1st State Home Healthcare, Inc.

“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 that the agency failed to maintain documentation of emergency preparedness training, resulting in the potential for inappropriate, unprepared responses to emergencies and an interruption in the provision of needed patient care and services. Findings include: During a review of the agency’s emergency preparedness (EP) program, it was discovered that no sign-in sheets were available to document the 4 employees’ participation in the EP ongoing annual training. The agency failed to document their employees ongoing annual EP training after their initial training. Staff-A had no documented annual training since 2012. Staff-B had no documented annual EP training for 2025. Staff-C had no documented annual training since 2022, and Staff-D had no documented training since 2023. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 3 of 7 records reviewed (P-5, P-6 and P-7), resulting in the potential for unmet patient needs. Findings include: Patient #5 (P-5): P-5’s start of care (SOC) was 11/28/23, with diagnoses of malignant neoplasm, lymph disorder and atrial fibrillation. During review of the record on 7/8/26 at 11:30 AM, it was discovered that the Plan of Care dated 5/16/26 had a skilled nursing (SN) visit frequency ordered for 2 visits a week for 8 weeks. There were no documented SN visits during weeks 3, 6, 7, and 8. There were no missed SN visit notes documented in the record. There was a home health aide visit frequency of 2 visits a week for 8 weeks ordered, but there were no documented aide visits for week 7. Patient #6 (P-6): P-6’s start of care (SOC) was 11/28/23, with diagnoses of type 2 diabetes mellitus and hypertension. During review of the record on 7/8/26 at 3:00 PM, it was discovered that the POC dated 5/10/26, had a skilled nursing frequency of 2 visits a week for 8 weeks. There was a missed skilled nursing visit noted during week 5, with no missed visit note documented in the record. Patient #7 (P-7): P-7’s start of care (SOC) was 3/7/26, with diagnoses of heart failure, neuropathy and chronic obstructive pulmonary disease. During review of the record on 7/8/26 at 11:30 AM, it was discovered that the POC had physical therapy services ordered at a frequency of 1 visit a week for 2 weeks, then 1 visit a week for 7 weeks. Week 2 had a missed PT visit with no note documented in the record. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 that 2 (P-1, P-4) of 7 patients were included in the overall planning of their care, resulting in a lack of inclusion in planning their care, the potential for missed visits and unmet care needs. Findings include: Patient #1 (P-1): P-1’s start of care (SOC) was 4/28/26, with diagnoses of type 2 diabetes mellitus, hemiplegia, and chronic obstructive pulmonary disease (COPD). P-1’s referral dated 4/22/26, had skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) ordered. The consent to treat dated 5/21/26, only had PT services on it. During review of P-1’s record on 7/6/26, at 1:30 PM, it was discovered that PT was the only service provided. There was no documented evidence that the patient refused SN or OT services or that the physician was notified that the services were not provided. Patient #4 (P-4): P-4’s start of care (SOC) was 4/14/26, with diagnoses of heart failure, atherosclerotic heart disease of coronary arteries, and acute kidney failure. P-4’s referral dated 4/8/26, had SN and PT ordered. The consent to treat dated 4/14/26, only had PT services on it. During review of P-4’s record on 7/8/26, at 9:15 AM, it was discovered that PT was the only service provided. There was no documented evidence that the patient refused SN services or that the physician was notified that the service was not provided. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 record review, and interview, it was determined the Home Health Agency (HHA) failed to inform their patients of the names, addresses and phone numbers of the Federally funded and State funded entities, in the areas where their patients reside, resulting in failure to provide access to community resources and services for the agency’s patients. Findings included: During review of the agency’s patient admission packet on 7/6/26 at 10:30 a.m. it was discovered that the folder failed to include the names, addresses and phone numbers of all five Federally and State funded entities (Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization). The home health agency failed to provide the contact information for the Federally and State funded entities that provide community services and resources to the agency’s patients. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 in 6 of 7 records reviewed (P1, P2, P3, P4, P5, P7), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: Patient #1 (P-1): P-1’s start of care (SOC) was 4/28/26, with diagnoses of type 2 diabetes mellitus, hemiplegia, and chronic obstructive pulmonary disease (COPD). During review of the record on 7/6/26 at 1:30 PM, it was discovered that the OASIS Comprehensive Assessment dated 4/28/26, under the Significant Past Health History Section, was blank, and the endocrine system section was blank, but the Plan of Care documented multiple diagnoses, including Type 2 Diabetes Mellitus as the primary, hemiplegia, chronic obstructive pulmonary disease, lumbago, lateral sclerosis, and unsteadiness on feet. There is also no baseline blood sugar on the comprehensive assessment with a primary diagnosis of Type 2 diabetes mellitus. Patient #2 (P-2): P-2’s start of care (SOC) was 5/21/26, with diagnoses of atherosclerotic heart disease of coronary arteries, diabetes mellitus, and Parkinson’s disease. During review of the record on 7/6/26 at 4:00 PM, it was discovered that the OASIS Comprehensive Assessment dated 5/21/26, documented atherosclerotic heart disease of coronary arteries and type 2 diabetes mellitus as diagnoses, but the endocrine and cardiac system sections are both blank. There is no past medical history or information related to the primary and secondary diagnoses documented in the Start of Care Comprehensive OASIS Assessment. Patient #3 (P-3): P-3’s start of care (SOC) was 12/13/23, with diagnoses of heart failure, pneumonia, and chronic obstructive pulmonary disease. During review of the record on 7/7/26 at 2:30 PM, it was discovered that the OASIS Recertification Assessment dated 3/31/26, documented heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD), but the cardiac and respiratory system sections are both blank. There is no past medical history or information related to the above diagnoses documented in the Start of Care Comprehensive OASIS Assessment. Patient #4 (P-4): P-4’s start of care (SOC) was 4/14/26, with diagnoses of heart failure, atherosclerotic heart disease of coronary arteries, and acute kidney failure. During record review on 7/8/26 at 9:14 AM, it was discovered that the OASIS Comprehensive Assessment dated 4/14/26, documented heart failure and arteriosclerosis of coronary arteries, but the cardiac system section is blank. There is no past medical history or information related to the above diagnosis documented in the Start of Care Comprehensive OASIS Assessment. Patient #5 (P-5): P-5’s start of care (SOC) was 11/28/23, with diagnoses of malignant neoplasm, lymph disorder and atrial fibrillation. During review of the record on 7/8/26 at 11:30 AM, it was discovered that the OASIS Comprehensive Assessment dated 5/15/26, does not have any diagnoses documented. The Plan of Care dated 5/16/26 documents multiple diagnoses, including malignant neoplasm, lymph disorder, and atrial fibrillation. Patient #7 (P-7): P-7’s start of care (SOC) was 3/7/26, with diagnoses of heart failure, neuropathy and chronic obstructive pulmonary disease. During review of the record on 7/8/26 at 11:30 AM, it was discovered that the OASIS Recertification Assessment dated 3/7/26, documented heart failure and chronic obstructive pulmonary disease (COPD), but the cardiac and respiratory system sections are both blank. There is no past medical history or information related to the above diagnoses documented in the Start of Care Comprehensive OASIS Assessment. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) 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 ensure the comprehensive assessment included a review of all the patient’s prescribed medications to determine any untoward interactions, for 4 (P-1, P-2, P-3 and P-5) of 7 patient’s records reviewed, resulting in the potential for harmful medication effects. Findings include: Patient #1 (P-1): P-1’s start of care (SOC) was 4/28/26, with diagnoses of type 2 diabetes mellitus, hemiplegia, and chronic obstructive pulmonary disease (COPD). During review of the record on 7/6/26 at 1:30 PM, it was discovered that there was no evidence in the record that a medication reconciliation was completed. There is a medication profile, but no reconciliation documented in the record. A medication reconciliation was completed on 7/6/26 and showed 2 minor and 2 moderate drug interactions. There was no documented evidence in the record that the physician was notified of the drug interactions and what follow-up was done. Patient #2 (P-2): P-2’s start of care (SOC) was 5/21/26, with diagnoses of atherosclerotic heart disease of coronary arteries, diabetes mellitus, and Parkinson’s disease. During review of the record on 7/6/26 at 4:00 PM, it was discovered that there was no evidence in the record that a medication reconciliation was completed. There is a medication profile, but no reconciliation documented in the record. A medication reconciliation was completed on 7/6/26 and showed 18 moderate drug interactions. There was no documented evidence in the record that the physician was notified of the drug interactions and what follow-up was done. Patient #3 (P-3): P-3’s start of care (SOC) was 12/13/23, with diagnoses of heart failure, pneumonia, and chronic obstructive pulmonary disease. During review of the record on 7/7/26 at 2:30 PM, it was discovered that there was no evidence in the record that a medication reconciliation was completed. There is a medication profile, but no reconciliation documented in the record. A medication reconciliation was completed on 7/7/26 and showed 12 moderate and 4 major drug interactions. There was no documented evidence in the record that the physician was notified of the drug interactions and what follow-up was done. Patient #5 (P-5): P-5’s start of care (SOC) was 11/28/23, with diagnoses of malignant neoplasm, lymph disorder and atrial fibrillation. During review of the record on 7/8/26 at 11:30 AM, it was discovered that there was no evidence in the record that a medication reconciliation was completed. There is a medication profile, but no reconciliation documented in the record. A medication reconciliation was completed on 7/8/26 and showed 2 minor, 8 moderate and 6 major drug interactions. There was no documented evidence in the record that the physician was notified of the drug interactions and what follow-up was done. Agency policy III.17, Medication Management (undated), stated, “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...” During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 safety measures for 1 of 1 (P-7) records with oxygen ordered, resulting in the potential for negative patient outcomes related to oxygen use. Findings include: Patient #7 (P-7): P-7’s start of care (SOC) was 3/7/26, with diagnoses of heart failure, neuropathy and chronic obstructive pulmonary disease. During review of the record on 7/8/26 at 11:30 AM, it was discovered that oxygen therapy was ordered but there were no oxygen precautions or safety measures on the Plan of Care (POC). Agency policy III.7 Professional/Ancillary Care Plan (undated) stated, “The POC will include.... safety measures, including use of specific equipment.” During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 a detailed discharge summary was included in the record for 1 of 2 discharge patient (P-2) records reviewed, resulting in a lack of information to the receiving facility or the patient’s physician to ensure continuity of care. Findings include: Patient #2 (P-2): P-2’s start of care (SOC) was 5/21/26, with diagnoses of atherosclerotic heart disease of coronary arteries, diabetes mellitus, and Parkinson’s disease. During review of the record on 7/6/26 at 4:00 PM, it was discovered that there was no discharge summary in the patient’s record that identifies the patient’s medications, past medical history, goals achieved/progress, or patient condition at discharge. There is no information to provide continuity of care to the receiving facility or information to the primary care physician. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”

“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 detailed discharge or transfer summary was included in the record and sent to the receiving facility or the patient’s physician within 5 business days of discharge for 2 of 2 transfer or discharge patient (P-1, P-2) records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: Patient #1 (P-1): P-1’s start of care (SOC) was 4/28/26, with diagnoses of type 2 diabetes mellitus, hemiplegia, and chronic obstructive pulmonary disease (COPD). During review of the record on 7/6/26 at 1:30 PM, it was discovered that there was no discharge/transfer summary in the record. There is a transfer OASIS dated 5/14/26 that does not include a summary, medications, past medical history or patient condition at transfer to provide continuity of care to the receiving facility and information to the primary care physician. Patient #2 (P-2): P-2’s start of care (SOC) was 5/21/26, with diagnoses of atherosclerotic heart disease of coronary arteries, diabetes mellitus, and Parkinson’s disease. During review of the record on 7/6/26 at 4:00 PM, it was discovered that there was no discharge summary in the patient’s record that identifies the patient’s medications, past medical history, goals achieved/progress, or patient condition at discharge. There is no information to provide continuity of care to the receiving facility or information to the primary care physician. During an interview on 7/8/26 at 6:00 PM, the Administrator (Staff-A) acknowledged the above findings.”