Mcguffey Home Health Care, LLC

“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 develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in the potential for poor patient outcomes due to the agency being ill-prepared in the event of an actual emergency or disaster. Findings include: On 6/23/26, review of the agency’s Emergency Preparedness (EP) binder revealed no evidence that the Agency’s Administrator (Staff-A) or the Governing Body (GB) had reviewed and updated its EP plan within the last 3 years. The agency failed to provide documentation that its EP plan was reviewed and updated at least annually as required. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 11:58 AM.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, communication plan, and reviewed and updated at least every two years. This deficient practice could affect the health and safety of all patients and staff in the event of a natural, man-made, or agency-based emergency. Findings included: On 6/23/26, review of the agency’s emergency preparedness (EP) binder revealed the agency had failed to perform any training or testing of its staff within the last 3 years. The agency did have documentation of emergency scenarios (weather related) but failed to document any participation by its staff at both the agency and community-based levels. In addition, no evaluation or after-action report was found concerning the emergency scenarios above. Subsequently, the agency had no evaluation of testing its EP plan by its staff and assessing the agency’s state of readiness to respond to patient(s) related emergencies within the last 2 years as required. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:01 PM.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to furnish the ordered services of occupational therapy (OT) and home health aide (HHa) services as needed in 1 (P-1) of 7 patient records reviewed, resulting in the potential for unmet patient care needs. Findings include: Patient #1 (P-1): This patient was admitted to the agency on 5/26/26 (per patient request) with diagnoses which included left hip fracture, Parkinsons disease and hypertension. On 6/23/26, review of the physician referral for home care (dated 5/20/26), ordered the following services to provide care: Skilled Nursing, Physical Therapy, Occupational Therapy (OT), and Home Health Aide (HHa). Further review found the OT and HHa services were never provided as ordered. No communication notes, patient refusal or patient/physician notification concerning this change was evidenced in the clinical record. The consent for home care also failed to include both OT and HHa services as required. Subsequently, P-1 was never given the opportunity to fully accept all the ordered disciplines. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:05 PM.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the written NOMNC (Notice of Medicare Non-Coverage) form in advance of terminating home care services in 1 (P-5) of 3 patient discharge records reviewed, resulting in patients not having the right or opportunity to dispute the termination of Medicare covered services. Findings include: Patient #5 (P-5): This patient was admitted to home care on 10/16/25, with ordered services of physical therapy (PT) and skilled nursing (SN). On 6/24/26, patient record review found the NOMNC form, which was not dated, had no details of what service(s) are being discontinued, and was not signed by who explained the NOMNC to the patient. P-5 was discharged from the home care agency on 11/26/25 and there was no evidence in the medical record that P-5 had signed a completed NOMNC form concerning the discontinuation of PT services at least 2 days before the last covered service date (11/26/25) as required.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to advise patients of the names, addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside in 2 (P-2, P-3) of 2 home care admissions packets reviewed, resulting in a lack of information regarding the above resources designated to assist elderly patient needs and concerns. Findings include: On 6/22/26, separate joint home care visits were performed for P-2 (skilled nursing services) and P-3 (occupational services) to observe direct care and services provided. The home care agency’s admission packet documentation was reviewed and noted that the section intended to inform the patient of the 5 listed Federally and State funded entities were found to be void of any information. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:14 PM. Staff-C stated an update containing the required information will be added to the admission packet very soon.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a timely review of all current medications and failed to alert the physician of significant medication interactions for 1 (P-1) of 7 patient records, resulting in the potential for unsafe medication administration and poor patient outcomes. Findings include: Patient #1 (P-1): This patient was admitted to the agency on 5/26/26 (per patient request) with diagnoses which included left hip fracture, Parkinsons disease and hypertension. On 6/23/26, review of P-1’s medication reconciliation (1 of 1) was performed on 6/17/26, 3 weeks after admission. This review flagged 5 medications that further review was suggested due to the combination of narcotics and psychotropic medications. The findings above were reviewed and acknowledged by the agency’s Administrator (Staff-A), Clinical Director (Staff B), and Alternate Clinical Director (Staff C) during an interview on 6/25/26 at 12:08 PM. Staff-C stated this did not meet agency expectations when asked, or its policy referenced below. Agency Policy: “Medication Management” III.17 (undated) stated, “A Medication Profile comprised of a list of all medications... shall be completed for each patient at the time of admission... and sent to the physician as part of the patient’s plan of care. The medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and for patient non-compliance with drug therapy.””

“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) for skilled nursing (SN) included objective measurable goals in 5 (P-1, P-2, P-3, P-4, and P-5) of 6 patient records with SN services; and failed to have appropriate reportable pain parameters in 2 (P-2 and P-6) of 7 patient records, resulting in unidentified clinical trends, and the potential for severe pain levels being untreated with poor patient outcomes. Findings include: Patients #1 through #5: On 6/25/26, review of each of the patient’s POC noted the following: P-1 (10 of 10 SN goals), P-2 (5 of 6 SN goals), P-3 (9 of 9 SN goals), P-4 (12 of 12 SN goals), and P-5 (11 of 11 SN goals) were not written in objective measurable terms to track and trend progress made (or lack of) as required. Example goals include: “The client will verbalize understanding of individualized emergency plan by end of cert… The patient will be free from injury during the certification period... The patient will have no hospitalization during the certification period.” The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:11 PM. Staff-A stated this did not meet agency expectations when asked, or its policy referenced below. Agency Policy: “Physician’s Plan of Treatment/Change Orders” III.6 (undated) stated, “The plan of treatment shall include but not limited to: Measurable outcomes and goals.” Patient #2 (P-2) and #6 (P-6) both had reportable pain parameters listed on their POC to notify the physician if pain increased to the most severe/worst possible level (10 out of 10). Both patient records were reviewed which found baseline pain levels were 4-6 out of 10 for P-2 and P-6 having 0/10 (no pain) in 2 of 2 assessments. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:13 PM. All staff agreed the pain parameters to notify the physician were set too high and not appropriate.”

“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 transfer summaries were completed and forwarded to receiving facility and or receiving physician within 2 days of becoming aware of a transfer for 2 (P-1, P-4) of 2 patients who were admitted/transferred to a hospital, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Patient #1 (P-1): This patient was admitted to the agency on 5/26/26 with diagnoses which included left hip fracture, Parkinsons disease and hypertension. On 6/23/26, patient record review noted P-1 was transferred to the hospital on 5/29/26 for a lung blood clot. No evidence was found in the medical record that a transfer OASIS was sent to the physician within 2 days as required. Patient #4 (P-4) was admitted to the agency on 3/18/26, with diagnoses which included left hip fracture, congestive heart failure, and generalized muscle weakness. On 6/23/26, patient record review noted P-4 was transferred to the hospital on 4/3/26 for a GI (gastro-intestinal) bleed. No evidence was found in the medical record that a transfer OASIS was sent to the physician within 2 days as required. The above findings were reviewed with and acknowledged by Staff A, the Clinical Director (Staff-B), and Alternate Clinical Director (Staff-C) during an interview on 6/25/26 at 12:14 PM.”