New Horizon Home Care, LLC

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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 the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on observation, interviews, record review, policy review, document review and review of the Agency’s Emergency Preparedness Plan (EPP), the agency failed to ensure an individualized EPP was in place in the patient’s home to address agency procedures during an emergency/disaster for six Patients ((P) P2, P3, P5, P8, P9 and P10) of a total of 11 patients reviewed in the sample. This failure had the potential to affect the current 98 patients receiving care by the agency in the event of an emergency. Findings include: Review of the facility’s EPP with the Director of Nursing (DON), revealed the agency failed to ensure an individualized EPP was in place in the patient’s home to address agency procedures during an emergency/disaster for six Patients (P2, P3, P5, P8, P9 and P10). 1.Review of P2’s Electronic Medical Record (EMR) revealed the patient was initially admitted to the agency for services on 02/24/16. The patient’s most recent certification for services was dated 03/08/25 and indicated the patient was to receive skilled nursing services and Home Health Aide services during the certification period. The record indicated P2’s diagnoses included Chronic obstructive pulmonary disease (COPD), heart failure, abnormalities of gait and mobility, pain in left knee, hypertension, and type 2 diabetes. Observation during a homecare visit performed by Certified Nursing Assistant (CNA1) on 04/24/25 from 2:30 PM until 3:30 PM revealed that P2 did not have an individualized safety/emergency plan implemented and available to the patient in his home. During an interview on 04/24/25 at 3:00 PM with the patient, he confirmed he had no knowledge of an individualized emergency plan being in place for himself and he was not able to locate an individualized plan in the home. 2.Review of P3’s EMR revealed the patient was initially admitted to the agency for services on 04/08/25. The patient’s most recent certification for services was dated 04/08/25 and indicated the patient was to receive an initial skilled nursing evaluations and indicated Physical Therapy and Occupational Therapy staff was to evaluate and treat the patient as indicated. The record indicated P2’s diagnoses included recent history of lumbar (back) surgery and type 2 diabetes. Observation during a homecare visit performed by Occupational Therapist (OT1) on 04/23/25 from 3:15 PM until 4:30 PM revealed that P3 did not have an individualized safety/emergency plan implemented and available to the patient in her home. During an interview on 04/23/25 at 3:00 PM with the patient and her caregiver, both confirmed they had no knowledge of an individualized emergency plan being in place for P3 and neither party was able to locate an individualized plan in the home. 3.Review of P5’s EMR revealed the patient was initially admitted to the agency for services on 11/30/23. The patient’s most recent certification for services was dated 03/24/25 and indicated the patient was to receive skilled nursing services during the certification period. The record indicated P5’s diagnoses included hydronephrosis, type 2 diabetes, chronic kidney disease, and retention of urine. . Observation during a homecare visit performed by Registered Nurse (RN1) on 04/24/25 from 10:00 AM until 11:15 AM revealed that P5 did not have an individualized safety/emergency plan implemented and available to the patient in his home. During an interview on 04/24/25 at 10:30 AM with the patient and his caregiver, both confirmed they had no knowledge of an individualized emergency plan being in place for P5 and neither party was able to locate an individualized plan in the home. 4.Review of P8’s EMR “admission records” dated 09/29/23 and 09/30/24 revealed the “Plan for Evacuation” was left blank during the admission process. There was no other documentation in the medical record showing that training was provided. 5. Review of P9’s EMR “admissions record” date 09/30/24 24 revealed the “Plan for Evacuation” was left blank during the admission process. There was no other documentation in the medical record showing the training was provided. 6. Review of P10’’s admission form dated 06/30/23, 24 revealed the “Plan for Evacuation” was left blank during the admission process. There was no other documentation in the medical record showing the training was provided. Interview with the Administrator/ Director of Nurses on 04/25/25 at 11:00 AM, confirmed the above findings. Review of the form titled “Review of Admission Documents” under the “Plan for Evacuation During an Emergency/disaster situation” indicated, …”with family, to a shelter, stay at home, other.” Review of facility’s policy titled “Emergency Services” dated 02/25 indicated, “Patient/Clients and their families are instructed upon admission how to respond to emergencies. If time permits and the emergency appears non-life threatening, patients/families are advised to call the office…””

“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 staff interviews, policy review, and review of the Emergency Preparedness Plan (EPP), the facility failed to ensure that all staff was trained at least annually in the emergency preparedness plan. This deficient practice affected12 of 24 staff (Registered Nurse (RN1), RN2, RN3, RN4, RN5, Occupational Therapist (OT1), Physician Therapist (PT1!), PT3, PT4, PT5, Certified Nurse’s Aide (CNA3), and Office Assistant (OAF2) failed to have emergency preparedness training and have the potential to cause harm to all facility staff and patients. Findings include: Review of the EPP training records that were conducted on 04/09/25 revealed that 12 of the 24 staff did not have the emergency preparedness training. The “training document” indicated RN1, RN2, RN3, RN4, RN5, OT1, PT1, PT3, PT4, PT5,CNA3, and OA did not attend the training. In an interview with the Administrator/Director of Nursing on 04/25/25 at 11:AM confirmed the above findings. Review of the facility’s policy titled “Emergency Preparedness Operation Details” dated 04/2025 indicated, “Educated agency Staff (employees, volunteers, contractors) regarding their responsibilities in the agencies Emergency Preparedness Plan upon hire and annually thereafter…””

“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 record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of Outcome and Assessment Information Set (OASIS) to Internet Quality and Improvement and Evaluation System (IQIES). The failure had the potential to affect all 98 patients receiving services from the HHA who require evaluation and care. Findings include: The facility’s “OASIS submission data” for calendar year 2024 was reviewed and revealed that 28 out of a total of 809 assessments were coded as being transmitted to IQIES more than 30 days late during that time period. This resulted in an error code of -3330 (late submission) for 3.46% of all assessments submitted in the 2024 calendar year. During an interview on 04/25/25 at 3:45 PM, the Administrator/Director of Nursing (DON) confirmed she was responsible for submitting OASIS data to IQIES and stated the delay in timely transmission of OASIS data was due to being “just the nature of the OASIS assessment process.””

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on document review, policy review and interview, the Home Health Agency (HHA) failed to ensure a functioning process was in place to track incidents and accidents that occurred related to patients and/or their care. This deficient practice had the potential to affect all 98 patients currently receiving services from the HHA by increasing the possibility of incident patterns to be unidentified and therefore unaddressed. Findings include: Review of the Agency’s policy titled, “Incident Reporting” dated 01/2024 revealed, “It is the policy of our Agency to provide accurate and timely documentation of unusual occurrences, accidents, and incidents, in order to: Review and evaluate episodes which are disruptive of our Agency, Examine the conditions which jeopardize the safety of patients/employees, Determine which incidents require fact finding, Correct isolated adverse events. Complete Root Cause Analysis for the event, Identify trends and patterns, Continuously improve quality of care, and Hazardous Materials Management…Incidents to be reported include, but are not limited : Personal injury or endangerment, Motor vehicle accidents when conducting Agency business, Environmental safety hazards, Equipment safety hazards, malfunctions or failures, and unusual occurrences.” Review of the Agency’s “Incident Reporting documentation” revealed no organized process for monitoring and responding to incidents. Review of the Agency’s “Incident Logs” for the previous eight months prior to survey (September 2024 through April 2025) revealed falls were entered into the logs. No information was populated for any other type of incident occurring at the Agency during that time period. During an interview on 04/23/25 at 1:11 PM, the Office Assistant (OA) stated he/she was responsible for tracking any reported incidents. He/She stated he/she was only tracking falls and was not aware he/she was supposed to be tracking any other type of incident as it had never been communicated to him/her to do so. The OA stated he/she reported falls to the Administrator/Director of Nursing (DON) when they occurred, and the Administrator/DON was responsible for addressing the falls. The OA stated he/she collected information about falls when staff reported them to him/her and by documenting them when he/she saw them in records. During an interview on 05/24/25 at 4:45 PM, the Administrator/DON confirmed falls were being tracked if they were noted in a patient record during record review or when reported by staff in the field and stated rehospitalizations and infections were supposed to be tracked, as well. The Administrator/DON was not able to provide documentation to show an organized system of tracking infections or hospitalizations and confirmed all falls were not documented in the record provided to the survey team. He/She stated his/her expectation was all incidents occurring involving the Agency were to be tracked and then addressed and analyzed to ensure future appropriate response to incidents.”

“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 interview, the Home Health Agency (HHA) failed to ensure appropriate implementation of infection control procedures during home visits for three Patients (P) P3, P4, and P5) out of five patient home visits were conducted by the survey out of sample of 11 patients. This deficient practice had the potential to affect all 98 patients currently receiving services from the HHA by increasing the possibility of transmission of infection. Findings include: The Agency’s policies and procedure related to hand hygiene and sanitizing of multi-use equipment were requested by the survey team on 04/24/25 and were not received prior to survey exit on 04/25/25. 1.Review of P3’s electronic medical record (EMR) revealed “physician orders” for the patient to be seen by the Occupational Therapy (OT) twice weekly to assist with therapy exercises and provide teaching related to strengthening and regaining her ability to walk independently. Observation during P3’s homecare visit performed by OT1 on 04/23/25 at 3:30 PM revealed OT1 provided treatment and education related to her functional status. OT1 was observed to have a gate belt in his pocket during the visit, which he used to assist with P3. The gate belt was not observed to be sanitized prior to or after the visit. During an interview with OT1 on 04/23/25 at 4:20 PM, he/she stated he/she usually sanitized his reusable equipment, and he/she knew this was required by the Agency for all patients. 2.Review of P4’s EMR revealed “physician orders” for the Licensed Practical Nurse (LPN) to see the patient twice weekly during the certification period to generally assess the patient, obtain vital signs, and provide wound care (a dressing change) for the patient’s left shin wound. Observation during P4’s homecare visit performed by LPN1 on 04/24/25 at 1:00 PM revealed that LPN1 completed a wound dressing change to the patient’s left shin, obtained the patient’s vital signs, and conducted a full physical assessment of the patient on that date. LPN1 placed a clean barrier on the patient’s bed, placed his computer and reusable equipment on the clean barrier. During the visit, the patient’s cat was observed walking on and across LPN1’s computer and sniffing his medical equipment. At the end of the visit, LPN1 was observed using hand sanitizer to sanitize all of the reusable medical equipment deployed during his visit, including his computer, the stethoscope, the oxygen saturation monitor, the scissors used to cut the dressing for the patient’s wound care/dressing change, and the blood pressure cuff. During an interview with LPN1 on 04/25/25 at 1:45 PM, he/she stated he/she was not aware he/she was not supposed to use hand sanitizer to clean his equipment. He/she stated this was his/her usual practice and no one had ever told him/her or trained him/her to use anything else. 3.Review of P5’s EMR on 04/25/25 at 9:00 AM (after the visit occurred) revealed “physician orders” for skilled nursing to visit P5 twice weekly for wound care and general nursing assessment, including obtaining the patient’s vital signs. Observation during P5’s homecare visit performed by Registered Nurse (RN)1 on 04/24/25 at 10:30 AM revealed RN1 completed a dressing change to the patient’s nephrostomy tube site. The care included removing an old dressing from the patient’s nephrostomy tube site, observing the site for signs and symptoms of infection, then cleaning the site with a wound cleansing solution and applying a new dressing to the site. During the procedure, RN1 did not sanitize his/her hands or apply new gloves after removing the old dressing and cleaning the site and preparing and applying the new dressing (between clean and dirty procedures. In addition, RN1 cleaned her reusable equipment, including the blood pressure cuff and stethoscope that he/she used for multiple patient visits with a Lysol Sanitizing wipe. After cleaning the equipment with the wipe RN1 immediately used the equipment to obtain P5’s vital signs. During an interview with RN1 on 04/25/25 at 11:30 AM, he/she confirmed he/she did not complete appropriate hand hygiene during P5’s nephrostomy tube dressing change and stated he/she was not aware of how long reusable equipment needed to remain wet after using the sanitizer on it to ensure sanitization of the equipment. During an interview on 04/25/25 at 10:45 AM, the Administrator/Director of Nursing (DON) confirmed his/her expectation was hand hygiene was to be performed and gloves changed after cleaning a wound or removing a dressing and before applying a clean dressing and equipment was expected to be cleaned with agency provided sanitizing wipes and wet time was expected to be observed per instructions on the sanitizing container. He/She confirmed hand sanitizer was not an appropriate sanitizing solution for use in sanitizing reusable medical equipment.”

“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 document review, interview, and policy review, the Home Health Agency (HHA) failed to ensure a functioning process was in place to track infections that occurred related to patients under their care. This deficient practice had the potential to affect all 98 patients currently receiving services from the HHA by increasing the possibility of infections or their cause to be unidentified and therefore unaddressed. Findings include: Review of the Agency’s policy titled, “Infection Monitoring” dated 05/2023 revealed, “The Agency shall monitor for the onset of nosohusial patient infection (infections acquired in the patient home within the first 72 hours after admission to the Agency) and/or evidence of pandemic flu/COVID-19 outbreaks. Employee infections shall be monitored for quality assurance and Performance Improvement activities.” Review of the Agency’s “Infection Logs/Documentation” revealed no organized process for monitoring of infections for staff or patients. Review of the Agency’s “Infection Logs” for the previous eight months prior to survey (September 2024 through April 2025) revealed no entries at all into the logs. The logs were blank for the entire period. During an interview on 04/23/25 at 1:11 PM, the Office Assistant (OA)stated that he/she was responsible for tracking infections. He/She stated he/she would add infections to the log if they were reported to him/her by staff and stated it was the Administrator/ Director of Nursing (DON)’s responsibility to follow up. During an interview on 05/24/25 at 4:45 PM, the Administrator/DON confirmed the OA was supposed to be documenting infections in the Agency’s infection logs. He/She confirmed he/she would tell the OA about infections if he/she was aware of them and nursing and provider staff was also supposed to report infections to the OA if they became aware of them. The Administrator/DON confirmed residents and staff had experienced infections during the previous eight months and stated he/she was not aware the infections were not being put into the log. The Administrator/DON stated his/her expectation was infections would be monitored and addressed according to Agency policy and procedure.”

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on document review and interview, the facility failed to have a valid Clinical Laboratory Improvement Amendments (CLIA) certificate. This deficient practice has the potential to affect all patients needing waived laboratory tests. Findings include: Review of the CLIA certificate revealed it had expired on 02/25/25. Interview with the Administrator/Director of Nurses (DON) on 04/25 at 12:30PM, she confirmed the certificate was expired and stated they had applied for renewal on 03/07/25. The Administrator/DON confirmed they did not have a CLIA certificate policy.”

“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, record review, policy review and interview, the Home Health Agency (HHA) failed to ensure the medical record accurately reflected current medication orders in place for one of 11 sampled patients (Patient (P) P2) reviewed for medication reconciliation. This deficient practice had the potential to affect all 98 patients currently receiving services from the HHA. Findings include: Review of the Agency’s undated policy titled, “Medication Profile” revealed, “Purpose: To ensure all patients have a current list of medications…The medication list is collectively maintained in the clinical record. The plan of care will demonstrate the patient’s current medication regimen, and additions and/or modifications, will be identified in clinical notes, progress notes, summary reports, or communication notes…The profile will include over the counter drugs.” Review of P2’s Electronic Medical Record (EMR) revealed “physician’s orders” for the patient to receive visits from a Skilled Nurse (SN) every other week during the certification period beginning 03/08/25 and revealed the following medication orders were currently in place during the same time frame: Cholestyramine take four grams by mouth (GM) mix with 8 ounces (oz) water twice daily Reglan (medication to treat gastrointestinal symptoms) take 10 milligrams (MG) by mouth as needed every 4-6 hours prednisone (corticosteroid medication) take 20 MG by mouth daily Celecoxib (medication to reduce pain and inflammation) take 200 MG by mouth daily Eplerenone (medication treats high blood pressure) take 100 MG by mouth daily Lisinopril (medication treats high blood pressure)take 40 MG by mouth daily. Omeprazole (medication to treat excess stomach acid) take 40 MG by mouth daily Observation during a homecare visit performed by Certified Nursing Assistant (CNA1) on 04/23/25 from 2:30 PM until 3:30 PM revealed that P2’s “Medication List” found in P2’s EMR did not accurately reflect the medications being administered to the patient in his home. Medications found in P2’s home included Eplerenone take 25 MG by mouth daily (instead of the 100 MG daily as indicted in the Agency’s record), Omeprazole 20 MG by mouth daily (instead of the 40 MG daily as indicated in the Agency’s record), and Lisinopril take 20 MG by mouth daily (instead of the 40 MG daily as indicated in the Agency’s record). In addition, P2 confirmed he was no longer receiving the above indicated Cholestyramine, Reglan, Prednisone, or Celecoxib as indicated in the Agency’s record. The medications administered in the home did not match the orders in place in the Agency’s EMR. During an interview on 04/23/25 at 3:00 PM, P2 confirmed his current prescribed medications and confirmed he was taking the medications indicated on the medication list in his home routinely per his primary physician’s orders. During an interview on 05/24/25 at 4:45 PM, the Administrator/Director of Nursing (DON) confirmed P2 was receiving routine skilled nursing visits every two weeks and indicated that medications were expected to be reconciled by the nurse at every visit. She stated her expectation was that the medications being administered to patients in their homes should match the Agency’s medication order set.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that a physician’s order for a nephrostomy dressing change observed performed by Registered Nurse (RN1) was in place and current for one Patient (P) P5 of a total of 11 sampled patients reviewed during the survey. This deficient practice had the potential to affect all 98 patients receiving services from the HHA who have physician’s orders in place for care. Findings include: Review of the Agency’s undated policy titled, “Physician’s Plan of Treatment” revealed, “A physician prepares a plan of treatment, and it is made available to the Agency…Physician’s orders are established and documented for the health care services the Agency provides.” Observation during P5’s homecare visit performed by Registered Nurse (RN)1 on 04/24/25 at 10:30 AM revealed that RN1completed a dressing change to the patient’s nephrostomy tube site. The care included removing an old dressing from the patient’s nephrostomy tube site, observing the site for signs and symptoms of infection, then cleaning the site with a wound cleansing solution and applying a new dressing to the site. During the procedure, RN1 stated this was the usual procedure provided related to P5’s nephrostomy tube site. Review of P5’s electronic medical record (EMR) on 04/25/25 at 9:00 AM (after the visit occurred) revealed no current physician orders for P5’s nephrostomy tube dressing to be changed. Review of P5’s EMR revealed his nephrostomy tube dressing was being changed with each twice weekly skilled nursing visit. During an interview on 04/25/25 at 10:45 AM, the Administrator/Director of Nursing (DON) confirmed there was no current order in place in P5’s record for his nephrostomy tube dressing change. She stated an order had been entered into the patient’s record on the previous day (04/24/25) after the surveyor asked about it. She stated her expectation was an order would be in place for all nursing care provided for patients, including P5’s nephrostomy tube dressing change.”

“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 observation, record review, interviews, and policy review, the Home Health Agency (HHA) failed to ensure physician’s orders were routinely followed for two of 11 patients (Patient (P ) P2, and P9) reviewed in the sample. This failure had the potential to affect all 98 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, “Care Plan” revealed, “In order to ensure that a patient’s needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential. A care plan is started upon initiation of services by the RN [Registered Nurse], based upon the plan of treatment and assessment of the patient’s needs, resources, family and environment…Home health services from members of the Agency staff, as well as those under contractual agreements, shall be provided in accordance with the plan of treatment and the patient care plan.” 1.Review of P2’s electronic medical record (EMR) revealed “physician’s orders” for the patient to receive visits from a Skilled Nurse (SN) every other week during the certification period beginning 03/08/25 and revealed the skilled nurse was to evaluate the patient’s medications, his safety when administering the medications, and the patient’s understanding of the medications he was prescribed. The record indicated a skilled nurse had most recently been at the patient’s home for an ordered and care planned visit on 03/26/25 (one month prior to the survey). The record indicated a missed visit document for a skilled nursing visit scheduled on 04/11/25 (two weeks prior to the survey) but there was nothing in the patient’s EMR to indicate any attempt had ever been made to reschedule that visit as of the survey review date of 03/25/25. Review of the “nursing documentation” for the most recent visits entered into the record (03/21/25 and 03/26/25) revealed nothing to indicate P2’s medications had been reviewed by the SN or with the patient during the visits as care planned and ordered by the patient’s physician. Observation during a homecare visit performed by Certified Nursing Assistant (CNA1) on 04/23/25 from 2:30 PM until 3:30 PM revealed that P2’s “Medication List,” found in P2’s EMR did not accurately reflect the medications being administered to the patient in his/her home. There was nothing documented in the patient’s home to indicate his/her medications and safety related to taking his medications had been reviewed with him/her. During an interview on 04/23/25 at 3:00 PM, P2 confirmed he/she had not received a nursing visit for about one month. He/she stated he/she did not recall a nurse reviewing his medications or updating his/her medication list any time recently. During an interview on 04/25/25 at 4:30 PM, he/she stated an attempt was made to reschedule a missed patient visit as soon as possible after the missed visit. He/She stated his/her expectation was all services were to be provided according to each patient’s physician’s orders and current plan of care. 2. Review of the Agency’s undated policy titled “Admission Documentation/Patient Education” indicated, “A record will be maintained for all home patients; the record will include vital signs.” Review of P9’s EMR revealed the shilled visit on 10/04/25 and 10/18/25 record did not have any of the vital signs, consisting of temperature (T), blood pressure (BP), pulse (P), respirations (R), and oxygen saturation (O2 sat) recorded. Review of the “Physician Certification and Plan of Care” indicated, “notify physician of: T greater than 100.4, P greater than 120 or less than 60, systolic BP greater than 160 or less than 90. Diastolic greater than 90 or less than 60, R, greater than 24 or less than 12, O2 sat at less than 88.” Interview with the Administrator/DON on 04/25/25 at 11:40 AM confirmed the above findings.”

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on observation, record review, and interview, the Home Health Agency (HHA) failed to ensure the medical record accurately reflected current demographic information for one of 11 patients (Patient (P) P2) reviewed in the sample. This deficient practice had the potential to affect all 98 patients currently receiving services from the HHA. Findings include: Review of the Agency’s policy titled, “Records: Clinical Policy” dated 01/2024 revealed, “Clinical records containing past and current information are maintained for every patient accepted by our Agency and receiving home health services…Clinical records are accurate and adhere to current clinical record documentation standards of practice.” Review of P2’s Electronic Medical Record (EMR) revealed an incorrect address for the patient. The record indicated a past address as the patient’s current address, even though the patient had not been living at that address for two months Observation during a homecare visit performed by Certified Nursing Assistant (CNA1) on 04/23/25 from 2:30 PM until 3:30 PM revealed the wrong address was entered into the patient’s medical record when the surveyors arrived at the indicated address and were told, by someone visiting the home, P2 had not been residing at that address for at least two months. During an interview on 04/23/25 at 3:00 PM, P2 confirmed he had not been living at the address indicated in his clinical record for approximately two months. During an interview on 05/24/25 at 4:45 PM, the Administrator/Director of Nursing (DON) confirmed P2 was no longer residing at the address indicated in his clinical record and stated the address had been updated in the record on 04/23/25 after the surveyor inquired about it. The Administrator/DON stated her expectation was patient’s demographic information was to be correctly entered into each patient’s record and the information was expected to be kept up to date.”