Mercy Home Health Services

“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 reviews and interviews, the agency failed to ensure direct care staff were trained on their emergency preparedness (EP) plan upon hire, and at least every 2 years thereafter for 4 (S6HHA, S7HHA, S8HHA, and S15RN) of 14 personnel files reviewed. Findings: Review of the agency’s Emergency Operations Plan (EOP) dated 04/08/2025 revealed in part: V. Training A. All new staff will be trained on the EOP in orientation. D. Emergency Preparedness training will be conducted annually. Review of S6HHA’s personnel file revealed a hire date of 02/26/2024. Further review revealed there was no documented evidence EP training was completed upon hire on or after 02/26/2024 or 2025. Review of S7HHA’s personnel file revealed a hire date of 08/17/2021. Further review revealed there was no documented evidence EP training was completed in 2024 or 2025. Review of S8HHA’s personnel file revealed a hire date of 02/19/2026. Further review revealed there was no documented evidence EP training was completed upon hire on or after 02/19/2026. Review of S15RN’s personnel file revealed a hire date of 01/20/2025. Further review revealed there was no documented evidence EP training was completed upon hire on or after 01/20/2025. On 04/20/2026 at 12:55 p.m., an interview was conducted with S2HR. S2HR confirmed there was no documentation available indicating S8HHA had completed EP training upon hire, and there was no documentation EP training had been completed for all other direct care staff mentioned above in 2024 or 2025. On 04/20/2026 at 1:00 p.m., an interview was conducted with S1ADM. S1ADM stated EP training should be completed upon hire and annually. S1ADM confirmed there was no documentation of EP training available for the direct care staff mentioned above for 2024 or 2025.”

“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 agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) within 30 days of completion date of the assessment. Findings: Review of the agency’s undated policy titled “Encoding and Reporting OASIS Data” revealed, in part: Policy: The agency will electronically report all OASIS data collected in accordance with federal regulations. Special Instructions: 1. Agency will encode and electronically transmit each completed OASIS assessment to the Center for Medicare and Medicaid Services (CMS) system within 30 days of completing the assessment of the client. Review of the agency’s OASIS Agency Final Validation Report dated 01/05/2026 revealed 1 out of 1 record submitted was greater than 30 days after the completion date of 12/05/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/06/2026 revealed 1 out of 41 records submitted was greater than 30 days after the completion date of 12/05/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/21/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 12/21/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/24/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 12/06/2025. Review of the agency’s OASIS Agency Final Validation Report dated 02/14/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 01/13/2026. Review of the agency’s OASIS Agency Final Validation Report dated 03/04/2026 revealed 1 of 8 records submitted was greater than 30 days after the completion date of 01/31/2026. Review of the agency’s OASIS Agency Final Validation Report dated 03/31/2026 revealed 1 of 8 records submitted was greater than 30 days after the completion date of 02/28/2026. On 04/20/2026 at 12:25 p.m., an interview was conducted with S1ADM. S1ADM stated she submitted all OASIS data for the agency. S1ADM confirmed all OASIS should be submitted within 30 days of the completion date and the above-mentioned assessments were late.”

“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 observations, record reviews, and interviews, the agency failed to maintain an accurate medication profile for 2 (#2 and #5) of 7 sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 228 patients, according to the agency’s current active census reported on 04/13/2026. Findings: Review of the agency’s undated policy titled “Medication Reconciliation” revealed, in part: Policy Agency will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient facility stays, at 60-day reassessment visits, and at the time of discharge. Special Instructions 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter (OTC), prescribed, and as needed (PRN) medications. Patient #2 Review of Patient #2’s Resumption of Care (ROC) orders dated 04/09/2026, for Certification Period 02/27/2026 through 04/27/2026, revealed a Skilled Nursing frequency of two visits every week for one week and one time every week for two weeks effective 04/09/2026; Physical Therapy 2 visits every week for 3 weeks effective 04/14/2026, and Occupational Therapy one visit per week for three weeks effective 04/09/2026. Review of Patient #2’s medication profile provided by the agency on 04/14/2026 revealed the following, in part: Metoprolol Tartrate 25 mg 1 tablet twice daily Combigan Ophthalmic 0.2-0.5% 1 ml both eyes daily Denosumab Subcutaneous 60 mg/ml 1-daily On 04/15/2026 at 3:00 p.m., a home visit observation was conducted with Patient #2, her spouse, sitter, and S14COTA present. Review of the medications on Patient #2’s current medication profile list provided by the agency was reviewed with Patient #2’s sitter, who stated she was familiar with all of Patient #2’s medications. Further review revealed the following discrepancies: 1. Metoprolol Succinate 50 mg 1 tablet once daily- this medication was observed in home, sitter verified Patient #2 was currently taking the medication, but medication was not on the agency med profile. 2. Polyethylene Glycol 17 gms by mouth daily- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 3. Fluticasone Propionate 50 mcg 1 spray each nostril once daily as needed- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 4. Spironolactone 25 mg 1 tablet once daily- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 5. Combigan Ophthalmic 0.2-0.5% 1 ml twice daily both eyes-sitter verified Patient #2 was currently taking this medication twice daily, but the agency med profile had patient taking this once daily. 6. Denosumab Subcutaneous 60 mg/ml daily- sitter verified Patient #2 was not currently taking this medication, but medication was on the agency med profile. On 04/15/2026 03:15 p.m., an interview was conducted with Patient #2’s Sitter, who stated Patient #2’s daughter managed all the patient’s medications and pre-filled her pill boxes weekly. Sitter stated Patient #2’s Metoprolol medication and dose had changed during her recent hospitalization. The Sitter confirmed Patient #2 was now taking Metoprolol Succinate 50 mg daily, Polyethylene Glycol 17 gms daily, Fluticasone nasal spray one spray each nostril daily as needed, and Spironolactone 25 mg daily. Sitter confirmed Patient #2’s Combigan eye drop was changed to twice daily prior to hospital discharge on 04/08/2026, and she was no longer taking the Denosumab injections. On 04/15/2026 at 3:55 p.m., an interview was conducted with S14COTA. S14COTA stated she asked Patient #2 if medication changes had occurred during their visits, and any medication changes were reported to the nurse. S14COTA stated she had not reviewed or reconciled any of Patient #2’s medication since hospital ROC on 04/09/2026. S14COTA stated all medications used by the patient should be accurately reflected on the agency medication profile. On 04/16/2026 at 2:58 p.m., an interview was conducted with S16RN. S16RN stated he was assigned to Patient #2. S16RN confirmed there was no medication reconciliation completed during Patient #2’s SN visits completed on 04/09/2026 or 04/10/2026. S16RN stated a Discharge Medication list was not provided with Patient #2’s ROC orders prior to visits on 04/09/2026 or on 04/10/2026. S16RN confirmed Patient #2’s med profile did not accurately reflect all current medications taken or not taken. On 04/16/2026 at 12:51 p.m., an interview was conducted with S1ADM. Patient #2’s med profile provided from the agency was compared to the hospital discharge medication list dated 04/08/2026 available in Patient #2’s home. S1ADM confirmed Patient #2’s medication profile from the agency did not accurately reflect all medications Patient #2 was currently taking or no longer taking. Patient #5 Review of Patient #5’s Start of Care (SOC) orders dated 03/30/2026 for Certification Period 03/31/2026 through 05/29/2026, revealed a Skilled Nursing frequency of two visits every week for two weeks and one time every week for seven weeks effective 03/31/2026; Physical Therapy one visit every week for one week, then two visits every week for two weeks, then one visit per week for one week effective 03/31/2026, and Occupational Therapy one visit per week for one week, then two visits per week for two weeks effective 03/31/2026. Review of Patient #5’s medication profile provided by the agency on 04/14/2026 revealed the following, in part: Amiodarone HCL 200 mg 1 tablet by mouth twice a day Furosemide (Lasix) 20 mg 1 tablet daily as needed for shortness of breath (SOB) On 04/15/2026 at 1:00 p.m., a home visit observation was conducted with Patient #5 and S12PTA present. Review of the medications on Patient #5’s current medication profile list provided by the agency was reviewed with Patient #5, who stated she managed all of her own medications. Further review revealed the following discrepancies: 1. Amiodarone HCL 200 mg 1 tablet by mouth twice a day; Patient #5 stated she was currently taking 200 mg once daily as of 03/31/2026. 2. Furosemide (Lasix) 20 mg 1 tablet daily as needed for shortness of breath; Patient #5 stated she was taking 20 mg daily as of 03/31/2026. 3. Aldactone 25 mg take 0.5 tablets (12.5 mg) once daily was observed in the home, taken currently by Patient #5 as of 03/31/2026, but medication was not on the agency med profile. 4. Fluticasone-Salmeterol (Advair) 250-50 mcg inhaler- Patient #5 stated she was currently taking this medication twice daily as of 03/31/2026, but medication was not listed on the agency med profile. 5. Tylenol 325 mg take 650 mg every 4 hours as needed for pain; Patient #5 stated she was currently taking this medication as needed as of 03/31/2026, but medication was not listed on the agency med profile. 6. Ezetimibe 10 mg daily; Patient #5 stated she was taking this medication daily as of 03/31/2026, but this medication not listed on the agency med profile. 7. Cyclobenzaprine 10 mg three times daily as needed; Patient #5 stated she was currently taking this medication three times daily as needed as of 03/31/2026, but this medication was not listed on the agency med profile. 8. Sacubitril-Valsartan 24-26 mg two times daily; Patient #5 stated she was currently taking this medication two times daily, but this medication was not listed on the agency med profile. On 04/15/2026 at 1:50 p.m., an interview was conducted with S12PTA. S12PTA confirmed the medication profile in Patient #5’s home did not accurately reflect all medications Patient #5 was currently taking. On 04/17/2026 at 3:25 p.m. a phone interview was conducted with S15RN. S15RN stated she had completed the SOC for Patient #5 on 03/31/2026. S15RN stated Patient #5 managed all of her own medications. Patient #5’s discharge med list dated 03/30/2026 was reviewed. S15RN stated she was unaware of the discharge med list provided to the agency on 03/30/2026, and she had not reconciled Patient #5’s medications according to the hospital discharge list and should have. S15RN confirmed the agency medication profile should have accurately reflected Patient #5’s current medications. On 04/17/2026 at 9:50 a.m., an interview was conducted with S1ADM. The above medication profile discrepancies were discussed. S1ADM stated she expected all nurses to check patient’s medication bottles and compare their home medications against the discharge medication list provided by the referring provider. S1ADM confirmed the information on Patient #5’s referral was incorrect and did not include all of Patient #5’s discharge medication orders. S1ADM confirmed Patient #5’s medication profile from the agency did not accurately reflect all medications Patient #5 was currently taking.”

“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 reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 1(#6) of 17 sampled patients reviewed. Findings: Review of the agency’s undated policy titled, “Plan of Care” revealed in part: Policy Home care services are furnished under the supervision and direction of the client’s physician/ allowed non-physician practitioner (NPP). The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. The plan will be consistently reviewed to ensure the client needs are met, and will be updated as necessary, but at least every sixty (60) days. Review of Patient #6’s clinical record revealed a SOC date of 12/27/2025. Review of the POC for certification period 12/27/2025 through 02/24/2026 revealed the physician did not review and sign the POC until 03/31/2026. On 04/17/2026 at 11:05 a.m., an interview was conducted with S1ADM. The above POC orders for certification period 12/27/2025 through 02/24/2026 were reviewed. S1ADM confirmed Patient #6’s POC was not reviewed and signed by Patient #6’s physician within the every 60-day timeframe.”

“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 record reviews and interviews, the agency failed to provide skilled professional services as ordered by the physician in the Plan of Care (POC) for 1 (#2) of 7 sampled patients reviewed with home visits. Findings: Review of the agency’s undated policy titled, “Skilled Professional Services” revealed, in part: Special Instructions 1. Skilled professionals must assume the responsibility for, but not be restricted to the following: c. Providing services that are ordered by the physician/allowed non-physician practitioner (NPP) as indicated in the plan of care. Review of Patient #2’s clinical record revealed she began receiving services from the agency on 02/27/2026, with a primary diagnosis of Laceration without Foreign Body of Other Part of Head, Subsequent Encounter. Review of Patient #2’s POC for Certification Period 02/27/2026 through 04/27/2026 revealed in part: Physical Therapy one time a week for one week, then two times a week for three weeks, effective 03/04/2026. Review of Patient #2’s Episode Manager Visit Calendar for Physical Therapy (PT) visits made during this episode of care revealed, in part: there were two (2) ordered PT visits, per the POC the week of 03/23/2026. Further review revealed only one (1) PT visit was completed on 03/27/2026. There were no other PT visits attempted or documented as refused or missed during the week of 03/23/2026. On 04/14/2026 at 2:20 p.m., an interview was conducted with S18PT. S18PT confirmed she had completed Patient #2’s PT Evaluation on 03/04/2026 and Patient #2’s physician had approved the ordered PT frequency of 1w1, 2w3, per her evaluation. S18PT stated once the PT evaluation was completed, the agency’s scheduler setup the PT visits. S18PT stated she would expect PT services to be provided per the POC orders. Patient #2’s PT schedule for the week of 03/23/2026 was reviewed. S18PT confirmed Patient #2 did not receive PT services per physician’s orders. On 04/14/2026 at 2:48 p.m., an interview was conducted with S17LPN. Patient #2’s PT evaluation dated 03/04/2026 and signed by Patient #2’s physician on 03/16/2026 was reviewed. S17LPN confirmed PT services were not provided to Patient #2, per the physician-ordered frequency the week of 03/23/2026 and should have been. On 04/14/2026 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM reviewed the above PT Episode Visit Calendar for Patient #2, the POC dated 02/27/2026, and the PT evaluation dated 03/04/2026 and signed by the physician on 03/16/2026. S1ADM confirmed there was no missed visit or refusal documentation recorded the week of 03/23/2026, and only one (1) PT visit was completed instead of two (2) PT visits, as per POC orders. S1ADM confirmed all skilled professional services should be provided per physician’s orders and Patient #2’s PT services were not.”