Senior Friend Home Care

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the CFR 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. The facility failed to promptly report a change of condition to the provider and family on 8/8/25 when the registered nurse (RN) was made aware of P1’s change of condition. On 8/12/25, the homemaker failed to report P1s worsened condition to the RN, and on 8/13/25 P1 was found deceased in her apartment. The survey resulted in an Immediate Jeopardy (IJ) at CFR 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. The IJ began on 8/8/25 at 10:32 a.m., when the agency failed to notify the provider of P1’s change of condition. The nurse was notified by the home health aide P1 had a change of condition and was willing to go to emergency room. The nurse did not notify the provider or family of change of condition. On 8/12/25 the homemaker performed a visit with P1 and found worsening symptoms compared to the visit on 8/8/25. The homemaker failed to notify the nurse of the change of condition. On 8/13/25 P1 was found deceased in her apartment. The administrator and the director of nursing were notified of the IJ on 9/16/25 at 8:58 a.m. The immediate jeopardy that began on 8/8/25, was removed on 9/16/24 when it was verified the facility had reviewed the change of condition policy and educated all staff related to notification of RN, provider and family promptly of any noted change of condition, but non compliances remained at a condition level due to the number of deficient practice findings cited under this condition. Findings include: Refer to G590. Based on interview and record review, the agency failed to notify a provider and family of change of condition when on 8/8/25, home health Aide (HHA)-A and homemaker (HMK)-A noted P1 to have had a change in health condition. HHA-A reported the change of condition to registered nurse (RN)-B who failed to notify the provider or family. On 8/12/25, HMK-A visited P1 and noted worsening symptoms. HMK-A failed to notify the agency or provider of the worsening change of condition. On 8/13/25, P1 was found deceased in her apartment chair. This failure affected 1 of 8 patients (P1) reviewed for change of condition.”

“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 interview and document review, the facility failed to develop and maintain annual emergency preparedness training and testing based on the emergency plan, risk assessment, policies and procedures, and the communication plan for 1 of 1 Emergency Preparedness (EP) plan. On 9/17/25, the facility’s EP plan was reviewed, and the records lacked evidence of annual training on the current EP plan. The EP manual included a document titled Emergency Disaster Plan Drill dated 12/21/24 and 12/22/24. The document included a one sentence description included an inclement weather drill. The document lacked evidence of analysis of the facility’s response, and revision of the EP plan based on the exercise. During interview on 9/17/25 at 11:20 a.m., administrator stated the facility completed a scenario based on winter weather. The Administrator confirmed they did not document details or discussion regarding the drill.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and document review the agency failed to encode and electronically transmit completed OASIS assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the for 10 of 12 (P1, P2, P3, P4, P6 P8, P9, P10, P11, P12, ) patients reviewed. Findings include: The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 9/15/24 through 9/15/25, identified multiple patients whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P1’s plan of care (POC) identified a start of care date (SOC) of 2/27/14. P1’s recertification OASIS assessment with completion date 10/31/24, was submitted to CMS 2/4/25, over 90 days after completion of the assessment. P2’s POC identified a SOC date of 9/16/24. P2’s recertification OASIS assessment with completion date of 3/11/25, was submitted to CMS 4/11/25, 31 days after completion of the assessment. P3’s POC identified a SOC of 9/23/24. P3’s recertification OASIS assessment with completion date of 11/20/24, was submitted to CMS 2/4/25, over 90 days after completion of the assessment. P4’s POC identified a SOC of 6/23/25. P4’s start of care OASIS assessment with completion date of 6/23/25, was submitted to CMS 8/26/25, 85 days after completion of the assessment. P6’s POC identified a SOC of 9/17/24. P6’s start of care OASIS assessment with completion date of 9/17/24, was submitted to CMS 2/4/25, over 90 days after completion of the assessment. P8’s POC identified a SOC of 5/19/25. P8’s recertification OASIS assessment with completion date of 7/18/25, was submitted to CMS 9/10/25, 39 days after completion of the assessment. P9’s POC identified a SOC of 3/20/25. P9’s discharge OASIS assessment with completion date of 7/15/25, was submitted to CMS 9/10/25, 45 days after completion of the assessment. P10’s POC identified a SOC of 4/19/24. P10’s recertification OASIS assessment with completion date of 7/18/25, was submitted to CMS 9/10/25, 39 days after completion of the assessment. P11’s POC identified a SOC of 6/7/25. P11’s start of care OASIS assessment with completion date of 6/7/25, was submitted to CMS 8/26/25, 78 days after completion of the assessment. P12’s POC identified a SOC of 12/5/24. P12’s recertification OASIS assessment with completion date of 5/29/25, was submitted to CMS 7/2/25, 33 days after completion of the assessment. During an interview on 9/16/25 at 3:05 p.m., licensed practical nurse (LPN)-A stated she was the staff member who submitted the OASIS to CMS. Once a week on Tuesday she would go into IQIES (program to submit OASIS assessments) and submit all of the finished and closed OASIS assessments that showed up to be submitted. She clicked on the boxes to submit each one. LPN-A confirmed the listed OASIS assessments were submitted past the 30-day mark. The reason most, if not all, OASIS assessments would be late is because the nursing staff would not complete and close them timely so they could be submitted within the 30-day timeframe. During an interview on 9/17/25 at 12:14 p.m. the director of nursing stated all OASIS assessment should be submitted within 30 days of being completed. A facility OASIS policy was requested but not provided. The Center for Medicare and Medicaid Services OASIS E Manual, updated 1/1/24, identified OASIS data was collected as part of the comprehensive assessment required by the Medicare Conditions of Participation. The CMS Home Health Conditions of Participation required a home health agency electronically transmit accurate, completed, and encoded OASIS data to a centralized data submission.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on interview and document review the facilility failed to completed and submit to provider a discharge summary for a resident that was discharged from services. This affected 1 of 2 (P1) client reviewed for discharge. Findings include: P1’s plan of care (POC) dated 6/229/25 to 8/27/25 indicated a start of care on 2/27/24. P1’s Miscellaneous Communication form dated 8/13/25 indicated P1 passed away on 8/13/25. On 9/16/25 P1’s medical record was reviewed and lacked a discharge (DC) summary . P1’s DC summary was requested and not provided. During an interview on 9/17/25 at 12:14 p.m., the director of nursing (DON) stated a discharge summary would be performed on all clients after they were discharge from services. The DON reviewed P1’s medical record and confirmed the discharge summary was not complete. She had not had time to do the discharge summary yet. Facility policy Discharge from Services, undated, indicated all clients would have a discharge summary completed. The summary would include date of discharge, reason for discharge, location and person responsible along with summary of problems, interventions and client response.”

“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 interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 1 of 7 patients (P3), and failed to notify the physician when the visits were not conducted in accordance with the plan of care (POC). Findings include: P3’s POC for certification period 7/20/25 to 9/17/25, indicated a start of care date of 9/23/24 and diagnosis of macular degeneration (eye disease causing loss of central vision), anxiety disorder, hypertension (high blood pressure), and discoid lupus erythematosus (skin rash). P3’s POC included orders for skilled nurse visits 1 time a week for 9 weeks. POC did not include visit frequency for home health aide. Review of P3’s medical record included missed visits on 8/30/25 and 9/2/25 for home health aide and a missed nurse visit on 5/26/25 and 7/29/25. P3’s medical record lacked evidence of notification to the provider for missed visits. During interview on 9/17/25 on 11:26 a.m., licensed practical nurse (LPN)-A stated she would update the case manager and the business office manager if there was a missed visit. LPN-A stated the business office manager would fax an update to the provider, however she was informed of a change in the process for future missed visits that would not require the business office manager to send a fax. During interview on 9/17/25 at 12:26 p.m., registered nurse (RN)-A stated a missed visit form in the electronic medial record would be filled out when a visit was missed, and the form would be faxed to the provider. RN-A stated each nurse would be responsible for updating the provider for missed visits and the home health aides would update the business office manager for a missed visit and they would send a fax. The fax would be scanned into the medical record. During interview on 9/17/25 at 1:15 p.m., the director of nursing (DON) confirmed the there were missed visits for P3 without notifications to the provider. The DON stated missed visits were previously faxed by the business office manager, however that had changed because of staffing changes, and the missed visits were no longer being faxed to the providers. Agency policy for missed visits dated 12/17/24, included missed visits would be tracked through the electronic medical record and sent to the provider in a timely manner.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview, the agency failed to implement an infection control program that included tracking, trending and analysis of client infections. The has the potential to effect all patients and staff. Findings include: During interview on 9/17/25 at 11:07 a.m., director of nursing (DON) confirmed the agency did not have a surveillance program and did not have a process to track infections. Agency infection control policy dated April 2018, included clinical staff would assist with targeted surveillance for infections and information would be reported to the clinical manager on a monthly basis.”

“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 interview and document review the facility failed to perform a compatency evaluation on 2 of 5 staff reviewed employee compatence. This had the possibility to affect all patients the staff cared for. Findings include: Home health aide (HHA)-E’s employee file was reviewed and lacked an employee competency evaluation with return demonstration to verify the aide was able to perform the duties of employment without training. HHA-F’s employee file was reviewed and lacked an employee competency evaluation with return demonstration to verify the aide was able to perform the duties of employment without training. A copy of HHA-E’s and HHA-F’s competency evaluation was requested but not provided. During an interview on 9/17/25 at 12:14 p.m., the director of nursing (DON) stated all staff would have a competency evaluation and checklist performed. They may not all get done before start of work with clients, especially if there was a history of employment with a different home health agency doing the same job. The DON reviewed HHA-Es and HHA’Fs employee file and confirmed there was no competency evaluation and was unsure if one had been performed. Facility policy Training, Supervision and Competency Evaluations of Unlicensed Personnel, undated, indicated all unlicensed personnel would have a competency evaluation completed.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and document review the facility failed to offer 12 hours per year of register nurse led inservice training to the home health aide staff. This was lacking in 5 of 5 staff members reviewed for inservice education. Findings include: Home health aide (HHA)-F’s employee file was reviewed and lacked documentation 12 hours (hrs) of registered nurse (RN) lead inservice per year was completed. HHA-B’s employee file was reviewed and lacked documentation 12 hrs of RN lead inservice per year was completed. HHA-C’s employee file was reviewed and lacked documentation 12 hrs of RN lead inservice per year was completed. HHA-D’s employee file was reviewed and lacked documentation 12 hrs of RN lead inservice per year was completed. HHA-e’s employee file was reviewed and lacked documentation 12 hrs of RN lead inservice per year was completed. A copy of HHA-B’s, HHA-C’s, HHA-D’s, HHA-E’s, and HHA-F’s documented 12 hr’s of RN lead inservice per year was requested but not provided. Home Health Aide Meeting dated 6/11/25 to 6/12/25 lead by the director of nursing (DON) and assistant director of nursing (ADON) was performed. Agenda items discussed as part of the meeting included missed visits, insurance items, closures of other home health agencies, new hires, communicating with nurses, and increased services. Discussion points included what’s going well, what are opportunities, and supplies. The meeting notes lacked information related to any RN lead inservice training. During an interview on 9/17/25 at 12:14 p.m., the director of nursing (DON) stated all staff had the annual training packet that was required by federal and state. The packet involved items to read and tests to take. Once a month there would be a meeting with the aides and the homemakers where several items were discussed. part of that meeting included inservices for the aides and homemakers. Other than that there is no other inservices performed with the aides that are lead by the RN. Facility policy Training, Supervision & Competency Evaluations of Unlicensed Personnel undated, lacked information related to 12 hr of RN lead inservice for aides. Facility policy Annual Education with an effective date of 12/17/25 indicated all staff that performed home care services would complete at least 8 hrs of annual training each 12 month of employment. the training could be obtained from the home care provider or another source and must include topics relevant to home care services.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review the facility failed to admit the patient to services or have a provider order to delay admission within 48 hours (hr) of referral. This had the potential to effect 4 of 7 ( P2, P4, P5, P6) patients reviewed for admission. P2’s Plan of Care (POC) dated 5/14/25 to 7/12/25, indicated a start of care (SOC) on 9/16/24. P2 referral form undated, indicated referral was received on 9/9/25. A copy of the referral form and actual referral were requested but not received. P4’s POC dated 8/22/25 to 10/20/25, indicated a SOC on 6/23/25. P4’s referral form undated, indicated referral was received on 6/3/25. A copy of the referral form and actual referral were requested but not received. During an interview on 9/17/25 at 12:14 p.m., the director of nursing (DON) stated admissions were suppose to start wthin two days of receiving the referral. If the admission would not occur within two days of referral there should be a provider order to delay admission. The facility does not always get an order to delay admission, especially if the need is only for home health aide or homemaker services. We would set up a time that worked for the agency and the patient and then admit at that time. The DON reviewed P2’s and P4’s medical record and confirmed there was a delay in admission and no provider order to delay admission. Facility policy Client Admission, Comprehensie Assessment, Monitoring and Reassessment undated, indicated the facility would notify the referral source within 48 hours that the client cannot be admitted to home care. the policy lacked documentation a provider order was required to delay start of care. P5’s POC dated 9/5/25 to 11/3/25, indicated a SOC on 9/5/25. P5’s referral form included a referral date of 8/28/25. A copy of actual referral was requested and not received. P6’s POC dated 9/12/25 to 11/10/25, indicated a SOC of 9/17/24. P6’s referral form included a referral date of 9/9/24. A copy of actual referral was requested and not received. During interview on 9/17/25 at 11:08 a.m., DON reviewed P5’s and P6’s medical record and confirmed there was a delay in admission and not provider order for the delayed admission.”

“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 observation, interview and document review, the facility failed to complete a full medication reconciliation for 1 of 2 patients (P5) reviewed during home visit. Findings include: P5’s plan of care (POC) for certification period 9/5/525 to 11/3/25, indicated P5’s SOC was on 9/5/25. P5’s diagnosis included hypertension (high blood pressure), overactive bladder, and lumbago with sciatica (low back pain with pain that runs down a nerve in the low back through the legs). P5’s POC included the following medications: - Alendronate (a medication for weakening of the bones) 35 milligrams (mg) 1 tab once a week - Calcium (as carbonate) 500 mg chewable tab once per day - Gabapentin (a medication for nerve pain) 300 mg 1 capsule once a day - Losartan (a medication for high blood pressure) 25 mg 1 tablet once a day - Mirabegron (a medication for overactive bladder) 25 mg extended release 1 tab once a day - Miralax oral powder 17 granules once a day - Vitamin D3 10 micrograms (mcg) 1 tab once a day During a home visit on 9/17/25, P5 stated medication bottles were not reviewed during SOC visit. Medication in bottles in the home that differed from the POC included the following: - Alendronate 70 mg 1 tab once weekly - Calcium 600 mg with Vit D3 once daily - Gabapentin 100 mg capsules 1 capsule by mouth up to 3 times a day as needed - Losartan 50 mg 1 tab once daily - Mirabegron extended release 50 mg 1 tab once daily - Vitamin D3 25 mcg once daily During interview on 9/17/25 at 10:55 a.m., the director of nursing (DON) confirmed she completed the start of care (SOC) for P5. DON stated she completes a medication reconciliation during the SOC. DON stated she did not review medication bottles during the medication reconciliation for P5 but reviewed a printed index card in P5’s home. DON confirmed the medication index card did not include dosing, only medication name and number of pills taken. DON stated she entered the medication name and selected the lowest dose available for the medication but was unsure what the actual dose P5 was taking. DON confirmed she was unsure the medication dosing she entered on the POC was what P5 was taking because she never reviewed the medication bottles or clarified with P5. Facility policy for medication reconciliation requested and not provided.”

“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 interview and record review, the agency failed to notify a provider and family of change of condition when on 8/8/25, home health Aide (HHA)-A and homemaker (HMK)-A noted P1 to have had a change in health condition. HHA-A reported the change of condition to registered nurse (RN)-B who failed to notify the provider or family. On 8/12/25, HMK-A visited P1 and noted worsening symptoms. HMK-A failed to notify the agency or provider of the worsening change of condition. On 8/13/25, P1 was found deceased in her apartment chair. This failure affected 1 of 8 patients (P1) reviewed for change of condition. The immediate Jeopardy (IJ) began on 8/8/25 at 10:33 a.m., when HHA-A notified RN-A about the change of condition and RN-A failed to notify provider or family. On 8/12/25, HMK-A failed to report a worsened change of condition, and on 8/13/25, P1 was found deceased in her apartment. The administrator and director of nursing were notified of the IJ on 9/16/25 at 8:58 a.m. The IJ was removed on 9/16/25 at 8:00 p.m., after it could be verified the agency had implemented an acceptable removal plan. Findings include: P1’s plan of Care (POC) dated 6/29/25 to 8/27/25, indicated a start of care (SOC) of 2/27/24. Diagnoses included pulmonary embolism (blood clot in lung), diabetes, and chronic obstructive pulmonary disease. P1 was oriented but forgetful and functional limitations included dyspnea (shortness of breath) with minimal exertion. P1’s medical record was reviewed and indicated following: · On 8/8/25, home health aide (HHA)-A cleaned the living room, swept and mopped, and was in contact with the nurse about P1’s reported change of condition. · On 8/8/25, homemaker (HMK)-A assisted in making bed due to bottom sheet and mattress soaked in urine and patient reported not feeling well. HHA-A was present and contacted nurse about change of condition. · On 8/12/25 HMK-A visited P1 due to concern P1 was not well. P1 reported that she was constantly sleeping, suffering from stomach pain, and pointed to belly button area stating she was “just not feeling good”. HMK-A observed pale color, hoarse voice, dry mouth and P1 was warm to touch. HMK-A notified family but did not notify the assistant director of nursing (ADON) or provider. P1’s medical record lacked documentation that ADON or anyone else from the agency had notified the provider or family regarding P1’s change of condition on 8/8/25. It also lacked documentation regarding notification to nursing or the provider regarding P1’s worsening symptoms on 8/12/25. HHA-A’s text messages to ADON on 8/8/25 at 10:32 a.m., identified HHA-A reported to RN-B that P1 was demonstrating frequent urination and vomiting on 8/7/25 and 8/8/25, and had not slept well. Observations included P1 appearing run down and tired and having urine that had a slight smell to it. P1’s temperature recorded as less than 96 degrees Fahrenheit (F) (normal temp is around 98.6). RN-B asked HHA-A if P1 would be willing to go in for a urine test if ADON called family and HHA-A responded yes. Text messages discontinued at that time. Home Health Agency investigation report dated 8/13/25, confirmed HHA had reported concerns related to a possible change of condition to the ADON. The RN (ADON) did not call family due to thinking that HMK-A had called family. Investigation did not show if ADON notified provider related to change of condition. The conclusion indicated a possible change of condition and P1 should have went in for evaluation. P1’s Minnesota Documentation of Death dated 8/13/25, indicated cardiac arrest was the cause of death. During an interview on 9/15/25 at 9:44 a.m., HMK-A stated she and HHA-A had worked together to provide services to P1 on 8/8/25. The first thing that was noticed was her bottom sheet and mattress were soaked in urine. P1 had issues with incontinence but P1 wore briefs, and the bed had never been that wet before. HHA-A asked P1 different questions while HMK-A took care of the bed, but P1 looked very tired and worn out. P1 reported she had not slept well last night. HKM-A overheard HHA-A ask P1 if she wanted to go get evaluated if the nurse called the family and P1 responded “yes.” KMK- A further stated after that, HHA-A and I finished our visits and left. We did not call any family at that time because the ADON said in the text she was going to. On 8/12/25, HKM-A stated she was completing a visit with a different client who knew P1. It was reported at this time that P1 looked bad and was not feeling well and asked if somebody could check on her. As HMK-A left that visit another client approached HMK-A and reported the same concerns related to P1 and also asked if somebody could check on her. HMK-A stopped to see P1 and found P1 warm to touch, hoarse, and pale. P1 complained of pain and pointed to her belly button. HMK-A asked P1 is she could call family and HMK-A proceeded to call family and left a message to call her back. Family member (FM)-A did call HMK-A back later in the day. HMK-A stated the ADON was not notified of the new symptoms related to the change of condition. HMK-A confirmed she was a non-medical trained staff member and had not had any formal medical training and just called the family member as a friend. During an interview on 9/15/25 at 10:18 a.m., HHA-A stated when she and HMK-A arrived at P1’s apartment, P1 started reporting right away she was not feeling well. P1 reported symptoms of frequent urination and vomiting twice prior to arrival of staff. HHA-A text the ADON right away and reported the symptoms P1 had. The ADON text back and asked if P1 would be willing to go in for evaluation if the ADON called family and P1 responded “yes.” Then checked her temperature but no other vital signs. Her Temperature was reading less than 96 degrees F. The family was not called at this time because the ADON text indicating she would. During an interview on 9/15/25 at 11:49 a.m., family member (FM)-A stated a phone call was never received on 8/8/25 from anybody at the agency and the first call about P1’s change of condition was received from HMK-A on 8/12/25. FM-A stated he did not want to answer any further questions after that and hung up the phone. On 9/15/25 at 12:57 p.m., the ADON stated on 8/8/25 at around 10:30 a.m., HHA-A text that P1 had reported symptoms of frequent urination and vomiting two times. HHA-A reported P1 looked worn out and urine had a slight smell to it. Symptoms sounded like the start of a urinary tract infection (UTI) so it was asked if P1 would be willing to go in to be tested for a UTI and HHA-A responded yes. The ADON indicated she tried to find FM-A’s phone number but was not in P1’s chart so she called HHA-A back right away and left a message to call back. when she did not hear back was not worrird about it because HMK-A said she called the family member on 8/8/25. The ADON was not made aware of P1’s worsening symptoms from 8/12/25, until after she had passed on 8/13/25. The ADON reviewed their call log, then showed the screen and stated the call made to HHA-A on 8/8/25 was not there. The phone was observed to have several calls made to different people on that day, but no calls were made to HHA-A. During an interview on 9/15/25 at 1:12 p.m., the director of nursing (DON) stated an investigation was performed on 8/13/25 when P1 was found deceased. It was found that the nurse had not notified the provider or the family about P1’s change of condition because it was understood HMK-A had notified FM-A on 8/8/25. The agency was not aware of the concerns on 8/12/25 until 8/13/25 when P1 passed because HMK-A had not notified anyone from the agency. During an interview on 9/15/25 at 3:13 p.m., the administrator and the director of nursing stated the expectation was that unlicensed staff report symptoms related to a change of condition to the registered nurse case manager (RNCM) immediately. The RNCM would then call the client and decide if the change of condition required a home visit from an RN, a recommendation to be seen by their provider, or if emergency services needed to be called. If a nurse does a home visit, the provider may or may not be called, depending on the findings at the home visit. If the recommendation was to go in for evaluation or call 911, the provider and family would be called promptly to notify them of the change of condition. During an interview on 9/15/25 at 4:02 p.m., P1’s physician stated he had not received any calls related to P1’s change of condition on either 8/8/25 or 8/12/25. He was made aware of P1’s passing when he received a death certificate to sign. the Physician further indicated, based on the symptoms reported alone, P1 may have had a UTI and turned septic, which may have triggered cardiac arrest. There was a chance that had P1 been evaluated on 8/8/25, the outcome might have been different. Facility policy Coordination of Care/Case Conference Form undated, indicated the provider would be notified of any significant change in client condition. The immediate jeopardy that began on 8/8/25, was removed on 9/16/25 when it was verified the facility reviewed its policy and procedures related to notification of a condition change and educated all staff about who to notify when there is a noted change of condition.”

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on interview, and document review, the HHA failed to develop an emergency preparedness program that met all of the standards specified within the condition, including a comprehensive approach to meet the health, safety and security needs of the staff and client population during an emergency or disaster situation. The plan also lacked how the agency would communicate with staff and the whole community during an emergency or disaster. This had the possibility to affect all staff and clients that received care from the agency. The Condition of Participation: Establishment of the emergency program 42 CFR at 484.102 Review of the facility emergency preparedness plan revealed the facility had not utilized an all-hazards approach to establish an emergency procedures program; failed to develop a risk assessment, identifying both community and agency-based risk; failed to develop policies and procedures based on an emergency plan, failed to develop a communication plan, and failed to develop processes for training and testing. On 11/14/24, at 1:18 p.m. the administrator stated he had started work on his emergency preparedness plan on 6/1/24, however, never completed per appendix Z guidelines.”

“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 interview and document review, the facility failed to ensure compliance with all applicable Federal, State and local emergency preparedness requirements. The facility failed to develop, establish and maintain, a comprehensive emergency preparedness program that meets the requirements of this section. The facility failed to develop an Emergency Plan and failed to review and update the plan as required. This had the possibility to affect all staff and clients that received care from the agency. Findings include: A review of the facility policy Emergency Preparedness dated 6/1/24, lacked a complete emergency plan that was reviewed and updated as required. The facility also failed to ensure the following of their emergency preparedness program: -§484.102(a)(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. -§484.102(a)(2) Include strategies for addressing emergency events identified by the risk assessment. -§484.102(a)(3) Address patient population, including, but not limited to, the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. -§484.102(a)(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the HHA’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. During an interview on 11/14/24 at 1:18 p.m., the administrator stated they were not aware of any comprehensive emergency plan that discussed the facility and community risk assessment using an all-hazards approach or a comprehensive list of outside organizations the agency could work with if needed.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to conduct a comprehensive all-hazards community-based risk assessment to determine potential disasters which could impact the HHA and develop corresponding policies and procedures to ensure patient safety and quality care during a disaster. This had the possibility to affect all staff and clients that received care from the agency. Findings include: Review of the facility policy Emergency Preparedness dated 6/1/24, revealed the plan did not contain the following standard policies and procedures: -§484.102(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 annually. -§484.102(b)(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. -§484.102(b)(2) The procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. -§484.102(b)(3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. -§484.102(b)(4) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. -§484.102(b)(5) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency. During interview on 11/14/24 at 1:18 p.m., the administrator stated he had not developed policies and procedures for all identified hazards based on the risk assessment for the home health agency.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on interview and document review, the home health agency failed to develop in its emergency preparedness plan (EPP) a written emergency communication plan that contained a description of how the facility will coordinate patient care within the facility, across healthcare providers, and with state and local public health departments in order to protect the health and safety of their patients/residents. This had the possibility to affect all staff and clients that received care from the agency. Findings include: The facility policy emergency preparedness, dated 6/1/24, was reviewed. There was no information of a communication plan that included the following: -§484.102(c) Communication plan. The HHA 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 annually. -§484.102(c)(1) Names and contact information for the staff entities providing services under arrangement, patients’ physicians, and volunteers. -§484.102(c)(2) Contact information for Federal, State, tribal, regional, or local emergency preparedness staff, as well as other sources of assistance. -§484.102(c)(3) Primary and alternate means for communicating with the HHA’s staff, Federal, State, tribal, regional, and local emergency management agencies. -§484.102(c)(4) A method for sharing information and medical documentation for patients under the HHA’s care, as necessary, with other health care providers to maintain the continuity of care. -§484.102(c)(5) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). -§484.102(c)(6) A means of providing information about the HHA’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. During interview at 1:18 p.m. on 11/14/24, the facility administrator said the facility had not established a plan for communication for emergency preparedness, and there was no policy for communication.”

“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 document review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures and an appropriate communication plan. This had the possibility to affect all staff and clients that received care from the agency. Review of the facility’s emergency preparedness policy dated 6/1/24, revealed the facility had not developed and implemented training and testing policies and procedures that included the following: -§484.102(d) Training and testing. The HHA 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. -§484.102(d)(1) Training program. The HHA must do all of the following: 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. Provide emergency preparedness training at least annually. Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures. -§484.102(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. 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 a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event. Complete a second full-scale that is community-based or individual, facility-based. 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. During interview on 11/4/24 at 1:18 p.m., the administrator stated there was no testing or training policies and procedures.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on interview and document review the facility failed to obtain signatures to show the Patient Bill of Rights and Responsibilities were given to the patient for 6 of 7 (P1, P2, P3, P4, P6, P7) residents reviewed for patient bill of right signature pages. Findings include: The facilities’ admission packet undated, indicated the home care bill of rights was included in the packet. Number 6 of the admission packet indicated Home Care Bill of Rights, I have received, read, and understand the home care bill of rights. page seven of the admission packet is the signature page for patients to sign they received the home care bill of rights. P3’s plan of care (POC) dated 11/3/24-1/1/25, indicated P3’s start of care (SOC) was 5/7/24. P3’s admission signature page was requested but not provided. P4’s POC dated 10/6/24 - 12/4/24, indicated P4’s SOC was 10/12/23. P4’s admission signature page was requested but not provided. P6’s POC dated 5/10/24 - 7/8/24, indicated P6’s SOC was 5/10/24. P6’s admission signature page was requested but not provided. During an interview on 11/14/24 at 1:24 p.m. the Director of Nursing (DON) stated when a patient is admitted the admitting nurse will go over the admission packet, which included the POC, and would have the patient sign to indicate paperwork was received and explained to the patient. The DON reviewed P3’s, P4’s, and P6’s medical records and acknowledged the signature page was missing for all three patients. The assumption would be the signature pages were not signed by the patients. The DON expected all admitting nurses would have patients sign the signature page and the return to the office to have the page added to the patient chart. Facility admission paperwork policy was requested but not received. Findings include: The facilities’ admission packet undated, indicated the home care bill of rights was included in the packet. Number 6 of the admission packet indicated Home Care Bill of Rights, I have received, read, and understand the home care bill of rights. page seven of the admission packet is the signature page for patients to sign they received the home care bill of rights. P1’s plan of care (POC) dated 11/6/24-1/4/25, indicated P1’s start of care (SOC) was 11/22/21. P1’s admission signature page was requested but not provided. P2’s POC dated 10/28/24 - 12/26/24, indicated P2’s SOC was 5/1/24. P2’s admission signature page was requested but not provided. P7’s POC dated 7/14/24 - 9/11/24, indicated P7’s SOC was 5/15/24. P7’s admission signature page was requested but not provided. During an interview on 11/14/24 at 1:24 p.m. the Director of Nursing (DON) stated when a patient is admitted the admitting nurse will go over the admission packet, which included the POC, and would have the patient sign to indicate paperwork was received and explained to the patient. The DON reviewed P1’s, P2’s, and P7’s medical records and acknowledged the signature page was missing for all three patients. The assumption would be the signature pages were not signed by the patients. The DON expected all admitting nurses would have patients sign the signature page and the return to the office to have the page added to the patient chart. Facility admission paperwork policy was requested but not received.”

“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 interview and document review the facility failed to obtain signed service agreements to show a participation in Care for 5 of 7 (P1, P2, P3, P6, P7) residents reviewed for participation in care. Findings include: The facilities’ admission packet undated, indicated the service agreement plan was included on page one. Number 1 of the Agreement for Home Services-Client Signature Form, the services provided by the home health agency have been explained to the patient and the patient agrees to the service plan. As indicated a new service agreement made if the patient of the agency request a change in services. Then page seven of the admission packet is the signature page for patients to sign they participated and agreed to the service plan set up by the patient and the home health agency. P1’s plan of care (POC) dated 11/6/24-1/4/25, indicated P1’s start of care (SOC) was 11/22/21. P1’s signed service agreement was requested but not provided. P2’s POC dated 10/28/24 - 12/26/24, indicated P2’s SOC was 5/1/24. P2’s signed service agreement was requested but not provided. P7’s POC dated 7/14/24 - 9/11/24, indicated P7’s SOC was 5/15/24. P7’s signed service agreement was requested but not provided. During an interview on 11/14/24 at 1:24 p.m. the Director of Nursing (DON) stated when a patient is admitted the admitting nurse will go over the admission packet, which included the service agreement plan, and would have the patient sign to indicate paperwork was received and explained to the patient. The DON reviewed P1’s, P2’s, and P7’s medical records and acknowledged the signature page was missing for all three patients. The assumption would be the signature pages were not signed by the patients. The DON expected all admitting nurses would have patients sign the signature page and the return to the office to have the page added to the patient chart. Facility admission paperwork policy was requested but not received. Findings include: The facilities’ admission packet undated, indicated the service agreement plan was included on page one. Number 1 of the Agreement for Home Services-Client Signature Form, the services provided by the home health agency have been explained to the patient and the patient agrees to the service plan. As indicated a new service agreement made if the patient of the agency request a change in services. Then page seven of the admission packet is the signature page for patients to sign they participated and agreed to the service plan set up by the patient and the home health agency. P3’s plan of care (POC) dated 11/3/24-1/1/25, indicated P3’s start of care (SOC) was 5/7/24. P3’s signed service agreement was requested but not provided. P6’s POC dated 5/10/24 - 7/8/24, indicated P6’s SOC was 5/10/24. P6’s signed service agreement was requested but not provided. During an interview on 11/14/24 at 1:24 p.m. the Director of Nursing (DON) stated when a patient is admitted the admitting nurse will go over the admission packet, which included the service agreement plan, and would have the patient sign to indicate paperwork was received and explained to the patient. The DON reviewed P3’s, and P6’s medical records and acknowledged the signature page was missing for all three patients. The assumption would be the signature pages were not signed by the patients. The DON expected all admitting nurses would have patients sign the signature page and the return to the office to have the page added to the patient chart. Facility admission paperwork policy was requested but not received.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide notification of consideration for discharge for cause for 1 of 2 (P6) patients reviewed for discharge. Findings include: P6’s plan of care (POC) dated 5/10/24 - 7/8/24, identified start of care (SOC) date of 5/10/24. P6’s undated face sheet identified a discharge date of 9/9/24. During an interview on 11/14/24 at 1:13 p.m., the director of nursing (DON) stated they had been running to issues with P6 being manipulative and aggressive with home care agency staff. The DON reported trying to work with P6 and her provider but were not receiving support. The county case worker was involved and found another home care agency for P6, so a 14-day notice was served to P6, but was not retained for the medical record. Further, the DON stated none of the conversations with P6, her provider or her case worker, regarding these behaviors and potential for discharge were recorded in the medical record. Documentation of the 14-day discharge notice and progress notes were requested but not received.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on interview and record review, the agency failed to make efforts to resolve problems with patient’s behavior for 1 of 2 (P6) patients reviewed for discharge. Findings include: P6’s plan of care (POC) dated 5/10/24 - 7/8/24, identified start of care (SOC) date of 5/10/24. P6’s undated face sheet identified a discharge date of 9/9/24. During an interview on 11/14/24 at 1:13 p.m., the director of nursing (DON) stated they had been running to issues with P6 being manipulative and aggressive with home care agency staff. The DON reported trying to work with P6 and her provider but were not receiving support. The county case worker was involved and found another home care agency for P6. Further, the DON stated none of the conversations with P6, her provider or her case worker, regarding these behaviors and potential for discharge were recorded in the medical record. The progress notes for P6 were requested but not received.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide information on other community agencies who may be able to provide services to the patient for 1 of 2 (P6) patients reviewed for discharge. Findings include: P6’s plan of care (POC) dated 5/10/24 - 7/8/24, identified start of care (SOC) date of 5/10/24. P6’s undated face sheet identified a discharge date of 9/9/24. During an interview on 11/14/24 at 1:13 p.m., the director of nursing (DON) stated they had been running to issues with P6 being manipulative and aggressive with home care agency staff. The DON reported trying to work with P6 and her provider but were not receiving support, so once the county case worker was able to find another agency for P6’s services they discharged her. Further, the DON stated none of the conversations with P6, her provider or her case worker, regarding these behaviors and potential for discharge were recorded in the medical record. P6’s progress notes were requested but not received.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on interview and record review, the agency failed to document attempts to resolve problems with a patient’s behavior in the medical record of 1 of 2 (P6) patients reviewed for discharge. Findings include: P6’s plan of care (POC) dated 5/10/24 - 7/8/24, identified start of care (SOC) date of 5/10/24. P6’s undated face sheet identified a discharge date of 9/9/24. During an interview on 11/14/24 at 1:13 p.m., the director of nursing (DON) stated they had been running to issues with P6 being manipulative and aggressive with home care agency staff. The DON reported the agency tried to make attempts to work with her and her provider but were unsuccessful and served the patient with a 14-day notice and then discharged P6. Further, the DON stated none of the conversations with P6, her provider or her case worker, regarding these behaviors and potential for discharge were recorded in the medical record. Documentation of the 14-day discharge notice and progress notes were requested but not received.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review the home health agency failed to admit the patient within 2 days of receiving referral or obtain an order to delay admission for 4 of 7 (P1, P3, P6, P7) patients reviewed for admission. P1’s plan of care (POC) for certification period of 11/6/24 to 1/4/25 indicated a start of care (SOC) date of 11/22/21. P1’s referral form undated, indicated a referral to admit to services was received on 11/16/21 P1’s medical record lacked documentation of provider approval to delay admission past 2 days after referral received. A copy of P1’s referral form was requested but not provided. P7’s plan of care (POC) for certification period of 7/14/24 to 9/11/24 indicated a start of care (SOC) date of 5/15/24. P7’s referral form undated, indicated a referral to admit to services was received on 4/30/24 P7’s medical record lacked documentation of provider approval to delay admission past 2 days after referral received. During an interview on 11/14/24 at 1:24 p.m. the director of nursing (DON) stated she was not aware admission had to be done within 2 days of receiving the referral. The thought was the home health agency needed to wait for insurance approval. The DON reviewed P1’s and P7’s medical record and acknowledged there was no provider order to delay admissions past the required 2 days. Findings include: P3’s plan of care (POC) for certification period of 11/3/24 to 1/1/25 indicated a start of care (SOC) date of 5/7/24. P3’s medical record indicated the date of referral was 4/30/24. A copy of P3’s referral form was requested but not received. P3’s medical record lacked documentation of provider approval to delay admission past two days after referral received. P6’s POC for certification period of 5/10/24 to 7/8/24 indicated a SOC date of 5/10/24. P6’s medical record indicated the date of referral was 5/6/24. A copy of P6’s referral form was requested but not received. P6’s medical record lacked documentation of provider approval to delay admission past two days after referral received. During an interview on 11/14/24 at 1:24 p.m. the director of nursing (DON) stated she was not aware the admission had to be done within two days of receiving the referral. She thought the home health agency needed to wait for insurance approval. The DON reviewed P3’s and P6’s medical record and acknowledged there was no provider order to delay admissions past the required two days.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 2 of 7 patients (P3, P7), failed to notify the physician when the visits were not conducted according to the plan of care (POC), and to educate the patient on the risks of missed visits or attempt to reschedule the missed visit. P7’s plan of care (POC) for certification period 7/14/24 through 9/11/24, indicated a start of care (SOC) date 5/15/24. Diagnoses included Other congenital malformation syndrome. Ordered services included skilled nursing visits (SNV) one time per week for nine weeks Review of P7’s medical record indicated P7 did not receive an ordered SNV visits the weeks of 7/14/24, 7/21/24, 7/28/24, 8/11/24, or 8/18/24. The medical record lacked evidence the physician had been notified of the missed visits the missed visits were rescheduled or that the home health agency educated the patient of the risks related to a missed visit. During an interview on 11/14/24, at 1:18 p.m. the director of nursing (DON) stated she was not aware of the need to notify the provider after each missed visit and document education with the patient related to the risks of missed appoinemtns. the DON reviewed P7s medical record and acknowledged the provider was not notified of the misses visits/ The agency’s undated policy, Refusal and Missed Visit Report Policy and Procedure, indicated all missed visits would be reported to the case manager and tracked using the Saniso Missed Visit Report and is sent to the physician. Findings include: P3’s plan of care (POC) for certification period 11/3/24 - 1/1/25, indicated a start of care (SOC) date 5/7/24. Diagnoses included type two diabetes, venous insufficiency, and depression. Ordered services included skilled nursing visits (SNV) one time per week for nine weeks. Review of P3’s medical record identified P3 did not receive an ordered SNV visits on 5/14, 6/4, 6/11, 7/9, 7/16, 7/24, 8/6, 9/3, 9/17, 10/1, 10/22, and 11/5/24. The medical record lacked evidence the physician had been notified of the missed visits, that attempts to reschedule the visit were made, or that the home health agency educated the patient of the risks related to a missed visit. During an interview on 11/14/24, at 1:18 p.m. the director of nursing (DON) stated she was not aware of the need to notify the provider after each missed visit and document education with the patient related to the risks of missed visits. The DON reviewed P3s medical record and acknowledged the provider was not notified of the missed visits. The agency’s undated policy, Refusal and Missed Visit Report Policy and Procedure, indicated all missed visits would be reported to the case manager and tracked using the Saniso Missed Visit Report which would be sent to the physician.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to have the plan of care reviewed or revised by the provider no less than every 60 days for 2 of 7 (P4, P6) patients reviewed for plan of care. Findings include: P4’s initial plan of care (POC) dated 10/12/23 - 12/10/23 identified start of care (SOC) was 10/12/23. P4’s services included skilled nursing one to three times per month for three months and nursing aid services one to two times per week for nine weeks. The POC was not signed by P4’s physician until 2/20/24. P4’s medical record contained other POCs with physician signatures dated 3/29, 4/16, 5/14, 6/12, 7/19 and 8/20/24. P6’s POC dated 5/10/24 - 7/8/24, identified SOC was 5/10/24. P6’s services included skilled nursing once a week for nine weeks and nursing aid services one to five times per week for nine weeks. The POC was not signed by P6’s physician until 6/10/24. During an interview on 11/14/24 at 1:06 p.m., the director of nursing (DON) confirmed P4’s and P6’s medical records didn’t have a physician-signed POCs at the start of care. The DON was not aware these POCs were not signed by the physicians in a timely manner. A policy and procedure for plan of care signatures was requested but not received.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure a patient’s discharge was communicated to the physician issuing orders for the agency’s plan of care (POC) and other health care professionals who would be responsible for providing care and services to the patient after discharge from the home health agency for 1 of 2 patients (P7) reviewed for discharge from the home health agency. P7’s plan of care (POC) for certification period 7/17/24 through 9/11/24, identified start of care (SOC) date 5/15/24. Diagnoses included other congenital malformation syndrome. Skilled nursing visits (SNV) were ordered one time a week for nine weeks. P7’s medical record dated 9/11/24, revealed a discharge oasis was completed without a patient visit with a date of discharge of 911/24. P7’s medical record lacked reasoning for the discharge. The medical record also lacked documentation to show a discharge summary was sent to the provider after services stopped. During interview on 11/14/24 at 1:24 p.m., the director of nursing (DON) stated P7 called on 9/11/24, and requested to be discharged from the home health agency on that day. The DON completed P7’s discharge over the phone without doing an actual visit. the DON was not aware at that time a discharge summary had to be completed and sent to the provider when a patient was discharged from services. Facility policy Discharge from Services undated, indicated a client’s record would have a discharge summary which included date of discharge, reason for discharge, discharge location, summary of the problems, interventions, and client response. The policy indicated the provider would be notified of discharge but lacked language stating that documentation of the discharge summary would be provided to the provider.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure nursing aid services provided to patients were ordered by the patient’s physician for 2 of 7 (P4, P6) patients reviewed for nursing aid services. Findings include: P4’s initial plan of care (POC) dated 10/12/23 - 12/10/23 identified start of care (SOC) was 10/12/23. P4’s services included nursing aid services one to two times per week for nine weeks. The POC was not signed by P4’s physician until 2/20/24. P6’s initial POC dated 5/10/24 - 7/8/24, identified SOC was 5/10/24. P6’s services included skilled nursing once a week for nine weeks and nursing aid services one to five times per week for nine weeks. The POC was not signed by P6’s physician until 6/10/24. During an interview on 11/14/24 at 1:06 p.m., the director of nursing (DON) confirmed P4’s and P6’s medical records didn’t have physician-signed POCs at the start of care. The DON was not aware these POCs were not signed by the physicians in a timely manner. A policy and procedure for plan of care signatures was requested but not received.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the facility failed to provide supervision via supervisory visits for nurse aids who performed home health services for 1 of 7 (P6) patients reviewed for nurse aid services. Findings include: P6’s plan of care (POC) dated 5/10/24 - 7/8/24, identified a start of care (SOC) of 5/10/24. Diagnoses included borderline personality disorder, bipolar disorder, and conversion disorder with seizures or convulsions. P6’s services included nursing aid services one to five times per week for nine weeks. P6’s medical record lacked evidence of supervisory visits as required. During an interview on 11/14/24 at 1:20 p.m., the director of nursing (DON) confirmed supervisory visits of nurse’s aids had not been performed for P6. An undated policy, Supervision of Direct Contact Personnel, identified all staff members who provide direct patient care will have an initial direct supervisory visit completed in a client’s home within their first 30 days of hire and annually thereafter. Home health aids will be supervised by a registered nurse. Clients who receive skilled care and home health aid services will have a direct or indirect supervision no less than every 14 days.”