Optimum Plus Home Care

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) included all pertinent interventions and monitoring precautions for 1 (Patient/P-1) of 1 record reviewed with congestive heart failure, out of a total of 3 records reviewed, resulting in the potential for this patient not receiving care specific to their individual needs and the potential for poor clinical outcomes. Findings include: P-1: This 98-year-old was admitted to the home health agency on 4/9/25 with a diagnosis of heart disease with congestive heart failure, chronic kidney disease, and type-2 diabetes. On 9/10/25, review of P-1’s POC (effective 4/9/25), noted a failure to include any measures or interventions to monitor the patient’s primary diagnoses of congestive heart failure for fluid overload. Safety parameters to report to the physician or expected interventions to help ensure the patient’s well-being were not found such as monitoring for sudden weight gain, lower extremity circumference measurements, breath sounds and oxygen saturation levels. The agency’s alternate administrator (A-AD) reviewed and acknowledged the findings above during an interview on 9/11/25 at 11:10 AM. A-ADM noted this did not meet agency expectations and will work to correct this going forward.”

“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 coordinate patient care services to meet the needs of the patient for 1 (Patient/P-1) of 1 record reviewed with an adverse event, resulting in a poor clinical outcome for this patient and the potential for all 63 patients currently receiving services from this agency. Findings include: P-1: This 98-year-old was admitted to the home health agency on 4/9/25 with a diagnosis of heart disease with congestive heart failure, chronic kidney disease, and type-2 diabetes. On 9/10/25, a review of agency records concerning a fall experienced by P-1 during a home visit with a contracted home health aide (HHa) on 4/21/25, noted an incident report written by the RN manager (RN-C) of the contracted agency. This incident report noted the HHa used a gait belt and walker when assisting P-1 to the bathroom when “her left leg went out on her.” The HHa called RN-C to inform her of the fall and to ask for guidance (per 4/21/25 incident report). The HHa documented, “I called the office (home health agency) to let them know what happened before I got off work.” Further record review found a communication note by the home health agency’s alternate administrator on 4/21/25, which stated, “Patient knee gave out while walking to the bathroom with the aide. Aide sat down with the patient and confirmed the patient was ok.” Further record review found no evidence that the home health agency had notified the aide’s supervisory RN or the physician regarding the fall. Subsequently, documentation of a follow-up assessment for potential orders and treatments was not found in the medical record for P-1. The alternate administrator (A-ADM) for the home health agency was interviewed on 9/11/25 at 11:10 AM who acknowledged the findings that no notification or clinical assessment was coordinated with an appropriate professional after the 4/21/25 communication note. On 4/22/25, P-1 was transferred to the hospital per “OASIS-E1 Transfer” documentation due to a fall on 4/21/25. The home health agency failed to coordinate and assign an appropriate clinician to perform an assessment to ascertain the nature and extent of injuries incurred from the fall on 4/21/25 and meet the needs of the patient during an adverse event. However, A-ADM did note during the interview that on 8/8/25, the home health agency on their own accord did initiate a corrective action by providing an in-service to both direct hire and contracted staff (including the HHa involved with P-1) with further fall risk training. No evidence was found during the survey that other patient falls have occurred since 4/21/25.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the clinical record was complete, including assessments, notes and evaluations for 1 (Patient/P-1) of 1 record reviewed with an adverse event, from a total of 3 records reviewed, resulting in an incomplete clinical record that failed to document an adverse event/fall, and the unmet patient care needs experienced during the time of the fall. Findings include: P-1: This 98-year-old was admitted to the home health agency on 4/9/25 with a diagnosis of heart disease with congestive heart failure, chronic kidney disease, and type-2 diabetes. On 9/10/25, review of P-1’s clinical record noted a fall experienced during a home visit with a contracted home health aide (HHa) on 4/21/25. The only documentation found in the clinical record which pertained to the 4/21/25 fall was a “Patient Communication” note entered by the agency’s alternate administrator (A-ADM) on 4/21/25 which stated, “Patient knee gave out while walking to the bathroom with the aide. Aide sat down with the patient and confirmed the patient was ok.” Further record review found appropriate visit notes performed by the HHa (3 of 3) on 4/9/25, 4/10/25, and 4/18/25. However, the day that P-1 fell with the home health aide present on 4/21/25, no documentation other than the communication note above was found in the clinical record. The alternate administrator (A-ADM) for the home health agency was interviewed on 9/11/25 at 11:10 AM who acknowledged there was no documentation of any kind in the clinical record on 4/21/25 (day P-1 fell with injury). When A-ADM was asked why the agency didn’t document the 4/21/25 HHa visit with the adverse event, A-ADM responded that due to the fall, he felt they (agency) would not charge for the care provided that day. Subsequently no documentation was created concerning the events that led to the fall and the actions (or lack of) that followed. The agency failed to incorporate pertinent clinical findings into the medical record as required.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aides were qualified to provide home health aide service (See 754), failed to maintain sufficient documentation that demonstrated the required training for this section was met (See 766), failed to ensure the home health aide competency evaluation addressed each of the subjects listed in paragraph (b)(3)(1), (iii), (ix), (x), and (xi) of this section and completed through observation, the aide’s performance of each task, with a patient by a registered nurse prior to being deemed competent as described in this section (See G768), failed to maintain documentation of competency evaluations (See G772), failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services (See 778), failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions and needed care equipment prior to the provision of care (See G798), failed to ensure its skilled disciplines conducted the required on-site Home Health Aide supervisory visits in the patient’s home to ensure the adequate provision of care and services (See G810), and failed to ensure home health aides that provided services under arrangement met the competency evaluation requirements (See G820). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of safe and quality services by competent home health aides, for all patients receiving aide services, for the Condition of Participation of 42 CFR §484.80, Home Health Aide Services.”

“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 facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient’s physicians, entities providing services under arrangement and any volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency’s emergency preparedness documents on 11/20/24 at 1:20 p.m., it was noted that there was no contact information for all current staff, patient’s physicians, entities providing services under arrangement or any volunteers, as appropriate. These findings were reviewed with the Administrator, Alternate Administrator and Clinical Manager during an interview on 11/21/24”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to provide initial training and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate; and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 11/20/24 at 1:20 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that there was no documented evidence that all staff, including contracted personnel had received initial and ongoing training in Emergency Preparedness, as per this requirement. During an interview on 11/20/24 at 1:50 p.m., the Administrator (Adm #1) acknowledged that no one received initial training in Emergency Preparedness. Adm #1 further stated, “No one received training prior to 2024 and none of the contracted staff have received training in Emergency Preparedness. These findings were reviewed, discussed and acknowledged by Adm #1 at the time of discovery.”

“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 provide sufficient documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect staff and all patients currently serviced by this Agency. Findings include: On 11/20/24 at 1:20 p.m., a review of the agency’s Emergency Preparedness documents was conducted with the Administrator (Adm #1). Adm #1 provided documentation of an Ice Storm as reported by the Detroit Free Press on 2/23/23. On 2/22/23, the agency documented, “There was no power outage or property damage to the Agency...” Upon further review, there was no documented staff involvement, no activation of the Emergency system and no post drill analysis. The document was signed by the Administrator as the only participant in this drill. The agency failed to provide sufficient documentation of an event with staff participation, that would qualify as a test of the agency’s emergency plan. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.”

“Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This Standard is not met as evidenced by: Based on record review and interview, it was determined the physical therapist failed to supervise the services provided by the physical therapy assistant at least every 30 days for 1 (P-5) of 2 records reviewed with physical therapy assistant services provided at least 30 days, out of a total of 7 records reviewed, resulting in the potential for unmet therapy needs. Findings include: P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. The plan of care (POC) ordered therapy services of 1w1 (1 time a week for 1 week), 2w6. The Physical Therapy Assistant (PTA) performed a total of 7 visits from 11/21/23 through 12/12/23. The physical therapist (PT) completed a 30-day re-evaluation on 12/15/23. The 30-day re-evaluation and all therapy visit notes were reviewed on 11/18/24; no documentation was found that PT had performed an evaluation of the PTA concerning the following areas: provision of treatments, patient satisfaction, patient education and data collection/documentation. There was no PTA supervision documented by the PT throughout the certification period. This finding was reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 11:20 am.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide’s performance of the required tasks with a patient for 4 of 4 contracted aides (HHA #1-4) , resulting in the potential for the provision of substandard care and unmet care needs. Findings include: Policy: “Home Health Aide Services and Training Program 4.12.1”, (Revised February 2022) stated, “All Home Health Aides employed or contracted by Optimum Plus Home Care, LLC will satisfactorily complete a home health aide training program and competency evaluation program prior to performing patient care.” During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to ensure the home health aides were qualified and competent to provide patient focused home health aide care.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions and needed care equipment prior to the provision of care in 6 (P-1, P-2, P-3, P-4, P-5, P-6) records in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care, injury and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 9/24/24 with diagnoses that included Multiple Sclerosis and Hypertensive Heart disease without Heart Failure. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. During the record review on 11/18/24 at 11:25 a.m., it was noted that the Aide Care Plan was void of the following safety precautions as listed in the POC: Slow position change, Support during transfer and ambulation and Fall Precautions. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:30 a.m. P-2: The patient’s SOC was 12/22/23 with a diagnosis of Congestive Heart Failure. The referral for home care ordered SN, PT, OT, MSW and HHa services to be provided. During the record review on 11/18/24 at 1:30 p.m., it was noted that there was no Aide Care Plan available for review that provided direction on the course of care to be provided by the Aide. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 9:55 a.m. P-3: The patient’s SOC was 10/21/24 with diagnoses that included Congestive Heart Failure and wound right upper arm. During the record review on 11/19/24 at 10:40 a.m., it was noted that the Aide Care Plan was void of the following safety precautions and equipment as indicated in the POC such as, wheelchair, elevated toilet seat, slow position change, support during transfer and ambulation and Fall precautions. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:05 a.m. P-4: The patient’s SOC was 10/1/24 with diagnoses that included Syncope, GERD and Hypertension. During the record review on 11/19/24 at 11:14 a.m., it was noted that the Aide Care Plan was void of the following safety precautions as indicated in the POC such as, slow position change, support during transfer, and Fall precautions. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:20 a.m. P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. The POC ordered Home Health Aide (HHa) services at a frequency of 5w9 (5 times a week for 9 weeks) with the following safety measures: Keep pathway clear, instructed on disaster/emergency plan, slow position change, instructed on mobility safety, support during transfer and ambulation, emergency plan developed, anticoagulant precautions, safety in ADLs, instructed on safety measures, sharps safety, fall precautions, use of assistive devices, standard precautions/infection control. Other: Diabetic precautions. During record review on 11/18/24, the “Aide Care Plan” dated 11/14/23 completed by the Registered Nurse (RN) contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. P-6: The Start of Care (SOC) was dated 9/23/24. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hemiplegia, Hypertension and Diabetes Type 2. The POC ordered HHa services at a frequency of 5w9 with the following safety measures: Keep pathway clear, instructed on disaster/emergency plan, instructed on DMW & electrical safety, slow position change, instructed on mobility safety, support during transfer and ambulation, emergency plan developed, instructed on safe utilities management, anticoagulant precautions, safety in ADLs, instructed on safety measures, proper position during meals, sharps safety, fall precautions, use of assistive devices, standard precautions/infection control, instructed on sharps container. During record review on 11/19/24, the “Aide Care Plan” dated 9/23/24 completed by the RN contained no safety precautions. The HHa care plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. These findings were reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 11:00 am.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 11/18/24 during the Entrance Conference, the Alternate Administrator (Adm #2) was asked what services were provided by the agency and reported, “Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health Aide (HHa) services.” When asked if the agency utilized contract personnel, Adm #2 responded, “Yes.” When asked to clarify which service was provided directly by the Agency, Adm #2 reported, “Skilled Nursing.” Upon further review, it was noted that the agency also contracted Skilled Nursing services. The agency failed to ensure that at least one qualifying service was provided directly by agency employees. These findings were reviewed with and acknowledged by the Administrator, Alternate Administrator and Clinical Manager during an interview on 12/21/24 at 10:35 a.m.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all documents were appropriately signed, dated and timed as appropriate in 2 (P-2, P-3) records, from a total of 7 sampled records reviewed, resulting in lack of verification of consent for treatment and the potential for unmet care needs. Findings include: P-2: The patient’s start of care (SOC) was 12/22/23 with diagnoses that included Congestive Heart Failure. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW) and Home Health Aide (HHa) services to be provided. On 11/18/24 at 1:30 p.m., during a review of the “Patient Consent” form dated 12/22/24, it was noted that the areas titled “Agency Representative, date and time” were left blank. The agency failed to ensure the documents were appropriately authenticated. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:55 a.m. P-3: The patient’s SOC was 10/21/24 with diagnoses that included Congestive Heart Failure and wound right upper arm. The referral for home care ordered SN, PT, OT and HHa services to be provided. On 11/19/24 at 10:40 a.m., during a review of the Patient Consent form dated 10/21/24, it was noted that the areas titled Agency Representative, date and time were left blank. The agency failed to ensure the documents were appropriately authenticated. These findings were reviewed with and acknowledged by the Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:05 a.m.”

“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 5 (P-2, P-3, P-5, P-6, P-7) patients were included in the overall planning of care, including being informed of the ordered disciplines and frequency in which visits were to be conducted from a total of 7 sampled records reviewed, resulting in lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: Policy: Consent, 3/2019 stated, “At time of admission and on an ongoing basis, each patient will be informed of the name of the staff member responsible for care and the name of the staff member providing care...., The frequency of visits...” P-2: The patient’s start of care (SOC) was 12/22/23 with diagnoses that included Congestive Heart Failure. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW) and Home Health Aide (HHa) services to be provided. During the record review on 11/18/24 at 1:30 p.m., it was noted that the “Patient Consent” form dated 12/22/23 was void of the ordered disciplines and the frequency in which services were to be provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:55 a.m. P-3: The patient’s SOC was 10/21/24 with diagnoses that included Congestive Heart Failure and wound right upper arm. The referral for home care ordered SN, PT, OT and HHa services to be provided. During the record review on 11/19/24 at 10:40 a.m., it was noted that the Patient Consent form dated 10/21/24 was void of the ordered disciplines and the frequency in which services were to be provided. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:05 a.m. **Agency Policy: “Consent for Treatment and Services 11.7.1” (Revised March 2018). The policy states, “Purpose: The patient has the right to be informed in advance regarding the care to be furnished and any subsequent changes in the care. Procedure: 1. The staff member performing the admission visit will explain the Consent/Release of Information form during the initial visit in addition to: Frequency of visits to be provided.” P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. During record review on 11/18/24, it was noted that the referral stated, “Home health care, PT/OT.” The consent signed by the patient on 11/14/23 was blank under the Occupation Therapy section and not checked to notify the patient of anticipated services to be provided. Additionally, the Registered Nurse (RN) completed the SOC assessment on 11/14/23 and ordered Skilled Nursing (SN) at a frequency of 1w9 (1 visit a week for 9 weeks) and Home Health Aide (HHA) 5w9. The consent was blank under the proposed frequency for both SN and HHA. The agency failed to notify the patient in advance of skilled services ordered and frequencies. P-6: The Start of Care (SOC) was dated 9/23/24. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hemiplegia, Hypertension and Diabetes Type 2. During record review on 11/19/24, it was noted that the referral stated, “I certify that, based on my findings, the following service(s) are medically necessary home health service(s): Nursing, Physical Therapy, Occupational Therapy, HHA (Home Health Aide).” The consent signed by the patient on 9/23/24 and the comprehensive assessment completed by the Registered Nurse (RN) on 9/23/24 was blank under the Occupational Therapy (OT) section and there was no documentation of the patient refusing OT. The agency failed to provide services as ordered. Additionally, the Physical Therapist (PT) completed a re-evaluation on 10/25/24 with an ordered frequency of 2w2 (2 visits a week for 2 weeks), 1w1. During a joint home visit on 11/19/24 with the Registered Nurse, P-6 was question regarding Physical Therapy scheduling and stated, “The PT does not give the time or schedule for the next appointment. I have not heard from him in a while, since last week.” The agency failed to notify the patient in advance of the care to be completed. P-7: The Start of Care (SOC) was dated 7/30/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Spinal Stenosis. During record review on 11/20/24, During record review on 11/19/24, it was noted that the referral stated, “I certify that, based on my findings, the following service(s) are medically necessary home health service(s): Physical Therapy, Occupational Therapy.” The consent signed by the patient on 7/30/24 and the comprehensive assessment completed by the Physical Therapist (PT) on 7/30/24 was blank under the Occupational Therapy (OT) section and there was no documentation of the patient refusing OT. The agency failed to provide services as ordered. These findings were reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 11:20 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 patient’s clinical record documented all medications reviewed in 1 (P-6) of 7 records reviewed. This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all patients serviced by the agency. Findings included: **Agency Policy: “Medication Profile 11.8.1” (Revised March 2018). The policy states, “Procedure: 1. 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.” P-6: The Start of Care (SOC) was dated 9/23/24. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hemiplegia, Hypertension and Diabetes Type 2. During record review on 11/19/24, it was noted that a medication profile was completed on 9/23/24 but failed to document review of the current medications in order to identify any possible medication interactions or side effects. This finding was reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 10:45 am.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all pertinent interventions with reportable parameters and objectively measurable goals specific to the needs of the patient for 4 (P-2, P-3, P-4, P-5, P-6, P-7) records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-2: The patient’s start of care (SOC) was 12/22/23 with diagnoses that included Congestive Heart Failure. The referral for home care ordered Skilled Nursing (SN), Occupational Therapy (OT), Physical Therapy (PT), Home Health Aide (HHa) and Medical Social Work (MSW) services to be provided. During a review of the Plan of Care (POC) on 11/18/24 at 1:30 p.m., it was noted that there were no Skilled Nursing (SN) interventions. OT and MSW services had not been included on the POC. Additionally, all the listed diagnoses were documented as having exacerbated on the date of admission (12/22/23). These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:55 a.m. P-3: The patient’s SOC was 10/21/24 with diagnoses that included Congestive Heart Failure and Wound right upper arm. The referral for home care ordered SN, PT, OT and HHa services to be provided. During a review of the POC on 11/19/24 at 10:40 a.m., it was noted that there were no SN interventions. PT services had not been added to the POC. Additionally, all diagnoses were listed as having exacerbated on the date of admission (10/21/24). These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:05 a.m. P-4: The patient’s SOC was 10/1/24 with diagnoses that included Syncope, GERD and Hypertension. The referral for home care ordered SN, HHa, PT and OT services to be provided. During a review of the POC on 11/19/24 at 11:14 a.m., it was noted that there were no reportable pain parameters in which to notify the Physician. OT services had not been included in the POC. The SN interventions were vague such as, SN to teach on disease process... There were no goals that addressed the identified diagnoses that were documented as having exacerbated on the date of admission (10/1/24). These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:20 a.m. **Agency Policy: “Plan of Care – CMS #485 and Physician Orders,” (Revised April 2023). The policy states, “4. The individualized plan of care must include the following: All pertinent diagnoses. Safety measures to protect against injury. Patient-specific interventions and education, measurable outcomes and goals identified by the Agency and the patient.” P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. During record review on 11/18/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient skin integrity will remain intact during this episode.” Additionally, another goal stated, “Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Additionally, noted that the SOC comprehensive assessment dated 11/14/23, documented under “Primary Diagnosis and Other Diagnoses”, all 7 diagnoses had an exacerbation or onset date of 11/14/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-6: The Start of Care (SOC) was dated 9/23/24. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hemiplegia, Hypertension and Diabetes Type 2. During record review on 11/19/24, it was noted that there were no SN interventions contained within the POC. Additionally, noted that the SOC comprehensive assessment dated 9/23/224, documented under “Primary Diagnosis and Other Diagnoses”, all 9 diagnoses had an exacerbation or onset date of 9/23/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-7: The Start of Care (SOC) was dated 7/30/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Spinal Stenosis. During record review on 11/20/24, noted that the SOC comprehensive assessment dated 7/30/24, documented under “Primary Diagnosis and Other Diagnoses”, all 11 diagnoses had an exacerbation or onset date of 7/30/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 11:25 am.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines performed ongoing assessments for 1 (P-2) of 1 patient with documented health concerns, from a total of 7 sampled records reviewed, resulting in unidentified, untreated health concerns and untimely death of a patient. Findings include: Policy: Reassessments/Update of the Comprehensive Assessment, 4/2023 stated, “Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. Such reassessments will be documented on discipline-specific visit notes.” P-2: The patient’s start of care was 12/22/23 with a diagnosis of Congestive Heart Failure. The referral for home care ordered SN, PT, OT, MSW and HHa services to be provided. The Plan of Care ordered SN at a frequency of 1x/wk. x 9 wks. During the clinical record review on 11/18/24 at 1:30 p.m., the Initial Comprehensive Assessment, dated 12/22/23, completed by the SN documented, “SN performed complete multi body systems assessment and evaluation. Patients [sic] vital signs unstable, general weakness, handgrips are weak, needs assist in standing up, is short of breath on exertion, needs maximum assist in ADLs. Complain of back pain 7/10...” Further review of the clinical record revealed that the SN made no follow up visits to the patient’s home to conduct a follow up assessment. The clinical record revealed the patient subsequently passed away in his home on 12/28/23. These findings were reviewed with and acknowledged by the Administrator, Alternate Administrator and Clinical Manager during an interview on 11/21/24 at 9:55 a.m. During the interview, the Clinical Manager confirmed “the SN should have gone back the next day or so to assess the patient.””

“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 that services were provided as ordered by the Physician and indicated in the Plan of Care for 2 (P-1, P-4) patients who required the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for decline in health and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 9/24/24 with diagnoses that included Multiple Sclerosis and Hypertensive Heart Disease without Heart Failure. During the record review on 11/18/24 at 11:25 a.m., it was noted that the referral for home care dated 9/20/24, ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide (HHa) and Medical Social Work (MSW) services to be provided. Upon further review of the clinical record, and at the time of this writing, no OT or MSW services had been provided as ordered. Additionally, there was no documented evidence of patient refusal of the ordered services. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:30 a.m. P-2: The patient’s SOC was 12/22/23 with a diagnosis of Congestive Heart Failure. The referral for home care ordered SN, PT, OT, MSW and HHa services to be provided. During the record review on 11/18/24 at 1:30 p.m., it was noted that the patient was transferred to an inpatient facility the following week on 10/28/24. It was further noted that the ordered disciplines failed to provide care and services as ordered, prior to the patient’s transfer to the hospital. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 1:30 p.m. P-4: The patient’s SOC was 10/1/24 with diagnoses that included Syncope, GERD and Hypertension. During the record review on 11/19/24 at 11:14 a.m., it was noted that the referral for home care ordered SN, HHa, PT and OT services to be provided. Upon further review of the record, and at the time of this writing, no OT services had been provided as ordered. Further, there was no documented evidence that the patient refused/declined the ordered service. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:20 a.m.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to ensure the home health aides were qualified to provide home health aide service for 4 of 4 contracted aides (HHA #1-4) providing service, for a potential of substandard aide services. Findings include: **Agency Policy: “Job Description: Home Health Aide (HHA) 4.17M.34,” (Revised March 2018). The policy states, “Qualifications: 1. Must meet Medicare Conditions of Participation for Home Health Aide training program and competency.” During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to ensure the home health aides were qualified and competent to provide patient focused home health aide care.”

“HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to maintain sufficient documentation that demonstrated the required training for this section was met for 4 of 4 contracted aides (HHA #1-4), resulting in the potential for proving substandard care and unmet care needs. Findings include: During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to maintain documentation that the home health aides were qualified and competent to provide patient focused home health aide care.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to maintain documentation of competency evaluations in 4 of 4 contracted Home Health Aides (HHA #1-4) whose personnel file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to ensure the home health aides were qualified and competent to provide patient focused home health aide care.”

“Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services for 4 (HHA #1-4) of 4 contracted Home Health aide files reviewed, resulting in lack of evidence of ongoing education and training and the potential for the provision of unsafe care for all patients receiving Home Health Aide services. Findings include: During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to ensure the home health aides were qualified and competent to provide patient focused home health aide care.”

“If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines conducted the required on-site Home Health Aide supervisory visits in the patient’s home to ensure the adequate provision of care and services for 4 (P-1, P-4, P-5, P-6) patients ordered to receive Aide services, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of unsafe care and unmet care needs. Findings include: Policy: Home Health Aide Supervision, 4/2023 stated, “All home health aide supervisory visits will be made at least every 14 days. Optimum Plus Home Care, LLC will conduct the 14 day supervisory visit during an on-site visit, in person visit.” P-1: The patient’s start of care (SOC) was 9/24/24 with diagnoses that included Multiple Sclerosis and Hypertensive Heart Disease without Heart Failure. During the record review on 11/18/24 at 11:25 a.m., it was noted that the Skilled Nurse (SN) documented Aide Supervisory Visits on 10/8/24, 10/22/24 and 11/5/24. Upon further review, the supervisory notes did not include the clinician’s name who would be supervised. Additionally, the SN documented the supervisory visits when no SN visits were scheduled to be conducted on the aforementioned dates. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:30 a.m. P-4: The patient’s SOC was 10/1/24 with diagnoses that included Syncope, GERD and Hypertension. During the record review on 11/19/24 at 11:14 a.m., it was noted that the SN documented Aide Supervisory Visits on 10/15/24, 10/29/24 and 11/12/24. Upon further view, the supervisory notes did not include the clinician’s name who would be supervised. Additionally, the SN documented the supervisory visits when no SN visits were scheduled to be conducted on the aforementioned dates. These findings were reviewed with and acknowledged by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:20 a.m. P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. The Registered Nurse (RN) completed supervisory visits on 11/28/23, 12/11/23, 1/8/24, 1/22/24, 2/5/24, and 3/4/24. During record review on 11/18/24, it was noted that the RN documented supervisory visits, but no visits were scheduled or completed by the RN on the days noted. The agency failed to follow policy and complete an onsite supervisory visit. P-6: The Start of Care (SOC) was dated 9/23/24. The Plan of Care (POC) identified diagnoses of Cerebral Infraction, Hemiplegia, Hypertension and Diabetes Type 2. The RN completed supervisory visits on 10/7/24 and 10/21/24. During record review on 11/19/24, it was noted that the RN documented supervisory visits, but no visits were scheduled or completed by the RN on the days noted. The agency failed to follow policy and complete an onsite supervisory visit. These findings were reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 10:55 am.”

“HH aide services under arrangement CFR(s): 484.80(h)(5) If the home health agency chooses to provide home health aide services under arrangements, as defined in section 1861(w)(1) of the Act, the HHA’s responsibilities also include, but are not limited to: (i) Ensuring the overall quality of care provided by an aide; (ii) Supervising aide services as described in paragraphs (h)(l) and (2) of this section; and (iii) Ensuring that home health aides who provide services under arrangement have met the training or competency evaluation requirements, or both, of this part. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides (HHa) that provided services under arrangement met the competency evaluation requirements of this part for 4 of 4 aides (HHA #1-4), from a total sample of 4 aide personnel files reviewed, resulting in the provision of aide services by aides that had not been deemed competent to provide aide services. Findings include: Agency Policy: “Home Health Aide Services and Training Program 4.12.1”, (Revised February 2022) stated, “All Home Health Aides employed or contracted by Optimum Plus Home Care, LLC will satisfactorily complete a home health aide training program and competency evaluation program prior to performing patient care. Procedure: 1, A qualified Home Health Aide is a person who has successfully completed: A training and competency evaluation program as specified; or. A competency evaluation program that meets the requirements; or. A nurse aide training and competency evaluation program approved by the state as meeting the requirements and is currently listed in good standing on the state nurse aide registry; or. The requirements of a state licensure program that meets the provisions.” During the home health aides’ personnel file review on 11/20/24, 4 contracted files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 11/20/24 at 12:45 pm and stated, “That is all they (contracted agency) gave me, there is no competency or training in the files.” The agency failed to ensure the home health aides were qualified and competent to provide patient focused home health aide care.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was complete and included detailed Physical Therapy and Skilled Nursing notes for 3 (P-1, P-3, P-7) records with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: P-1: The patient’s start of care (SOC) was 9/24/24 with diagnoses that included Multiple Sclerosis and Hypertensive Heart Disease without Heart Failure. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Home Health Aide (HHa) and Medical Social Work (MSW) services to be ordered. SN services were ordered at a frequency of 1x/wk. x 9 wks. PT services were ordered 2x/wk. x 3 wks. During the record review on 11/18/24 at 11:25 a.m., it was noted that there were no documented SN visit notes for 3 weeks in a row, including the 6th, 7th and 8th week of care. Additionally, PT failed to document 1 of 2 visits made the week of 11/3/24. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 9:30 a.m. P-3: The patient’s SOC was 10/21/24 with diagnoses that included congestive Heart Failure and Wound right upper arm. During the clinical record review on 11/19/24 at 10:40 a.m., it was noted that the patient was transferred to an inpatient facility on 10/28/24 due to non-documented reasons. There was no Transfer Summary available for review. Hospital paperwork dated 10/30/24 at 11:28 a.m., documented “Pt current with Optimum HHC...” A separate hospital document titled, “CarePort - View Web Referral” dated 11/5/24 at 1:10 p.m., documented, “Referral Type: Home Care..., Date first sent: 10/30/24..., Respond by: 11/5/24 2:34 p.m...., Referral Comments: Patient current with your homecare. Can you provide resumption of care for RN/PT/OT at dc? DC probably in next 24-48hrs.” Upon further review of the record, there was no documentation of the whereabouts or health status of the patient. The agency failed to ensure the clinical record was complete and painted a clear clinical picture of the whereabouts and status of the patient. These findings were reviewed with Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:05 a.m. During the interview, the administrative staff acknowledged not knowing the patient’s whereabouts or health status and acknowledged that a Resumption of Care had not been done. **Agency Policy: “Medical Record Content 11.1.1” (Revised April 2023). The policy states, “1. Optimum Plus Home Care, LLC will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations.” P-7: The Start of Care (SOC) was dated 7/30/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Spinal Stenosis. During record review on 11/20/24, it was noted the Physical Therapist (PT) completed a comprehensive assessment on 7/30/24 and a recertification assessment on 9/25/24. The section titled “Clinical Statement of Assessment Finding and Recommendations” contained the same exact wording for both evaluation visits. Additionally, the documentation stated, “This is an elderly female who is referred to home care PT…” The patient’s documented gender is male. The agency failed to ensure that the medical record was complete and accurate. This finding was reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 11:05 am.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the discharge/transfer summary was complete, provided the patient’s current health status at the time of discharge/transfer, and forwarded to the physician/receiving facility within the required time frame as per this requirement in 3 (P-3, P-4, P-5) records from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health care concerns, lack of continuity of care and unmet care needs. Findings include: P-3: The patient’s start of care (SOC) was 10/21/24 with diagnoses that included Congestive Heart Failure and Wound right upper arm. The referral for home care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the clinical record review on 11/19/24 at 10:40 a.m., it was noted that the patient was transferred to an inpatient facility on 10/28/24 due to undocumented reasons. At the time of this review, no transfer summary had been completed which detailed the course of care provided and the status of the patient at the time of transfer and sent to the receiving facility. Additionally, there was no documented evidence that the Physician had been notified of the patient’s transfer to an inpatient facility. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Alternate Administrator (Adm #2) and Clinical Manager (CM #1) during an interview on 11/21/24 at 10:05 a.m. Adm #2 confirmed that no summary had been sent to the receiving facility. P-4: The patient’s SOC was 10/1/24 with diagnoses that included Syncope, GERD and Hypertension. The referral for home care ordered SN, OT, HHa AND PT services to be provided. During the record review on 11/19/24 at 11:14 a.m., it was noted that the patient was discharged from PT services on 11/13/24. At the time of this review, the PT discharge summary had not been forwarded to the Physician. Additionally, the PT discharge summary had not been forwarded to the Physician by the survey exit date of 11/21/24. These findings were reviewed with and confirmed by Adm #1, Adm #2 and CM #1 during an interview on 11/21/24 at 10:20 a.m. P-5: The Start of Care (SOC) was dated 11/14/23. The Plan of Care (POC) identified diagnoses of Hypertension, Chronic Kidney Disease and Diabetes Type 2. During record review on 11/18/24, it was noted that the Registered Nurse completed a discharge on 3/12/24. The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. This finding was reviewed with and acknowledged by the Adm #1 (Administrator), Adm #2 (Alternate Administrator) and CM #1 (Clinical Manager) during an interview on 11/21/24 at 10:45 am.”