at least every two years (Tag E0004); failed to review and update the EP policies and procedures at least every two years (Tag E0013); failed to develop and implement EP policies and procedures which included procedures to inform State and local EP officials about patients in need of evacuation from their residences due to an emergency situation (Tag E0019); failed to develop EP procedures to follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency (Tag E0021); failed to develop a system of medical documentation that preserves patient information, protects the confidentiality of patient information, secures and maintains the availability of medical records in an emergency situation (Tag E0023); failed to develop procedures for the use of volunteers and other emergency staffing strategies to address surge needs during an emergency situation (Tag E0024); agency failed to ensure the EP communication plan included the names and contact information for staff and patients’ physicians (Tag E0030); failed to develop an EP communication plan which included a primary and alternate means for communicating with agency staff and Federal, State, tribal, regional and local emergency management agencies (Tag E0032); failed to develop an EP communication plan which included a method for sharing information and medical documentation for patients under the agency’s care with other health providers and failed to develop a means for providing information about the general condition and location of patients under the agency’s care (Tag E0033); failed to develop an EP communication plan which included a means of providing information about the agency’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee (Tag E0034); and failed to ensure all employees completed EP training (Tag E0037). The cumulative effect of these systemic problems evidenced the home health agency’s describe a facility’s comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation, and resulted in the agency being found out of compliance with the condition 42 CFR 484.102 Emergency Preparedness.”

“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 record review and interview, the home health agency failed to ensure the patients/patient representatives received the home health agency administrator’s name and contact information to report complaints (See G414); failed to ensure patients were informed about and received the initial therapy assessment (See G434); failed to ensure patients received services as ordered in the POC (See G436); failed to follow the required steps related to discharge for cause (See G462); failed to advise the patient and the patient’s provider that discharge for cause was being considered (See G464); failed to make efforts to resolve the problems presented by the behavior of the patient’s caregiver (See G466); and failed to provide the patient or the patient’s representative with contact information for other agencies or providers (See G468). Findings include: The cumulative effect of these systemic problems had the potential to impact all 103 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.50 Patient Rights.”

“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 record review and interview, the home health agency failed to ensure the plan of care was reviewed by the attending practitioner at recertification (See G572); failed to ensure the POC included measures to address all safety concerns, accurate wound treatment orders, patient-specific interventions, and measurable outcomes and goals (See G574); failed to ensure all wound clinic orders were recorded into the POC (See G576); failed to ensure services were provided only as ordered (See G580); failed to ensure a physician or allowed practitioner reviewed and revised the POC no less frequently than once every 60 days (See G588); and failed to provide the patient and/or caregiver with accurate clinical manager information (See G622). Findings include: The cumulative effect of these systemic problems had the potential to impact all 103 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure a clinical manager was available during operating hours (See G950); failed to ensure a qualified alternate clinical manager was identified and available in the absence of the clinical manager (See G952); failed to ensure the clinical manager was involved in daily activities of the agency (See G958); failed to ensure the clinical manager oversaw patient and personnel assignments (See G960); failed to ensure the clinical manager coordinated patient care (See G962); failed to ensure the clinical manager coordinated referrals (See G964); failed to ensure the clinical manager assured patient needs were continually assessed (See G966); and failed to ensure the clinical manager assured the development, implementation, and updates of the individualized plan of care (See G968). Findings include: Policy: 1. The agency policy “Scheduling Patient Care”, last revised 12/27/22, indicated the clinical manager or designee will ensure patients are scheduled for visits in accordance with their plan of care. 2. The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager who has sufficient education and experience in the scope of services offered. This person, or a similarly qualified alternate, will be available at all times and participate in activities relevant to the services furnished, including the development of qualifications and the assignment of personnel. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 3. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency and was unsure who the alternate CM was at that time. 4. Review of CMS provider details, last updated on 12/28/23, evidenced Admin 6 as the Clinical Manager of the agency. 5. The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care & services, etc. and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 6. The review of the personnel file for RN 1 (person identified during the entrance conference as the Clinical Manager) failed to include a signed CM job description. 7. The review of the personnel file for OT 1 (person identified as alternate clinical manager) failed to include a signed alternate CM job description. The cumulative effect of these problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.105 Organization and Administration of Services.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to review and update the EP plan at least every two years for 1 of 1 agency. Findings include: Review of an agency policy titled “Emergency Management Plan” identified the most recent policy revision date as 05/20/2022. The agency failed to provide evidence that the EP plan was reviewed and updated at least every two years. During an interview on 01/10/2025 at 2:31 PM, when asked for the date of the most recent review and update to the EP plan, Administrator indicated she was unsure. The agency failed to provide further information prior to survey exit.”

“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 record review and interview, the agency failed to review and update the EP policies and procedures at least every two years for 1 of 1 agency. Findings include: Review of an agency policy titled “Emergency Management Plan” that included policy, and procedures identified the policy revision date of 05/20/2022. The agency failed to provide evidence that the EP policies and procedures were reviewed and updated at least every two years. During an interview on 01/10/2025 at 2:31 PM, when asked for the date of the most recent review and update to the EP plan, Administrator indicated she was unsure. The agency failed to provide further information prior to survey exit.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement EP policies and procedures which included procedures to inform State and local EP officials about patients in need of evacuation from their residences due to an emergency situation for 1 of 1 agency. Findings include: Review of the agency policy titled “Emergency Management Plan” failed to evidence procedures to inform State and local EP officials about patients in need of evacuation in an emergency situation. During an interview on 01/10/2025 at 2:31 PM, when asked to see the procedures to inform local and State EP officials about patients in need of evacuation, the administrator indicated that information is not in the EP binder.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop EP procedures to follow up with on-duty staff and patients to determine services that are needed, in the event there is an interruption in services during or due to an emergency for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the agency EP plan will include a means to inform state and local EP officials before, during and after an emergency of on-duty staff the agency is unable to locate, patients the agency has not been able to locate, and patients in need of evacuation. 2.Review of the EP plan failed to evidence the EP plan included procedures the agency would take to follow up with on-duty staff and patients to determine if services are needed during an emergency situation. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the procedures to take to follow up with on-duty staff and patients and to determine if services are needed during an emergency situation, the administrator indicated those procedures are not in the EP binder.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop a system of medical documentation that preserves patient information, protects the confidentiality of patient information, and secures and maintains the availability of medical records in an emergency situation for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated electronic health care records and other vital assets will be protected against loss from unexpected natural or man-made disasters. 2.Review of the EP plan failed to evidence the EP plan included procedures the agency takes in an emergency situation to preserve patient information, to protect the confidentiality of patient information, and how to secure and maintain the availability of medical records. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the agency procedure for a system of documentation to preserve patient information and to maintain confidentiality of patient information, the administrator indicated the procedure is not in the EP binder.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop procedures for the use of volunteers and other emergency staffing strategies to address surge needs during an emergency situation for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the agency will define the agency’s role with the use of volunteers, and other emergency staff to address surge needs. 2.Review of the EP plan failed to evidence procedures were developed for the use of volunteers and other emergency staffing strategies to address surge needs during an emergency situation. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the agency procedure for use of volunteers or other emergency staffing during an emergency situation, the administrator indicated the procedure is not in the EP binder.”

“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 record review and interview, the agency failed to ensure the EP communication plan included the names and contact information for staff and patients’ physicians for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the agency maintains a hard copy of the patient’s physician contact information in the event of a power failure and the names and contact information of staff. 2.Review of the EP plan failed to evidence hard copies of patient’s physician contact information and failed to evidence the names and contact information of staff. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see hard copies of patient’s physician contact information, the administrator indicated was not in the EP binder. When asked to see the names and contact information of staff, the administrator indicated was not in the EP binder.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an EP communication plan which included a primary and alternate means for communicating with agency staff and Federal, State, tribal, regional and local emergency management agencies for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the EP communication plan will include a primary and alternate means of communicating with staff, federal, state, tribal, regional and local emergency management agencies. 2.Review of the EP communication plan failed to evidence the agency developed a primary and alternate means of communicating with staff, federal, state, tribal, regional and local emergency management agencies. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the agency primary and alternate means of communicating with emergency management agencies, the administrator indicated that information was not in the EP binder.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an EP communication plan which included a method for sharing information and medical documentation for patients under the agency’s care with other health providers and failed to develop a means for providing information about the general condition and location of patients under the agency’s care for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the communication plan will include a method for sharing information and medical documentation for patients under the agency’s care and will include a means of providing information about the general condition and location of patients under the agency’s care. 2.Review of the agency’s EP communication plan failed to evidence a method for sharing information and medical documentation for patients under the agency’s care and failed to evidence a means of providing information about the general condition and location of patients under the agency’s care. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the agency procedure for sharing patient information with other health care providers, the administrator indicated that information is not in the EP communication plan.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an EP communication plan which included a means of providing information about the agency’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee for 1 of 1 agency. Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated the communication plan will include a means of providing information about the agency’s needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command, or designee. 2.Review of the agency’s EP communication plan failed to evidence a means of providing information about the agency’s needs and failed to evidence its ability to provide assistance to the authority having jurisdiction, the Incident Command, or designee. 3.During an interview on 01/10/2025 at 2:31 PM, when asked to see the procedure in the communication plan for providing info about the agency’s needs, and its ability to provide assistance, the administrator indicated that information is not in the communication plan.”

“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 record review and interview, the agency failed to ensure all employees completed EP training for 1 of 2 PT personnel files reviewed (PT 1). Findings include: 1.Review of an agency policy titled “Emergency Management Plan” indicated EP training is completed by all new and existing staff and then training is provided annually. 2.Review of the personnel file for PT 1, with hire date of 06/01/2024, failed to evidence completion of EP training. 3.During an interview on 01/10/2025 at 4:00 PM, when asked when employees complete EP training, the administrator indicated employees’ complete EP training at hire and annually.”

“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 record review and interview, the home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency. Findings include: 1. The agency policy “OASIS Collection and Transmission”, last revised 9/26/22, indicated completed OASIS date for all applicable patients will be encoded and electronically reported to CMS in a format that meets CMS electronic data and edit specification and this data will be transmitted within 30 days of the M0090 (date assessment completed) date. 2. The “OASIS Error Summary by Agency Report” evidenced a 2.63% late submission rate for the previous month of 12/02/24 to 1/02/25. This rate is higher than late submission rate of 2.14% total for the prior 11 months. 3. The “OASIS Error Detail Report” evidenced 35 late submissions (2.2%) for the period 1/02/24 to 1/02/25 as follows: On 12/02/23 an OASIS assessment of Patient #16 was completed. This assessment was transmitted on 1/17/24, 78 days later. On 10/31/23 an OASIS assessment of Patient #17 was completed. This assessment was transmitted on 1/17/24, 46 days later. On 10/20/23 an OASIS assessment of Patient #18 was completed. This assessment was transmitted on 1/29/24, 101 days later. On 11/21/23 an OASIS assessment of Patient #19 was completed. This assessment was transmitted on 4/12/24, 143 days later. On 12/31/22 an OASIS assessment of Patient #20 was completed. This assessment was transmitted on 5/03/24, 489 days later. On 1/20/23 an OASIS assessment of Patient #20 was completed. This assessment was transmitted on 5/03/24, 469 days later. On 12/21/22 an OASIS assessment of Patient #21 was completed. This assessment was transmitted on 5/20/24, 516 days later. On 12/25/23 an OASIS assessment of Patient #19 was completed. This assessment was transmitted on 5/21/24, 148 days later. On 12/29/23 an OASIS assessment of Patient #19 was completed. This assessment was transmitted on 5/21/24, 144 days later. On 1/17/24 an OASIS assessment of Patient #19 was completed. This assessment was transmitted on 5/21/24, 125 days later. On 3/15/24 an OASIS assessment of Patient #19 was completed. This assessment was transmitted on 5/21/24, 67 days later. On 11/14/23 an OASIS assessment of Patient #22 was completed. This assessment was transmitted on 5/30/24, 198 days later. On 12/27/23 an OASIS assessment of Patient #22 was completed. This assessment was transmitted on 5/30/24, 155 days later. On 11/14/23 an OASIS assessment of Patient #23 was completed. This assessment was transmitted on 6/04/24, 203 days later. On 4/27/24 an OASIS assessment of Patient #24 was completed. This assessment was transmitted on 6/07/24, 41 days later. On 7/26/23 an OASIS assessment of Patient #25 was completed. This assessment was transmitted on 6/11/24, 321 days later. On 9/20/23 an OASIS assessment of Patient #25 was completed. This assessment was transmitted on 6/11/24, 265 days later. On 1/19/24 an OASIS assessment of Patient #25 was completed. This assessment was transmitted on 6/11/24, 144 days later. On 3/09/24 an OASIS assessment of Patient #25 was completed. This assessment was transmitted on 6/11/24, 94 days later. On 6/29/24 an OASIS assessment of Patient #26 was completed. This assessment was transmitted on 8/13/24, 45 days later. On 5/10/24 an OASIS assessment of Patient #27 was completed. This assessment was transmitted on 8/23/24, 105 days later. On 6/17/24 an OASIS assessment of Patient #27 was completed. This assessment was transmitted on 8/23/24, 67 days later. On 7/04/24 an OASIS assessment of Patient #27 was completed. This assessment was transmitted on 8/23/24, 50 days later. On 7/22/24 an OASIS assessment of Patient #6 was completed. This assessment was transmitted on 8/23/24, 32 days later. On 7/27/24 an OASIS assessment of Patient #28 was completed. This assessment was transmitted on 8/28/24, 32 days later. On 6/27/24 an OASIS assessment of Patient #29 was completed. This assessment was transmitted on 8/29/24, 63 days later. On 8/31/24 an OASIS assessment of Patient #30 was completed. This assessment was transmitted on 10/18/24, 48 days later. On 9/19/24 an OASIS assessment of Patient #30 was completed. This assessment was transmitted on 10/31/24, 42 days later. On 9/20/24 an OASIS assessment of Patient #31 was completed. This assessment was transmitted on 10/31/24, 41 days later. On 9/21/24 an OASIS assessment of Patient #32 was completed. This assessment was transmitted on 10/31/24, 40 days later. On 10/17/24 an OASIS assessment of Patient #33 was completed. This assessment was transmitted on 11/19/24, 33 days later. On 11/08/24 an OASIS assessment of Patient #34 was completed. This assessment was transmitted on 12/11/24, 33 days later. On 11/20/24 an OASIS assessment of Patient #35 was completed. This assessment was transmitted on 12/24/24, 34 days later. On 11/19/24 an OASIS assessment of Patient #36 was completed. This assessment was transmitted on 12/24/24, 35 days later. On 11/22/24 an OASIS assessment of Patient #37 was completed. This assessment was transmitted on 12/27/24, 35 days later. 4. During an interview on 1/10/25 at 4:35 PM, the Administrator, who was appointed on 11/28/24, indicated the corporate department was responsible for submitting the OASIS reports and the reports are submitted multiple times daily when the home health agency is open. She was able to look up the submission errors for Patients #34, 35, 36 and 37, who were submitted late after she had been placed in the Administrator role, and she confirmed they were submitted late due to the 485 not being approved on time. She also relayed she and the Alternate Administrator were responsible for approving the 485.”

“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 record review and interview, the agency failed to ensure the plan of care was reviewed by the attending practitioner at recertification for 1 of 1 active record reviewed who didn’t have a signing practitioner (Patient #2). Findings include: 1. The agency policy “Plan of Care and Physician Orders”, last revised 1/12/24, indicated the individualized plan of care must be reviewed and revised by the physician/allowed practitioner who is responsible for the home health plan of care and the agency as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, with the start of care date and communication with the physician/allowed practitioner will be documented in the clinical record and include the name of the person spoken with who provided verbal approval of the frequency and specific orders. 2. Patient #2’s clinical record evidenced a SOC on 10/09/24, a POC for the certification period 10/09/24 to 12/07/24 and a recertification POC for the certification period 12/08/24 to 2/05/25. The original POC was created by RN 1 on 10/09/24 and evidenced Person E as the attending physician. The POC was signed on 12/28/24, 81 days after SOC. The recertification POC was created by RN 2 on 12/04/24. The POC evidenced Person F as the attending practitioner. The clinical record failed to evidence a signed recertification POC had been obtained for Patient #2. 3. During a home visit observation with Patient #2 and RN 2 on 1/03/25, Patient #2 informed RN 2 that she still does not have an attending physician and she was working on getting an in-home physician appointment scheduled for later this month. 4. During an interview on 1/09/25 at 4:13 PM, RN 1 relayed she thought Person E was the attending physician for Patient #2 at SOC and after SOC she received a call from the Entity G stating they were not the provider for Patient #2. 5. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed she left a message requesting recertification POC orders with Person F’s office on 12/04/24 and she received a call from the office stating Person F does not work there. She also relayed the clinical record failed to include documentation of the telephone calls. 6. During an interview on 1/10/25 at 2:48 PM, the Administrator was unsure who the attending provider was for Patient #2 and she was aware of the home health agency trying to establish an in-home practitioner to see the patient. She confirmed the clinical record for Patient #2 failed to include verbal or signed orders for the recertification POC.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure staff followed agency infection control policies and procedures and manufacturer’s recommendations of use related to hand hygiene and/or bag technique for 4 of 5 home visit observations (Patient #1, #2, #3, and #5). Findings include: 6.During a home visit on 01/07/2025 with Patient #5 beginning at 11:00 AM, observed OT 1 place a barrier on the floor and placed work bag on top of barrier. After completing the medication review, observed OT 1 remove gloves, apply hand sanitizer and reached into center section of unzipped work bag and removed an unlabeled zip lock bag of wipes. Observed OT 1 apply gloves and using a wipe cleaned the stethoscope, blood pressure cuff, and thermometer and held each item for one minute before placing into center section of work bag. During an interview on 01/08/2025 at 3:02 PM, when asked what type of cleaning wipes he/she carries in a zip lock bag, OT 1 indicated they were sani-wipes that he/she gets from the office and places in a zip lock bag. When asked how long he/she allows the equipment to dry after cleaning, OT 1 indicated holds each piece of equipment in his/her hand for one minute to dry and holds the blood pressure cuff for 2 minutes before placing in work bag. During a tour of the agency supply room on 01/08/2025 at 3:11 PM, observed individual packages with 80 Super Sani-Cloth wipes that read disinfects in 2 minutes. During an interview on 01/09/2025 at 11:51AM, when asked where the work bag should be placed in a patient home, the administrator indicated the bag should be placed on a barrier on a hard surface. When asked if the floor would be considered a place to set the work bag, the administrator indicated the bag is never to be placed on the floor. When asked if the nursing bag should be left open during a home visit, the administrator indicated the bag should not be left open during the visit and should be opened to remove equipment and then zipped up. During an interview on 01/09/2025 at 4:24 PM, when asked where his/her work bag should be placed in the home of Patient #5, OT 1 indicated on the floor. 5. A home visit observation of RN 2 providing care for Patient #3 was conducted on 01/07/2025 at 10:16 AM. RN 2 doffed gloves after removing wound dressing, performed hand hygiene, got more supplies from the supply bag, and then donned new gloves without first performing hand hygiene. After wound care was performed, RN 2 performed hand hygiene and then wiped the stethoscope with a Sani-wipe and immediately placed into a reusable zippered bag. RN 2 then wiped the blood pressure cuff and placed it on the clean barrier for a few seconds before placing in the zippered case. The RN then wiped the thermometer and bandage scissors with Sani-wipe and placed directly into the zippered case. During an interview on 01/07/2025 at 11:14 AM, RN 2 indicated the wet time for the Sani-wipes that were used was two minutes. During an interview on 01/07/2025 at 11:20 AM, RN 2 indicated hand hygiene should be performed upon arrival at the patient’s home, before leaving, and before and after gloves. 1. The agency policy “Hand Hygiene Procedure”, last revised 2/24/22, indicated hand hygiene should be performed at a minimum before contact with a patient and after removal of person protective equipment and an alcohol-based hand sanitizer should be used before placing on gloves and immediately after glove removal. 2. The agency policy “Bag Technique Procedure”, last revised 3/10/23, indicated the bag should be placed on a barrier and never be placed on the floor and the bag should always be closed before performing patient care. The policy also indicated when the visit is completed, reusable equipment will be cleaned using alcohol, disinfectant wipe, and/or soap and water as appropriate and placed on a clean surface. 3. During a home visit observation conducted with Patient #1 and RN 1 on 1/03/25 at 10:04 AM, RN 1 was observed using Person A’s phone to call the physician’s office. RN 1 then applied gloves to continue her assessment of Patient #1’s legs and feet. RN 1 failed to perform hand hygiene before applying gloves. RN 1 cleansed the thermometer, blood pressure cuff, stethoscope and tablet and placed the items back on the dirty barrier next to the nurse bag to dry. RN 1 failed to place the clean thermometer, blood pressure cuff and tablet on a clean barrier. RN 1 failed to cleanse the pulse oximeter. The nurse bag was also left open during the entire observation period. During an interview on 1/08/25 at 11:11 AM, RN 1 relayed hand hygiene should have been performed before and after gloves, the nurse bag should have been closed, all used vitals equipment should have been cleaned and all cleaned vitals equipment should have been placed on a clean barrier to dry. 4. During a home visit observation conducted with Patient #2 and RN 2 on 1/03/25 at 4:35 PM, RN 2 was observed to cleanse her hands with an alcohol-based hand sanitizer (ABHS) then remove her jacket and continue with the assessment of Patient #2. RN 2 failed to perform hand hygiene after removing her jacket. During an interview on 1/10/25 at 2:28 PM, RN 2 relayed hand hygiene should be performed all the time, when you arrive, before you leave and before and after glove use. 7. During an interview on 1/09/25 at 11:59 AM, the Administrator relayed hand hygiene should be performed when entering the home, every time you get into the nurse bag, between removing dirty dressing, before and after gloves, and after touching anything dirty and all clean equipment should be placed on a clean area or barrier to dry.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure a Clinical Manager had been clearly identified to provide oversight of patient care services and personnel for 1 of 1 home health agency surveyed. Findings include: 1. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 2. Review of CMS provider details, last updated on 12/28/23, evidenced Former Employee 6 was the Clinical Manager of the agency. 3. The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager who has sufficient education and experience in the scope of services offered. This person, or a similarly qualified alternate, will be available at all times and participate in activities relevant to the services furnished, including the development of qualifications and the assignment of personnel. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 4. The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care & services, etc. and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 5. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 6. During an interview on 1/02/24 at 9:02 PM, RN 2 relayed they were unsure who was the agency’s clinical manager. 7. During an interview on 1/03/25 at 8:23 AM, RN 4 relayed she thought maybe Administrator 1 was filling in as the clinical manager. 8. During an interview on 1/08/25 at 11:11 AM, RN 1 (who was listed as the Clinical Manager during the entrance conference) relayed Admin 1 was the interim Administrator and Clinical Manager. 9. During an interview on 1/08/24 at 4:12 PM, the Administrator relayed she and Alternate Administrator were both taking on the Clinical Manager role and responsibilities. 10. During an interview on 1/09/25 at 4:48 PM, ST 1 relayed she thought Administrator 1 was the clinical manager.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that all verbal orders for POCs were complete and accurate for 3 of 5 active records reviewed with home visits (Patient #2,3,5). Findings include: 2. Patient #2’s clinical record included a start of care (SOC) on 10/09/24 and a recertification POC for the certification period 12/08/24 to 2/05/25 signed by RN 2. The clinical record evidenced RN 2 performed a recertification SN visit on 12/04/24 at 1:21 PM and the POC evidenced RN 2 received a verbal order for the POC on 12/04/24 at 12:30 PM, 51 minutes prior to the recertification visit. The POC failed to include an accurate date and time for the POC verbal order. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed she did not receive a verbal order for the recertification POC for Patient #2 due to the patient not having an attending physician at the time of recertification. 3. Patient #3’s clinical record included a recertification POC for the certification period 11/29/24 to 1/27/25 signed by RN 5. The clinical record evidenced RN 5 performed a recertification SN visit on 11/27/24 at 2:04 PM and the POC evidenced RN 5 received a verbal order for the POC on 11/27/24 at 10:10 PM. The POC failed to include an accurate date and time for the POC verbal order. During an interview on 1/09/25 at 10:44 AM, Person K, an employee at Entity J, verified the hours for Physician I were 7:30 am to 4:30 pm Monday through Friday. During an interview on 1/10/25 at 10:36 AM, the Administrator relayed the verbal order for Patient #3’s POC was not received at 10:10 PM and the clinical record did not include a physician order for the POC. 1.Review of an agency policy titled “Plan of Care and Physician Orders” indicated all verbal orders will include the date and time the order was received, and the name and title of the person providing the order. 4. Review of the clinical record of Patient #5, included a POC completed by RN 5 for certification period 12/04/2024 – 02/01/2025 that indicated a verbal order was received for the POC on 12/04/2024 at 11:14 PM. In the orders section of the POC, RN 5 documented contacted office of Person N and spoke with Person O for verbal orders. Documentation failed to evidence the correct time of receiving the verbal order and failed to include the title of the person providing the order. During an interview on 01/10/2025 at 11:29 AM, when asked why the POC had the time for receiving a verbal order as 11:14 PM, the administrator indicated did not know why that time was in the POC and would expect to see the verbal order entered in the paragraph of orders with the time and who was contacted.”

“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 record review, observation, and interview, the agency failed to ensure the patients/patient representatives received the home health agency administrator’s name and contact information to report complaints for 1 of 2 home visits with SOC in the past 90 days (Patient #1, 5). Findings include: The clinical record of Patient #1 indicated the SOC date of 11/07/24. During a home observation visit on 1/03/25 beginning at 10:04 AM, observed the Patient Handbook for Patient #1 was missing the name of the current administrator to contact for complaints. During an interview on 1/03/25 at 11:26AM, Person A relayed she called Corporate Person 6 on 12/31/24 requesting a nurse visit. She stated this was her contact person for the home health agency. During an interview on 1/08/25 beginning at 4:21 PM, the Administrator relayed the admission packet should include accurate contact information for the Administrator and CM and all patients should have been notified of the current Administrator and CM contact information.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients were informed about and received their initial therapy assessment for 3 of 5 active records reviewed with a referral for therapy services in the past 90 days (Patient #1, 2 and 4) and 2 of 5 discharge records (Patient #9 and 10). 5. Review of Patient #10’s clinical record included a coordination note dated 06/13/2024 which indicated referral orders from the primary care physician included SN, PT, and OT services with a projected discharge date of 06/19/2024 from a facility and a projected SOC date of 06/20/2024. The clinical record included a POC with a SOC date of 06/20/2024. The record failed to evidence an OT and PT evaluation within 5 days of the SOC. The OT evaluation was dated 06/27/24 and the PT evaluation was completed on 07/12/2024, 22 days after SOC. The clinical record failed to evidence the patient or caregiver was informed there would be a delay in receiving the PT and OT evaluations. The complaint log included a complaint report dated 07/18/2024 which relayed a statement by Patient #10’s caregiver regarding they were told clinicians would call the first week of service and schedule their initial visit the first week on service; indicated they were not informed of a delay in therapy services. During an interview on 01/10/2025, the Administrator indicated when PT and/or OT services were ordered in the referral, the evaluations should be done within 5 days of the initial assessment and indicated the PT and OT evaluations were not completed in a timely manner for Patient #10. Review of the clinical record of Patient #4 included a POC for certification period 12/06/2024 – 02/03/2025 completed by RN 1 with orders for ST to evaluate the patient. Review of the documentation failed to evidence Patient #4 was contacted or visited by ST. During an interview on 01/08/2025 at 11:10 AM, when asked when a ST evaluation was completed, Person D indicated could not recall a ST evaluation had been done. During an interview on 01/08/2025 at 11:26 AM, when asked when ST saw Patient #4, RN 1 indicated did not see in the medical record that ST contacted or visited the patient. Findings include: 1. The agency policy “Patient Rights and Responsibilities”, last revised 9/08/22, indicated the patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to completion of all assessments, establishing and revising the plan of care, the disciplines that will furnish the care, the frequency of visits and any changes in the care to be furnished. 2. Patient #1’s clinical record included a referral received on 11/05/24 for SN, PT, OT and ST services. The record included an initial SOC assessment completed by RN 2 on 11/07/24 and a POC for the certification period 11/07/24 to 1/05/25. The POC included orders for PT and ST. The POC failed to include orders for an OT Evaluation. The record evidenced an OT Evaluation was performed on 11/19/24, 12 days after SOC and the record failed to evidence documentation that the Patient was notified of the lapse in OT services. During an interview on 1/08/25 at 2:44 PM, OT 1 relayed she thought only 2 evaluations could be plotted on the initial POC and she was unsure if the patient had been notified of the delay. During an interview on 1/08/25 at 4:12 PM, the Administrator relayed all referred services should be placed on the POC for initial evaluation and the OT evaluation should have been completed within 5 days of SOC. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed she was unsure why the OT evaluation was not listed on the POC. 3. Patient #2’s clinical record included a referral received on 10/07/24 for SN, PT, OT and ST services. The record included an initial SOC assessment completed by RN 1 on 10/09/24 and a POC for the certification period 10/09/24 to 12/07/24. The POC included orders for PT and OT evaluations. The POC failed to include orders for an ST Evaluation. The clinical record evidenced a discharge order for speech therapy dated 10/15/24 per patient request. During an interview on 1/06/25 at 4:15 PM, Patient #2 relayed he/she was not offered a ST evaluation and said he/she was told by the nurse that a ST Evaluation was not needed. Patient relayed he/she did not refuse the ST Evaluation as it had never been offered by the agency. During an interview on 1/09/25 at 4:48 PM, ST 1 relayed she was unsure if she offered a ST Evaluation to Patient #2 and she relayed she did not document the telephone conversation in the clinical record. 4. Patient #9’s clinical record included a referral received on 6/25/24 for SN, PT and OT services. The record included an initial SOC assessment completed by RN 6 on 6/28/24 and a POC for the certification period 6/28/24 to 8/26/24. The POC included orders for SN visits 1 time a week for 4 weeks; PT visits 1 time a week for 1 week and an OT visit 1 time a week for 1 week effective 6/30/24. The clinical record failed to evidence the PT and OT Evaluation visits were performed during the week of 6/30/24. The clinical record evidenced an OT Evaluation was performed on 7/09/24, 11 days after SOC and the record failed to evidence documentation that the patient was notified of the lapse in OT services. During an interview on 1/08/25 at 2:44 PM, OT 1 verified the OT Evaluation was not completed within 5 days of SOC and she was unsure the reason of the delay. During an interview on 1/08/25 at 4:12 PM, the Administrator relayed all PT and OT Evaluations should have been completed within 5 days of SOC. During an interview on 1/09/25 at 9:37 AM, PT 1 relayed he did not complete the PT Evaluation for Patient #9 as he was new to the home health agency, and he did not start seeing patients until the week of July 8th.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients received services as ordered in the POC for 6 of 10 active records reviewed (Patient #1, 2, 3, 4, 5 and 10). 7. Review of Patient #10’s clinical record included orders for a MSW evaluation for the week of 07/14/2024. A coordination note dated 07/21/2024 indicated the MSW attempted a visit and there was no answer. The record failed to evidence the agency attempts to reschedule the MSW evaluation. During an interview on 01/10/2024 at 11:00 AM, the Administrator indicated she did not see anything in the clinical record regarding follow up to reschedule Patient #10’s missed MSW evaluation. 5.A review of the clinical record of Patient #4 included a POC for certification period 12/06/2024 – 02/03/2025 that included orders for ST to evaluate the patient to determine the type, severity and prognosis of patient condition, to establish goals, treatment plan, and the frequency and duration of ST treatment. Review of documentation for Patient #4 failed to evidence ST contacted the patient/patient representative or made visit(s) to patient as ordered in the POC. During an interview on 01/08/2025 at 11:10 AM, when asked when ST completed an evaluation after 12/06/2024, Person D indicated could not say a ST evaluation was done. During an interview on 01/08/2025 at 11:26 AM, when asked what was done with the order for a ST evaluation for Patient #4, RN 1 indicated ST did not contact Patient #4. When asked what was done with the ST order if no visits were made, RN 1 indicated should have contacted the physician to discontinue. 6. A review of the clinical record of Patient #5 included a POC for certification period 12/04/2024 – 02/01/2025 that included orders for PT to evaluate the patient to determine his/her condition and to develop a PT POC and determine rehabilitative potential. Review of an RN admission assessment completed on 12/04/2024 indicated Patient #5 needed range of motion from PT. Review of documentation for Patient #5 failed to evidence PT made visit(s) as ordered in the POC. During an interview on 01/09/2025 at 10:55 AM, when asked what happened to the order for a PT evaluation for Patient #5, PT 1 indicated left voice messages and texts with Patient #5 on 12/16/2024 – 12/18/2024 with no response. PT 1 indicated PT had not made visits to Patient #5. During an interview on 01/09/2025 at 11:20 AM, when asked if the agency offered PT services, Patient #5 indicated could not remember and when asked if could benefit from PT services, Patient #5 indicated would. Findings include: 1. The agency policy “Patient Rights and Responsibilities”, last revised 9/08/22, indicated the patient has the right to receive all services outlined in the plan of care. 2. The review of Patient #1’s clinical record included a POC for the certification period 11/07/24 to 1/05/25. The POC indicated the patient was to receive PT visits 1 time a week for 1 week; 2 times a week for 4 weeks and then 1 time a week for 3 weeks effective 11/10/24. The clinical record failed to evidence Patient #1 received PT visits as ordered during the weeks of 11/24/24 and 12/01/24 and failed to evidence documentation that Patient #2 was notified of not receiving PT POC frequencies as ordered. During an interview on 1/09/25 beginning at 9:37 AM, PT 1 confirmed Patient #1 did not receive PT services as ordered on the POC during the weeks of 11/24/24 and 12/01/24. 3. The review of Patient #2’s clinical record included a POC for the certification period 12/08/24 to 2/05/25. The POC indicated the patient was to receive SN visits 3 times a week for 8 weeks effective 12/08/24. The clinical record failed to evidence Patient #2 received SN visits as ordered during the weeks of 12/22/24 and 12/29/24 and failed to evidence documentation that Patient #2 was notified of not receiving SN POC frequencies as ordered. During an interview on 1/09/25 beginning at 8:22 PM, RN 2 confirmed Patient #2 did not receive SN visits as ordered in the POC during the weeks of 12/22/24 and 12/29/24 and she was unsure if Patient #2 was notified of the missed visits. 4. The review of Patient #3’s clinical record included a POC for the certification period 11/29/24 to 1/27/25. The POC indicated the patient was to receive SN visits 1 time a week for 1 week; 2 times a week for 1 week; 3 times a week for 2 weeks; 2 times a week for 2 weeks; 3 times a week for 3 weeks and 1 time a week for 1 week effective 11/29/24. The clinical record failed to evidence Patient #3 received SN visits as ordered during the weeks of 12/08/24, 12/15/24, and 12/29/24 and failed to evidence documentation that Patient #3 was notified of not receiving SN POC frequencies as ordered. During an interview on 1/09/25 beginning at 8:22 PM, RN 2 confirmed Patient #3 did not receive SN visits as ordered in the POC during the weeks of 12/08/24, 12/15/24, and 12/29/24 and she was unsure if Patient #3 was notified of not meeting the POC frequencies.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence they met and followed their discharge policy, related to discharge for cause, for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10). 1. Review of the Transfer and Discharge policy, revised 04/26/2023, indicated “… The Agency may only transfer or discharge the patient under the following circumstances… Discharge for Cause… The Agency determines that the patient (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that staff are not safe or that delivery of care to the patient or the ability of the Agency to operate effectively is seriously impaired… The clinical record should reflect… Identification of the problems encountered… Assessment of the situation… Communication among agency management, patient caregiver, legal representative and the physician/ allowed practitioner responsible for the plan of care… a plan to resolve the issues… Results of the plan implementation… Only in extreme situations when there is a serious imminent threat of physical harm to Agency staff, the Agency may take immediate action to discharge or transfer the patient without first making efforts to resolve the underlying issue. 2. Review of Patient #10’s clinical record included, but not limited to physician orders, Coordination Notes dated 06/20/2024 through 10/04/2024, PT notes dated 08/20/2024, 08/22/2024, 08/27/2024, and 08/29/24, OT notes dated 08/23/2024 and 08/30/2024, HHA notes dated 08/23/2024 and 08/30/2024, and an RN note dated 08/23/2024. A coordination note, dated 08/08/2024, indicated Patient’s caregiver got loud and used swear words, they were upset the HHA came a day earlier than planned. Another coordination note, dated 08/08/2024, indicated Patient #10’s caregiver was upset over the agency changing the schedule without notifying nor consulting with them. The note further indicated the caregiver came in and out of the OT session, was loud and talking negatively about the agency and their personnel. A PT visit note dated 08/29/2024 indicated Patient reported to the PT that he / she got into a screaming match with his / her caregiver the previous night and the caregiver had withheld Patient’s morning medication. The note further indicated the Administrator, at the time of the visit, was notified and who indicated the situation was to be re-addressed at the next visit, 5 days later. An OT visit note dated 8/30/2024 indicated Patient’s caregiver was upset about the OT’s tardiness. The note further indicated that later in the visit the caregiver got loud and said swear words to the OT about the company and the OT. The note indicated the OT asked the caregiver to stop using those words; the caregiver continued. The note further indicated the OT then started to leave, then stopped on the porch where the caregiver apologized profusely and reported having mental issues and suicidal ideations. The note indicated the OT went back into the home and finished Patients’ care. The note further indicated the OT assured Patient not to worry, Patient apologized to the OT, that their caregiver had a lot on their plate. The note indicated the Administrator and Clinical Manager, at the time of the visit, were notified of what happened during the visit. A coordination note dated 09/04/2024, five days after Patient’s last visit by agency staff, indicated the Administrator at that time spoke with someone at the attending physician’s office in detail who agreed with the plan to discharge for cause. An order dated 09/04/2024 indicated to discharge Patient #10 for cause according to conditions of participation. The complaint log was reviewed. An entry on 07/24/2024 indicated Patient #10’s caregiver said swear words to the PT because he or she did think the PT was addressing Patient’s goals. The agency failed to document a plan to resolve the problems or attempts to resolve the problems leading to discharge for cause. The agency failed to follow the require steps for discharge for cause in the absence of serious imminent threat of physical harm to agency staff. 3. During an interview on 01/09/2025 at 4:14 PM, OT 2 indicated that after the events, recorded in her clinical note, she called the Clinical Manager at the time to report the incident and the received a call from the Administrator, at the time, who told her not to go back to Patient #10’s home. OT 2 indicated she told the Administrator at the time it was okay, that she just had some obstacles with the caregiver. OT 2 indicated that prior to this incident, she had a good communication relationship with the caregiver. 4. During an interview on 01/10/2025 at 11:00 AM, the Administrator indicated she did not see documentation Patient or their attending provider were advised discharge for cause was being considered, and couldn’t figure out from the documentation in the clinical record what was done to resolve the problems leading to the discharge for cause, and did not see in the clinical record the patient was provided with contact information for other agencies to provide care. 5. During an interview on 01/10/2025 at 2:32 PM, the previous Administrator at the time of Patient #10’s discharge, when queried about the events leading up to Patient #10’s discharge for cause, she indicated she remembered multiple reports Patient’s caregiver was aggressive, and Patient told clinicians he / she was afraid of their caregiver. IN addition, Patients caregiver was withholding medications and food, so, the clinician called the physician, who was already aware, and APS was called. RN 4 indicated Patient #10 was advised discharge for cause was being considered before it happened, she wasn’t sure when. RN 4 indicated it should be documented in the clinician’s notes, at the time, and in coordination notes. RN 4 further indicated efforts made to resolve the problems, leading to discharge for cause, included calling Patient’s physician and clinicians speaking to Patient’s caregiver, should be documented; RN 4 indicated she didn’t know where that was documented. RN 4 indicated she did not remember whether Patient was provided with contact information for other agencies, for their care.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to advise the patient and the patient’s provider that discharge for cause was being considered for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10). Findings include: 1. Review of the Transfer and Discharge policy, revised 04/26/2023, indicated “… Discharge for Cause… The Agency will advise the patient, representative (if any) the physician/ allowed practitioner issuing orders for the home health plan of care and the patient’s primary care practitioner who will be responsible for providing care and services to the patient after discharge from the Agency that a discharge for cause is being considered…” 2. Review of Patient #10’s clinical record included an order for discharge dated 09/04/2024 which indicated the discharge was due to cause according to the conditions of participation. The agency failed to advise the patient and the attending provider that discharge for cause was being considered. 3. During an interview on 01/10/2025 at 11:00 AM, the Administrator indicated she did not see documentation Patient or their attending provider were advised, discharge for cause was being considered. 4. During an interview on 01/10/2025 at 2:32 PM, the previous Administrator at the time of Patient #10’s discharge, indicated Patient #10 was advised discharge for cause was being considered before it happened, but she wasn’t sure when. RN 4 indicated it should be documented in the clinician’s notes at the time and in coordination notes.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to make efforts to resolve the problems presented by the behavior of the patient’s caregiver for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10). Findings include: 1. Review of the Transfer and Discharge policy, revised 04/26/2023, indicated “… The Agency will make every effort to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the home, or situation…The clinical record should reflect… Identification of the problems encountered… Assessment of the situation… Communication among agency management, patient caregiver, legal representative and the physician/ allowed practitioner responsible for the plan of care… a plan to resolve the issues… Results of the plan implementation…” 2. Review of Patient #10’s clinical record included a coordinated note dated 09/04/24, 5 days after the last date the patient was seen by the agency. The note indicated RN 4 spoke in detail with a person at the attending physician’s office who agreed to discharge for cause. The clinical record also included an order for discharge dated 09/04/2024 which indicated the discharge was due to cause according to the conditions of participation. The agency failed to show communication among the agency management, the patient and caregiver, the attending physician regarding the problems leading to discharge for cause and failed to include a plan to resolve the issues. 3. During an interview on 01/10/2025 at 11:00 AM, the Administrator indicated she couldn’t figure out from the documentation in the clinical record what had been done to resolve the problems leading to the discharge for cause. 4. During an interview on 01/10/2025 at 2:32 PM, the previous Administrator at the time of Patient #10’s discharge, indicated efforts made to resolve the problems leading to discharge for cause included calling the patient’s physician and clinicians speaking to the patient’s caregiver. RN 4 indicated she didn’t know where that was documented, but it should be in there.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient or the patient’s representative with contact information for other agencies or providers who may have been able to provide care for 1 of 1 patient discharged for cause in the previous six-month period (Patient #10). Findings include: 1. Review of the Transfer and Discharge policy, revised 04/26/2023, indicated “… The Agency will provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care… Evidence in the clinical record should document that the Agency provided the patient and his or her representative (if any) with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient..” 2. Review of Patient #10’s clinical record included an order for discharge dated 09/04/2024 which indicated the discharge was due to cause according to the conditions of participation. Patient #10’s clinical record failed to include evidence the patient or representative were provided with contact information for community resources or other agencies or providers that may have been able to provide services to the patient. 3. During an interview on 01/10/2025 at 11:00 AM, the Administrator indicated she did not see in the clinical record the patient was provided with contact information for other agencies to provide care. 4. During an interview on 01/10/2025 at 2:32 PM, the previous Administrator at the time of Patient #10’s discharge, indicated she did not remember whether the patient was provided with contact information for other agencies to provide care.”

“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 record review and interview, the home health agency failed to ensure patient’s wounds were measured during each initial and/or recertification comprehensive assessment (CA) for 4 of 7 active patients with wounds reviewed (Patient #3, # 6, #8, and #11). Findings include: 4.Review of the clinical record of Patient #8 identified an admission assessment, completed on 12/16/2024, by RN 2 that indicated a surgical wound to left pretibial (in front of the shin bone) leg. Documentation failed to evidence wound measurements were obtained at time of admission. During an interview on 01/10/2025 at 7:30 AM, when asked when baseline wound measurements are obtained, RN 2 indicated measurements are taken at the admission assessment. 2. Patient #3’s clinical record included a recertification CA completed on 11/27/24 by RN 5. The CA indicated the patient had wounds to the left lower leg but failed to include a wound assessment or wound measurements. During an interview on 1/10/25 beginning at 10:36 AM, the Administrator relayed wounds should have been assessed and measured during the recertification visit. 1. Review of the Comprehensive Assessment of Patients policy, revised 12/02/2022, indicated “The Comprehensive Assessment will include but not be limited to the following… The patient’s current health… status… integumentary status…” 3. Review of Patient #6’s clinical record included a recertification CA completed on 11/13/2024. The CA indicated the patient had wounds but failed to include wound measurements. During an interview on 01/10/2025 at 3:02 PM, RN 3 indicated she did not take wound measurements during Patient 6’s recertification CA on 11/13/2025 because the patient’s wounds had already been measured that week, and wounds are only measured once per week. RN 3 indicated that she would not measure the wound more than once per week, even for a CA. 5. Review of Patient #11’s clinical record included a recertification CA completed on 11/15/2024. The CA indicated the patient had a wound but failed to include wound measurements. During an interview on 01/10/2025 at 2:42 PM, RN 2 indicated she wasn’t sure why she marked unable to measure Patient #11’s wound in his CA on 11/15/24. RN 2 indicated the CA was conducted on a Friday so she would assume the patient had already had wound measured that week. RN 2 further indicated she did not think wounds needed to be measured during a recertification CA if it wasn’t the first nurse visit of the week. 6. During an interview on 01/09/2025 at 4:33 PM, the Clinical Manager indicated wounds should be measured during a CA. 7. During an interview on 01/10/2025 at 3:55 PM, the Administrator indicated wounds should be measured as part of the CA regardless of whether the wounds were measured previously that week.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure an accurate review of all medications for 3 of 4 records reviewed with home visit observations with a RN (Patient #1, 2 and 3). 4. A home visit observation of RN 2 performing care for Patient #3 was conducted on 01/07/2025 at 10:16 AM. During the visit, RN 2 reconciled the medication list against the medication bottles in the patient’s home. The RN could not locate aspirin (a medication used as a blood thinner) or Simvastatin (a medication used to lower cholesterol) in the patient’s home. Patient #3 indicated Aspirin should not be on the list because his doctor told him a while ago to never take Aspirin. The patient had 3 bottles of Atorvastatin (a medication used to lower cholesterol) in the home dated 04/05/2024, 06/27/2024, and 12/01/2024. Patient #3 indicated that was what he has been taking for cholesterol. Review of Patient #3’s clinical record included an agency medication list which included Aspirin and Simvastatin. During an interview on 01/07/2025 at 10:47 AM, RN 2 indicated the agency medication list should be checked against the medication bottles in the patient’s home at every nurse visit. Findings include: 1. The agency policy “Medication Administration & Management”, last revised 10/28/24, indicated for accuracy and to reconcile medications across continuum of care, a drug history will be taken during the start of care assessment and a comparison made between the physician’s orders and the current medication the patient is taking. Any discrepancies or contraindications must be reported to the physician for resolution. 2. Patient #1’s clinical record evidenced a start of care (SOC) on 11/07/24 and included a POC and medication list as of 1/03/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #1’s medications. During a home visit observation conducted with Patient #1 and RN 1 on 1/03/25 beginning at 10:04 AM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Trazodone (used to treat depression) 50 milligram (mg), 1 tablet daily at bedtime was found in the home. The home health agency’s medication profile failed to evidence an order for Trazodone. b) Insulin Glargine (used to treat diabetes) 10 units daily at bedtime. The home health agency’s medication profile failed to evidence the dose Patient #1 has been taking. During an interview on 1/03/25 beginning at 11:26 AM, Person A reports Patient #1 has been taking Trazodone 50 mg and 12 units of Insulin Glargine at bedtime for several months now. During an interview on 1/08/25 beginning at 11:11 AM, RN 2 relayed she reconciled medications during every visit. During record review on 1/8/25 it was noted that a physician order had been created by RN 1 on 1/8/25 at 3:35 PM to change the Insulin Glargine dose to 12 units at bedtime. During an interview on 1/9/25 beginning at 11:59 AM, the Administrator relayed the nurse should have collaborated with the physician for correct insulin dosage orders. 2. Patient #2’s clinical record evidenced a start of care (SOC) on 10/09/24 and included a POC and medication list as of 1/03/25. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #2’s medications. During a home visit observation conducted with Patient #2 and RN 2 on 1/03/25 beginning at 4:35 PM, Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Dakin’s solution (used to treat wounds) 0.125% daily for wound care was listed on the home health agency’s medication profile. This wound treatment solution was not in the home. The home health agency’s medication profile failed to evidence a discontinue order for Dakin’s solution. During an interview on 1/10/25 beginning at 2:28 PM, RN 2 relayed she reviewed medications and treatments orders during every visit and was unsure why the Dakin’s solution was listed on the medication profile as it has not been used for wound care. 3. During the entrance conference on 1/02/25 beginning at 9:53 AM, the Administrator relayed medications should be reconciled during every visit.”

“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, record review, and interview, the home health agency failed to ensure the POC included measures to address all safety concerns, accurate wound treatment orders, patient-specific interventions, and measurable outcomes and goals for 5 of 10 active records reviewed (Patient #1, 2, 3, 5 and 8). 5.Review of the clinical record of Patient #5 included a POC for certification period 12/04/2024 – 02/01/2025 that included the following goals: Patient/caregiver will verbalize/demonstrate understanding of fall prevention/safety by 02/05/2025 and urinary tract infection will be identified and measures to resolve infection implemented promptly by 2/4/25. The POC failed to evidence measurable goals. During an interview on 01/09/2025 at 11:51 AM, when asked how the following goals were measurable: Patient/caregiver will verbalize/demonstrate understanding of fall prevention/safety by 02/05/2025 and urinary tract infection will be identified and measures to resolve infection implemented promptly by 2/4/25, the administrator indicated the goals should include what is discussed with the patient. 6. Review of the clinical record of Patient #8 included a POC for certification period 12/16/2024 – 02/13/2025 that included orders for the SN to perform surgical wound care and included a goal, patient will demonstrate improved decubitus ulcer status. The POC failed to evidence the SN frequency for performing wound care and failed to include a goal with the correct type of wound. During an interview on 01/09/2025 at 9:23 AM, when asked how often the wound dressing is changed for his/her family member, Person C indicated the wound dressing is changed every three days and that he/she changes the wound dressing on the days the RN doesn’t visit. During an interview on 01/10/2025 at 7:30 AM, when asked how often wound care is performed, RN 2 indicated wound care is done three times a week. When asked if Patient #8 had a decubitus ulcer, RN 2 indicated no. When asked if the goal to demonstrate an improved decubitus ulcer status is correct, RN 2 indicated that’s not correct. Findings include: 1. The agency policy “Plan of Care and Physician Orders”, last revised 1/12/24, indicated the individualized POC must include safety measures to protect against injury, patient-specific interventions and education, patient-specific measurable outcomes and goals, treatments/orders and expected patient outcomes/goals. 2. Patient #1’s clinical record included a SOC assessment completed on 10/07/24 by RN 2. The assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking an anticoagulant. The POC for Patient #1 for the certification period of 10/07/24 to 1/05/25, created by RN 1, failed to evidence safety measures for anticoagulant precautions and failed to include updated goals and interventions. During an interview on 1/09/25 at 4:13 PM, RN 1 relayed the POC for Patient #1 should have included bleeding precautions and she verified the POC included expired goals and interventions. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed the POC goals and interventions should have been updated to reflect current dates and all goals and interventions should have an expiration date. 3. Patient #2’s clinical record included a recertification POC for the certification period of 12/08/24 to 2/05/25, created by RN 2. The POC failed to include measurable goals with end dates. The POC evidenced SN visit frequencies of 3 times a week for 8 weeks and wound treatment orders of every other day. During an interview on 1/08/25 at 4:12 PM, the Administrator relayed wound care should be performed every other day as ordered on the POC. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed the home health agency was seeing Patient #2 Monday, Wednesday and Friday and the wound treatment order should be changed to reflect these days. She also relayed the POC goals should be measurable with an expiration date. 4. Patient #3’s clinical record included a recertification POC for the certification period of 11/29/24 to 1/27/25, created by RN 5. The POC evidenced a goal as follows: patient/caregiver will demonstrate wound care and improved wound status as evidenced by a decrease in size/drainage of wound, no s/s of infection, and decreased pain within 30 days. The POC failed to evidence this goal had been updated as of 1/08/25. During an interview on 1/08/25 at 11:11 AM, RN 1 relayed she was not the case manager for Patient #3 and she relayed each team member is responsible for updating goal end dates. During an interview on 1/10/25 at 10:36 AM, the Administrator confirmed the wound goal for Patient #3 has expired and should have been updated. 7. During an interview on 1/08/25 at 11:11 AM, the Administrator relayed all clinicians who see the patient are responsible for update the POC goals, interventions and dates.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all wound clinic orders were recorded into the POC for 1 of 2 active patients reviewed with wound clinic orders (Patient #3). Findings include: 1. The agency policy “Coordination of Care”, last revised 10/19/22, indicated the agency will coordinate care by integrating orders from all physicians/allowed practitioners involved in the POC to assure the coordination of all services and interventions provided to the patient. 2. The agency policy “Plan of Care and Physician Orders”, last revised 1/12/24, indicated all patient care orders, including supplemental, orders are part of the POC. 3. Patient #3’s clinical record included updated wound care treatment orders received from Entity H dated 12/24/24 and 1/03/25. The clinical record failed to include the updated wound care orders effective 12/24/24 and 1/03/25. 4. During an interview on 1/08/25 at 11:11 AM, RN 1 relayed all outside wound clinic orders should be implemented by the nurse who sees the patient at the next visit. 5. During an interview on 1/08/25 at 4:12 PM, the Administrator relayed when wound clinic orders are received at the home health agency, they are sent to nurse to transcribe into the POC and the nurse who saw the patient after the wound clinic appointment should have updated any orders received from the wound clinic. 6. During an interview on 1/10/25 at 2:04 PM, RN 1 relayed she did not integrate the 12/24/24 wound clinic orders into the POC due to not having the treatment medication Gentamycin in Patient #3’s home. 7. During an interview on 1/10/25 at 2:28 PM, RN 2 relayed she did not integrate the 1/03/25 wound clinic orders into the POC until 1/09/25.”

“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 record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 3 of 10 active patient records reviewed (Patient #2, 3 and 15). 4.Review of the clinical record for Patient #15 with SOC date 12/18/2024 included a POC completed by OT 1, for certification period 12/18/2024 – 02/15/2025 with a narrative that indicated Person L was contacted for verbal orders on 12/18/2024 with no time of contact documented. The POC included orders for OT visits once a week for eight weeks. Review of visits made to Patient #15 indicated an OT visited on 12/18/2024 and completed the SOC OASIS assessment, and an OT visited on 12/26/2024 and on 01/02/2025. Documentation failed to evidence orders were received to provide OT services. During an interview on 01/09/2025 at 4:24 PM, when asked when Person L was contacted for verbal orders for SOC, OT 1 indicated had sent email to Person L and received no response. During an interview on 01/10/2025 at 11:29 AM, when asked to see the verbal orders to begin OT services for Patient #15, the administrator indicated there was no verbal order and when asked to see where Person L signed orders to provide OT, the administrator indicated there were no signed orders, and when asked if OT was providing care without an order, the administrator indicated yes. Findings include: 1. The agency policy “Plan of Care and Physician Orders”, last revised 1/12/24, indicated the individualized plan of care must be reviewed and revised by the physician/allowed practitioner who is responsible for the home health plan of care and the agency as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, with the start of care date and communication with the physician/allowed practitioner will be documented in the clinical record and all verbal orders will include the date and time the order was received, the name and title of the person providing the order, the reason for the order and the specific orders received. 2. Patient #2’s clinical record included a POC for certification period 12/08/24 to 2/05/25 with orders for SN visit frequencies of 3 visits a week for 8 weeks; 2 visits a week for 1 week effective 12/08/24. The record evidenced SN visits were performed on 12/09/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, 12/20/24, 12/23/24, 12/27/24, 12/30/24 and 1/03/25. The clinical record for Patient #2 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed the clinical record for Patient #2 does not include a verbal order for the POC frequencies due to Patient #2 not having an attending physician. During an interview on 1/10/25 at 2:48 PM, the Administrator was unsure who the attending provider was for Patient #2 and she was aware of the home health agency trying to establish an in-home practitioner to see the patient. She confirmed the clinical record for Patient #2 failed to include verbal or signed orders for the recertification POC. 3. Patient #3’s clinical record included a POC for certification period 11/29/24 to 1/27/25 with orders for SN visit frequencies of 1 visit a week for 1 week; 2 visits a week for 1 week; 3 visits a week for 2 weeks; 2 visits a week for 2 weeks; 3 visits a week for 3 weeks and 1 visit a week for 1 week effective 11/29/24. The record evidenced SN visits were performed on11/29/24, 12/02/24 and 12/04/24. The clinical record for Patient #3 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visits performed. During an interview on 1/10/25 at 10:36 AM, the Administrator verified the clinical record for Patient #3 did not include a verbal order for the POC frequencies and SN visit performed above.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a physician or allowed practitioner reviewed and revised the POC no less frequently than once every 60 days, beginning with the start of care date for 3 of 4 active records reviewed that received SN, PT, and OT services (Patient #2, 4, 11). Findings include: 4. Review of Patient #11’s clinical record failed to evidence the physician or allowed practitioner was provided with a 60-day summary of the patient’s status. During an interview on 01/10/2025 at 4:17 PM, the Patient Care Secretary relayed the Administrator did not have fax confirmation of a 60-day summary being sent to Patient #11’s provider. 3. Patient #2’s clinical record evidenced a SOC on 10/09/24 and included a POC for certification period 12/08/24 to 2/05/25. The record failed to include documentation of collaboration with the physician for the recertification POC and failed to evidence a 60-day summary was provided to an attending physician for Patient #2. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed she left a message requesting recertification POC orders with Person F’s office on 12/04/24 and she received a call from the office stating Person F does not work there. She also relayed the clinical record failed to include documentation of the telephone calls and she was unsure what a 60-day summary was and she thought the previous Administrator or Clinical Manager created this for all patients. During an interview on 1/10/25 at 2:48 PM, the Administrator was unsure who the attending provider was for Patient #2 and she was aware of the home health agency trying to establish an in-home practitioner to see the patient. She confirmed the clinical record for Patient #2 failed to evidence collaboration with the physician for the recertification POC orders. 1.Review of an agency policy titled “Coordination of Care” indicated a written summary report for each patient will be sent to the physician at least every two months. 2. Review of the clinical record of Patient #4 for recertification period 12/06/2024 – 02/03/2025 failed to evidence the physician or allowed practitioner was provided with a 60-day summary of Patient #4 status. During an interview on 01/08/2025 at 11:26 AM, when asked where the 60-day summary would be for the certification period that began 12/06/2024, RN 1 indicated she was not sure that 60-day summaries were being done and sent to the physician.”

“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 observation, document review and interview, the home health agency failed to provide the patient and/or caregiver with accurate clinical manager information for 2 of 2 active patients with home visit observations who have been admitted in the past 60 days (Patient #1 and 5). Findings include: 1. During a home visit observation with Patient #1 on 1/03/25 beginning at 10:04 AM, the home health agency’s folder was reviewed and failed to evidence the correct name and contact information of the clinical manager. During an interview on 1/08/25 beginning at 4:21 PM, the Administrator relayed the admission packet should include accurate contact information for the CM and all patients should have been notified of the current CM contact information. 2.A review of the clinical record of Patient #5 indicated the SOC date of 12/04/2024. During a home observation visit on 01/07/2025 beginning at 11:00 AM, observed the Patient Handbook for Patient #5 was missing the name and contact information of the current clinical manager. During an interview on 01/10/2025 at 10:55 AM, when asked what clinical manager contact information should be in the patient handbook for a patient with a SOC date on 12/4/2024, the administrator indicated it should be the current clinical supervisor. Findings include: 1. During a home visit observation with Patient #1 on 1/03/25 beginning at 10:04 AM, the home health agency’s folder was reviewed and failed to evidence the correct name and contact information of the clinical manager. During an interview on 1/08/25 beginning at 4:21 PM, the Administrator relayed the admission packet should include accurate contact information for the CM and all patients should have been notified of the current CM contact information. 2. A review of the clinical record of Patient #5 indicated the SOC date of 12/04/2024. During a home observation visit on 01/07/2025 beginning at 11:00 AM, observed the Patient Handbook for Patient #5 was missing the name and contact information of the current clinical manager. During an interview on 01/10/2025 at 10:55 AM, when asked what clinical manager contact information should be in the patient handbook for a patient with a SOC date on 12/4/2024, the administrator indicated it should be the current clinical supervisor.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient’s wounds were measured accurately and/or at least weekly for 2 of 7 active patients with wounds reviewed (Patient #3 and #7) and the RN failed to adequately assess heart tones, lungs and bowel sounds for 1 of 4 RN home visit observations (RN 2). Findings include: 3. During a home visit observation conducted with Patient #2 and RN 2 on 1/03/25 at 4:35 PM, observed RN 2 assess Patient #2’s pulse at the radial site for 15 seconds. RN 2 failed to assess Patient #2’s heart tones, lung sounds and bowel sounds during the home visit observation. During an interview on 1/10/25 at 2:28 PM, RN 2 relayed heart tones, lung sounds and bowel sounds should be assessed every visit. 4. Review of Patient #3’s clinical record included SN visit notes from the period 11/10/24 to 01/07/25. The SN notes failed to include wound measurements for the weeks of 11/24/24 and 12/22/24. During an interview on 1/08/25 at 11:11 AM, RN 1 relayed wounds should be measured weekly or if any changes in the wound. During an interview on 1/10/25 at 10:36 AM, the Administrator relayed wounds should have been assessed and measured during the recertification visit and she confirmed the SN visits notes for the weeks of 11/24/24 and 12/22/24 did not include wound measurements. 1. Review of the Wound Care policy, revised 07/06/2022, indicated “… Wounds will be assessed weekly, and per physician orders...” 2. Review of Patient #7’s clinical record included SN visit notes from the period 1/14/2024 to 01/04/2024. The SN notes failed to include wound measurements for the week of 12/08/2024 to 12/14/2024 and for the week of 12/29/2024 to 01/04/2025. During an interview on 01/09/2025 at 4:33 PM, RN 1 indicated she said in a previous interview that wounds were to be measured weekly, but she thinks the policy is every two weeks. RN 1 relayed she tries to measure wounds weekly or if there is a change in status. RN 1 relayed there were missing wound measurements because the patient was difficult to position. During an interview on 01/10/2025 at 3:55 PM, the Administrator relayed Patient #7’s wounds were not measured at least weekly from wound onset of 11/26/2024. The Administrator indicated she would have to read all of the patient’s nursing notes to see why the wounds were not measured.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, record review and interview, the RN failed to provide wound care as ordered for 2 of 3 home visit observations with a RN providing wound care (Patient #2 and 3). A home visit observation of RN 2 providing care for Patient #3 was conducted on 01/07/2025 at 10:16 AM. RN 2 performed wound care during the visit. While performing wound care to Patient’s left leg wound, RN 2 applied Hydrofera Blue (a foam dressing) to the wound bed. The nurse failed to provide wound care as ordered in the agency’s POC. During an interview on 1/10/25 at 2:28 PM, RN 2 relayed she did not integrate the 1/03/25 wound clinic orders into the POC until 1/09/25. Findings include: 1. The agency policy “Wound Care”, last revised 7/26/22, indicated wound care provided will be consistent with physician orders. 2. During a home visit observation conducted with Patient #2 and RN 2 on 1/03/25 at 4:35 PM, RN 2 was observed performing wound care to Patient #2’s wounds. RN 2 used a skin-prep wipe (used to prepare damaged or intact skin for attachment sites, tapes, films, and adhesive dressings) before applying the cover dressing. RN 2 failed to follow the wound treatment orders as identified in the POC. During an interview on 1/09/25 at 8:22 PM, RN 2 relayed she used the skin prep because it was available in the home. RN 2 looked back in the clinical record to see if Patient #2 had a previous order for skin prep and verified the clinical record did not include an order to use skin prep. 3. Patient #3’s clinical record included a plan of care, signed by Person I, a physician. The POC failed to evidence orders could be received from other physicians or providers. The POC indicated the wound care to be performed included applying Fibracol Plus (a collagen wound dressing) as a primary dressing, then Algisite M (a calcium alginate dressing) as a secondary dressing. The record included wound care treatment orders received from Entity H, a wound clinic, dated 1/03/25. The orders indicated wound care to be performed included applying Hydrofera Blue as the only dressing directly on the wound bed. The clinical record failed to evidence home health orders could be accepted from Entity H and failed to evidence an order from the attending physician for the updated wound care treatment.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to maintain documentation which demonstrates the HHA completed a skills competency evaluation prior to caring for agency patients for 1 of 1 HHA reviewed (HHA 1). Findings include: 1. Review of the Orientation and Training policy, revised 09/08/2022, indicated “Home Health Aides… The Agency must ensure that skills learned or tested elsewhere can be transferred successfully to the care of the patient in their place of residence…” 2. Review of the Personnel Records policy, revised 05/30/2024, indicated “… Personnel files, whether hard copy or electronic, for staff employed by the organization will include, but not be limited to… Verification of initial and ongoing competency as required for position…” 3. Review of HHA 1’s personnel file failed to include an initial skills competency evaluation. 4. During an interview on 01/08/2025 at 12:28 PM, Corporate Human Resources (HR) Staff 1 indicated the file she had did not include a skills competency test for HHA 1. 5. During an interview on 01/10/2025 at 4:54 PM, the Administrator indicated all available requested HR documentation had been provided.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on record review and interview the Administrator failed to ensure a clinical manager was identified and available to all staff and patients in the role of CM for 1 of 1 home health agency surveyed. Findings include: During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the clinical manager of the home health agency. 2.The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager. This person, or a similarly qualified alternate, will be available at all times. 3. The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care and services, and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 4. Review of CMS provider details, last updated on 12/28/23, evidenced Former Employee 6 was the last known clinical manager of the agency. 5. During an interview on 1/02/24 at 9:02 PM, RN 2 relayed they were unsure who was the agency’s clinical manager. 6. During an interview on 1/03/25 at 8:23 AM, RN 4 relayed she thought maybe Administrator 1 was filling in as the clinical manager. 7. During an interview on 1/08/25 at 11:11 AM, RN 1 (who was listed as the Clinical Manager during the entrance conference) relayed Administrator 1 was the interim clinical manager. 8. During an interview on 1/09/25 at 4:48 PM, ST 1 relayed she thought Administrator 1 was the clinical manager.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview the Administrator failed to ensure a qualified alternate clinical manager was identified and available in the absence of the clinical manager for 1 of 1 home health agency surveyed. Findings include: 1.The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager who has sufficient education and experience in the scope of services offered. This person, or a similarly qualified alternate, will be available at all times and participate in activities relevant to the services furnished, including the development of qualifications and the assignment of personnel. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 2.The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care & services, etc. and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 3. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator was unable to identify an alternate clinical manager of the home health agency. 4. During an interview on 1/02/25 at 2:50 PM, the Administrator relayed OT 1 was the alternate clinical manager. 5. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified OT 1 as the Alternate Clinical Supervisor. 6. During an interview on 1/08/25 at 2:44 PM, OT 1 relayed she was asked by Corporate Person 1 to be the alternate clinical manager on 1/02/25 after survey had begun. She relayed she had not signed a job description and had not had any training yet. 7. Review of the OT 1’s personnel record failed to include an Alternate CM job description and/or orientation to the Alternate CM position. 7. During an interview on 1/10/25 at 10:36 AM, when questioned by Surveyor if OT 1 was qualified to be the alternate clinical manager, the Administrator stated, “we deemed her competent to be the alternate clinical manager.””

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on record review and interview the Clinical Manager failed to oversee patient and personnel assignments to ensure the patient received all services according to the plan of care for 6 of 10 active records reviewed (Patient #1, 2, 3, 4, 5, and 10). Findings include: 1. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 2. The agency policy “Scheduling Patient Care”, last revised 12/27/22, indicated the clinical manager or designee will ensure patients are scheduled for visits in accordance with their plan of care. 4. The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager. This person, or a similarly qualified alternate, will be available at all times and participate in activities relevant to the services furnished, including the assignment of personnel. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 5. The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care and services, and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 6. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 7. During an interview on 1/02/25 at 8:46 PM, RN 1 (who was listed as the Clinical Manager during the entrance conference) relayed Corporate Persons 1 and 2 oversee scheduling for the home health agency. She reported the Corporate Persons work remotely. 8. During an interview on 1/10/25 at 3:58 PM, the Administrator relayed Corporate Persons 1 and 2 oversee scheduling for the home health agency. 9. The review of clinical records for Patients #1, 2, 3, 4, 5, and 10 failed to evidence the patients received services as ordered in the POC. See Tag G436 for additional findings.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the Clinical Manager oversaw the coordination of care for all patients discharged for cause for 1 of 1 records reviewed of a patient discharged for cause (Patient #10). Findings include: 1. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 2. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 3. During an interview on 1/10/25 at 3:58 PM, the Administrator relayed she and the Alternate Administrator oversee patient care at the home health agency office. 4. The review of Patient #10’s clinical record evidenced the Clinical Manager failed to ensure the agency followed its policy and completed all required steps prior to discharging a patient for cause. See Tag G462 for further findings.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the Clinical Manager coordinated referrals to ensure patients were informed of and received all initial therapy assessments for 3 of 5 active reviewed with a referral for therapy services in the past 90 days (Patient #1, 2, 4) and 2 of 5 discharge records reviewed (Patient #9, 10). Findings include: 1. The agency policy “Referral and acceptance of Patients”, last revised 6/16/23, indicated referral information will be evaluated by the clinical manager or designees to determine appropriateness for home care. 2. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 3. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 4. During an interview on 1/10/25 at 3:58 PM, the Administrator relayed all referrals are processed by the central intake team and then reviewed by the Administrator, Alternate Administrator or Corporate Person 1 and the clinical manager does not have any oversight of referrals for the home health agency. 5. The review of clinical records for Patients #1, 2, 4, 9, and 10 failed to evidence the Clinical Manager oversaw the coordination of referrals to ensure patients were informed of and received all initial therapy assessments. See Tag G434 for further findings.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the Clinical Manager assured patient needs were continually assessed, including measuring all wounds during the initial and recertification comprehensive assessment, for 4 of 7 active records reviewed of patients with wounds (Patients #3, 6, 8, 11). Findings include: 1. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 2. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 3. The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 5. The Clinical Manager job description indicated the CM is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 6. During an interview on 1/10/25 at 3:58 PM, the Administrator relayed she and the Alternate Administrator are currently overseeing patient care remotely and they have asked RN 1 and OT 1 to assist since they are local to the home health agency office. 7. The review of clinical records for Patients #3, 6, 8, 11 failed to evidence staff were measuring patient wounds during the initial and recertification comprehensive assesments. See Tag G528 for further findings.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the Clinical Manager oversaw the development, implementation, and updates of the individualized plan of care for 3 of 10 active patient records reviewed (Patient #2, 3, 15). Findings include: 1. During the entrance conference on 1/02/25 at 9:53 AM, the Administrator named RN 1 as the Clinical Manager of the home health agency. 2. The review of the required survey form titled “Home Health Agencies Report”, last updated 1/8/25 identified RN 1 as the Clinical Manager. 3. The agency policy “Supervision of Patient Care”, last revised 1/26/23, indicated all patient care services will be furnished under the direction and oversight of a qualified clinical manager. The policy also indicated there will be administrative and clinical oversight of personnel in all care/service areas provided 24 hours per day, 7 days per week, as applicable. 4. The Clinical Manager job description indicated the CM is accountable for overseeing the day-to-day clinical operations to ensure quality of care and services, and is responsible for the oversight, direct supervision and development of clinicians and direct-care staff. 5. During an interview on 1/08/25 at 4:12 PM, the Administrator relayed the clinician who is seeing the patient is responsible for updating the POC and the Administrator is responsible for overseeing all clinical staff. 6. The review of clinical records for Patients #2, 3, and 15 failed to evidence services were provided according to physician order and the POC. See Tag G580 for further 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 record review and interview, the home health agency failed to submit the discharge summary to the physician with 5 days of discharge for 1 of 1 hospital discharge record reviewed (Patient #9). Findings include: 1. The agency policy “Transfer and Discharge”, last revised 4/26/23, indicated a complete discharge summary will be 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 agency within five (5) business days of the patient’s discharge. 2. Patient #9’s clinical record evidenced a discharge date of 7/17/24. The clinical record failed to include a discharge summary that was faxed to the physician within 5 days of discharge. During an interview on 1/09/25 beginning at 11:44 AM, the Administrator relayed the clinical record for Patient #9 did not evidence a discharge summary had been completed yet and failed to include a discharge summary that had been faxed to the physician.”