Optimum Health Care, LLC

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(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 every 2 years. At a minimum, the policies and procedures must address the following:] (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. This Standard is not met as evidenced by: Based on observation, record review, interview and review of the facility’s Emergency Preparedness Plan (EPP), the agency failed to ensure three out of a total of seven patients reviewed (Patients (P) P1, P2 and P3) in the sample had individualized emergency / disaster plans in place to direct care and services in the event of a natural or man-made disaster. This failure had the potential to affect all 64 patients currently receiving care from the agency. Findings include: 1. Review of P1’s medical record revealed P1 was admitted to the agency on 04/01/2025 and was certified to receive ongoing services on 05/31/2025. The medical record indicated P1 had diagnoses including End Stage Renal Disease (ESRD) and type 2 diabetes. Comprehensive review of P1’s medical record revealed no individualized emergency / disaster plan had been developed and placed in the patient’s medical record. Observation during P1’s homecare visit performed by Registered Nurse (RN1) on 06/25/2025 at 12:00 PM revealed P1 did not have individualized emergency / disaster plan accessible to caregivers in the home. During an interview on 06/25/2025 at 12:45 PM, RN1 was unable to locate an individualized emergency / disaster for P1 in the home. RN1 was unaware of what the patient’s individualized emergency / disaster plan would entail. During an interview on 06/25/2025 at 12:30 PM, P1 was unaware of having any individualized emergency preparedness plan in the home. 2. Review of P2’s medical record revealed P2 was admitted to the agency on 05/15/2025 and was certified to receive ongoing services on 05/15/2025. The medical record indicated P2 had diagnoses including hypertension, type 2 diabetes, and a history of stroke. Comprehensive review of P2’s medical record revealed no individualized emergency / disaster plan had been developed and placed in the patient’s medical record. Observation during P2’s homecare visit performed by Physical Therapist (PT1) on 06/25/2025 at 1:15 PM revealed P2 did not have an individualized emergency / disaster plan accessible to the caregivers in the home. During an interview on 06/25/2025 at 1:45 PM, PT1 was unable to locate an individualized emergency / disaster for P2 in the home. PT1 was unaware of what the patient’s individualized emergency / disaster plan would entail. During an interview on 06/25/2025 at 1:30 PM, P2 was unaware of having any individualized emergency preparedness plan in the home. 3. Review of P3’s medical record revealed P3 was admitted to the agency on 02/27/2025 and was certified to receive ongoing services on 04/28/2025. The medical record indicated P3 had diagnoses including pressure sore to the sacrum, hypertension, dementia, and hemiplegia. Comprehensive review of P3’s medical record revealed no individualized emergency / disaster plan had been developed and placed in the patient’s record. Observation during P3’s homecare visit performed by RN2 on 06/25/2025 at 10:00 AM revealed P3 did not have an individualized emergency / disaster plan accessible to the caregivers in the home. During an interview on 06/25/2025 at 10:45 AM, RN2 was unable to locate an individualized emergency / disaster for P3 in the home. RN2 was unaware of what the patient’s individualized emergency / disaster plan would entail. During an interview on 06/25/2025 at 3:30 PM, the Director of Nursing (DON) confirmed individualized emergency preparedness plans had not been developed or placed in the homes of P1, P2, or P3. The DON was unaware that the agency was required to develop an individualized emergency preparedness plan for each patient and a copy of the plan was to be left in each patient’s home.”

“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 document review, review of the Centers for Medicare & Medicaid Services (CMS) Outcome and Assessment Information Set (OASIS) manual and interview, the Home Health Agency (HHA) failed to electronically transmit completed OASIS assessments to the CMS system within 30 days after completing the assessment. This failure had the potential to affect all patients for the agency. Findings include: The CMS OASIS assessment reference manual, effective 01/01/23 and located at https://www.cms.gov/files/document/oasis-e-guidance-manual51622.pdf, directed that the OASIS assessments must be transmitted to CMS within 30 days of completion. Review of the “Transmission Summary Report” provided by the facility, revealed OASIS assessments were submitted to CMS greater than the 30 days after the completion of the assessment for 21 assessments submitted for 2021, Quarter (Q) 2; 33 assessments submitted for Q4, 2021; 22 assessments submitted for 2022, Q1; 21 assessments submitted for 2022, Q2; 12 assessments submitted for 2022, Q3; and 12 assessments submitted for 2024, Q2. During an interview on 06/25/25 at 2:30 PM, the Director of Nursing (DON) stated the HHA used the CMS manual for the completion, transmission, and submission of the patients’ OASIS assessments. The DON confirmed the HHA had failed to submit OASIS assessments within 30 days of completion. The DON confirmed the OASIS assessments were delayed in being submitted due to HHA’s process for completing the OASIS for transmission.”

“Exercise of rights CFR(s): 484.50(b)(1)(2)(3) Standard: Exercise of rights. (1) If a patient has been adjudged to lack legal capacity to make health care decisions as established by state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient’s behalf. (2) If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient’s representative may exercise the patient’s rights. (3) If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient may exercise his or her rights to the extent allowed by court order. This Standard is not met as evidenced by: Based on review of agency policy, record review and interview, the Home Health Agency (HHA) failed to ensure Advanced Directives were entered into the medical record for one of seven patients (Patient 3) reviewed in the sample. This failure had the potential to affect all 64 patients receiving services from the HHA who may have had designated Advance Directives in place. Findings include: Review of the Agency’s undated policy titled, “Advance Directives” revealed “…recognizes that all people have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse treatment…During the admission process the clinician shall ask the patient whether or not she/he has executed an Advance Directive, appointment of Power of Attorney, or has made any executive decisions in regards to Life Sustaining Treatment or Living Will. The Physician shall be notified of the Advance Directives that the patient has executed, and a copy of the Advance Directives dated and signed by the patient shall be kept in the patient’s chart.” Review of Patient (P) 3’s medical record revealed P3 was admitted to the agency on 02/27/2025 and was certified to receive ongoing services on 04/28/2025. The record indicated P3 had diagnoses including pressure sore to the sacrum, hypertension, dementia, and hemiplegia. Review of P3’s “Admission Service Agreement” signed by the patient’s representative and dated 02/27/2025, revealed the resident had an Advance Directive, and a copy of the Advance Directive would be placed in P3’s medical record. Comprehensive review of P3’s record revealed P3’s Advance Directive had not been obtained and placed in the patient’s record. During an interview with P3’s family member in P3’s home on 06/25/2025 at 10:30 AM, confirmed P3 had an Advance Directive in place and did not recall agency staff requesting a copy of the document to be placed in P3’s medical record. During an interview on 06/25/2025 at 3:30 PM, the Director of Nursing (DON) confirmed P3’s Advance Directive had not been obtained and placed in the medical record. The DON’s expectation was that the Advance Directive was to be obtained and placed in the patient’s medical record.”

“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, observations and interviews, the Home Health Agency (HHA) failed to ensure Infection Control Procedures were appropriately followed for one of seven patients in the sample (Patient (P)3). This failure had the potential to affect all 64 patients receiving services in their homes. Findings include: The Agency’s policies related to staff hand hygiene and infection control procedures were requested on 06/25/2025 at 3:00 PM. The requested policies and procedures were not provided prior to survey exit on 06/26/2025. Review of P3’s medical record revealed P3 was admitted to the agency on 02/27/2025 and was certified to receive ongoing services on 04/28/2025. The record indicated P3 had diagnoses including pressure sore to the sacrum, hypertension, dementia, and hemiplegia. The record revealed P3 had a “physicians orders” to receive routine wound care to a stage 2 pressure ulcer on the sacrum. The treatment order indicated to cleanse sacral wound with normal saline, pat dry with gauze, apply xeroform / Hydrfera Blue wound dressing, then cover with foam dressing Observation during P3’s homecare visit performed by Registered Nurse (RN2) on 06/25/2025 at 10:00 AM, revealed RN2 failed to consistently sanitize their hands while providing the ordered wound care treatment. RN2 did not sanitize their hands after removing P3’s old sacral dressing and before cleaning the area; did not sanitize their hands after cleaning P3’s sacral area and before providing the ordered wound treatment; placing a new dressing on the patient’s sacrum, and did not sanitize their hands after finishing P3’s wound care treatment; and beginning the patient’s head to toe assessment and vital sign monitoring. During an interview on 06/25/2025 at 11:15 AM, RN2 confirmed hand hygiene was not performed while providing R3’s wound care and physical assessment / vital sign monitoring. RN2 was nervous during the observation and forgot to follow infection control procedures. During an interview on 06/25/2025 at 3:45 PM, the Director of Nursing (DON) confirmed the expectation was that staff should perform frequent hand hygiene while providing wound care / obtaining vital signs / assessing a patient, hand hygiene was expected to be performed when moving from a dirty task to a clean task (i.e. between removing a soiled / old dressing and cleaning the wound and providing wound treatment and placing a new dressing or after providing wound care and before completing a head to toe assessment on a patient).”

“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 review of facility policy, record review and interview, the Home Health Agency (HHA) failed to ensure the plan of care contained all required components for two out of seven patients in the sample (Patient (P)2 and P3). This failure had the potential to affect all 64 patients receiving services from the HHA who required a comprehensive plan of care. Findings include: Review of the Agency’s undated “Plan of Care Policy” indicated, “The individualized plan of care shall include the following: …nutritional requirements; …all medications and treatments.” 1. Review of P2’s medical record revealed P2was admitted to the agency on 05/15/2025 and was certified to receive ongoing services on 05/15/2025. The record indicated P2 had diagnoses including hypertension, type 2 diabetes, and history of stroke. Review of P2’s “Home Health Certification and Plan of Care” dated 05/15/2025 through 07/13/2025 revealed no dietary / nutrition orders or required Durable Medical Equipment (DME) / supplies. During an interview with P2 on 06/25/2025 at 1:30 PM, P2 confirmed eating a regular diet and routinely used a cane, a walker, and a motorized wheelchair for assistance with ambulation. 2. Review of P3’s medical record revealed P3was admitted to the agency on 02/27/2025 and was certified to receive ongoing services on 04/28/2025. The record indicated P3 had diagnoses including pressure sore to the sacrum, hypertension, dementia, and hemiplegia. Review of P3’s “Home Health Certification and Plan of Care” dated 04/28/2025 through 06/26/2025 revealed no dietary / nutrition orders or required Durable Medical Equipment (DME) / supplies. During an interview with P3’s Family Member on 06/25/2025 at 10:30 AM, confirmed P3 was eating a soft regular diet with nutritional supplements three times per day and confirmed the patient routinely used wound care supplies, a shower chair, and a hospital bed in the home. During an interview on 06/25/2025 at 3:30 PM, the Director of Nursing (DON) confirmed dietary orders and DME were expected to be included in each patient’s physician’s orders / plan of care.”

“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 record review, interview and policy review, the facility failed to ensure medication orders were complete to indicate the parameters for use of an as need medication for one of seven sampled patients (Patient (P)2). Specifically, P2’s Ibuprofen medication order did not indicate parameters regarding how often the medication could be taken. Findings include: Review of the Agency’s undated policy titled, “Medical Orders” indicated, “All orders for medication must contain d. frequency.” Review of P2’s medical record revealed P2 was admitted to the agency on 05/15/2025 and was certified to receive ongoing services on 05/15/2025. The medical record indicated P2’s diagnoses including hypertension, type 2 diabetes, and a history of stroke. Review of P2’s “Home Health Certification and Plan of Care,” dated 05/15/2025 through 07/13/2025 revealed a “physician’s order” for P2 to receive Ibuprofen 800 milligrams (mg) one tablet by mouth as needed. The order did not include timing parameters to indicate how frequently P2 could take the Ibuprofen. During an interview with P2 in her home on 06/25/2025 at 1:30 PM, P2 confirmed was taking the ibuprofen medication two doses of the 800 mg tablets per day for pain. During an interview on 06/25/2025 at 3:30 PM, the Director of Nursing (DON) confirmed P2’s Ibuprofen order did not indicate timing parameter and stated all ordered medications were expected to include parameters for timing of administration of the medication.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure physician orders for occupational therapy (OT) evaluation was followed for one of seven patients (Patient (P)3) reviewed in the sample. This failure had the potential to affect all 64 patients who relied on accurate implementation of physician’s orders and their plan of care to ensure safe and quality care. Findings include: Review of the Agency’s undated policy titled, “Referral Criteria for Occupational Therapy Services” revealed, “The Occupational Therapist (OT) shall conduct, and evaluation as ordered by a physician. Establish and implement a medically approved plan of care based on the assessment performed.” Review of P3’s medical record revealed P3 was admitted to the agency services on 02/27/2025 and was certified to receive ongoing services on 04/28/2025. The medical record indicated P3 had diagnoses including pressure sore to the sacrum, hypertension, dementia, and hemiplegia. P3’s medical record included a “physician’s referral order” to initiate home healthcare services dated 02/25/2025. The order indicated P3 was to receive nursing visits and indicated R3 was to be evaluated and treated by OT. Review of P3’s comprehensive record revealed no documentation to indicate the OT evaluation for potential treatment occurred. During an interview on 06/25/2025 at 3:45 PM, the Director of Nursing (DON) confirmed P3 had not been evaluated by an OT as indicated in the service referral order dated 02/25/2025. The DON stated the order for an OT evaluation had been missed and stated that physician’s orders for services were expected to be followed.”