All About Family Home Health Services, LLC

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide accurate information to patients in the start of care folder. Findings include: During record review on 8/3/26, it was discovered that the patients start of care (SOC) folders had the Community Health Accreditation Program (CHAP) listed as an association of the agency. The agency is no longer associated with CHAP and that resource is no longer available to the patients or the agency. During an interview on 8/5/26 at 3:45 PM, the administrator Staff-A, and the Director of Clinical Services Staff-B acknowledged the above findings.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was provided with written notice of patient’s rights and information on transfer and discharge policies in a language that was understandable for 1 (P-7) of 1 patient records reviewed with limited English proficiency. Patient #7 (P-7): During the review on 08/05/2026 at 9:21 AM of the comprehensive assessment it revealed that the patient’s preferred language is Spanish. The assessment also noted that the patient has two granddaughters who provide interpretation during visits. The “Admission Consent” which includes patient’s rights and responsibilities, consent for treatment, advance directives, grievance, abuse, emergency, safety, infection control, and authorization for payment information was provided in English. Although the record noted that the granddaughter was present during the visit to translate, no evidence was found that the patient was provided with written information in her preferred language. During the interview with the director of clinical services (Staff-B) on 8/5/26 at 4:10 PM, Staff-B explained that the agency can print consents and patient education materials in Spanish and that interpretation services are available for staff to use when translation is needed during visits. The administrator (Staff-A) and Staff-B reviewed and acknowledged the findings above during an interview on 08/05/2026 at 4:15 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 observation, record review, and interview, the agency failed to ensure the patient’s rights to participate in, be informed about, and consent or refuse care in advance of treatment for 7 (P-1, P-2, P-3, P-4, P-5, P-6, & P-7) of 7 records reviewed, resulting in the patient’s inability to make fully informed decisions regarding their care. Findings include: Patient #4 (P-4): During the record review on 08/03/26 at 2:00 PM, it noted that the start of care “Admission Consent” signed by the patient on 07/17/2026, noted that the patient was informed and consented to the treatment under the care of skilled nursing (SN) services and did not include a visit frequency. Additionally, during the home visit on 08/04/2026 at 10:33 AM, it was observed that the admission packet in the patient’s home included the hard copy of the same consent. No evidence was found during the observation that the patient consented in advance to the frequency that services would be provided. Patient #5 (P-5): During the record review on 08/04/2026 at 9:34 AM, it noted that the start of care “Admission Consent” signed by the patient on 05/11/2026, noted that the patient was informed and consented to the treatment under SN, physical therapy (PT), and occupational therapy (OT) services and did not include a visit frequency for each service. Patient #6 (P-6): During the record review on 08/04/2026 at 2:06 PM, it noted that the start of care “Admission Consent” signed by the patient on 07/13/2026, noted that the patient was informed and consented to the treatment under SN, PT, and OT services and did not include a visit frequency for each service. Patient #7 (P-7): During the record review on 08/05/2026 at 9:21 AM, it noted that the start of care “Admission Consent” signed by the patient on 10/17/2025, noted that the patient was informed and consented to the treatment under SN and PT services and did not include a visit frequency for each service. During an interview on 08/05/2026 at 4:15 PM, the administrator (Staff-A) and the director of clinical services (Staff-B) reviewed and acknowledged the findings that patients were not informed of the frequency in which services would be furnished before obtaining consent for treatment, which did not meet the agency’s policy referenced below. Review of agency policy on 08/5/26 at 1:30 PM, titled “Bill of Rights”, revised 10/2019, revealed that the agency procedure included, “The patient will be informed verbally and in writing during the initial evaluation visit and in advance of furnishing care, of their rights.” And further noted the right of the patient to, “Be advised in advance of the disciplines that will furnish care, and the frequency of visits proposed to be furnished.” Patient #1 (P-1): During the record review on 08/03/2026 at 11:00 AM, it was noted that the start of care “Admission Consent” signed by the patient on 07/09/2026, documented that the patient was informed of and consented to treatment under the care of skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services, but the consent failed to include a visit frequency for those services. Patient #2 (P-2): During the record review on 08/04/2026 at 10:00 AM, it was noted that the start of care “Admission Consent” signed by the patient on 11/17/2025, failed to document what services or visit frequency would be provided to P-2. Patient #3 (P-3): During the record review on 08/05/26 at 9:00 AM, it noted that the start of care “Admission Consent” signed by the patient on 05/13/2026, noted that the patient was informed of and consented to the treatment under the care of skilled nursing (SN) services, but the consent failed to include a visit frequency for those services. During an interview on 8/5/26 at 3:45 PM, the administrator Staff-A, and the Director of Clinical Services Staff-B acknowledged the above findings.”

“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 provide the required written notice of discontinuation of services in advance for 1 (P-7) of 2 discharged patient records reviewed. Findings include: Patient #7 (P-7): During the record review on 08/05/2026 at 9:21 AM, it was noted that the patient was admitted to the agency on 10/17/2025, for post operative care following a total left knee replacement and included skilled nursing (SN) and physical therapy (PT) services. The patient was discharged from SN on 10/23/2025 and from PT services on 11/07/2025. No evidence was found in the clinical record indicating that the patient and caregivers were provided with written notice, in advance to the date that home care services would be ending. During interview with the director of clinical services (Staff-B) on 08/05/26 at 1:38 PM, Staff-B explained there is no written document of notice to be found because the patient did not have Medicare. The agency did not comply with the patient’s rights requirement at §484.50(c)(8) that the patient has the right to receive proper written notice, in advance of the home health agency reduction or termination of services. During an interview on 08/05/2026 at 4:15 PM with the administrator (Staff-A) and the director of clinical services (Staff-B), the findings were reviewed and acknowledged.”

“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 patient-specific, comprehensive assessment that accurately reflected the patient’s current health status with baseline data for future assessments, in 1 (P-2) of 7 records reviewed, resulting in the potential for unmet care needs, and negative patient outcomes. Findings included: P-2: The start of care (SOC) was dated 4/18/26. The plan of care (POC) identified diagnoses of diabetes mellitus, hypertension, and congestive heart failure. P-2 has Metformin (Antidiabetic) 1000 MG ordered for 2 times a day. Upon review of the comprehensive assessment on 8/4/26 at 10:00 AM, it was noted that the Registered Nurse (RN) failed to obtain objective data for future assessments to measure the patient’s specific status. For example, there was no baseline blood sugar (BS) documented on the start of care (SOC) Comprehensive OASIS Assessment dated 4/18/26 or the Physical Therapist (PT) recertification OASIS dated 6/13/26. A note under the Nutrition/Endocrine/Appetite section of the SOC OASIS stated, “Patient does not check her blood sugar.” There was no documented evidence in the record that the agency followed up on the patient not checking her blood sugar, in order to establish a baseline, and continued monitoring of the BS with a primary diagnosis of Type 2 diabetes mellitus (DM). There was no documented evidence in the record that the RN or the PT provided education to the patient regarding her type 2 DM. During an interview on 8/5/26 at 3:45 PM, the Administrator Staff-A, and the Director of Clinical Services Staff-B acknowledged the above findings.”

“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 perform an updated medication reconciliation following an in-patient hospital discharge 1 (P-5) of 7 records reviewed, resulting in an incomplete medication list and the inability to assess for potential drug duplicates, interactions and unrecognizable side effects. Findings include: Patient #5 (P-5): The patient was admitted to the agency as a resumption of care (ROC). The episode started 07/23/2026. During the record review on 08/04/2026 at 9:34 AM, it was noted that the hospital “Discharge Summary”, documented that the patient was being discharged from the hospital 07/22/2026 and instructed the patient to start taking the following new medications: Amiodarone 200mg take 2 tablets by mouth 2 times a day with meals for 4 days, then 1 tablet daily with breakfast. Start taking July 22, 2026.Ascorbic acid (vitamin c) 500 mg take 1 tablet by mouth daily for 12 doses. Start taking on: July 23, 2026.Furosemide 40 mg take 1 tablet by mouth 2 times daily.Sacubitril-valsartan 24-26 mg take 1 table by mouth 2 times daily. Replaces: sacubitril-valsartan 49-51 me per tablet.Zinc sulfate 50 mg zinc (220 mg) capsule take 1 capsule by mouth daily for 12 doses. Start taking on: July 23, 2026. The instructions also listed to stop taking sacubitril-valsartan 49-51 mg per tablet and listed 12 medications to continue as previously taken prior to admission which were: acetaminophen, apixaban, aspirin, atorvastatin, empagliflozin, famotidine, gabapentin, insulin glargine and lispro, methocarbamol, metoprolol succinate, and nitroglycerin. Review of the medication profile dated 07/23/2026 revealed that the agency documented the 12 continued medications but failed to complete an accurate medication reconciliation. The reconciliation did not include review or documentation of the patient’s new medications, or the dosage change for sacubitril-valsartan listed on the patient’s hospital discharge instructions. Review of the comprehensive assessment dated 07/23/2026 noted under the section (M2001) “Drug Regimen Review: Did a complete drug regiment review identify potential clinically significant medication issues?” It was documented, “No issues found during review.” Further review of the plan of care noted the drug sacubitril-valsartan was not listed with or without the dosage change. During an interview on 08/5/2026 at 4:15 PM with the administrator (Staff-A) and the director of clinical services (Staff-B), the findings were reviewed and acknowledged.”

“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 objectively measurable goals specific to the individualized needs of the patient in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed; and failed to document weights ordered on the plan of care for 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: Patient #4 (P-4): During the review on 08/03/26 at 2:00 PM, of the plan of care (POC) for the episode 07/17/26-09/14/26, it revealed that the skilled nursing (SN) goals were written in terms that were not patient specific, objectively measurable, and contained physician reportable metrics that were not ordered. For example, “SP02 (oxygen saturation commonly measured with a finger pulse oximeter) will be within physician established parameters by __within 5 weeks__.” The POC did not include physician established parameters for SP02. Another example stated “Pt/Pcg (patient/primary caregiver) will verbalize/demonstrate measures to manage pain: medication management/alterative pain relief measures, behavior modification to avoid factors that increase pain/use of pain scale to identify intensity and determine comfort goal by __within 5 weeks__.” Patient #5 (P-5): During the review on 08/04/2026 at 9:34 AM, of the POC for episode 07/23/26-09/20/26, it revealed the SN goals were written in terms that were not patient specific or objectively measurable. For example, the patient diagnoses included new onset of atrial fibrillation (irregular heart rhythm that increases risk of forming blood clots), heart failure (weakened heart function that decreases the functions of the heart to pump blood, causing fluid backup in lungs and legs), and the use of a wearable heart defibrillator (life vest- detects deadly heart rhythms and delivers a shock to the heart when detected). An example of a cardiac specific goal noted, “Pt/Pcg state understanding of measures to manage disease and identify s/s (signs and symptoms) to report by ___.” The patient also is a diabetic with an endocrine goal, “Pt/Pgc will verbalize & demonstrate understanding of diabetic self-care needs by __.” Patient #6 (P-6): During the review on 08/04/2026 at 2:06 PM, of the POC for episode 07/13/26-09/10/26, it revealed the SN goals were written in terms that were not patient specific or objectively measurable. For example, the patient diagnoses included COPD (chronic obstructive pulmonary disease), hypertension (elevated blood pressure), and bradycardia (low heart rate). The POC documented a respiratory goal, “Pt/cg will verbalize disease process, pathophysiology of___ by___.” And a cardiac goal, “Pt/Pcg state understanding of measures to manage disease and identify s/s to report by ___.” Patient #7 (P-7): During the review on 08/50/2026 at 9:21 AM, of the POC for episode 10/17/25-12/15/25, it revealed that the SN goals were written in terms that were not patient specific, objectively measurable and contained physician reportable metrics that were not ordered. For example, “SP02 will be within physician established parameters by __within 2 weeks__.” The POC did not include physician established parameters for SP02. The patient is admitted for home care services following a total left knee replacement. An example of a goal regarding the surgical incision included, “Pt/Pcg will verbalize/demonstrate joint replacement post op incision care and dressing removal by __within 2 weeks.” The administrator (Staff-A) and the director of clinical services (Staff-B) reviewed and acknowledged the findings above during an interview on 08/05/2026 at 4:15 PM, which did not meet the agency’s policy referenced below. Review of agency policy on 8/5/26 at 1:30 PM, titled “Care Planning Process”, updated 05/2020, revealed that the, “… The patient-specific clinical plan of care includes: … Measurable outcomes and goals identified by the organization and the patient...” Further noted that, “Based on the assessment and conclusions, the plan of care will include, but will not be limited to: … Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient.” Patient #1 (P-1): This patient was admitted to the agency on 7/9/26, with diagnoses of surgical aftercare, hypertension, diabetes mellitus, and gout. During record review on 8/3/26 at 11:00 AM, it was discovered that the nursing goals on the plan of care (POC) were not measurable. For example, “Patient and caregiver will demonstrate appropriate diabetes skin/foot care by7/18/26.” another stated, “Patient/caregiver will demonstrate symptoms to report, prevention of infection, nutrition and hydration to promote healing by 7/18/26.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient #2 (P-2): This patient was admitted to the agency on 4/18/26, with diagnoses of diabetes mellitus, hypertension, and gout. During record review on 8/4/26 at 10:00 AM, it was discovered that the nursing goals on the POC were not measurable. For example, “Patient/caregiver will demonstrate deep breathing/coughing exercises within 3 weeks.” another stated, “Patient/caregiver will demonstrate self-monitoring of pulse/blood pressure/weights and report findings outside of physician established parameters within 3 weeks.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Patient #3 (P-3): This patient was admitted to the agency on 5/13/26, with diagnoses of congestive heart failure, hypertension, and atrial fibrillation. During record review on 8/5/26 at 9:00 AM, it was discovered that the nursing goals on the POC were not measurable. For example, “Patient/caregiver will verbalize signs and symptoms of bleeding to report related to anticoagulant use and bleeding precautions by 6/13/26.” another stated, “Patient/caregiver will verbalize/demonstrate knowledge of and compliance with medication management, dose, route and schedule/actions, interactions and contraindication/administration and compliance with pre-filled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms, by 5/30/26.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The Skilled Nurse and Physical Therapist also failed to document weights for P-3 with a diagnosis of congestive heart failure. Under the Cardiovascular section of the POC dated 5/13/26, there were interventions ordered and goals for monitoring patient weights. “CARDIOVASCULAR INTERVENTIONS: Assess/Instruct Pt/Pcg: Self-monitoring for: pulse/blood pressure/weights/Other _____ Start Effective Date: 05/13/2026. CARDIOVASCULAR GOALS: Pt/Pcg will demonstrate self-monitoring of pulse/blood pressure/weights/other _____ and reporting readings outside physician established parameters by _____ Achieve by Date: 06/13/2026 Start Effective Date: 05/13/2026. There were parameters for reporting weights on the POC. There were 8 PT visits after the SN discharged P-3 from nursing services, and none of the PT visits documented a weight. During an interview on 8/5/26 at 3:45 PM, the Administrator Staff-A, and the Director of Clinical Services Staff-B acknowledged the above findings.”