Patient Care Professionals 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 review of personnel files, policy review, and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire and every two years in three of three personnel records reviewed (Employees #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Emergency Disaster Plan Orientation and Training,” showed in part the following: - All employees will be oriented to the Emergency Disaster Plan (EDP), including their responsibilities in carrying out the plan, upon hire, and will participate in the in-service educational sessions annually; - Initial EDP will be provided to individuals providing services under arrangement consistent with their expected roles; and - Attendance and demonstration of staff knowledge will be notated in the employee’s personnel file. EMPLOYEE #1: Review of Employee #1’s personnel file showed in part: - The employee’s position was registered nurse; - Orientation in-service training took place on 09/02/2025; and - The personnel file failed to contain evidence that EDP training was completed upon hire. EMPLOYEE #2: Review of Employee #2’s personnel file showed in part: - The employee’s position was physical therapist; - Orientation in-service training took place on 12/30/2025; and - The personnel file failed to contain evidence that EDP training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part: - The employee’s position was (contract) occupational therapist; - Orientation in-service training took place on 09/27/2024; and - The personnel file failed to contain evidence that EDP training was completed upon hire. During an interview on 01/29/2026 at 10:00 AM, the home health administrator stated that: - Emergency Preparedness (EP) training was not completed during orientation or annually (only required during orientation and every two years) for several years; - He/she thought training was done in 2024 but he/she was unable to locate the sign-in sheets (last EP training sign-in sheets for provider was dated 2022); and - Employee’s #1, #2, and #3 personnel folders failed to include EP training.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on OASIS E (Outcome and Assessment Information Set; a standardized data collection tool) Guidance Manual review, record review, and interview, the home health provider failed to ensure that the OASIS assessment was completed by a registered nurse (RN) in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the OASIS-E Guidance Manual, dated 01/01/2023, showed in cases involving nursing, the RN is responsible for completing the start of care comprehensive assessment, including OASIS if applicable. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the referral order, dated 05/01/2025, showed the patient was being referred to home health for registered nursing, physical therapy, and occupational therapy. Review of the OASIS-E1 Start of Care Assessment, dated 06/02/2025, showed the assessment was completed by a physical therapist (PT). A RN did not complete the OASIS assessment. During an interview on 01/29/2025 at 11:15 AM, the home health clinical manager stated that they thought if therapy was ordered, the therapist could complete the OASIS assessment to meet the start of care date.”

“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 policy review, record review, and interview, the home health provider failed to ensure that a registered nurse (RN) completed an initial assessment on the patient in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s policy titled, “Registered Nurse,” dated 09/2006, showed the RN performs comprehensive assessments of client status, including physical, psychosocial, and environmental parameters. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the skilled nurse visit note, dated 06/02/2025, showed the visit was completed by a licensed practical nurse (LPN). Review of the skilled nursing visits, dated 06/02/2025 - 06/20/2025, showed three LPN visits a week for three weeks. The RN failed to perform a visit on the patient. During an interview on 01/29/2025, the clinical manager stated that he/she could not locate any RN visits for this patient, and he/she would expect the RN to do a comprehensive assessment and supervise the LPN.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure nursing services were provided under the supervision of a registered nurse (RN) in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the initial skilled nurse visit note, dated 06/02/2025, showed the visit was completed by a licensed practical nurse (LPN). Review of the skilled nursing visits dated 06/02/2025 through 06/20/2025, showed three LPN visits a week for three weeks. The RN failed to perform a visit on the patient. Review of the clinical record failed to show a RN supervised the LPN. During an interview on 01/29/2025, the clinical manager stated that he/she could not locate any RN visits for this patient, and he/she would expect the RN to supervise the LPN.”