Dependable Healthcare Services Inc.

“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 the Emergency Plan (EP) review and interview, the agency failed to develop an emergency plan that included a process for cooperation and collaboration with local, regional, tribal, State and Federal emergency preparedness officials. Findings include: Review of the Agency EP, dated 1/15/25, failed to indicate a plan for cooperation and collaboration with the required officials. During an interview on 4/23/25 at 2:30 P.M., the Administrator said that the agency had not been in contact with any local, regional, tribal, State or Federal emergency preparedness officials.”

“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 the Emergency Plan (EP) review and interview, the agency failed to ensure that 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 and to inform State and local officials of any on duty staff or patients that they are unable to contact. Findings include: Review of the agency’s EP dated 1/15/25, indicated there was no procedure in place for services needed for patients in case of an ongoing emergency. Further review indicated there was not a policy in place on how to inform the State and local officials of any staff or patients that the agency was unable to contact. During an interview on 4/23/25 at 2:30 P.M., the Administrator said that the agency EP did not include policies or procedures in place on how to inform the State and local official of any staff or patients that the agency was unable to contact.”

“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 the Emergency Plan (EP) review and interview, the agency failed to ensure that the EP plan includes alternate means identified for communicating with Federal, State, tribal, regional, and local emergency management staff. Review of the agency’s EP dated 1/15/25 indicates that it did not include an alternative means of communicating with facility staff or local emergency management agencies. During an interview on 4/23/25 at 2:30 P.M., the Administrator said that the agency EP does not include an alternative means of communicating with facility staff or local emergency management agencies other than land lines or cell phone.”

“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 the Emergency Plan (EP) review and interview, the agency failed to ensure that EP plan includes a method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other healthcare providers to maintain the continuity of care during an emergency. Findings include: Review of the agency’s EP dated 1/15/25, indicated there was not a method to share the agency’s patient medical information to entities receiving their patients. During an interview on 4/23/25 at 2:30 P.M., the Administrator said that the agency EP plan did not include the agency’s method of sharing pertinent patient medical information as required to allow for continuity of care.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on Emergency Preparedness (EP) review and interview, the agency failed to conduct exercises to test their Emergency Preparedness Plan annually, which may be a community based full scale exercise or an individual facility-based exercise. Findings include: Review of the agency’s EP dated 1/15/2025 indicated no evidence that the agency conducted testing of their Emergency Preparedness Plan by conducting an annual exercise as required. During an interview on 4/23/25 at 2:30 P.M., the Administrator said that the agency participated in a Fire Drill that was conducted by building management 2-3 weeks ago. The Administrator failed to provide the surveyor with any documentation (date/time, attendance, results) of the fire drill.”

“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 and staff interview, the agency staff failed to ensure that accepted standards of practice were followed for infection control for one patient (#4) of 2 home visits conducted out of 7 sampled patients. Specifically, the Agency failed to disinfect medical devices after use. Findings include: On 4/23/25 at 8:20 A.M., a home visit was conducted with Registered Nurse (RN) 1. RN #1 performed an assessment for patient #4 which included taking a finger stick blood sugar, taking blood pressure reading, and oxygen saturation reading. RN #1 took the blood glucose meter out of a black pouch, performed hand hygiene and applied gloves. She placed a new testing strip in the blood glucose meter and proceeded to perform the blood glucose test. After obtaining this patient’s blood sugar, RN #1 disposed of the contaminated lancet, removed her gloves and performed hand hygiene. Without disinfecting the blood glucose meter, RN #1 placed the meter back into the black pouch, removed her gloves and perform hand hygiene. RN #1 removed the blood pressure cuff, and pulse oximeter from a zip bag, performed hand hygiene and applied gloves. She then took patient #4’s blood pressure reading with the blood pressure cuff as well as the pulse oximeter which was placed on the patient’s finger. RN #1 then removed the blood pressure cuff from Patient #4’s upper arm and oximeter finger and placed both items back to the zip bag without disinfecting the equipment. During an interview on 4/23/25 at 8:35 A.M., RN #1 said that the medical device she uses was Patient #4’s property. She acknowledged not disinfecting it after use. She said that she should have disinfected it after using it even though Patient #4 is the only one using it. During an interview on 4/23/25 at 12:00 P.M., the Administrator said that the expectation of any medical device’s was to be disinfected after each use.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on employee file review and interview, the agency failed to ensure 1 Home Health Aide (HHA #1) received at least 12 hours of in-service training during each 12 month period, out of 2 HHA employees files reviewed. Findings include: Review of the agency’s policy entitled Inservice Education, revised 2015, indicated the following: *HHA are required to attend 12 hours of in-service each calendar year. *All in-service and education programs will be documented. Review of HHA #1’s employee file indicated she was hired 8/16/21. Further review of the file indicated no documented in-service training for 2024. There was no evidence in the employee file that indicated upon return in January 2025 that any education has conducted. During an interview on 4/23/25 at 12:30 P.M., the Administrator said HHA #1 worked from January 2024 through May 2024. She said HHA #1 was on leave from June 2024 through January 2025. The Administrator said HHA #1 did not receive any in-service training in 2024 before taking a leave, as required.”

“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 review and staff interview, the Agency failed to ensure that the physician ordered plan of care was followed for 1 patient (#7) from 7 sampled patients. Specifically, the Agency failed to provide Occupational Therapy (OT)and Physical Therapy (PT) assessment/evaluation. Findings include: Patient #7 was admitted to the agency in February 2025 with diagnosis of stage 2 pressure ulcer (a partial thickness skin loss of epidermis or dermis, superficial and appears as abrasion, blister, or shallow). Review of the physician’s order for certification period of 2/10/25-4/10/25, indicated orders for OT and PT assessment/evaluation and treatment if needed. Review of the clinical record did not indicate that OT and PT assessments/evaluations were conducted as ordered. During an interview on 4/23/25 at 11:30 A.M., the Administrative Assistant said that she could not find any documentation that the OT and PT assessments/evaluations were done for Patient #7. During an interview on 4/23/25 at 12:00 P.M., the Administrator said that the OT and PT assessments/evaluations were not done.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that clinical notes were completed timely for 2 patients (#4 and #7), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled Timely Submission of Patient Documentation, revised 2014, included the following: *The agency will ensure the timely and proper submission of patient documentation. *Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding 3 business days. All patient visits reports from contracted personnel must be submitted within 3 business days from the date of the visit 1. For Patient #4, the agency failed to ensure that the nurse completed his documentation with 72 hours per policy. Patient #4 was admitted to the agency in January 2025 with a diagnosis of post hemorrhagic anemia, requiring skilled care. Review of the clinical record indicated that during the certification period of 1/31/25 - 3/31/25 and 4/1/25 - 5/30/25, the patient was to receive one skilled nursing visit a week. Further review of the clinical record indicated that for 9 of 12 visits, the documentation for the visits were not signed and/or within 72 as required, including the following: *The visit note for 2/13/25 was not signed and dated. *The visit note for 2/27/25 was completed and signed on 3/14/25. *The visit note for 3/6/25 was completed and signed on 3/28/25. *The visit note for 3/13/25 was completed and signed on 3/28/25. *The visit note for 3/20/25 was completed and signed on 4/14/25. *The visit note for 3/27/25 was completed and signed on 4/22/25. *The visit note for 4/3/25 was completed and signed on 4/22/25. *The visit note for 4/10/25 was completed and signed on 4/16/25. *The visit note for 3/13/25 was completed and signed on 3/28/25. *The visit note for 4/15/25 was not signed and dated. During an interview on 4/23/25 at 12:00 P.M., the Administrator said staff are expected to complete their documentation within 48 hours after the visit, if it is not done during the visit. She said the nursing documentation for Patient #4’s visits were not completed timely, as required. 2.For Patient #7, the Agency failed to ensure that clinical notes were signed after providing home visits. Patient #7 was admitted to the agency in February 2025 with diagnosis of stage 2 pressure ulcer (a partial thickness skin loss of epidermis or dermis, superficial and appears as abrasion, blister, or shallow). Review of the physician’s order for certification period of 2/10/25-4/10/25, indicated orders for skilled nursing services three times a week. Review of the clinical record indicated that 10 of 21 skilled nursing visits notes were not signed and/or within 72 hours as required, including the following: *Visit note for 2/11/25 was completed and signed on 2/23/25. *Visit note for 2/13/25 was completed and signed on 2/25/25. *Visit note for 2/14/25 was completed and signed on 2/25/25. *Visit note for 2/15/25 was completed and signed on 2/25/25. *Visit note for 2/18/25 was completed and signed on 2/27/25. *Visit note for 2/19/25 was completed and signed on 2/28/25. *Visit note for 2/20/25 was completed and signed on 3/1/25. *Visit note on 2/21/25 was completed and signed on 3/1/25. *Visit note on 2/25/25 was completed and signed on 3/1/25. *Visit note on 2/26/25 was not signed and dated. During an interview on 4/23/25 at 12:00 P.M., the Administrator said staff are expected to complete their documentation within 48 hours after the visit, if it is not done during the visit. She said the nursing documentation for Patient #7’s visits were not completed timely, as required.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the Agency failed to ensure that staff communicated with the physician that the plan of care was not implemented for 1 patient (#7), out of a total of 7 sampled patients. Specifically, the Agency failed to provide Occupational Therapy (OT) and Physical Therapy (PT) assessment/evaluation as ordered. Findings include: Patient #7 was admitted to the agency in February 2025 with diagnosis of stage 2 pressure ulcer (a partial thickness skin loss of epidermis or dermis, superficial and appears as abrasion, blister, or shallow). Review of the physician’s order for certification period of 2/10/25-4/10/25, indicated orders for OT and PT assessment/evaluation and treatment if needed. Review of the clinical record did not indicate that OT and PT assessments/evaluations were conducted as ordered. During an interview on 4/23/25 at 11:30 A.M., the Administrative Assistant said that she could not find any documentation that OT and PT assessments/evaluations were done for Patient #7. During an interview on 4/23/25 at 12:00 P.M., the Administrator said that OT and PT assessments/evaluations were not done. She said that the physician should have been notified that the OT and PT assessments/evaluations were not done.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review, policy review and interview, the facility failed to ensure a registered nurse (RN) or other appropriate skilled professional who was familiar with the patient, the patient’s plan of care, and the written patient care instructions completed a supervisory assessment of 1 Home Health Aide (HHA #1) out of 2 applicable patient (#4) records with HHA services, services being provided no less frequently than every 14 days, for 1 of 2 applicable records, out of a total sample of 5 patients. Findings include: Review of the agency’s policy entitled Home Health Aide Supervision, revised 2015, indicated the following: *HHAs are closely supervised to ensure their competence in providing care. At least every 14 days the RN makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide’s presence. Patient #4 was admitted to the agency in January 2025 with a diagnosis of Acute Post-hemorrhagic Anemia, requiring skilled care. Review of the physician’s ordered Home Health Plan of Care and Certification, dated 1/31/25-3/31/25, indicated the following: *Skilled Nursing Visit (SNV) daily for 60 days, and 3 as needed (PRN) visits for diabetes complications. *HHA visit (HHAV) 85 hours a week for 9 weeks. Review of a verbal physician’s order, dated 2/1/25, indicated the following change: *SNVs changed to 1 time weekly for 60 days and 3 PRN. Review of the clinical record indicated that during certification period 1/31/25-3/31/25, HHA services were provided daily. Further review of the clinical record indicated the only documented HHA supervisory visit by the RN was completed on 3/27/25. Review of the physician’s ordered Home Health Plan of Care and Certification, dated 4/1/25-5/30/25, indicated the following: *SNV once a week, and 3 as needed (PRN) visits for diabetes complications. *HHAVs 10 hours daily. Review of the clinical record indicated that during certification period 4/1/25-5/30/25, HHA services were provided daily through 4/23/25 (through survey time frame). Further review of the clinical record indicated the only documented HHA supervisory visit by the RN was completed on 4/3/25. During an interview on 4/23/25 at 1:00 P.M., the Administrator said nursing is supposed to complete and document HHA supervisory visits every 14 days for patients receiving HHA services. She said the RN did not complete the HHA supervisory visits, as required, for Patient #4.”