Accelerated Homecare Services, Inc.

“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, it was determined the agency failed to provide evidence of its efforts to measure, track and analyze it’s quality indicators and show measurable improvement in patient care and services (See G 642); failed to develop Performance Improvement activities, as part of the agency’s Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions (See G 654); failed to document any of the required annual quality improvement projects since 2023 through 6/27/25, including the reasoning for conducting these projects and the measurable progress achieved each year (See G 658); and failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety which evaluated its effectiveness (See G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care for all 43 patients currently receiving services from the Home Health Agency regarding the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to develop an infection control program that focused on infection prevention and control, including communicable diseases for the last 3 years (See G682); failed to ensure the infection control program was active and provided surveillance, identification, prevention, control and investigation of infectious and communicable diseases and was a part of the agency’s Quality Assessment and Performance Improvement program for the last 3 years (See G684); and failed to provide infection control education to all direct and contracted staff for the last 3 years (See G686). The cumulative effects of these systemic problems resulted in the agency’s inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.”

“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 physical therapist (PT) followed accepted standards of practice in assuming responsibility for care in 1 (P-7) of 4 patients reviewed who received PT services, from a total of 7 records reviewed (see G704); failed to ensure services were provided as ordered by the physician in the plan of care for 3 (P-1, P-3, P-7) of 7 total records reviewed (see G710); and failed to ensure skilled professionals prepared clinical notes per agency policy in 4 (P-1, P-2, P-3, and P-4) of 7 records reviewed (see G716), resulting in the potential for poor patient outcomes. Findings include: The cumulative effects of these systemic problems resulted in the agency’s inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.75: Skilled professional services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained goals in the patient plans of care in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed (see G116); failed to ensure a completed discharge summary was sent to the health care professional responsible for care of the patient after discharge within 5 business days of the patient’s discharge in 1 (P-3) of 1 discharged record reviewed (see G1022); and failed to ensure all clinical record entries were appropriately authenticated, dated, and timed in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed (see G1024), resulting in the potential for an incomplete clinical record and poor patient outcomes. Findings include: The cumulative effects of these systemic problems resulted in the agency’s inability to ensure the provision of safe health care to all 43 patients currently receiving services for the condition of participation of 42 CFR§484.110: Clinical records.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness (EP) plan was reviewed and updated at least every 2 (2023 and 2024) of 2 years, 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 6/24/25 at 12:22 PM. During review of the binder, it was noted there was no documented evidence of when the EP plan was last reviewed and updated. During an interview with the alternate clinical manager (RN-1) on 6/25/25 at 2:56 PM, RN-1 was asked when the EP plan was last reviewed and updated. RN-1 stated the EP plan has not been reviewed or updated since before the agency was bought by the current owner in May of 2023; however, she was unable to provide an exact date. RN-1 acknowledged the findings at the time of interview. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan”(not dated) revealed, “The Agency will perform a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan to identify potential disasters likely to occur in the agency’s service area, which is reviewed annually or as the need arises.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the hazard vulnerability assessment (HVA) was reviewed and updated at least every 2 (2023 and 2024) of 2 years, 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 6/24/25 at 12:22 PM. During review of the binder, it was noted the last hazard vulnerability assessment (HVA) was dated 1/20/22. During an interview with the alternate clinical manager (RN-1) on 6/25/25 at 2:56 PM, RN-1 stated the HVA has not been updated since the agency was bought by the current owner in May of 2023. RN-1 acknowledged the findings at the time of interview. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan”(not dated) revealed, “The Agency will perform a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan to identify potential disasters likely to occur in the agency’s service area, which is reviewed annually or as the need arises.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency Preparedness (EP) communication plan included updated staff names and contact information for 8 of 14 staff, 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 6/24/25 at 12:22 PM. During review of the binder, it was noted the emergency phone tree in the communication plan section listed the names and contact information for the previous administrator (RN-1), the office manager (OM), and 2 contract companies. During an interview with RN-1 on 6/25/25 at 3:38 PM, RN-1 reviewed this document and RN-1 stated, “that’s the old one.” At 4:01 PM, RN-1 provided a document titled “Emergency Fan-Out Call Tree: Accelerated Homecare Service”. This document included the name and phone number of the current administrator (Adm); however, it only included 6 of 14 other employees listed on the staff list. Additionally, there was no contact information listed for any of the other staff. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “A current listing of staff and all applicable contact numbers (i.e. home phone, cell phone, emergency numbers, emergency contact numbers of family/friends if employee is unreachable) will be maintained.” The policy also indicated the “Disaster calling tree is utilized for contacting Agency staff.” The Adm, RN-1, and alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/25/25 at 4:05 PM.”

“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 initial Emergency Preparedness (EP) training was provided for 1 (Adm) of 8 employees 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 6/24/25 at 12:22 PM. During review of the binder, it was noted the administrator (Adm) was listed as the “Emergency Incident Commander” on the emergency phone tree. Upon review of the personnel file for Adm on 6/26/25 at 12:55 PM, it was determined there was no documented evidence Adm received initial EP training. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “Each staff member receives initial training during orientation and at least annually thereafter.” During an interview with the alternate administrator (Alt-Adm) on 6/26/25 at 9:23 AM, Alt-Adm was asked to provide documentation that Adm received initial EP training. Alt-Adm reported Adm was present for EP training as “he is the boss”, however, Alt-Adm acknowledged Adm did not sign the form indicating he completed the training. Alt-Adm acknowledged the findings at the time of interview.”

“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) testing included the required criteria in 3 (2023, 2024, and 2025) of 3 years reviewed, resulting in the potential for an unprepared staff response on the event of an emergency. Findings include: The agency’s Emergency Preparedness (EP) binder was reviewed on 6/24/25 at 12:22 PM. During review of the binder, the following was noted regarding the EP testing drills: 1. There was no documentation of a drill completed in 2023. 2. The documentation for 2024 was an actual event regarding a pending snowstorm in the area. Upon review of the documentation, it was noted there was no documentation regarding if a snowstorm actually occurred or if the emergency plan had to be activated as a result. Additionally, there was no follow-up documentation to analyze the agency’s performance in following the EP plan. 3. The documentation for 2025 was a tabletop drill for an active shooter. Upon review of the documentation, it was noted there was no documentation of the emergency scenario that was presented to staff to review and discuss. A review of the agency policy titled “Disaster Readiness and Emergency Management Plan” (not dated) revealed, “Emergency drills will be conducted at least annually.” The policy also indicated, “Exercises will incorporate likely disaster scenarios that allow the Agency to assess its handling of communications, resources and assets, staff and patients. Exercises will review and confirm: Staff communication procedures and content; Assigned staff roles related to essential response functions; How Agency will communicate with patients during an emergency.” Additionally, “Exercises must sufficiently stress Agency’s plan to identify weaknesses;...Analyze the Agency’s response to and maintain documentation of all drills, tabletop exercises and emergency events.” [sic] The administrator (Adm), alternate clinical manager (RN-1), and alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/25/25 at 4:05 PM.”

“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, it was determined the agency failed to develop, implement, and maintain a Quality Assessment and Performance Improvement (QAPI) program which provided documentation of its efforts to measure, track and analyze quality indicators that represented pre-established performance improvement projects (PIP’s) designed to optimize patient care services, resulting in the inability to determine the quality of services provided and the potential for unmet care needs for all 43 patients currently being served by this agency. Findings include: On 6/26/25, the agency’s QAPI documentation was reviewed which revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body approved PIP’s. Review of the QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency to identify ways to improve the delivery of patient care in measurable terms. Subsequently, no data was found in the agency’s QAPI program for the last 3 years. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:48 AM.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop performance improvement activities, as part of the agency’s Quality Assessment Performance Improvement (QAPI) program, to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs for all 43 patients currently receiving services. On 6/26/25, during review of the agency’s QAPI documents since 2022, it was noted there was no evidence that the agency had attempted to implement any quality improvement measures or activities that would serve to track/trend adverse patient events, analyze causative factors and implement preventive interventions. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:51 AM.”

“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, it was determined the agency failed to develop a Performance Improvement Project (PIP) within its Quality Assessment Performance Improvement (QAPI) program, resulting in the agency’s inability to effectively monitor proposed improvements in patient care, health outcomes, patient safety, quality of care and overall performance for all 43 patients currently receiving services from this agency. Findings include: On 6/26/25, review of the agency’s QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency to identify ways to improve medication management or a methodology to collect data in this area. Further, no evidence was found of another patient care area to develop a potential PIP. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:53 AM.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care, maintained patient safety standards, and was evaluated for its effectiveness, resulting in the potential to adversely affect the quality of care to all 43 patients currently receiving services and all 95 patients admitted over the past year. Findings include: On 6/26/25, the agency’s QAPI documentation was reviewed and revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body (GB) meeting minutes. Review of the agency’s QAPI binder for the last 3 years noted 2 QAPI meetings dated 5/19/25 and 5/23/25. Documentation concerning both QAPI meetings mentioned the idea of monitoring medication management. However, no evidence was found within the QAPI program that showed an effort was made by the agency’s GB to ensure its QAPI program detailed key components such as patient safety and quality care measures are implemented and maintained. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/26/25 at 9:55 AM.”

“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 record review and interview, the agency failed to develop an infection control program which monitored staff’s performance to ensure infection control policies and accepted standard practices to prevent the transmission of infections and communicable diseases were followed in the last 3 years, resulting in a lack of oversight concerning infection control practices used during patient care by agency staff and the potential for poor clinical outcomes for all 43 patients currently receiving services. Findings include: On 6/26/25, a request was submitted to agency administration to review the agency’s infection control program for the last 3 years. Both the alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) stated that there was no infection control education, or in-services that had been provided to its staff (direct or contracted) for the last 3 years during an interview on 6/26/25 at 9:57 AM.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency’s Quality Assessment Performance Improvement (QAPI program), resulting in the potential spread of infections between patient care staff and the agency’s 95 patients admitted in the past 12 months. Findings include: On 6/26/25, a request was submitted to the agency’s administration to review its infection control program for the last 3 years. Both the alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) stated during an interview on 6/26/25 at 9:58 AM., that there was no evidence of infection control surveillance, identifying infectious diseases, data collection (with analysis) and planning which would be utilized to monitor its effectiveness for meeting infection control goals.”

“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 ensure infection control training was provided to 7 (Alt-Adm, RN-1, RN-2, RN-3, LPN, RPT-1, and RPT-2) of 7 sampled clinical staff, resulting in the potential for a lack of staff education in infection control practices. Findings include: Personnel files for 7 clinical staff were reviewed on 6/26/25 at 9:23 AM. During review of the files, it was noted there was no documentation of initial infection control training for the alternate administrator (Alt-Adm), alternate clinical manager (RN-1), 2 registered nurses (RN-2 and RN-3), licensed practical nurse (LPN), and 2 registered physical therapists (RPT-1 and RPT-2). The files for a RN-2 and LPN contained an orientation checklist form that included infection control, however, these forms were left blank. During an interview with RN-1 on 6/26/25 at 12:57 PM, RN-1 was asked where to find evidence of initial training for infection control. RN-1 stated it should be kept in the personnel files. RN-1 acknowledged the lack of documentation at the time of interview. A review of agency policy titled “Bloodborne Pathogens Standard” (revised February 2025) revealed, “The Agency provides a training program to each of its employees at the time of initial employment as a part of employee orientation and annually thereafter.” The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the physical therapist (PT) followed accepted standards of practice in assuming responsibility for the care of 1 (P-7) of 4 patients who received PT services, from a total of 7 sampled records reviewed, resulting in abrupt cessation of PT services and the potential for poor clinical outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, record review noted an unauthorized physical therapy (PT) evaluation on 5/23/25, with an intended visit frequency of 1W1 (once a week time one week), followed by 2W5, and 1W1. PT provided home visits with treatments on 5/23/25 (above), 5/27/25, 5/31/25, 6/4/25, 6/6/25, 6/9/25, and 6/11/25. Additional record review found no explanation why PT services stopped providing services to P-7. No communication notes, refusal by the patient, and no physician notification were found within the medical record. As of 6/27/25, no further PT visits were evidenced after 6/11/25, no PT discharge summary was found, and no physician order that authorized the PT visits noted above were found in agency records. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:12 AM. The Alt-CM stated the agency failed to allow the PT visit notes to be uploaded into the agency’s EMR (electronic medical records). Without evidenced documentation, the PT and agency professionals failed to responsibly authenticate physician orders (or lack of) and document the provision of all services rendered.”

“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 record entries were appropriately authenticated, dated, and timed in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in an incomplete clinical record. 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 6/24/25 and 6/27/25. Upon review of the documentation, it was determined the clinical record entries for P-1, P-2, P-3, P-4, P-5, P-6 and P-7 did not include the title of the person who electronically signed the entries, the time the visits occurred, or the time and date the visit notes were signed/completed. A review of agency policy titled “Medical Record Entries and Authentication” (revised February 2024) revealed, “All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed.” The policy also stated, “All entries in the medical records will be authenticated by staff signature and title.” During an interview with the office manager (OM) and alternate clinical manager (RN-1) on 6/25/25 at 11:31 AM, OM and RN-1 confirmed the medical record entries do not include authentication by title, the time the visit occurred, or the time and date the visit note was signed/completed. OM stated this is an issue with the electronical medical record system (EMR) they use. OM and RN-1 acknowledged the findings at the time of interview. The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“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 patients were informed of the disciplines that would furnish care and the frequency of visits in 4 (P-1, P-2, P-4, P-7) of 7 total sample records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25 at 10 AM., during a joint home visit with skilled nursing, it was observed the signed copy of P-7’s Plan of Care was void of all information such as: “Orders and Treatments”, “Disciplines on case and frequency of visits”, “Reason for admission”, “Interventions/treatment to be provided”, topics to be educated on, safety precautions, and patient goals. In addition, the form “Home Care Consent and Admission Service Agreement” was observed to be blank for assigned disciplines and intended home visit frequency. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:57 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 1 week and 1 time a week for 6 weeks. Upon review of the consent form signed by the patient upon admission, it was determined the agency failed to include information regarding initial services and frequency as the form was left blank. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 5 weeks and 1 time a week for 1 week. Upon review of the consent form signed by the patient upon admission, it was determined the agency failed to include information regarding initial services and frequency as the form was left blank. Patient #4 (P-4) was admitted to this home care agency on 6/5/25 with the diagnoses of cerebrovascular disease, hypertension (high blood pressure), and gait abnormalities. During record review on 6/26/25, it was noted the patient was receiving services from skilled nursing 1 time a week for 1 week. The patient was supposed to be receiving physical therapy 2 times a week for 5 weeks according to the plan of care, however, the patient had not been evaluated by physical therapy yet. Upon review of the consent form signed by the patient upon admission, it was noted check marks indicated the patient would receive services from skilled nursing, physical therapy, occupational therapy, and social work. Upon further review of the record, it was determined occupational therapy and social work services were not ordered, received, or included on the plan of care. A review of the agency policy titled, “Admission Information” (revised February 2024) revealed, “At time of admission, the Agency will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide an ordered skilled service on the plan of care for 3 (P-3, P-4, and P-7) of 4 records reviewed with physical therapy services, from a total of 7 sampled records reviewed, resulting in the potential for unmet clinical needs. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25, record review for the referral for home care ordered skilled nursing (SN) and physical therapy (PT) to evaluate and treat the patient. The Plan of Care (POC) effective 5/7/25, documented PT services were refused by P-7. However, during a joint home visit on 6/25/25 at 10 AM. with SN, P-7 was found to be alert and oriented x 2-3 and ambulatory with a cane. P-7 was then asked if she wanted to get stronger so she could walk better and be safer. P-7 responded, “I sure would like that!” Subsequently, P-7 was asked why she refused PT services. P-7 replied, “I never refused physical therapy.” SN was asked why PT services were not provided then as ordered? SN stated the granddaughter and brother of P-7 chose to decline PT services. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) were asked during an interview on 6/26/25 at 12:32 if the agency had any paperwork which showed full DPOA (Durable Power of Attorney) over P-7’s medical decisions by another individual such as the granddaughter or brother above. The Alt-Adm and Alt-CM both acknowledged there was no DPOA paperwork, and that P-7 was able to give informed consent. The agency failed to ensure P-7’s rights were granted in receiving the ordered PT services found in the POC. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the referral (dated 10/18/24) ordered services from physical therapy and skilled nursing. Upon further review of the record, it was determined physical therapy never evaluated the patient. There was no documentation regarding why the patient did not receive physical therapy as ordered. Patient #4 (P-4) was admitted to this home care agency on 6/5/25 with the diagnoses of cerebrovascular disease, hypertension (high blood pressure), and gait abnormalities. During record review on 6/26/25, it was noted the referral (dated 6/5/25) ordered services from physical therapy and skilled nursing. Upon further review of the record, it was determined physical therapy had not evaluated the patient as of 6/25/25. There was no documentation regarding why the patient did not receive physical therapy as ordered. A review of agency policy titled “Plan of Care – CMS #485 and Physician/Practitioner Orders” (revised February 2025) revealed, “20. Care and services provided will be provided according to physician/practitioner orders.” During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked why physical therapy had not evaluated P-3 and P-4. Alt-Adm stated the patients “may have refused,” however, she acknowledged there was no documentation to support that. Alt-Adm acknowledged the findings at the time of interview.”

“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 initial assessment was performed within 48 hours of referral to determine immediate care needs and Medicare eligibility in 4 (P-1, P-2, P-3, P-5) of 7 total sampled records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #5 (P-5) was admitted to the home care agency on 5/23/25, with diagnoses which included hypertension, chronic kidney disease, gout, diabetes type-2, and epilepsy. On 6/25/25, record review found a physician face-to-face visit on 4/14/25, and an insurance “Authorization/Referral Request” form submitted by the agency for payment reimbursement. However, no evidence of a physician referral for home care was found in the medical record. Subsequently, there was no time of receipt for the referral to note when the 48-hour window started to initiate the start of care visit. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:14 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the referral for home care services was written on 5/8/25. Upon further review of the record, it was determined the initial assessment did not occur until 5/14/25 – 7 days after the referral. There was no documentation regarding the reason for the delay. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the referral for home care services was written on 5/21/25. Upon further review of the record, it was determined the initial assessment did not occur until 5/29/25 – 8 days after the referral. There was no documentation regarding the reason for the delay. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the referral for home care services was written on 10/18/24. Upon further review of the record, it was determined the initial assessment did not occur until 11/6/24 – 19 days after the referral. There was no documentation regarding the reason for the delay. A review of the agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2025) revealed, “A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner-ordered start of care date.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“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-1, P-2) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients to assist developing the plan of care. Findings include: Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the Outcome and Assessment Information Set (OASIS) indicated the primary diagnosis was “Type 1 diabetes mellitus without complications.” Upon further review of the OASIS, it was noted the blood sugar section indicated the patient had Type II diabetes for “over 30 years.” This information is conflicting and does not show a clear picture of the patient’s status. Additionally, it was noted the OASIS reported the patient was “Dependent upon adaptive device(s) such as: wheelchair, walker,” and used a manual wheelchair under the “Prior Device Use” section. The OASIS also reported “Yes” under the question, “Does patient use wheelchair and/or scooter?” Upon further review of the OASIS, it was noted neither wheelchair nor walker were marked under the section labeled “DME” (durable medical equipment). It is unclear whether the patient used a wheelchair. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the OASIS reported the patient needed “supervision or touching assistance” to walk 150 feet, to walk 10 feet uneven surfaces, to go up and down a curb, and to go up and down 4-12 stairs without a railing. Upon further review of the OASIS, it was noted the patient “needed some help” with ambulation and was “dependent” on stairs prior to admission. Upon review of the physical therapy evaluation dated 6/7/25, it was documented the patient could only walk 15 feet and needed minimal assistance. This information is conflicting and does not show a clear picture of the patient’s status. A review of agency policy titled “Initial Assessments/Comprehensive Assessments” (revised February 2025) revealed, “The Initial Comprehensive Assessment also includes: Relevant diagnoses and current health status, including all active health and medical problems.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“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 medical record identified and reconciled patient medication interactions in 4 (P-1, P-2, P-3, P-7) of 7 total sampled records reviewed, resulting in the potential for adverse effects and poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/25/25 at 10 AM., during a joint home visit with skilled nursing (SN), it was observed that P-7’s medications available for use on the bedside nightstand did not match the current medication list found in the active plan of care (POC) for P-7. The 5 listed medications on the POC were found with the correct information. However, the following medications had no documented evidence that a review had taken place to check for potential interactions or expiration dates: Brimonidine Tartrate 0.2% solution (lowers pressure in the eye), Diclofenac Sodium Topical 1% (lowers eye inflammation), Lidocaine 5% topical (pain relief), Ammonium lactate 12% topical cream (treats dry skin), and Ventolin HFA 108 mcg. (helps breathing), all of which were non-expired. The two following medications that were also unaccounted for were severely expired: Doxycycline (antibiotic) 100 mg., with an expiration date of 4/22/21, and QVAR (helps with breathing) 80 mcg., had an expiration date of 6/7/16. No documentation was found which indicated SN tried to discover all prescribed medications in the home and documented education given to discard the severely expired medications noted above. The alternate clinical manager reviewed and acknowledged the findings on 6/26/25 at 9:35 AM., who noted this did not meet agency expectations or its policy referenced below. The agency’s policy titled “Medication Reconciliation” (Revised February 2024) 8.15.1 stated, “The Agency will reconcile patient’s medications at time of admission and on an ongoing basis 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 non-compliance with drug therapy.” (sic) Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was noted the Outcome and Assessment and Information Set (OASIS) reported “No – No issues found during review” under the section titled “Drug Regimen Review.” Upon running a drug interaction report on the agency’s electronic medication record (EMR) system, it was determined there were 5 moderate drug-to-drug interactions. Additionally, a skilled nursing note dated 6/17/25 stated “used to take monjaro but but caused him constipation.” [sic] Upon review of the mediation profile, it was determined Mounjaro was never removed from the active medication list. Patient #2 (P-2) was admitted to this home care agency on 5/29/25 with the diagnoses of type II diabetes mellitus, hypertension (high blood pressure), and weakness. During record review on 6/25/25, it was noted the OASIS reported “No – No issues found during review” under the section titled “Drug Regimen Review.” Upon running a drug interaction report on the agency’s EMR system, it was determined there were 3 moderate drug-to-drug interactions. Additionally, a skilled nursing note dated 6/13/25 stated, “Patient started on amox-clav 500-125 mg. for 2 days and loratadine 10 mg daily for runny nose.” [sic] Upon review of the mediation profile, it was determined Loratadine was never reconciled on an updated medication profile to check for any interactions. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was noted the OASIS reported “Yes – Issues found during review.” Additionally, the OASIS indicated a medication follow-up was completed “by midnight of the next calendar day” and competed “prescribed/recommended actions and reasons to the identified potentially significant medication issues.” Upon review of the fax confirmation sheet located in the clinical record, it was determined the medication interaction report with 12 moderate interactions wasn’t faxed to the physician until 1/30/25 – 84 days after the interactions were identified. During the entrance interview on 6/24/25 at 10:53 AM, the alternate clinical manager (RN-1) was asked what level interactions were reported to the physician. RN-1 stated all moderate and severe drug interactions were reported to and reconciled with the physician and that the communication should be documented in the record. RN-1 also reported the medications should be reconciled every time a new medication is added, and the list should be updated when a medication is discontinued. A review of the agency policy titled “Medication Profile” (revised February 2024) revealed, “The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that 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, duplicative drug therapy and noncompliance with drug therapy.” The policy also stated, “The nurse or therapist will add all new/changed medication(s) to the medication profile. Discontinued (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur.” The alternate administrator (Alt-Adm) reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“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 services were provided only as ordered by the physician in 1 (P-7) of 4 records reviewed with physical therapy services provided, out of a total sample of 7 records reviewed, resulting in the potential to negatively affect all 43 patients currently serviced by the agency. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, record review noted the referral for home care (dated 5/5/25), ordered skilled nursing (SN) and physical therapy (PT) to evaluate and treat the patient. The Plan of Care (POC) effective 5/7/25, documented PT services were refused by P-7. No physician order was found in the medical record reauthorizing PT services to treat the patient after the documented refusal by P-7. Further review noted that PT services provided home visits with treatments on 5/23/25, 5/27/25, 5.31.25, 6.4.25, 6/6/25, 6/9/25, and 6/11/25 without any physician order. The alternate clinical manager (Alt-CM) reviewed and acknowledged this finding during an interview on 6/26/25 at 2:42 PM. In addition, during a joint home visit on 6/25/25 at 10 AM. with SN, P-7 was found to be alert and oriented x 2-3 and ambulatory with a cane. P-7 was then asked if she wanted to get stronger so she could walk better and be safer. P-7 responded, “I sure would like that!” Subsequently, P-7 was asked why she refused PT services. P-7 replied, “I never refused physical therapy.” SN was asked why PT services were not provided then as ordered? SN stated the granddaughter and brother of P-7 chose to decline PT services. The alternate administrator (Alt-Adm) and the Alt-CM were asked during an interview on 6/26/25 at 12:32 if the agency had any paperwork which showed full DPOA (Durable Power of Attorney) over P-7’s medical decisions by another individual such as the granddaughter or brother above. The Alt-Adm and Alt-CM both acknowledged there was no DPOA paperwork, and that P-7 was able to give informed consent. The agency failed to fulfill the PT order in the POC effective 5/7/25 as the patient did not refuse and failed to obtain an order to authorize the PT visits noted above. The Alt-Adm and Alt-CM reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:57 AM.”

“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 services were provided as ordered by the physician in the plan of care for 3 (P-1, P-3, P-7) of 7 total sampled records reviewed, resulting in the potential for poor patient outcomes. Findings include: Patient #7 (P-7) was admitted to the home care agency on 5/7/25, with diagnoses of hypertension, chronic low back pain, and gastro-esophageal reflux disease (GERD). On 6/26/25, review of P-7’s plan of care (POC) noted skilled nursing (SN) services had an ordered visit frequency of 1W6 (once a week time 6 weeks). Further record review noted after the initial start of care visit by SN on 5/7/25, the next SN visit occurred on 5/21/25. No evidence that P-7 had refused the SN visit, and no order or communication note which explained or excused the missed visit (5/11/25 through 5/17/25) was found in the medical records. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 10:59 AM. Patient #1 (P-1) was admitted to this home care agency on 5/14/25 with the diagnoses of type I diabetes mellitus, hypertension (high blood pressure), and morbid obesity. During record review on 6/24/25, it was determined the plan of care ordered skilled nursing 1 time a week for 4 weeks and physical therapy 2 times a week for 1 week and 1 time a week for 6 weeks. Upon further review of the record, it was determined there were no skilled nursing visits during weeks 3, 4, and 5. Additionally, there were no physical therapy visits during weeks 5 and 6. There was no documentation regarding the reason the patient was not seen. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was determined the plan of care ordered skilled nursing 1 time a week for 5 weeks. Upon further review of the record, it was determined there were no skilled nursing visits during weeks 4 and 5. There was no documentation regarding the reason the patient was not seen. A review of agency policy titled “Plan of Care – CMS #485 and Physician/Practitioner Orders” (revised February 2025) revealed, “20. Care and services provided will be provided according to physician/practitioner orders.” During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked where missed visits were documented in the record. Alt-Adm reported they should be documented in a communication note; however, she acknowledged there were no communication notes for P-1 or P-3 regarding missed visits. Alt-Adm acknowledged the findings at the time of interview.”

“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 per agency policy in 4 (P-1, P-2, P-3, and P-4) of 7 records reviewed, resulting in the potential for poor coordination of care and poor patient outcomes. Findings include: During the entrance conference on 6/24/25 at 10:53 AM, the alternate clinical manager (RN-1) was asked about the agency expectation for the timeline for completion of visit notes. RN-1 stated, “2-3 days.” Upon review of visit notes for Patient #1 (P-1) on 6/25/25, it was determined the daily visit notes did not include a date and time stamp of when the note was completed by the clinician. On 6/25/25 at 11:31 AM, the office manager (OM) was asked how to know when the visit note was completed. OM was able to run a separate report that showed “date submitted.” OM stated this is when the note is complete and sent to her for review. A review of agency policy titled “Timely Submission of Patient Documentation” (revised February 2024) revealed, “Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc.” [sic] During review of the records for P-1, Patient #2 (P-2), Patient #3 (P-3), and Patient #4 (P-4) between 6/24/25 and 6/27/25, the following notes were found to be submitted after more than 3 days: P-1: The physical therapy evaluation visit was dated 5/20/25 and submitted on 6/9/25 (20 days). A skilled nursing visit was dated 5/22/25 and submitted on 5/26/25 (4 days). A physical therapy visit was dated 5/27/25 and was submitted on 6/25/25 (29 days). A physical therapy visit was dated 5/29/25 and was submitted on 6/25/25 (31 days). A physical therapy visit was dated 6/3/25 and had not been submitted as of 6/24/25 (21 days). P-2: A skilled nursing visit was dated 6/2/25 and was completed on 6/10/25 (8 days). The physical therapy evaluation was dated 6/7/25 and was submitted on 6/17/25 (10 days). A physical therapy visit was dated 6/10/25 and was submitted on 6/23/25 (13 days). A physical therapy visit was dated 6/12/25 and was submitted on 6/23/25 (11 days). A skilled nursing visit was dated 6/13/25 and was submitted on 6/23/25 (10 days). A physical therapy visit was dated 6/19/25 and was submitted on 6/24/25 (5 days). P-3: The skilled nursing start of care (initial evaluation) was dated 11/6/24 and was submitted on 1/3/25 (58 days). A skilled nursing visit was dated 11/14/24 and was submitted on 11/27/24 (13 days). A skilled nursing visit was dated 11/20/24 and had not been submitted as of 6/25/25 (217 days). A skilled nursing discharge visit was dated 12/4/24 and had not been submitted as of 6/25/25 (203 days). P-4: A skilled nursing visit was dated 6/13/25 and was submitted on 6/19/25 (6 days). The alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/27/25 at 9:18 AM.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator was appointed by the governing body in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for a lack of direction and oversight for the agency. Findings include: During the entrance conference with the administrator (Adm) on 6/24/25 at 10:53 AM, it was determined Adm was the current administrator of the agency. On 6/25/25 at 10:23 AM, the alternate clinical manager (RN-1), who was also the previous administrator, was asked to provide documentation of when the current administrator (Adm) was appointed by the governing body. RN-1 provided governing body meeting minutes from 6/15/23 that indicated Adm was the new owner, however, the current alternate administrator (Alt-Adm) was listed as the administrator. It was also noted the “Authorization of Agency Responsibility” form located in the governing body binder was left blank. There was no evidence Adm was appointed by the governing body. A review of agency policy titled “Governing Body” (revised March 2018) revealed, “The Governing Body appoints a qualified Administrator or approves an Administrator selected by the corporation or another group and annual evaluates the Administrator’s performance.” The consultant (Con) and alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/25/25 at 12:12 PM.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a qualified, pre-designated person was identified and approved by the governing body as the alternate administrator to be responsible in fulfilling the roll of the administrator in his absence in 2 (2023 and 2024) of 2 years reviewed, resulting in the potential for lack of direction and oversight for the agency. Findings include: During the entrance conference on 6/24/25 at 10:53 AM, the administrator (Adm) was asked for the name of the alternate administrator in the event of his absence. Adm stated the alternate administrator was Alt-Adm. Following review of the governing body meeting minutes on 6/25/25 at 10:23 AM, the alternate clinical manager (RN-1), who was also to the previous administrator, was asked to provide documentation of when Alt-Adm was appointed by the governing body. RN-1 provided governing body meeting minutes from 3/21/25 that indicated Alt-Adm was the DON (director of nursing)/Clinical Manager, however, there was no mention of her also being appointed as the alternate administrator. RN-1 also provided a form titled “Succession of Leadership” which stated Alt-Adm would be responsible for day-to-day operations in the absence of Adm, however, there were no signatures to indicate this position was approved and accepted. The consultant (Con) and alternate administrator (Alt-Adm) also reviewed and acknowledged the findings during an interview on 6/25/25 at 12:12 PM.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical manager provided oversight in coordinating patient care for 19 of 43 active patients, resulting in the potential for missed visits and poor patient outcomes. Findings include: On 6/26/25 at 2:07 PM, the office manager (OM) was asked to provide the patient schedule for the week. Upon review of the schedule, it was determined only 24 of the current 43 active patients were scheduled for the week. OM was asked how the agency tracked who was scheduled to ensure frequencies in the plan of care were met. OM stated she “plotted” visits when the clinicians told her the frequency, however, she reported the agency does not track who has and has not been scheduled each week to ensure plan of care frequencies were met. OM also stated the clinicians often scheduled their own appointments and she added them to the schedule for them to document later, so more visits may show up on the schedule later in the week. OM reported it was more difficult to track patient visits since they recently admitted so many new patients, however, she acknowledged the importance. Upon further review of the schedule with OM at 2:27 PM, it was noted Patient #2 (P-2) was scheduled for one visit on 6/24/25. During a home visit with P-2 and the physical therapist (RPT-2) on 6/26/25 at 10:00 AM, P-2 and RPT-2 confirmed 6/26/25 was the second visit for the week. P-2 reported she was also seen on 6/23/25. A review of P-2’s plan of care confirmed physical therapy was ordered 2 times per week, however, these visits were not reflected in the “plotted” schedule or the patient record. OM stated the clinician can move the visits to the day they were done; however, she did not know why the second visit was not “plotted” on the schedule if the frequency was supposed to be 2 times per week. During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, the above information was reviewed. Alt-Adm was asked how she coordinated patient care to ensure frequencies in the plan of care were met. Alt-Adm reported it was harder to coordinate patient care since they recently admitted so many new patients, however, she agreed she needed to do a better job. Alt-Adm was also unable to provide an explanation as to why 19 of the active patients were not on the weekly schedule. Alt-Adm acknowledged the findings at the time of interview.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained goals in the patient plans of care in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. 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 6/24/25 and 6/27/25. Upon review of the documentation, it was determined the records for P-1, P-2, P-3, P-4, P-5, P-6, and P-7 did not include any skilled nursing goals on the plans of care. A review of agency policy titled “Medical Record Content” (revised February 2024) revealed, “4. Each medical record will contain the following:…Identification of problems, interventions and goals (care planning) for each discipline and updates to the plan of care…”. During an interview with the alternate administrator (Alt-Adm) on 6/27/25 at 9:18 AM, Alt-Adm was asked to find the goals written by skilled nursing for P-1, P-2, P-3, P-4, P-5, P-6, and P-7. Alt-Adm stated they should be on the plans of care; however, she was unable to locate them for any of the patients listed above. Alt-Adm acknowledged the findings at the time of interview”

“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 a completed discharge summary was sent to the health care professional responsible for care of the patient after discharge within 5 business days of the patient’s discharge in 1 (P-3) of 1 discharged record reviewed; and failed to send out a transfer summary within 2 business days of becoming aware of an unplanned transfer in 1 (P-5) of 1 record reviewed with a transfer, resulting in the potential for unmet care needs following discharge and/or transfer. Findings include: Patient #5 (P-5) was admitted to the home care agency on 5/23/25, with diagnoses which included hypertension, chronic kidney disease, gout, diabetes type-2, and epilepsy. On 6/25/25, record review noted P-5 was transferred to the hospital on 6/10/25. No evidence that a transfer summary was sent to the receiving hospital within 2 days of the agency becoming aware of the transfer as required. The alternate administrator (Alt-Adm) and the alternate clinical manager (Alt-CM) reviewed and acknowledged the findings above during an interview on 6/27/25 at 11:12 AM. Patient #3 (P-3) was admitted to this home care agency on 11/6/24 with the diagnoses of hypertension (high blood pressure), fatigue, and dementia. During record review on 6/25/25, it was determined skilled nursing was ordered to see the patient 1 time a week for 5 weeks. The patient’s last visit with skilled nursing was documented on 11/20/24 (during week 3). Upon further review of the record, it was determined a discharge Outcome and Assessment Information Set (OASIS) was started on 12/4/24. This note was not completed or signed by the nurse; therefore, it could not have been sent to the physician within 5 business days of discharge. A review of agency policy titled “Discharge Summary” (revised February 2024) revealed, “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.” The alternate administrator (Alt-Adm) reviewed the findings during an interview on 6/27/25 at 9:18 AM. Alt-Adm was unsure why the discharge note was not completed and sent and acknowledged the findings at the time of interview.”