Primary Home Health Care, Inc.

“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 had been reviewed, updated and included mitigating strategies to address the potential hazards identified in the Hazardous Vulnerability Assessment. This deficient practice could negatively affect staff and all 12 patients currently serviced by this agency. Findings include: On 9/2/25 at 12:15 p.m., during a review of the agency’s Emergency Preparedness Plan (EPP), it was noted that the plan was undated. There was no additional information provided to support that the plan had been reviewed and updated at least every 2 years as per this requirement. Further, the agency’s EPP failed to include mitigating strategies to address the potential hazards identified in their Hazardous Vulnerability Assessment such as, ice snow [sic], fire, tornado, terrorist attacks and altered air quality pollution. The Administrator reviewed and acknowledged these findings during an interview on 9/4/25 at 12:44 p.m.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to include a complete, individual emergency preparedness plan for 2 of 7 patients (P-5, 7), resulting in the potential for unprepared responses to emergencies, which could negatively affect the 12 patients currently serviced by this agency. Findings include: Patient #5 (P-5): The SOC was dated 8/7/25. The Plan of Care (POC) identified the diagnoses of hemiplegia, atrial fibrillation, hypertension, and heart failure. During record review on 9/3/25, it was discovered that no individualized emergency preparedness plan was documented in the record. Patient #7 (P-7): The SOC was dated 7/25/25. The POC identified the diagnoses of lumbago and sciatica. During record review on 9/4/25, it was discovered that the individualized emergency preparedness plan documented in the record was incomplete and lacked adequate information to respond effectively to an emergent situation. The administrator (Adm-1) acknowledged the above findings during an interview on 9/5/25 at 12:20 p.m.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure its skill discipline appropriately assessed the patient’s needs for 1 (P-1) of 1 patient who required weight and blood glucose monitoring, from a total of 7 sampled records reviewed, resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: Patient #1’s start of care was 5/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Dementia. The Plan of Care (POC) ordered Skilled Nursing (SN) services to be provided. During the clinical record review on 9/2/25 at 1:45 p.m., it was noted that the POC read, “SN to provide patient with written instructions in large font: Notify Physician of Weight greater than (>) 150 lbs. or less than () 200 or less than () 250 or less than (<) 70.” The specified goals were set as, “Weight gain of 2 lb./1 day, 5 lb./1 week. SN to assess patient’s weight log every visit, Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode.” Upon further review of the SN visit notes dated 5/8/25, 5/13/25, 6/4/25 and 6/11/25 there were no documented weights or blood sugars as indicated in the POC.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 1 (P-2) of 2 patients observed during home visits, from a total of 7 sampled records reviewed, was included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: Patient #2’s start of care was 8/18/25 with diagnoses that included Chronic Low Back Pain, Sciatica, Hypertension and Falls. The Plan of Care ordered Physical Therapy (PT) services to be provided. On 9/3/25 at 10:30 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During a review of the patient’s admission packet, it was noted that there was no calendar of proposed visits to be made by the PT. The Administrator reviewed and acknowledged these findings during an interview on 9/4/25 at 1:35 p.m.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapist conducted the initial assessment visit within 48 hours of referral to home care to determine the immediate care and support needs of the patient, including homebound status for 1 (P-2) of 1 patient who experienced a delay in needed services, from a total of 7 sampled records reviewed. Findings include: Patient #2’s start of care (SOC) was 8/18/25 with diagnoses that included Degenerative Disc Disorder, Falls, Hypertension and Sciatica. The Plan of Care ordered Physical Therapy (PT) services to be provided. During the record review on 9/3/25 at 2:47 p.m., it was noted that the referral for home care was dated 8/15/25, however, care was not initiated until 72 hours later. There was no documented rationale for the delay in needed services. During an interview on 9/4/25 at 1:35 p.m., the Administrator reported, “The Physical Therapist wrote an order dated 8/18/25 that the SOC would be delayed.” Upon further review, there was no evidence that PT #1 attempted to contact the patient prior to 8/18/25 to begin services within 48 hours of the date of the referral.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 3 of 7 records reviewed (P- 5, 6, 7), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: Patient #5 (P-5): The SOC was dated 8/7/25. The Plan of Care (POC) identified the diagnoses of hemiplegia, atrial fibrillation, hypertension, and heart failure. A review of the Comprehensive Assessment (OASIS) on 9/3/25, showed under the category of (M1021): “Patient Diagnoses”, the only information provided was a list of 14 diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. Patient #6 (P-6): The SOC was dated 7/16/25. The POC identified the diagnoses of osteoarthritis, pain, and heart failure. A review of the Comprehensive Assessment (OASIS) on 9/4/25, showed under the category of (M1021): “Patient Diagnoses”, the only information provided was a list of 17 diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. Patient #7 (P-7): The SOC was dated 7/25/25. The POC identified the diagnoses of lumbago and sciatica. A review of the Comprehensive Assessment (OASIS) on 9/4/25, showed under the category of (M1021): “Patient Diagnoses”, the only information provided was a list of 12 diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. The administrator (Adm-1) acknowledged the above findings during an interview on 9/5/25 at 12:20 p.m.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the Registered Nurse failed to promptly notify the Physician regarding an injury for 1 (P-1) of 1 patient who sustained an injury to his right hand, resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: Patient #1’s start of care was 5/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Dementia. The Plan of Care ordered Skilled Nursing (SN) services to be provided. During the clinical record review on 9/2/25 at 1:45 p.m., a SN visit note dated 5/13/25 documented, “Patient has skin peel on right hand (dorsal).” A photographic image was taken by the nurse and uploaded to the Electronic Medical Record (EMR). The picture showed the patient’s right posterior hand with obvious redness. Upon further review, there was no documented evidence that the nurse promptly notified the Physician of the patient’s right hand injury. The Administrator reviewed and acknowledged these findings during an interview on 9/4/25 at 1:00 p.m. and reported, “The nurse did inform the Dr. about the patient’s elevated blood pressure.” When asked to provide evidence that the SN notified the Physician of the patient’s right hand injury, the Administrator was unable to respond.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed Transfer Summary was forwarded to the receiving facility and the Physician for 1 (P-1) of 1 patient who was transferred to an inpatient facility with subsequent hospitalization, from a total of 7 sampled records reviewed resulting in lack of continuity of care and the potential for unmet care needs. Findings include: Patient #1’s start of care was 5/5/25 with diagnoses that included Hypertensive Chronic Kidney Disease and Dementia. The Plan of Care ordered Skilled Nursing (SN) services to be provided. During the clinical record review on 9/2/25 at 1:45 p.m., it was noted that the patient was transferred to and admitted to an inpatient facility on 5/21/25 due to Altered Mental Status. Upon further review, there was no documented evidence that the Transfer Summary was forwarded to the receiving facility or the Physician. The Administrator reviewed and acknowledged these findings during an interview on 9/4/25 at 1:00 p.m.”