Star Care Home Health

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview the facility failed to meet the Condition of Participation to ensure that the patients medications were updated during the comprehensive assessment. The findings are: A. The agency failed to update patient’s medications. Refer to Tag 536.”

“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 record review and interview the facility failed to meet the Condition of Participation to ensure the plan of care was individualized and revised based on changes in the patient needs and condition. The Findings are: A. The facility failed to revise and individualize the plan of care as needed. Refer to Tag G592.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (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. * * [For ESRD facilities only at §494.62(a)(4)]: (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. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a process of emergency preparedness collaboration with the local emergency preparedness (EP) agency to confirm it is aware of the agency’s needs in the event of an emergency. This deficient practice could lead to delays in meeting the agency’s needs in an emergency, which could impact on all patients receiving care at this agency. The findings are: A. Record review of the agency’s Emergency Preparedness (EP), undated, revealed that no documented communication was noted between local, tribal, regional, state and federal EP officials. B. During an interview with S(Staff) 1, nonclinical, confirmed that there is no evidence of communication with local, tribal, regional, state and federal EP officials at least annually.”

“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 record review and interview, the agency failed to 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. This deficient practice could lead to delays in contacting Emergency Preparedness (EP) services, which could negatively impact all patients receiving care at this agency in an emergency. The findings are: A. Record review of the agency’s EP, undated, revealed contact information for staff, patients, and local EP have not been updated in the past two years. B. During an interview on 02/13/2025 at 9:38AM, S(Staff)1, nonclinical, confirmed that this agency’s EP communication plan was not updated in the past two years.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following: Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. This deficient practice could lead to communication breakdown between emergency preparedness agencies and this agency and could also negatively impact the health and safety of all patients who receive services at this agency if an emergency were to occur. The findings are: A. Record review of the agency’s Emergency Preparedness Plan (EP), undated, the plan did not contain a policy or procedure in place regarding communication planning that would comply with federal, state and local laws. B. During an interview on 02/13/2025 at 9:38AM, S(Staff)1, nonclinical, confirmed that there was no alternate communication methods are used, and who uses them in place at this agency.”

“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 record review, observation, and interview, the agency failed to meet standard infection control requirements by not having a proper medical supply inventory management and monitoring system. This deficient practice could potentially result in using expired medical supplies, which can compromise patient safety and lead to negative health outcomes for all patients who require these supplies. The findings are: A. Record review of the agency’s document titled “Infection Control Program,” dated 01/01/2025, under Policy stated “II. The infection control Program will include: . . . 3. Implementing appropriate preventative measures. . . III. Coordinated activities: . . .C. Prevention and Control Activities 1. The agency will follow accepted standards of practice, including the use of standard precautions and as needed, transmission-based precautions with standard precautions, to prevent the transmission of infections and communicable diseases.” B. Observation on 02/11/2025 at 12:15 PM of S (Staff)3’s, clinical, supplies revealed a laboratory blood tube (a tube to collect and store blood for testing) with an expiration date of 10/31/2024. C. Observations on 02/11/2025 at 2:30 PM of the agency’s general supply room, revealed expired supplies. These expired supplies include two foley catheters (tube that goes through the urethra and ends in the bladder and drains urine) expired on 09/26/2023 and 10/28/2022; seven blood collecting tubes expired on 07/31/2024, 08/31/2024, and 10/31/2024; and 20 heparin filled syringes (a high-risk blood thinning medication) expiration years ranged from 2022 to 2024. D. Observation on 02/11/2025 at 2:30 PM of the agency’s general supply room, a carboard box full of supplies (like syringes, gauze, and other wound care supplies), labeled with a discharged patient’s personal health sensitive information, was placed on the counter next to other equipment for general use. Items released to a patient must remain with a patient and cannot be used for other patients. E. During an interview on 02/11/2025 at 2:45 PM with S (Staff)2, clinical, confirmed that it is not appropriate to have expired supplies, nor can the agency store patient’s personally issued supplies in the general supply room.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to advise patients of their right to report complaints to the state toll free home health hotline for 2 (P (Patients) 1 and P4 of 7 (P1-P7) patients reviewed for understanding of how to report concerns to the state. This deficient practice could possibly result in patient rights’ concerns about their care or complaints not being addressed. The findings are: A. An interview on 02/11/2025 at 12:04 PM, P 1 confirmed that he was not aware of how to report concerns to the state, nor that there is a state hotline. B. Record review of P4’s agency admission packet (a folder of information given by the agency to each patient at the start of care. This folder including important numbers, at-home emergency preparedness, and individualized health information regarding plan of care and medications), undated, revealed the state hotline’s number was not listed.”

“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 agency failed to ensure that a registered nurse completed an initial assessment within 48 hours of receiving a referral from a provider for 3 (P (Patients) 1, P2, and P6) of 7 (P1-P7) patients reviewed for accurate and timely care. This deficient practice could result in patients not receiving physician ordered treatment and services in a timely manner. The findings are: A. Record review of P1’s medical record revealed a referral was received by the agency on 08/13/2024. The start of care document stated the first assessment was performed on 08/16/2024, which exceeds 48 hours from referral to first assessment. B. Record review of P2’s medical record revealed a referral was received by the agency on 09/08/2023. The start of care document stated the first assessment was performed on 09/12/2023, which exceeds 48 hours from referral to first assessment. C. Record review of P6’s medical record revealed a referral was received by the agency on 06/21/2024. The start of care document stated the first assessment was performed on 06/26/2024, which exceeds 48 hours from referral to first assessment. D. During an interview on 02/12/2025 at 3:39 PM with S (Staff)1, non-clinical, confirmed P1, P2 and P6s first assessments were not performed within 48 hours of receiving the referral.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review, observation and interviews, the agency failed to maintain a current and accurate list of all prescribed and over the counter medications for 2 (P [Patients] 1 and P4) out of 7 (P1-P7) patients reviewed. This deficient practice could lead to polypharmacy and harm to all the patients admitted to the agency. The findings are: A. Record review of the facility’s Policy titled “Medication List and Monitoring” with the last review date of 05/02/2024, stated “The agency will maintain a current, accurate list of all prescriptions and over the counter (OTC) medications taken by the patients”. B. Record review of P1’s plan of care with the Certification Dates 12/14/2024 through 02/11/2025, under medications revealed CoQ10 (Vitamin) and Cranberry capsules were not documented on the list of medications and Lasix (medication to remove excess fluid from body) 20 mg (milligrams) oral tablets 1 tab every day by mouth was ordered. C. During an observation on 02/11/2025 at 11:30 am in the home of P1, S [Staff] 3 (clinical) was reconciling the patient’s medications and found the Lasix bottle had a different prescription order that read, Lasix 40 mg, 1 tablet by mouth daily, this was ordered on 08/26/2024. D. During an interview with P1 on 02/11/2025 at 2:15 pm, P1 confirmed the Lasix dose did get increased to 40 mg on 08/26/2024 because swelling in P1’s legs. E. During an interview on 02/11/2025 at 2:46 pm with S3, it was confirmed that P1’s Lasix dosage was changed on 08/26/2024 to 40 mg and the new order should have been placed on the prior recertification. F. Record review of P4’s plan of care with the certification period dated 01/13/2025 through 03/13/2025, revealed under the section Medication, an order for Fluoxetine HCL (antidepressant) 40 mg by mouth every day, Remeron (antidepressant) 15 mg oral tablet 1 tab by mouth at night, Hydroxyzine HCL (antianxiety) 10 mg 1- 2 tablets every 6 hours as needed by mouth. G. Record review of P4’s Medical Profile dated 01/13/2025 through 03/13/2025, revealed the order for Fluoxetine HCL oral capsule 40 mg once a day by mouth with the start date 09/11/2024, Remeron was discontinued on 09/11/204 and that hydroxyzine was discontinued on 09/25/2023. H. During an observation on 02/12/2025 at 10:15 am in the home of P4 the Fluoxetine prescription bottle stated Fluoxetine 30 mg every day by mouth and there was no prescription bottle for Remeron or Hydroxyzine. I. During an interview on 02/12/2025 at 10:16 am with P4 it was confirmed that the medications Fluoxetine dose was changed to 30 mg, and Remeron was stopped on 09/11/2024 and “I haven’t taken Hydroxyzine in over a year”. J. During an interview on 02/12/2025 at 10:30 am with S4, it was confirmed that the medications should be reconciled with every visit by the nurse and the plan of care medication list should be updated with every recertification.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review, interviews and observations, the facility failed to have an updated plan of care to include all changes throughout the certification period for 1 (P[Patients]4) of 7 (P1-P7) patients. This deficient practice could lead to the staff not being able to appropriately care for the patients and could cause the patient harm The findings are: A. Refer to Tag 536 for medication updates related to P4 not being updated in the plan of care. B. Record review of P4’s plan of care for the certification period dated 01/13/2025 through 03/13/2025 under principal diagnosis stated, “Acute Bronchitis” (a short-term inflammation of the lungs). Under SN (skilled nursing) orders stated, “ SN to perform complete physical assessment each visit with emphasis on Hypertensive heart disease with heart failure [heart failure related to high blood pressure]” also “SN to minimize/eliminate risk for hospitalization due to high-risk principal diagnosis HTN; multiple comorbidities [having more than one medical condition] COPD (chronic obstructive pulmonary disease), Lupus (autoimmune disease), anticoagulant syndrome (bleeding disorder), Fibromyalgia (autoimmune disease that causes pain throughout the body), Hypothyroidism (decrease function of the thyroid), Depressive disorders and Hyperlipidemia ( high fat level in the blood), There was no monitoring or mentioning of the principal diagnosis Acute Bronchitis. C. During an interview with S4, clinical, on 02/12/2025 at 10:50 am, it was confirmed the medications should be reconciled with every visit by the nurse and the medication plan of care updated. D. During an interview with S1, clinical, on 02/12/2025 at 4:30 pm, it was confirmed that P4’s plan of care was not individualized for the patient and the plan of care, and the medication list had not been updated with the last 2 recertifications.”