Phoenix Home Care

“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 personnel file review and interview, the provider failed to ensure staff were provided Emergency Preparedness (EP) training on hire in one (Employee #4) of four employee files reviewed. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: EMPLOYEE #4 (E4): Review of E4’s personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and - The file failed to include evidence of EP training on orientation. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. EP training is provided on orientation and every two years. Human Resources was not able to find evidence that E4 had completed EP training during orientation.”

“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 policy review, record review, and interview, the home health provider failed to develop a plan of care (POC) with measurable, patient-specific outcomes in two of five full records reviewed (Records/Patients #3 and #4) and failed to ensure that the patient’s physician was notified of missed home visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 05/02/2024, showed in part the following: - The individualized plan of care must specify the care and services necessary to meet the patient/client specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the agency (provider) anticipates will occur as a result of implementing and coordinating the plan of care; and - Measurable outcomes and goals identified by the agency and the patient. Review of the providers policy titled, “Monitoring Patient /Client Care/ Coordination of Care,” dated 05/02/2024, showed in part the following: - The agency will monitor, evaluate, and report to the patient’s/client’s physician and/or non­-physician practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care; and · - The agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies, out-patient clinics, etc.), the patient/client, and their representative (if applicable) to ensure appropriate coordination of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 09/03/2025 with a primary diagnosis of respiratory failure /chronic obstructive pulmonary disease- (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of hypertension (high blood pressure) and depression (a condition of persistent low mood). The patient resided with a significant other at home. Review of the updated POC dated 10/31/2025, showed the patient had the following goal: - Patient will remain free from signs and symptoms respiratory distress during this episode; and - The provider failed to ensure the POC included individualized, measurable outcomes toward established goals. Review of skilled nursing notes dated 11/14/2025, showed the patient declined a skilled nursing visit on 11/14/2025. The note failed to show documentation that the patient’s primary care physician was notified of the missed visit. Review of skilled nursing notes dated 11/28/2025, showed the patient declined a skilled nursing visit on 11/28/2025. The note failed to show documentation that the patient’s primary care physician was notified of the missed visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/31/2025 with a primary diagnosis of infective bursitis (an infection of the bursa, a small sac of synovial fluid that acts as a cushion between bones, tendons, and muscles around joints). The patient had secondary diagnoses of chronic obstructive pulmonary disease- (COPD; a group of lung diseases that block airflow and make it difficult to breath), atrial fibrillation- (abnormal heart rhythm characterized by rapid and irregular heartbeat), and chronic pain. The patient resided at home. Review of the updated POC dated 10/31/2025, showed the patient had the following goal: -Patient’s respiratory status will improve with reduced shortness of breath and improved lung sounds; and - The provider failed to ensure the POC included individualized, measurable outcomes toward established goals. During an interview on 12/03/2025 at 10:00 AM, the administrator stated that each patient’s POC should be individualized and should include measurable outcomes for each goal. Additionally, the administrator stated that staff should notify both the nursing supervisor and primary care physician of all missed home care visits.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observation, and interview, the home health provider failed to follow accepted standards of practice to prevent the transmission of infections in, one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the home health provider. Findings included: Review of the provider’s undated policy titled, “Bloodborne Pathogens and Standard Precautions,” showed in part standard precautions must be observed in all situations where there is potential for contact with blood or other potentially infectious body fluids. You should wear the appropriate barriers for the work you are doing. Gown if your clothing or skin could be splashed. Treat all linen soiled with blood or body secretions as potentially infectious. Observation on 12/02/2025 at 9:15 AM, showed licensed practical nurse (LPN)-A knelt on his/her knees on the patient’s floor without a barrier and changed the patient’s left great toe dressing. During an interview on 12/03/2025 at 9:53 AM, the administrator stated that he/she would expect staff to put down a barrier if a dressing change required staff to kneel or sit on the floor.”

“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 policy review, record review, observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Management,” last reviewed on 09/08/2025, showed in part the following: -Medication assessments will identify all medications, both prescription and non-prescription and as needed (PRN) that the patient/client is taking and document in the clinical record; -The provider will ensure that the assessments of a patient/client include a review of the medication regimen. This will include, but is not limited to; accuracy of the medication list/profile; -Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record; and -All qualified clinicians will initially and routinely evaluate the medication regimen. A complete and accurate medication profile will be established and monitored as part of the plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation and interview on 12/02/2025 at 09:15 AM, showed: -The provider’s medication list had levothyroxine sodium (used to treat hypothyroidism) 25 micrograms (mcg) one table by mouth daily. The patient’s medication bottle showed 125 mcg one tablet by mouth daily. The patient’s spouse stated that the patient’s primary care physician changed the dosage three to four weeks ago because the dosage was too strong; -The provider’s medication list had warfarin sodium (Coumadin) 2.5 milligrams (mg) (blood thinning agent) one tablet by mouth every Monday and Wednesday and two tablets the rest of the days in the evening. The patient’s spouse stated that the patient was taking two pills daily except on Tuesdays, and he/she took three pills on that day. The patient’s international normalized ratio (INR, a blood test commonly used to monitor the effectiveness of warfarin therapy) would be drawn again later today; -The patient stated that he/she used a Flonase nasal spray (cortisone-like medication used to treat runny nose) one to two sprays each nostril twice a day. The provider’s medication profile failed to include Flonase; -The patient’s spouse stated that he/she applied Silvadene cream (used to treat and prevent wound infections) to the patient’s left great toe with daily dressing changes. The provider’s medication profile failed to include Silvadene; and -The patient’s spouse stated that he/she applied triamcinolone cream (topical steroid cream used to treat inflammatory skin conditions) to the patient’s left shin area daily for eczema. The provider’s medication profile failed to include the Triamcinolone cream. During an interview on 12/03/2025, beginning at 9:53 AM, the administrator stated that clinicians were to update the patient’s medication list every time there was a change.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to develop an individualized plan of care (POC) that addressed the patient’s blindness and deafness in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 05/02/2024, showed in part the following: - Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems; - The agency (provider) will use data/information gathered during the patient/client assessments in the care planning process which involves the identification of patient/client goals, actions, or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs; and - Each patient/client 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/client-specific needs as identified in the comprehensive assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care assessment, dated 11/07/2025, showed in part: - The patient’s hearing was impaired on the left; and - The patient was blind in his/her left eye. Review of the plan of care, dated 11/07/2025, failed to be individualized and include any interventions related to the patient being deaf in his/her left ear and blind in his/her left eye. During an interview on 12/03/2025 at 9:55 AM, the administrator stated that the plan of care should have included interventions related to the patient being deaf in his/her left ear and blind in his/her left eye.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure each patient received complete/accurate written instructions related to their medication schedule/instructions in, but not limited to, one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Management,” last reviewed on 09/08/2025, showed in part the following: -The provider will provide to the patient/client and caregiver (if any) written information regarding the patient’s/client’s medication regimen based on the results of the medication assessment; and -The medication administration instructions must be written in plain language that does not use medical abbreviations. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025 at 9:15 AM, showed the home health provider failed to ensure a written medication schedule was placed in the patient’s home. Per interview conducted during observation, licensed practical nurse (LPN)-A stated that there was not a current medication list in the patient’s home. During an interview on 12/03/2025 at 9:53 AM, the administrator stated that he/she would expect patients to have a current medication list in the home.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on policy record review, observation, and interview, the home health provider failed to ensure staff provided the patient and/or caregiver with the name contact information for the provider’s clinical manager in, two of three home visit observations conducted (Records/Patients #1 and #2). This deficient practice has the potential to adversely affect the knowledge of self-care and provider expectations in all the patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Observation on 12/02/2025, beginning at 2:00 P.M., showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. Findings included: RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025, beginning at 9:15 AM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. During an interview on 12/02/2025, beginning at 9:53 AM, the administrator stated there had not been a clinical manager for quite a while and she would expect the admission packets to have the correct contact information. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Observation on 12/02/2025, beginning at 2:00 PM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with a primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025, beginning at 9:15 AM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. During an interview on 12/02/2025, beginning at 9:53 AM, the administrator stated that there had not been a clinical manager for quite a while and he/she would expect the admission packets to have the correct contact information.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on personnel file review and interview, the provider failed to ensure annual in-service training was completed for one of four employee files reviewed (Employee #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #4 (E4): Review of E4’s personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and - The file failed to contain evidence of annual in-service training. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. Infection control training was provided on orientation and annually. Annual in-services were scheduled during the slower months (around July/August) and he/she was unsure why E4 had not completed his/her annual in-services.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on personnel file review and interview, the provider failed to ensure Alzheimer’s/dementia training was completed for one of four employee files reviewed (Employee #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Employee Orientation,” last reviewed 10/20/2023, showed, in part, the following: -Dementia-specific training about Alzheimer’s disease and related dementias will be incorporated into orientation for new employees with direct patient/client contact and independent contractors wit direct patient/client contact; and -The training will be provided annually and updated as needed; EMPLOYEE #4 (E4): Review of E4’s personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and -The file failed to contain evidence of annual Alzheimer’s/dementia training. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. Alzheimer’s/dementia training was provided on orientation and annually. Human Resources was not able to find evidence that E4 had completed the annual Alzheimer’s/dementia training.”