Adoration Home Health

“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 review of the agency’s emergency preparedness documentation on 5/4/2025-5/5/2025 the agency staff did not test its emergency plan at least annually from 2022 through 2025. On 4/29/2025, when asked to review the agency’s emergency preparedness documentation of exercises, the DOO submitted documents of table-top exercises completed 6/13/2023 and 6/12/2024. The agency at the time of this survey, did not provide documentation of engagement in any full-scale community-based or individual facility-based functional exercise for 2022, 2023, 2024, or 2025 for the Salisbury office or the Cambridge office as required by 484.102(d)(2)(i).”

“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 with Director of Operations (DOO), in a 12-month period the agency did not transmit one thousand one hundred fifty-one OASIS assessments to the CMS system within 30 days of completing initial assessments, as required by regulation 484.45(a). This failure to adhere to the required time frame for Oasis transmission has the potential to compromise the accuracy and timeliness of data reporting and impact compliance with federal regulations. On 4/29/2025 review of the agency’s Error Summary Report for the period of 4/29/2024 through 4/29/2025 noted error #3330 with one thousand one hundred fifty-one (1151) records being transmitted beyond the 30-day requirement time frame.”

“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 during the home visits with agency clinical staffers and clinical supervisors adequate infection control prevention was not implemented during the provision of care with three out of five patients. The clinical staffers failed to demonstrate adequate infection control practices. Failure to adhere to infection control standards placed patients at risk for infection. Patient: #13, 15, and #16 Employee: #1, #3, and #4 Findings included: Infection prevention practices require the separation between dirty (contaminated: covered with disease-causing organisms) and clean (reduced level of contamination) tasks and areas during a dressing change an invasive procedure to prevent the transmission (cross-contamination) of bacteria/viruses, which can lead to infection. It means that hands must be washed or sanitized in addition to glove changes between dirty procedures (for example, removing a soiled dressing, cleansing a wound, removing used clinical supplies, cleansing before an invasive procedure and touching a cellular telephone) and clean procedures (for example, inserting a urinary catheter applying new dressing materials or handling new clinical supplies, including medications). Additionally, every attempt should be made to avoid the contamination of sterile (free of bacteria) or clean items. The regulation for standard infection prevention states that the home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This did not occur. 1. On 4/29/2025 during the observation of care with the home health aide with patient #13, the aide (Employee #1). a. The aide, after washing hands, turned off the faucet with bare hands. b. After taking the patient’s temperature orally, the aide placed the thermometer back into its holder without cleaning or disinfecting the thermometer. The aide then removed the used thermometer again from its holder and wiped the thermometer with disinfect and placed it once again into its holder without cleaning or disinfecting the inside of the thermometer holder. c. The aide failed to disinfect the used equipment before placing the equipment back into the main compartment of the supply bag. 2. On 4/29/2025 during observation of complex wound care with the licensed practical nurse (LPN) (Employee #3) for patient #15. a. The LPN used gloved hands to remove the patient’s old wound care bandages from the left lower extremity. The LPN removed the dirty gloves and put on new gloves to begin cleansing both lower extremities. The LPN did not sanitize hands between glove changes. b. The LPN cleansed the patient’s left lower extremity wounds with soap and water from a basin then proceeded to cleanse the right lower extremity from the same basin without changing the water or gloves. 3. On 5/5/2025 during the observation of care with the home health aide with patient #16, the aide (Employee #4). a. The aide placed one barrier down and set the equipment bag onto it. No barrier was place for clean or dirty equipment. The aide removed a stethoscope, a pulse oximeter, and a blood pressure cuff from the equipment bag and placed them onto a small corner of the barrier with the equipment bag. The clean equipment was touching the outside of the equipment bag which is considered dirty. b. After using each instrument, the aide placed the dirty equipment back onto the small corner of the barrier. c. The aide did not wash or sanitize hands during the patient’s care. The aide did wash hands at the completion of the visit. The accompanying clinical managers acknowledged the breaches in universal precautions and infection control.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not communicate delays in the start of care (SOC) for 4 out 17 patients reviewed. Placing the patients at risk for adverse or negative health care outcomes. Patient: #3, #5, #8, and #12 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1. All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records on 5/7/2025 and 5/8/2025. a) On 5/7/2025, during the review of patient #3 medical record, a referral dated 3/8/2025 to provide physical and occupational therapy services for the patient. It was documented on 3/12/2025 in client coordination note that the requested SOC date was 3/13/2025. No documentation communicating the reason for the delay in care with the patient or to the referring physician was in the record at the time of review. During the interview, the office manager stated that sometimes SOC gets delayed because of low staffing. b) On 5/7/2025, during the review of patient #5 medical record, it is documented that on 4/8/2025 the agency received and accepted a referral to provide skilled nursing, physical and occupational therapy services for the patient. The start of care date is documented as 4/12/2025. There was no documentation explaining the delay or contacting the physician for approval to delay the SOC. During the interview, the agency staff did not provide any further information or documentation for the delay. c) On 5/8/2025, during the review of patient #8 medical record, it is documented that on 1/10/2025 the agency received and accepted a referral to provide physical and occupational therapy services for the patient. The start of care date is documented as 1/14/2025. A client coordination note dated 1/13/2025 as a welcome call to patient arranging the 1/14/2025 SOC. An additional client coordination note entered on 1/17/2025 by the DOO as a late entry notes that a verbal order was requested of the physician to approve a 1/14/2025 SOC. There was no documentation explaining the reason for the delay in the SOC request. During the interview, the Cambridge DOO stated that the agency had staffing issues, so the physician was called to delay the SOC. did not provide any further information or documentation for the delay in care. d) On 5/8/2025, during the review of patient #12 medical record, it is documented that on 12/20/2024 the agency received and accepted a referral to provide skilled nursing, occupational and physical therapy services for the patient. The patient was discharged from the hospital on 12/20/2024. A note dated 1/8/2025 reported a welcome call was placed to the patient. The start of care date is documented as 1/9/2025. A client coordination note dated 1/13/2025 requests the physician provide a verbal order for a delay in SOC to 1/9/2025. There was no documentation of the reason for the delay request. During the interview, the agency staff did not provide any further information or documentation for the delay in care.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on the review of patient records and interview with agency staff, the agency did not follow physician orders for 1 out of 18 patients reviewed. An ordered occupational therapy evaluation was not done for the patient. Failure to follow all physician orders has the potential to cause negative health care outcomes. Patients: #5 Findings included: 1. The agency has an obligation to follow all physicians’ orders. This did not occur, as evidenced by the record review on 5/7/2025. a) During the record review on 5/7/2025, an occupational therapy evaluation was noted as ordered on 4/17/2025 for patient #5. A missed visit note was written for the occupational therapy evaluation and noted a rescheduled date of 4/20/2025. There was no documentation of the occupational therapy evaluation being done. No follow-up documentation for this matter was noted. No documentation of the patient declining the service. When asked the agency DOO had no further information or documentation explaining why the patient did not receive the occupational therapy evaluation.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not communicate potential negative health care issues for 1 out of 17 patients reviewed. The home health agency clinician and staff must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients’ plan of care, failure to do so places the patients at risk for adverse or negative health care outcomes Patient: #2 Employee: #4 Findings included: 1.All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records. a) On 5/7/2025, review of patient #2 medical record, Home Health Aide services were ordered 2 times per week for 6 weeks to start 3/16/2025. No Aide visits are noted from 3/16/2025 through the time of this review. On 3/16/2025, Employee #4 documented four separate notes for the patient having missed visits on 3/6/2025, 3/7/2025, 3/11/2025 and 3/13/2025. The notes reflected being reported to the physician and a clinical manager (no clinical manager’s name was provided). There were four notes dated 3/17/2025 titled missed visit notification-back office for 3/6/2025, 3/7/2025, 3/11/205 and 3/13/2025 notifying the physician by fax of the missed visits. The services were ordered to start 3/16/2025. The DOO had no documentation or explanation for the discrepancy in the care attempting to be initiated before an order was received by the agency. On 3/23/2025, Employee #4 documented two separate notes for the patient having missed visits on 3/17/2025 and 3/20/2025. The notes reflected being reported to the physician and a clinical manager (again no clinical manager’s name was provided). There were two notes dated 3/24/2025 titled missed visit notification-back office for 3/17/2025 and 3/20/2025 notifying the physician by fax of the missed visits. The was no documentation of the aide reporting the missed visits to the supervising nurse. There was no evidence of the Aide attending the weekly interdisciplinary team meeting to report the continued missed visits to the team. When asked, the agency staff were unable to provide evidence of the aide reporting these findings to the supervising nurse.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on review of the agency’s patient care conference attendance sheets 4/30/2025 the home health aides have not been participants of the interdisciplinary team meetings. Failure to comply with regulations places patients at risk for inadequate health care. Home health aides are members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. During interdisciplinary team meetings, all HHA staff involved in the patient’s care must be present for, and, where appropriate, should contribute to, any discussion regarding the patient’s care. This did not occur. On 4/29/2025, when asked for the agency interdisciplinary team meeting documentation for the prior 60 days, on 4/30/2025, the DOO presented for review the attendance sheets for the Cambridge and Salisbury offices. The patient care conferences were noted as taking place every Tuesday and Wednesday. The attendance sheets received covered the period from 2/19/205 through 4/30/2025 and notes the agency home health aides had attended two out of the eighteen meetings for that period 2/19/2025 and 4/30/2025.”