Community Home Health Care, Inc.

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency’s administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency concerning a change of address and ensuring the required paperwork was appropriately completed per Federal requirements, resulting in the agency’s continuance of operating at an unapproved location. On 3/18/26, the administrator (Staff-A) upon request at 9:31 AM, submitted a CMS-855A form that was dated 10/10/25 for NGS to review and approve a change in address approximately a mile away. Staff-A then submitted a revised CMS-855A to NGS via certified mail with paid receipt dated 11/6/25. An NGS letter dated 11/11/25 documented the following: “Missing or Incomplete Items: Section 3 (a required section) was not received with corrections. If you would like to resubmit an application, you must complete a new Medicare enrollment application(s). Please address the above issues as well as sign and date the new certification statement page on your resubmitted application(s).” No evidence that the agency had resubmitted a CMS-855A as noted on the 11/11/25 NGS letter. Subsequently, the agency remained at an unapproved location as required by CMS.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse conducted an initial assessment within 48 hours of the physician referral in 1 (P-2) of 7 records reviewed (see G514); failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-6 and P-7) of 7 records reviewed (see G528); failed to ensure the comprehensive assessment included the patient’s medical equipment, rehabilitation, and discharge planning needs in 1 (P-4) of 7 records reviewed (see G534); and failed to ensure the comprehensive assessment included the patient’s primary caregiver and their willingness and ability to provide care in 1 (P-7) of 7 records reviewed (G538), resulting in the potential for unmet care needs and poor patient outcomes. Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.55: Comprehensive assessment of patients.”

“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 agency failed to ensure the plan of care included all required elements to provide quality and safety in patient care in 2 (P-4, and P-7) of 7 records reviewed (see G574); failed to ensure the plan of care included all patient care orders for 1 (P-6) of 7 records reviewed (see G576); failed to ensure all services and treatments were administered only as ordered by a physician who establishes and reviews the plan of care in 2 (P-1 and P-7) of 7 records reviewed (see G580); and failed to ensure patients were provided with the name and contact information for the agency clinical manager for 7 of 7 patients serviced by the agency in the last 12 months (see G622), resulting in the potential for unmet care needs and poor patient outcomes. Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.60: Care planning, coordination of services, and quality of care.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence of its efforts to measure, track, and analyze its quality indicators in order to assess processes of care and services for 2023, 2024 and 2025 (See G0642); failed to utilize quality indicator data including measures derived from the Outcome and Assessment Information Set (OASIS), and other relevant data to monitor the effectiveness and safety of services; quality of care; and identify opportunities for improvement in the design of its Quality Assessment and Performance Improvement (QAPI) program for 2023, 2024 and 2025 (See G0644); and failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2023, 2024 and 2025 (See G0658), all resulting in the agency’s inability to make improvements in patient care, health outcomes, patient safety, quality of care and the agency’s performance. Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR §484.65 Quality Assessment and Performance Improvement (QAPI).”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse developed a plan of care with the patient in 1 (P-1) of 7 records reviewed, (See G0708); failed to ensure the patient received services as ordered by the physician or allowed practitioner as indicated in the plan of care for 3 (P-4, P-6 and P-7) of 7 records reviewed (See G0710); failed to ensure skilled professionals prepared clinical notes in 2 (P-1 and P-7) of 7 records reviewed (See G0716); and failed to ensure skilled professionals participated in agency-sponsored in-service training for 5 of 5 (CM-1, CM-2, RN-1, RN-2, and PT-1) employed skilled professionals resulting in the potential for a lack of staff education and training, unmet patient needs, and poor patient outcomes. Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality care for the condition of participation at 42 CFR §484.75 Skilled Professional Services.”

“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 observation and interview, the Administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency including ensuring the address change of the agency was properly completed as needed according to Federal requirements resulting in the agency operation which was outside of Federal reporting requirements (See G948); failed to ensure the agency employed qualified personnel in 1 (CM-1) of 4 clinical employee records reviewed, resulting in the potential for unqualified staff and poor patient outcomes (See G952); failed to ensure the administrator or pre-designated alternate administrator was available during all operating hours, resulting in the potential for a lack of oversight for the agency. (See G956); and failed to ensure that one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs (See G982). The cumulative effect of this systemic problem resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.105 Organization and Administration of 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 review and interview, the agency failed to ensure staff received on-going Emergency Preparedness (EP) training every 2 years in 1 (CM-1) of 5 employee records reviewed; and failed to ensure staff received initial EP training in 2 (CM-1 and RN-1) of 3 employee records reviewed who were hired since 2022, resulting in the potential for an unprepared staff response in the event of an actual emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 9/2/25 at 2:15 PM. During review of the binder, signed forms for on-going annual EP training were located for 2025. Upon review of the forms, it was noted the clinical manager (CM-1) did not sign a form. Additionally, there was no evidence of previous on-going annual EP training for CM-1. Upon further review of the binder, it was noted there was no evidence of initial EP training for any staff. The alternate clinical manager (CM-2) stated that information may be kept in the personnel files during an interview on 9/3/25 at 11:52 AM. Upon review of the personnel files on 9/4/25 at 10:00 AM, it was determined there was no evidence of initial EP training for the registered nurse (RN-1) who was hired in 2023. Additionally, there was no personnel file available for CM-1 to determine date of hire or verify evidence of initial or on-going EP training. The administrator (ADM) and CM-2 reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 record review and interview, the agency failed to ensure Emergency Preparedness (EP) drills were performed to test the agency’s EP program annually in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for an unprepared staff response in the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 9/2/25 at 2:15 PM. During review of the binder, it was determined there was no documentation of an EP drill performed in 2023. Upon review of the drills in the binder for 2024, the following was noted: A drill titled “Winter Storm Tabletop Community Drill” was performed on 2/5/24. Upon review of the drill, it was noted the administrator (ADM) was the only person who participated in the drill. There was no evidence of staff or group discussion used to test the agency’s emergency plan. Additionally, the drill included details of using emergency code “111” and a “backup system – buddy system” for transportation. Upon reviewing the agency’s procedure for a winter storm, it was noted there was no information regarding either, therefore, this drill did test not the effectiveness of the agency’s emergency plan. A second drill for 2024 was also located in the binder. This drill was titled “Fire Drill Report” and was dated 5/22/24. Upon review of the documentation for this drill, it was also noted that ADM was the only participant. Additionally, documentation in the drill stated, “American Nursing HHC accounted for all staff….” (a name of a different agency), therefore, there is no evidence the drill was performed by this agency. During an interview with ADM and the alternate clinical manager (CM-2) on 9/3/25 at 11:52 AM, ADM was asked who else participated in the drills mentioned above. ADM stated the office support (OS) person was part of the drill but acknowledged there was no evidence of that. Additionally, ADM was asked who “American Nursing HHC” was. ADM was unable to provide an answer. CM-2 also confirmed there was no drill conducted in 2023. ADM and CM-2 acknowledged the findings at the time of interview.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence of its efforts to measure, track, and analyze its quality indicators in order to assess processes of care and services for 2023, 2024 and 2025, resulting in the inability of the agency to determine the scope of services provided by the agency, and the potential for unmet care needs for any patient’s serviced by this agency. Findings include: On 9/2/25, the home care agency Quality Assurance and Performance Improvement (QAPI) binder was provided for surveyor review. During review, it was noted that the agency had quarterly documentation for the years of 2023 and 2024 which included patient clinical record reviews (noted as “Utilization Review/Record Review”). There was no data (including the previous quarters) entered for 2025. There was no evidence that the data from the clinical record reviews were measured or analyzed. There was an additional document in the QAPI binder titled “QAPI-PIP 2024” which had a list of pre-determined indicators on the right-hand side of the document, and section separated by quarters (Quarter-1 through Quarter-4) to enter performance indicator information in each quarter on rest of the document. Examples of the indicators included: timelines for service initiation; hospital re-admits in the 1st 30 days of care; infection incidents; fall incident reduction; etc. There was no information entered on the QAPI-PIP document dated for 2024 except a handwritten statement at the top of the document that stated, “No clients this review”. On 9/4/25 during interview at 11:55AM, the Alternate Clinical Manager (CM-2) was asked what quality indicators the agency was measuring, tracking and analyzing in 2023, 2024, and 2025 to assess the agency’s processes of care and services. CM-2 confirmed that the agency did see patients in 2024 and stated that a review was conducted on 10% of all the patient clinical records to ensure required elements were entered into the clinical record. CM-2 acknowledged that the clinical record reviews did not measure or analyze any data. CM-2 also stated that the other data being collected was “pulled” randomly from the agency admissions information through their electronic medical record system and entered on a document (QAPI-PIP) which gave the agency performance data. CM-2 confirmed that since no data was entered into the QAPI-PIP document for analysis in 2025, 2024, and 2023, no agency data could be measured, tracked, or analyzed to assess the agency’s processes of care and services.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to utilize quality indicator data including measures derived from the Outcome and Assessment Information Set (OASIS), and other relevant data to monitor the effectiveness and safety of services; quality of care; and identify opportunities for improvement in the design of its Quality Assessment and Performance Improvement (QAPI) program for 2023, 2024 and 2025. This action has the potential to result in a negative effect for any patient’s serviced by this agency. Findings include: On 9/2/25, the home care agency Quality Assurance and Performance Improvement (QAPI) binder was provided for surveyor review. During review, it was noted that the agency had quarterly documentation for the years of 2023 and 2024 which included patient clinical record reviews (noted as “Utilization Review/Record Review”). There was no data (including the previous quarters) entered for 2025. There was an additional document in the QAPI binder titled “QAPI-PIP 2024” which had a list of pre-determined indicators on the right-hand side of the document, and section separated by quarters (Quarter-1 through Quarter-4) to enter performance indicator information in each quarter on rest of the document. Examples of the indicators included: timelines for service initiation; hospital re-admits in the 1st 30 days of care; infection incidents; fall incident reduction; etc. There was no information entered on the QAPI-PIP document dated for 2024 except a handwritten statement at the top of the document that stated, “No clients this review”. There was no evidence that quality indicator data including measures derived from the Outcome and Assessment Information Set (OASIS) or other relevant data was being collected. On 9/4/25 during interview at 11:55AM, the Alternate Clinical Manager (CM-2) was asked what quality indicator data the agency was utilizing to monitor the effectiveness and safety of services; quality of care; and identify opportunities for improvement in the design of its QAPI program for 2023, 2024 and 2025. CM-2 stated that the OASIS data was being pulled randomly from the agency admissions, and this gave them quality indicator data. CM-2 acknowledged that there was no evidence in the QAPI binder to show the agency was using OASIS or any other relevant data to monitor the effectiveness and safety of services; quality of care; and identify opportunities for improvement in the design of its QAPI program for 2023, 2024 and 2025. No other QAPI documentation was provided for review during the survey.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2023, 2024 and 2025, resulting in the agency’s inability to make improvements in patient care, health outcomes, patient safety, quality of care and the agency’s performance. Findings include: On 9/2/25, the home care agency Quality Assurance and Performance Improvement (QAPI) binder was provided for surveyor review. During review, it was noted that the agency had quarterly documentation for the years of 2023 and 2024 which included a document titled “QAPI Project Data Collection and Analysis Summary” that was dated 4/5/24. It was noted that this document included a statement that the recommended action (for an undocumented problem) was “Agency to secure referrals”. Additional information in the document included that the agency would network with doctor offices and hospital case managers to increase agency census. There was no QAPI Project Data Collection and Analysis Summary for 2023 or 2025 found in the binder. The governing body meeting minutes were reviewed on 9/2/25. There were annual governing body meeting minutes which included 2023 and 2024. There were no governing body meeting minutes for 2025. The governing body meeting minutes for 2023 only included the meeting on 6/21/23 and documented the following “... GB (governing body) will continue to be monitor data from quarterly QAPI meetings, expecting 100% compliance and standards maintained.” [sic]. There was no evidence the governing body documented a quality improvement project and reason for conducting the project, or documented any measurable progress achieved in 2023. The governing body meeting minutes for 2024 only included the meeting dated 7/25/24. Under “Old business”, the following was entered regarding QAPI: “Reviewed trends related to infections, falls and rehospitalizations, Reviewed Utilization review findings and Qapi findings for last Quarter.” [sic]. There was no evidence in the governing body meeting minutes that a performance improvement project was discussed or approved in 2024. On 9/4/25 during interview at 11:55AM, the Alternate Clinical Manager (CM-2) was asked if a program improvement project could be provided for surveyor review. CM-2 stated that the “project” for the agency (in 2024) was to increase the agency census and stated that the project (how data would be collected, how data would be measured, and how data would be evaluated) was not included in the QAPI binder. No performance improvement project could be found in the binder for the years 2023, 2024, and 2025. This was acknowledged by CM-2 at the time of interview. Additionally, CM-2 acknowledged that the governing body did not show documented evidence of approval of a performance improvement project for 2023 or 2024.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review, and interview, the agency failed to provide documented evidence of the initial infection control education for 1 (CM-1) of 7 agency employees, and the ongoing infection control education for 7 (ADM; CM-1; CM-2; RN-1; RN-2; PT-1; and CNA-1) of 7 current employees, including those with clinical (direct patient care) privileges, resulting in the potential for the development and spread of infection. Findings include: On 9/3/25 at 11:52AM, an interview was conducted with the Administrator (ADM), and the Alternate Clinical Manager (CM-2). During the interview, CM-2 was asked to provide documentation of agency in-services for all staff including initial and ongoing infection control education. CM-2 stated that initial infection control education should be completed during the orientation of staff and marked off on an orientation checklist in personnel files. CM-2 also reported that the agency had no documented evidence regarding ongoing agency in-service education (including annual infection control) and acknowledged this as a finding. No in-service documentation was provided for surveyor review during the survey which included evidence of ongoing infection control education for all 7 current home care agency employees, ADM; CM-1; CM-2; RN-1; RN-2; PT-1; and CNA-1. Request for CM-1’s personnel record includes the following dates/times: On 9/3/25 at 3:15PM, a request was made to CM-2 for personnel files for all staff to be provided for surveyor review (including the personnel file for CM-1). On 9/4/25 at 9:00AM, personnel files were provided but failed to include the personnel file for CM-1. On 9/4/25 at 10:33AM, a request for CM-1’s personnel file was made to the Office Support person (OS) as directed by CM-2. OS stated she would look for it. On 9/4/25 at 1:33PM, an additional request was made to OS for CM-1’s personnel file. OS stated she couldn’t find it but would continue to look. On 9/4/25 at 4:07PM, a final request for the day was made to OS for CM-1’s personnel file. OS stated she would try and find it. On 9/5/25 at 9:18AM, an additional request for CM-1’s personnel file was made to both CM-2 and OS and was not provided for review prior to (surveyor) exit. On 9/5/25 at 2:30PM, an exit conference was conducted with ADM and CM-2 who both acknowledged that the personnel file for CM-1 was not provided for surveyor review and therefore no evidence was provided for CM-1’s initial infection control education. Additionally, ADM and CM-2 again acknowledged that there was no ongoing infection control education provided to all 7 agency employees, ADM; CM-1; CM-2; RN-1; RN-2; PT-1; and CNA-1.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 9/2/25 during the entrance conference with the Alternate Clinical Manager (CM-2) at 11:30AM, CM-2 stated the service provided directly by this home health agency was the Home Health Aide (CNA-1). CM-2 stated that CNA-1 was the only Home Health Aide currently employed by the agency. On 9/5/25 during interview with the Administrator (ADM) at 2:00PM, ADM was asked if CNA-1 was an employee receiving a W-2 statement of income (agency employee) or a 1099 statement of income (contract employee). ADM stated that CNA-1 received a 1099 (contracted employee) statement of income and did not receive a W-2 statement from the home care agency. There were no other services provided directly by agency employees. The agency failed to have one qualifying service provided directly by agency employees. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“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 agency failed to ensure all entries into the clinical record were appropriately authenticated and signed in 1 (P-1) of 7 records reviewed resulting in incomplete entries which were not reviewed or approved by the author. Findings include: Agency policy titled “Medical Record Entries: Authentication”; Policy I-210 (undated) was provided for surveyor review on 9/5/25. On page 1., it stated “All medical record entries will be dated and authenticated.” Patient #1 (P-1): This patient was admitted to the home care agency on 7/29/25 with diagnoses including high blood pressure and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). The medical record was reviewed on 9/4/25. During review, it was noted that 4 of 4 skilled nursing notes dated 7/29/25 through 8/21/25 were entered into the medical record with no date or signature of the nurse who completed the visits. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“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 and interview, the agency failed to ensure patients were provided with the name and contact information for the agency administrator for 7 of 7 patients serviced by the agency in the last 12 months, resulting in the potential for patients being unaware of who to contact regarding any complaints. Findings include During review of the agency’s admission packet on 9/2/25 at 1:23 PM, it was noted the folder and other documents in the folder included the address of the agency’s previous location. Additionally, a packet labeled “Orientation For Home Health Care,” included a phone number to contact the “administrator,” however, there was no name identified. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 agency failed to ensure the patient was informed of and consented to care in 3 (P-1, P-4, and P-7) of 7 records reviewed, resulting in the potential for a violation of patient rights. Findings include: Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was noted the form titled “Admission Consent” located in P-7’s paper folder included P-7’s name and “Proposed/projected services” from skilled nursing for 1 time a week for 8 weeks. Upon further review of the form, it was determined it was not signed or dated by P-7. A review of agency policy titled “Medical Record Content” (not dated) revealed, “2. Each medical record will contain the following:…Evidence of consent for care on admission and during the course of care…”. Additionally, a review of agency policy titled “Informed Consent” (not dated) revealed, “2. At the time of admission, the RN or appropriate therapist will obtain consent for care.” The policy also indicated that, “4. The consent form will be included in the patient’s medical record.” The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM. Patient #1 (P-1): This patient was admitted to the home care agency on 7/29/25 with diagnoses including high blood pressure and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). The medical record was reviewed on 9/4/25. During review, it was noted that there was no patient signed consent for home health care found in the electronic medical record (EMR), and no patient signed consent for home health care found in the patient’s paper medical record. Patient #4 (P-4): This patient was admitted to the home care agency on 5/15/24 with diagnoses including high blood pressure and type 2 diabetes. The medical record was reviewed on 9/5/25. During review, it was noted that the patient signed a consent for home health care on 5/15/24 but the consent failed to inform the patient which disciplines would be providing care during the certification period and the frequency of those services. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received written notice in advance of the agency terminating on-going care in 1 (P-7) of 7 record reviews, resulting in the potential for a violation of patient rights. Findings include: Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was determined the form titled “Notice of Medicare Non-Coverage” located in P-7’s paper folder included P-7’s name and indicated that home care services would end on 7/20/24, however, the form was not signed or dated by P-7. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 record review and interview, the agency failed to ensure the registered nurse conducted an initial assessment within 48 hours of the physician referral in 1 (P-2) of 7 records reviewed resulting in a delay in assessment of immediate care and support needs of the patient and the potential for a poor patient outcome. Findings include: Patient #2 (P-2): This patient was admitted to the home care agency on 5/28/24 with diagnoses including high blood pressure and lower back pain on the right side. The medical record was reviewed on 9/4/25. During review, it was noted that the physician order for home health care was signed on 5/19/24. The start of care (comprehensive assessment) was completed by the registered nurse on 5/28/24 (9 days later). There was no documentation found in the medical record indicating that the patient requested a delay in the start of care and no evidence that the physician requested (or was aware of) a delay in the start of care assessment for this patient. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission for 2 (P-6 and P-7) of 7 records reviewed, resulting in incomplete clinical information used to determine the needs of these patients and used to assist in developing the plan of care. Findings include: A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (not dated) revealed, “1. Each patient will receive a comprehensive assessment. The assessment will reflect the patient’s current health status…”. Patient #6 (P-6) was admitted to this home care agency on 3/13/25 with the diagnoses of peripheral edema (swelling in the extremities) and left leg cellulitis. During record review on 9/4/25, it was noted on the Outcome Assessment and Information Set (OASIS) in the “Gastrointestinal Assessment” that there were “No problems identified.” Also, the box next to “Bowel incontinence” was not checked. Upon further review of the OASIS, it was noted in the section titled “Bowel Incontinence Frequency” that the box next to “2 – One to three times weekly” was checked. The information above is conflicting and does not provide a clear picture of the patient’s current or potential status. Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was noted the OASIS indicated in the “Endocrine” section that “Patient’s Blood Sugar Status Unknown (no glucometer, paper logs, visit reports, nor patient ability to report).” Upon review of later skilled nursing notes throughout the episode of care, it was noted a “Caregiver” reported multiple ranges of blood sugars at each daily skilled nursing visit. The information above is conflicting and does not provide a clear picture of the patient’s current or potential status. Additionally, it was noted the “Endocrine” section on the OASIS also indicated P-7 took an oral hypoglycemic – a medication used to control blood sugar. Upon review of the medication profile in the comprehensive assessment, it was determined the patient does not take an oral hypoglycemic. The information above is conflicting and does not provide a clear picture of the patient’s current or potential status. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient’s medical equipment, rehabilitation, and discharge planning needs in 1 (P-4) of 7 records reviewed resulting in a lack of information to determine the needs of the patient. Findings include: Patient #4 (P-4): This patient was admitted to the home care agency on 5/15/24 with diagnoses including high blood pressure and type 2 diabetes. The medical record was reviewed on 9/5/25. During review of the comprehensive assessment completed by the registered nurse (RN) on 5/15/24, it was noted that the RN failed to complete the following sections: Durable Medical Equipment used by the patient; and the following “Summary of Care” sections: Patient Rights (including care coordination); Visit Interventions; Frequency and Duration of for services; Discipline Orders and Treatments; Rehabilitation Potential and Discharge Plans. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the patient’s primary caregiver and their willingness and ability to provide care in 1 (P-7) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (not dated) revealed, “8. The Initial Comprehensive Assessment also includes:…Patient’s family or support system and the care they are capable and willing to provide.” Additionally, a review of agency policy titled “Medical Record Content” (not dated) revealed, “2. Each medical record will contain the following:…Identity of others known to be involved in patient’s care/services…”. Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was noted the Outcome Assessment and Information Set (OASIS) indicated the following: Under “Patient Living Situation,” it was noted the “Patient lives alone Around the Clock.” Under “Plan of Care: Psychosocial Assessment”, the box next to “Lack of caregiver/family support” was checked. Under the “Endocrine” section, it was noted, “Intermittent Assistance: Family comes by often to visit and assist.” Under “Care Management,” the box next to “4 – Assistance needed, but no non-agency caregiver(s) available.” The daily skilled nursing notes indicated that “Blood Sugars Performed By Caregiver” [sic] in the “Endocrine/Hematologic” section. It is unclear who is able and willing to assist P-7 and how, therefore, the comprehensive assessment failed to identify the patient’s support system to accurately assess patient care needs. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 record review and interview, the agency failed to ensure the plan of care included all required elements to provide quality and safety in patient care in 2 (P-4, and P-7) of 7 records reviewed resulting in a lack of critical information to ensure the needs of the patient are met and potentially resulting in poor patient outcomes. Findings include: A review of agency policy titled “Plan of Care – CMS #485 and Physician Orders” (not dated) revealed, “…The Plan of Care includes:…Frequency of visits and duration…” Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was determined the plan of care (dated 5/16/24) failed to include a frequency for skilled nursing visits. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 5/15/24 with diagnoses including high blood pressure and type 2 diabetes. The medical record was reviewed on 9/5/25. During review of the plan of care for the certification period of 5/15/25 through 7/13/24, it was noted that the following required elements were not included and were left blank: durable medical equipment and supplies; medications; and, frequency and duration of nursing care. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“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 agency failed to ensure the plan of care included all patient care orders for 1 (P-6) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #6 (P-6) was admitted to this home care agency on 3/13/25 with diagnoses of peripheral edema (swelling in the extremities) and left leg cellulitis. During record review on 9/4/25, it was noted the initial referral from the physician (dated 3/12/25) included orders to “apply unna boot 2s/week x6 weeks - Please train family members on application of boot to LLE-.” [sic] Upon review of the plan of care (dated 3/13/25), it was noted there was no intervention written for the nurse to teach the family how to perform the unna boot application. Additionally, upon review of the skilled nursing discharge note dated 7/9/25, there was no documentation the family had received education on how to apply the unna boot going forward. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 agency failed to ensure all services and treatments were administered only as ordered by a physician who establishes and reviews the plan of care in 2 (P-1 and P-7) of 7 records reviewed resulting in care provided without the direction of the physician and potentially resulting in poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was determined there was no referral in the paper or electronic medical record for P-7 to start home care services with this agency. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM. Patient #1 (P-1): This patient was admitted to the home care agency on 7/29/25 with diagnoses including high blood pressure and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). The medical record was reviewed on 9/4/25. During review, no physician referral for home care was found in the electronic medical record or the paper medical record. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“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 record review and interview, the agency failed to ensure patients were provided with the name and contact information for the agency clinical manager for 7 of 7 patients serviced by the agency in the last 12 months, resulting in the potential for patients being unaware of who to contact regarding any issues. Findings include: During review of the agency’s admission packet on 9/2/25 at 1:23 PM, it was noted the folder and other documents in the folder included the address of the agency’s previous location. Additionally, a packet labeled “Orientation For Home Health Care,” included a phone number to contact the “nurse,” however, there was no name identified. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse developed a plan of care with the patient in 1 (P-1) of 7 records reviewed resulting in home care services being provided without a plan of care and the potential for unmet care needs. Findings include: Patient #1 (P-1): This patient was admitted to the home care agency on 7/29/25 with diagnoses including high blood pressure and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). The medical record was reviewed on 9/4/25. During review, it was noted that the registered nurse completed the comprehensive assessment on 7/29/25. Additionally, there was no plan of care developed for P-1. Care was documented as being provided by the agency RN from 7/29/25 through 8/21/25. The care was provided without a developed and approved plan of care. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“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 interview, the agency failed to ensure the patient received services as ordered by the physician or allowed practitioner as indicated in the plan of care for 3 (P-4, P-6 and P-7) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #6 (P-6) was admitted to this home care agency on 3/13/25 with the diagnoses of peripheral edema (swelling in the extremities) and left leg cellulitis. During record review on 9/4/25, it was noted the plan of care (dated 3/13/25) had an intervention of “SN (skilled nursing) to perform wound care to left leg cellulitis. Cleaned with soap and water, Abd pad applied on ankle fold and upper inner thigh gold, unna boot applied, wrapped with kerlix and ACE bandage twice weekly.” [sic] Upon review of skilled nursing visits dated between 3/13/25 to 4/10/25, it was determined 5 of 10 visits (dated 3/15/25, 3/18/25, 4/1/25, 4/3/25, and 4/8/25) did not have documentation regarding wound care being completed. Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was noted the plan of care (dated 5/16/24) listed orders for physical therapy and occupational therapy to assess the patient. Upon further review of the record, it was determined P-7 was never evaluated by physical therapy or occupational therapy. There was no documentation regarding the reason P-7 was not evaluated by therapy services. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM. Patient #4 (P-4): This patient was admitted to the home care agency on 5/15/24 with diagnoses including high blood pressure and type 2 diabetes. The medical record was reviewed on 9/5/25. During review of the plan of care for the certification period of 5/15/24 through 7/13/24, it was noted under “Orders For Discipline and Treatment”, nursing orders included: Skilled Nurse (SN) to perform fasting blood sugar every visit using patient’s glucometer; and SN to insert 16 FR/5cc (measure of size of catheter), every week. The SN made 7 visits to the patient over 6 weeks (5/15/24 through 6/20/24). None of the SN home visits (0 of 7) had documentation of a blood sugar which was taken by the nurse during the visit (ranges of blood sugar reported only). Additionally, catheter changes were recorded as follows: On the start of care SN visit (5/15/24): date of last catheter change was documented as 5/15/24 by “Home Health Agency” (no comments on size of catheter, procedure, or patient response). On 5/17/24 SN visit: date of last catheter change was reported as 5/31/24 (16 days in the future from date of this visit). On 5/21/24 SN visit: date of last catheter change was reported as 4/29/24 (1 week prior to start of care visit). There was no documentation about a catheter change during this weekly visit. On 5/28/24 SN visit: date of last catheter change was reported as 5/16/24. (2 weeks since the last reported catheter change). There was no documentation about a catheter change during this weekly visit. On 6/4/24 SN visit: date of last catheter change was reported as 5/28/24 (1 week earlier). There was no documentation about a catheter change during this weekly visit. On 6/11/24 SN visit: date of last catheter change was reported as 5/28/24 (2 weeks earlier). There was no documentation about a catheter change during this weekly visit. On 6/20/24 SN visit: date of last catheter change was reported as 5/31/24 (a date that no visit occurred by the home health agency). There was no documentation reflecting how a catheter change took place when the patient was not seen by the agency on the date of catheter change. The SN failed to follow the physician signed orders in the patient’s plan of care for testing blood sugar each visit and changing the patient’s catheter every week. On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals prepared clinical notes in 2 (P-1 and P-7) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to this home care agency on 5/16/24 with the diagnoses of hypertension (high blood pressure) and type II diabetes with hyperglycemia (high blood sugar). During record review on 9/4/25, it was noted there was a daily licensed practical nurse (LPN) note opened for the visit dated 6/25/24. Upon further review of the record, it was determined the note was blank of all information and was not signed by the clinician. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM. Agency policy titled “Timely Submission of Patient Documentation”; Policy I-270 (undated) was provided for surveyor review on 9/5/25. On page 1., it stated “Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) calendar days.” Patient #1 (P-1): This patient was admitted to the home care agency on 7/29/25 with diagnoses including high blood pressure and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). The medical record was reviewed on 9/4/25. During review, it was noted that the comprehensive assessment was completed by the registered nurse (RN) on 7/29/25 and documented an RN visit frequency of once a week for 5 weeks. The RN completed 4 of the 5 (once weekly) visit notes between 7/29/25 and 8/21/25. An RN discharge visit was scheduled for the 5th week (on 8/28/25). The visit note was not yet started on the date of review of this record (7 days later). On 9/5/25, an interview was conducted with the Administrator (ADM) and the Alternate Clinical Manager (CM-2) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals participated in agency-sponsored in-service training for 5 of 5 (CM-1, CM-2, RN-1, RN-2, and PT-1) employed skilled professionals, resulting in the potential for a lack of staff education and training. Findings include: A review of agency policy titled “Inservice Education” (not dated) revealed, “Regularly scheduled and appropriate inservice programs will be made available for all employees.” [sic] The policy also indicated, “12. All inservice and education programs will be documented.” [sic] During an interview with the administrator (ADM) and alternate clinical manager (CM-2) on 9/3/25 at 11:52 AM, ADM and CM-2 were asked to provide evidence of agency-sponsored in-services for the following skilled professional staff: clinical manager (CM-1), alternate clinical manager (CM-2), registered nurses (RN-1 and RN-2), and physical therapist (PT-1). CM-2 reported the agency provided staff in-services; however, she stated there was no documentation of topics, dates, or staff who participated. ADM and CM-2 acknowledged the findings at the time of interview.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation and interview, the Administrator failed to demonstrate responsibility for all day-to-day operations of the home health agency including ensuring the address change of the agency was properly completed as needed according to Federal requirements resulting in the agency operating outside of Federal reporting requirements. On 9/2/25 at 10:00AM, State surveyors arrived at the approved address listed for the agency to perform a recertification survey at: 15565 Northland Dr. Suite 403E, Southfield MI 48075. Upon arrival, signage was located on the door of the suite indicated however the lights were off, there was visible dust on the desks inside the office, and there was no evidence of a recently operating agency within (that could be seen from the outside of the door). The approved agency phone number was dialed and the answering message stated “…your call cannot be completed as dialed…”. An internet search of the agency was conducted and the agency phone number (as indicated by the internet) was called with an answer and confirmation of the home care agency location at a different (un-approved) address: 16250 Northland Dr. Suite 372, Southfield MI, 48075. Upon arrival to the reported address for the home care agency, it was noted that the home health agency signage was on the stated suite door. An Office Support person (OS) with an associated business in a suite nearby which was owned by the same Administrator (ADM) of this home care agency, was able to assist with entrance, initial information gathering, and notification to the alternate clinical manager (CM-2) of surveyor arrival. CM-2 was available by phone only on the day of entrance (9/2/25). ADM could not be reached, and surveyors were told “He had a doctor’s appointment today”. During entrance conference with CM-2, query was made regarding the address change. CM-2 stated that OS completed that paperwork. OS stated that she filed a notice with Centers for Medicare and Medicaid (CMS) via the National Provider Identifier at the following internet address: https://nppes.cms.hhs.gov . The home care agency had not changed their address with any other CMS applications including the CMS-855A Medicare Enrollment Application. The home care agency address was not changed per Federal requirements for Home Health Agencies. On 9/5/25, an interview was conducted with the Administrator (ADM), the Alternate Clinical Manager (CM-2), and the Office Support (OS) at 2:30PM to review the findings. During the interview, ADM and CM-2 acknowledged the findings. OS stated an 855A was completed and would be sent via united postal service mail with a tracking number and recipient signature request. The receipt was not available at the time of exit for this survey (on 9/5/25 at 3:10PM).”

“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 the agency employed qualified personnel in 1 (CM-1) of 4 clinical employee records reviewed, resulting in the potential for unqualified staff and poor patient outcomes. Findings include: Personnel files for the clinical manager (CM-1), alternate clinical manager (CM-2), registered nurse (RN-1), and home health aide (CNA-1) were requested for review on 9/3/25 at 3:15 PM. On 9/4/25 at 10:00 AM, the personnel files were reviewed. Upon review of the files, it was noted there was no personnel file for CM-1 provided. The file was requested again from CM-2 on 9/4/25 at 10:33 AM and 1:33 PM. The office support person (OS) was also asked for the file on 9/4/24 at 4:07 PM. On 9/5/25 at 9:18 AM, a final request was made via e-mail to CM-2 to provide the personnel file for CM-1. The personnel file CM-1 was not provided for review by the completion of the survey on 9/5/25 at 2:30 PM. A review of agency policy titled “Personnel Files” (not dated) revealed, “Personnel files will be established and maintained for all staff.” Additionally, the policy included a list of over 25 items that would be kept in the personnel files to ensure the employed staff were qualified. The administrator failed to provide evidence via personnel files that qualified personnel were hired to serve the agency. The administrator (ADM) and CM-2 reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator or pre-designated alternate administrator was available during all operating hours, resulting in the potential for a lack of oversight for the agency. Findings include: Upon arrival to the agency at 9/2/25 at 10:35 AM, surveyors were met by an office support person (OS) who worked for a business located down the hall from the home health agency with the same owner. OS stated she used to work for the home health agency, so she offered to try and contact the administrator (ADM). At 10:46 AM, the alternate clinical manager (CM-2) phoned the office and reported she was out of the state and that ADM was not available all day due to a doctor appointment. When asked if the appointed alternate administrator (CM-1) was available, CM-2 stated she was unsure where CM-1 was and did not think she would be available to assist anytime during the survey. At 11:18 AM, it was confirmed by OS that ADM would not be available at all that day, and CM-1 would be out of town until Friday. The agency failed to ensure the administrator or appointed alternate administrator was available during all operating hours. ADM and CM-2 reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record included all interventions, treatments, and services provided for 2 (P-5 and P-6), resulting in an incomplete and inaccurate medical record. Findings include: A review of agency policy titled “Medical Record Content” (not dated) revealed, “2. Each medical record will contain the following:…Actions/interventions/procedures…”. Patient #5 (P-5) was admitted to this home care agency on 1/26/23 with diagnoses of hypertension (high blood pressure), seizures, and gait (walking) difficulties. During record review on 9/5/25, it was noted the physical therapy evaluation dated 1/30/23 indicated P-5 was given a home exercise program (HEP). Upon further review of the record, it was determined there was no documentation regarding what exercises were provided for the patient to perform at home. Additionally, review of the physical therapy assistant visit notes dated between 2/3/23 and 2/16/23 revealed 5 of 5 notes (dated 2/3/23, 2/7/23, 2/9/23, 2/14/24 and 2/16/23) documented “B U/E,S x 10x3 reps” [sic] and “B L/E,S x 10x3 reps” [sic] under “Objective” information. There were no details documented regarding what specific exercises were performed with the patient. Patient #6 (P-6) was admitted to this home care agency on 3/13/25 with diagnoses of peripheral edema (swelling in the extremities) and left leg cellulitis. During record review on 9/4/25, it was noted 7 of 8 physical therapy visit notes dated between 3/17/25 and 4/1025 (dated 3/17/25, 3/24/25, 3/26/25, 3/31/25, 4/2/25, 4/8/25, and 4/10/25) indicated the patient had been educated in an HEP. Upon further review of the record, it was noted there was no documentation regarding what exercises were provided for the patient to perform at home. Additionally, review of the physical therapy visit notes dated between 3/17/25 and 3/31/25 revealed 3 of 5 notes (dated 3/24/24, 3/26/25, and 3/31/25) documented, “Active to bil LE x 10x3 reps” under “Objective” information. There were no details documented regarding what specific exercises were performed with the patient. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”

“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 agency failed to ensure completed discharge summaries were sent to the primary care practitioner or other health care professional responsible for caring for the patient after discharge within 5 days in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 discharged records reviewed, resulting in a lack of information communicated to ensure continuity of care for all patients being discharged from this agency. Findings include: The medical records for Patient #1 (P-1), Patient #2 (P-2), Patient #3 (P-3), Patient #4 (P-4), Patient #5 (P-5), Patient #6 (P-6), and Patient #7 (P-7) were reviewed between 9/2/25 and 9/5/25. Upon review of the documentation, it was determined there was no evidence in the records for P-1, P-2, P-3, P-4, P-5, P-6, and P-7 that a completed discharge was sent to the physician. The administrator (ADM) and alternate clinical manager (CM-2) reviewed and acknowledged the findings during an interview on 9/5/25 at 2:30 PM.”