Flagstar Home Health Services

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, it was determined that the home health agency (HHA) failed to document initial training in emergency preparedness policies and procedures for 28 of 28 employees, including contract employees, and failed to maintain documentation of ongoing training for 28 of 28 employees, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: During review of the emergency preparedness program on 6/26/25, it was discovered that 28 of 28 employees had no documented evidence of initial or ongoing Emergency Preparedness training. There was no indication that initial Emergency Preparedness training had been provided to all staff, including contracted staff, as required, and no staff attendance sheet was available. The agency failed to document initial training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees, and failed to maintain documentation of training. During an interview on 6/27/25 at 2:40 p.m., the administrator (Adm #1) acknowledged the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled discipline followed the ordered visit frequency for 1 (P-2) of 1 patient who required diabetic and pain management, from a total of 7 sampled records reviewed, resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 6/10/25 with diagnoses that included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. The Plan of Care ordered Skilled Nursing (SN) services to be provided at a frequency of two times per week for one week (2w1) and one time per week for two weeks (1w2) for management of pain and Diabetes and bladder training. During the record review on 6/25/25 at 3:15 p.m., it was noted that the SN missed the scheduled visits during the 2nd and 3rd weeks of service. The missed visit notes documented, “No answer.” There was no documented evidence that the SN attempted to reschedule the visits to honor the ordered visit frequency. The Administrator reviewed and acknowledged these findings during an interview on 6/27/25 at 1:38 p.m.”

“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, interview and record review, the agency failed to ensure its skilled disciplines utilized infection control standards of practice during the provision of care for 1 (P-2) of 2 patients observed during a home visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: Patient #2 (P-2)’s start of care was 6/10/25 with diagnoses which included Critical Illness Myopathy and Chronic Pain Syndrome. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 6/25/25 at 10:30 a.m., a scheduled joint survey home visit was conducted with the Occupational Therapist (OT #1). During the visit, OT #1 placed her string backpack and therapy equipment directly on the patient’s dining room table. OT #1 did not place a barrier on the patient’s table prior to placement of the equipment. The Administrator acknowledged the above findings during an interview on 6/27/25 at 1:38 p.m.”

“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 interview and record review, the agency failed to provide documented evidence that infection control education was provided to all staff directly employed by the agency and those of who were granted clinical privileges, resulting in the potential for the development and spread of infection to all 28 of 28 staff and all 36 patients currently serviced by this agency. Findings include: A review of the policy, “Employee Infection Control Training” dated 3/2019 stated, “Employees will receive education and training during orientation and at least annually..., Job-Specific, Infection Prevention Education and Training for all Respective Tasks.” On 6/25/25 at 1:45 p.m., the Administrator (Adm #1) was asked for permission to review the agency’s infection control in-services and education for all staff, including contracted staff and responded, “We do triennial (every 3 years) training, so the last training would’ve been during Covid.” At 3:34 p.m., Adm #1 reported, “I misunderstood. I thought our policy said we were to do infection control in-services/education triennially. Our policy actually says annually. I didn’t know that.” On 6/26/25 at 11:20 a.m., Adm #1 submitted an employee chart for review of infection control requirements. When queried about the remaining staff/contracted staff, Adm #1 stated, “This is my only direct employee. I’d have to call the contracted agency for their staff infection control information.” A review of the Registered Nurse (RN #1) file revealed infection control in-services on hand hygiene and bag technique had been provided in calendar years 2021 and 2024. There were no additional documented in-services available for review. A review of Adm #1’s (Adm #1 is a Registered Nurse) personnel file revealed infection control in-services on hand hygiene and bag technique were provided in calendar years 2016 and 2019. There were no additional in-services available for review. Adm #1 reviewed and acknowledged the above findings during the initial interview and again during the exit conference on 6/27/25 at 3:20 p.m.”

“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 at least 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 6/24/25 at 11:17 a.m., during the Entrance Conference, the Administrator (Adm #1) was asked what services were currently provided by the agency and reported, “Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health Aide (HHa ) services.” When asked which, if any, of the above services were provided by contracted staff, Adm #1 reported, “PT, OT, ST, SW and HHa.” When asked to clarify which service was directly provided by the agency, Adm #1 responded, “Nursing.” On 6/27/25 at 2:50 p.m., a review of the agency’s contracts revealed the following: Contract #1 stated, “The purpose of this agreement is to have Contractor provide Physical Therapy and Occupational Therapy.” Contract #2 stated, “Home Care: Physical Therapy, Occupational Therapy, Speech Therapy, Registered Nurse, Home Health Aid [sic], Medical Social Worker.” This contract indicated all services were available via contracted services. Adm #1 reviewed and acknowledged the above findings at the time of discovery and during the exit conference on 6/27/25 at 3:20 p.m.”

“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 clinical documents were complete, signed and dated for 2 (P-2, P-3) of 2 patients ordered to receive home care services, from a total of 7 sampled records reviewed. Findings include: Patient #2 (P-2)’s start of care was 6/10/25 with diagnoses that included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. During the clinical record review on 6/25/25 at 3:15 p.m., it was noted that the patient’s “Individual Patient Emergency Preparedness Plan” had not been signed or dated by the clinician. Additionally, the sections titled “Independent with Self-Administered Medications and Functional Disabilities were left blank. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 6/27/25 at 1:38 p.m. P-3’s start of care was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. During the record review on 6/26/25 at 12:00 p.m., it was noted that the patient was transferred to an inpatient facility on 5/20/25 for undocumented reasons. The patient resumed services under the agency’s care on 5/30/25. A document titled “Physician Order” dated 5/28/25 read, “Order to resume care for patient post hospitalization RN to evaluate for needs.” This document was neither signed nor dated by the author or the Physician. Additionally, the patient’s Individual Patient Emergency Preparedness Plan had not been signed or dated. Additionally, the sections titled Independent with Self-Administered Medications and functional disabilities were left blank. Adm #1 reviewed and acknowledged the above findings during an interview on 6/27/25 at 2:00 p.m. and reported, “We didn’t get the paperwork back in time from the hospital, so the nurse wrote an order.” Adm #1 offered no response regarding the unsigned/dated/incomplete Emergency Preparedness Plan.”

“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 observation, interview and record review, the agency failed to ensure that 1 (P-2) of 2 patients observed during home visits, were included in the overall planning of care including informing the patient in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 6/10/25 with diagnoses that included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. During the clinical record review on 6/25/25 at 3:15 p.m., it was noted that Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services were ordered to be provided. On 6/25/25 at 10:30 a.m., a scheduled survey home visit was conducted with the Occupational Therapist (OT #1). The patient’s admission packet was reviewed and revealed a blank visit calendar. There were no entries of proposed visits to be made by the SN, OT or PT. Additionally, the patient’s admission consent form did not include the provision of OT services or the frequency in which services would be provided. The Administrator and Chief Executive Officer reviewed and acknowledged these findings during an interview on 6/27/25 at 1:38 p.m.”

“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 initial comprehensive assessment accurately reflected the patient’s health status at the time of admission for 1 (P-1) of 1 patient who required wound care services, and 2 of 2 patients (P-5, 6) for baseline measurements, from a total of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings include: Patient #5’s (P-5) SOC was dated 8/8/24, with diagnoses of diabetes mellitus, peripheral vascular disease, and urinary tract infection. During record review on 6/25/25, it was discovered that the start of care (SOC) comprehensive assessment failed to document a baseline blood sugar for a patient with a diagnosis of diabetes. Patient #6’s (P-6) SOC was dated 3/20/25, with diagnoses of diabetes mellitus, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). During record review on 6/26/25, it was discovered that the SOC comprehensive assessment failed to document a baseline weight for a patient with a diagnosis of congestive heart failure. During a meeting on 6/27/25, at 2:40 p.m. the administrator (Adm #1) acknowledged the above findings. Patient #1 (P-1)’s start of care was Acute on Chronic Diastolic Congestive Heart Failure and Pressure Ulcers Bilateral Buttocks. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 6/24/25 at 12:25 p.m., the Initial Comprehensive Assessment dated 9/21/24 documented Wound #2/Left Buttock. There was no mention of any other wounds at the time of admission. Upon further review, a SN visit note dated 9/25/24 identified wound #2 to be on the patient’s right buttock and wound #1 to the patient’s left buttock. The SN failed to ensure the comprehensive assessment accurately reflected the location of the patient’s wounds at the time of admission. The Administrator reviewed and acknowledged these findings during an interview on 6/27/25 at 1:10 p.m. and stated, “I’m not sure what happened.””

“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 patient’s Activity of Daily Living needs were adequately met in the patient’s home for 2 (P-2, P-3) of 2 patients assessed as needing assistance with grooming, resulting in the potential for poor hygiene, psychological decline, and unmet care needs. Findings include: Patient #2’s (P-2) start of care (SOC) was 6/10/25 with diagnoses that included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 6/25/25 at 3:15 p.m., it was noted that section M1100 of the Initial Comprehensive Assessment, dated 6/10/25, revealed the patient lived alone around the clock. There was no documented willing or available caregiver to assist with grooming. Section M1800 stated that grooming utensils must be within reach, someone must help with dressing, putting on undergarments and helping to maintain toileting and bathing. The OT evaluation, dated 6/18/25, documented, “No assistance available. Current types of assistance received: Pt (patient) lives alone on the 8th floor where no care is provided to the residents.” Upon further review, there was no documented evidence that the patient was either offered or provided with a Home Health Aide (HHa) to assist with activities of daily living. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 6/27/25 at 1:38 p.m. Patient #3’s (P-3) SOC was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. The POC ordered SN and PT services to be provided. During the record review on 6/26/25 at 12:00 p.m., it was noted that section M1100 of the Initial Comprehensive Assessment, dated 5/13/25, was void of a documented caregiver who was available and willing to assist with the patient’s activities of daily living (ADL). Section M1800 revealed the patient’s utensils must be placed within reach, someone must assist with dressing, toileting, and transfers. Section MACH 10 Fall Risk Assessment Tool documented, “Incontinence-inability to make it to the bathroom or commode in timely manner.” The section titled “Supportive Assistance” documented, “Needs assistance.” Upon further review, there was no documented evidence that a HHa was either offered or provided. Adm #1 reviewed and acknowledged the above findings during an interview on 6/27/25 at 2:00 p.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all the patient’s prescribed medication to determine any untoward interactions, for 2 (P-1, 5) of 2 patients, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects. Findings include: Patient #1’s (P-1) start of care was 9/21/24 with diagnoses that included Acute on Chronic Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease. The Plan of Care ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. During the record review on 6/24/25 at 12:25 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented “No issues found during review.” There was no evidence available for review to support that a drug review had been conducted. The patient’s 17 prescribed medications were entered in Drugs.com (online drug interaction checker) and revealed 15 moderate drug to drug interactions. The Administrator (Adm #1) was asked to conduct a drug review using the agency’s Electronic Medical Record. Upon receipt, the report revealed duplicate drug therapy. Adm #1 reviewed and confirmed the above findings during an interview on 6/27/25 at 1:10 p.m. and reported, “I looked, and I didn’t see it (evidence of the drug review). She (Nurse) did not runt it (drug review) at start of care.” Patient #5 (P-5)’s Start of Care was 8/8/24, with diagnoses of Type 2 diabetes, peripheral vascular disease, and urinary tract infection. The Plan of Care ordered Skilled Nursing and Physical Therapy services. During record review on 6/25/25, it was discovered that section M2001 of the Initial Comprehensive Assessment documented “No issues found during review.” There was no documented evidence in the record that a medication drug review had been completed. The patient’s 27 medications were reviewed on 6/25/25, in the agency’s electronic medical record and revealed 8 drug-to-drug interactions, 3 duplicate drug therapies, and 8 drug to food/ alcohol interactions. The administrator (Adm #1) reviewed and confirmed the above findings during an interview on 6/27/25 at 2:40 p.m.”

“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 covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Patient #4: P-4’s start of care (SOC) was dated 9/17/21, with diagnoses of cellulitis, urinary device fitting, and hypertension. During record review on 6/24/25, it was discovered that the POC failed to include objectively measurable goals specific to the individualized needs of the patient. One goal stated, “Foley will remain patent during this episode and patient will be free of signs and symptoms of urinary tract infection.” Another goal stated, “Patient skin integrity will remain intact during this episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document anticoagulant/bleeding precautions for a patient on Eliquis (Anticoagulant). Patient #5: P-5’s SOC was dated 8/8/24, with diagnoses of diabetes mellitus, peripheral vascular disease, and urinary tract infection. During record review on 6/25/25, it was discovered that the POC failed to include objectively measurable goals specific to the individualized needs of the patient. One goal stated, “Patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications and side effects by 8/29/24.” Another stated, “Patient will be free from signs or symptoms of respiratory distress during the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient #6: P-6’s SOC was dated 3/20/25, with diagnoses of diabetes mellitus, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). During record review on 6/26/25, it was discovered that the POC failed to include objectively measurable goals specific to the individualized needs of the patient. One goal stated, “Patient will be free from signs and symptoms of respiratory distress during the episode.” Another stated, “The patient will be free from injury during the certification period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document diabetic precautions for a patient with a diagnosis of diabetes mellitus. Patient #7: P-7’s SOC was dated 5/15/24, with diagnoses of wound, peripheral vascular disease, and COPD. During record review on 6/26/25, it was discovered that the POC failed to include objectively measurable goals specific to the individualized needs of the patient. One goal stated, “Discharge when medical condition is stable and patient is no longer in need of skilled services.” Another stated, “Fair to achieve stated goals with skilled intervention and patient’s compliance with the plan of care.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to document diabetic precautions for a patient with a diagnosis of diabetes mellitus. During an interview on 6/27/25 at 2:40 p.m., the administrator (Adm #1) acknowledged the above findings. Patient #1 (P-1)’s start of care (SOC) was 9/21/24 with diagnoses that included Congestive Heart Failure and Chronic Obstructive Pulmonary disease. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical therapy (PT) and Occupational Therapy (OT) services to be provided. During the record review on 6/24/25 at 12:25 p.m., it was noted that the POC listed 16 diagnoses as having exacerbated on 9/21/24 (Date of admission). There were no interventions, reportable parameters or associated measurable goals to address the diagnoses said to have exacerbated on the date of admission. The Administrator (Adm #1) reviewed and acknowledged the findings during an interview on 6/27/25 at 1:10 p.m. and reported, “We were told that it was a billing issue if we didn’t do it that way.” P-2’s SOC was 6/10/25 with diagnoses which included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. The POC ordered SN, PT and OT services to be provided. During the record review on 6/25/25 at 3:15 p.m., it was noted that the POC listed all the patient’s 15 diagnoses as having exacerbated on the date of admission to the agency. There were no reportable pain parameters and no blood sugar parameters. Additionally, there were no interventions to address all diagnoses said to have exacerbated on the date of admission. Adm #1 reviewed and acknowledged the above findings during an interview on 6/27/25 at 1:38 p.m. P-3’s SOC was 5/13/25 at Quadriplegia, Falls and Hypotension. The POC ordered SN and PT services to be provided. During the clinical record review on 6/26/25 at 12:00 p.m., the POC revealed the patient had a Suprapubic Catheter (urinary collection). There were no interventions, parameters or associated measurable goals to address the patient’s catheter. A History and Physical report dated 5/8/25 documented, “He (patient) has ongoing issues with his Suprapubic Catheter which requires monthly changes by Urology.” There were no instructions to monitor the Suprapubic site for infection noted on the POC. Adm #1 reviewed and acknowledged the above findings during an interview on 6/27/25 at 2:00 p.m.”

“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 care and services were provided only as ordered by the Physician for 1 (P-3) of 1 patient who was resumed under the agency’s care after an inpatient stay, from a total of 7 sampled records reviewed, resulting in the potential for substandard, unsafe care and unmet patient needs. Findings include: Patient #3 (P-3)’s start of care was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. The Plan of Care ordered Skilled Nursing and Physical Therapy services to be provided. During the record review on 6/26/25 at 12:00 p.m., it was noted that the patient was transferred to an inpatient facility on 5/20/25. Reasons for the transfer were not documented. The patient resumed services under the agency’s care on 5/30/25. Upon further review, there was no Physician’s order to resume services. The Administrator reviewed and confirmed these findings during an interview on 6/27/25 at 2:00 p.m.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to provide 1 (P-3) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient’s prescribed medications from a total of 7 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: Patient #2 (P-2)’s start of care was 6/10/25 with diagnoses that included Critical Illness Myopathy, Diabetes Mellitus and Chronic Pain Syndrome. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 6/25/25 at 10:30 a.m., a scheduled joint survey home visit was conducted with OT #1. During a review of the patient’s admission packet, it was noted that there was no Medication Profile that listed the patient’s prescribed medications, dosages and side effects. OT #1 was queried as to the whereabouts of the patient’s Medication Profile and reported, “The patients don’t get the med profile, but I can access it in the system from my phone.” The Administrator reviewed and acknowledged the above findings during an interview on 6/27/25 at 1:38 p.m.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines performed accurate baseline and ongoing assessments for 2 (P-1, P-3) of 2 patients who required continuous monitoring, from a total of 7 sampled records reviewed, resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: Patient #1 (P-1)’s start of care (SOC) was 9/21/24 with diagnoses that included Congestive Heart Failure, Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the record review on 6/24/25 at 12:25 p.m., it was noted that the SN documented a baseline weight of 209 pounds (lbs.) in the Initial Comprehensive Assessment. It was not indicated if this was an actual or stated weight. The POC instructed, “Notify physician of weight greater than 215 lbs. or less than 200 lbs.” Upon further review of the SN visit notes dated 9/25/24, 10/1/24, 10/4/24, 10/8/24, 10/12/24, 10/15/24, 10/19/24, 10/22/24, 10/26/24 and 10/29/24, there was no documented evidence that the SN assessed the patient’s weights. The Administrator (Adm #1) reviewed and acknowledged the above findings during an interview on 6/27/25 at 1:10 p.m. Patient #3’s (P-3) SOC was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. The POC ordered SN and PT services to be provided. During the record review on 6/26/25 at 12:00 p.m., it was noted that the patient had a Suprapubic Catheter (for urinary drainage). The POC instructed the SN to assist the patient with monitoring intake and output (fluids/urine). Upon further review, there was no documented evidence that the nurse followed up to ensure adequate intake and output of fluids/urine. Additionally, there was no evidence that the SN continually assessed the patient’s Suprapubic Catheter site to ensure no infection had developed. Adm #1 reviewed and acknowledged all findings during an interview on 6/27/25 at 2:00 p.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included detailed clinical notes regarding the patient’s health status for 1 (P-1) of 1 patient admitted with pressure sores; and 1 (P-3) of 1 patient who received inpatient medical treatment, from a total of 7 sampled records reviewed resulting lack of continuity of care and the potential for unidentified, untreated health concerns. Findings include: Patient #1 (P-1)’s start of care (SOC) was 9/21/24 with diagnoses which included Acute on Chronic Diastolic Congestive Heart Failure and Pressure Ulcers Bilateral Buttocks. The Plan of Care (POC) ordered Skilled Nursing (SN), Occupational Therapy (OT) and Physical Therapy (PT) services to be provided. On 6/24/25 at 12:25 p.m., during the record review, it was noted that the Initial Comprehensive Assessment dated 9/21/24 documented Wound #2/Left Buttock. There was no mention of any other wounds being present at the time of admission. Further review of the record revealed a SN visit note dated 9/25/24 which documented Wound #1/Left Buttock; Wound #2/Right Buttock. The documentation was unclear, and it could not be determined which area was classified as wound #1 or wound #2. Further, the SN visit notes documented the wound was closed yet had a pink wound bed and required wound dressings. This was an inaccurate assessment of the patient at the time of admission and ongoing. The Administrator (Adm #1) reviewed and acknowledged the findings during an interview on 6/27/25 at 1:10 p.m. and reported, “I’m not sure what happened here.” When queried about the documentation of the wound being closed, Adm #1 reported, “We had someone come in and they told us that as long as there was no depth, the wound was considered closed.” Patient #3’s (P-3) SOC was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. The POC ordered SN and PT services to be provided. On 6/26/25 at 12:00 p.m., during the clinical record review, a document titled “After Visit Summary” revealed the patient received treatment at an inpatient facility during the dates of 5/19/25 - 5/20/25. The document read, “Procedures/Surgeries during current admission: CYSTOLITHOLAPAXY (Surgical procedure to remove bladder stones), CYSTOSCOPY (scope used to examine urethra and bladder), LASER LITHOLAPAXY (surgical procedure to remove bladder stones). Discharge to home. SP (Suprapubic urinary Catheter) to DRAINAGE.” [sic] Upon further review of the record, it was unclear if the patient was admitted for overnight stay or the health status of the patient post treatment. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 6/27/25 at 2:00 p.m., and reported, “These (documents) shouldn’t even be in his (P-3) chart.” Adm #1 did not provide any additional information that would explain the course of treatment or status post treatment/hospitalization.”

“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 the transfer/discharge summaries were documented in the record and sent to the Physician in 4 (P-1, P-3, P-4, 5) records in which the patient was discharged/transferred from the agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: Patient #4 (P-4)’s start of care (SOC) date was 9/17/2021, with diagnoses of cellulitis, urinary device placement, and hypertension. During review of the record on 6/24/25, it was noted that the patient had skilled nursing (SN) services ordered. The patient was transferred on 5/7/25 with a resumption of care on 5/8/25. There was a transfer OASIS dated 5/7/25 in the record, however, there was no documented evidence of a transfer summary in the patient’s record. The agency failed to include a transfer summary in the patient’s medical record to help facilitate continuity of care. Patient #5 (P-5)’s SOC date was 8/8/24, with diagnoses of type 2 diabetes mellitus, peripheral vascular disease (PVD), and urinary tract infection (UTI). During record review 6/25/25, it was noted that the patient had skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services. P-5 had a discharge summary in the record dated 9/4/2024, however, there was no documented evidence in the record that the discharge summary was sent to the physician. The agency failed to send the discharge summary for physician review. During an interview 6/27/25 at 2:40 p.m., the administrator (Adm #1) acknowledged the above findings. Patient #1 (P-1)’s start of care (SOC) was 9/21/24 with diagnoses that included Congestive Heart Failure and Acute Respiratory Failure. The Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the record review on 6/24/25 at 12:25 p.m., it was noted that the patient was transferred to an inpatient facility on 10/29/24. At the time of this review, no Transfer Summary had been completed which detailed the course of care provided, the reason for the transfer, the patient’s health status at the time of transfer and forwarded to the receiving facility. Additionally, there was no documented evidence that the Physician had been notified of the transfer. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 6/27/25 at 1:10 p.m. Patient #3 (P-3)’s SOC was 5/13/25 with diagnoses that included Quadriplegia, Falls and Hypotension. The POC ordered SN and PT services to be provided. During the clinical record review on 6/26/25 at 12:00 p.m. it was noted that the patient was transferred to an inpatient facility on 5/20/25. At the time of this review, no Transfer Summary had been completed which detailed the course of care provided, the reason for the transfer and the patient’s health status at the time of the transfer and subsequently forwarded to the receiving facility. Further, there was no evidence that the Physician had been made aware of the inpatient transfer. Adm #1 reviewed and acknowledged the above findings during an interview on 6/27/25 at 2:00 p.m.”