Amara Home Care

“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, policy review, and staff interviews, the agency failed to ensure all patients had an individualized physician’s plan of care and failed to notify the physician of all missed visits. (G572) The agency failed to ensure the services provided were per physician orders. (G580) The agency failed to ensure the physician’s plan of care was reviewed and signed every 60 days. (G588) The agency failed to ensure the physician had been notified of a discharge. (G598) .”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on policy review and staff interview, the agency failed to develop, implement, evaluate, and maintain an effective, ongoing Quality Assessment and Performance Improvement (QAPI) program. (G642) The agency failed to conduct performance improvement projects. (G658) .”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on the record review and staff interview, the provider failed to update and review their emergency preparedness plan. This had the potential to affect all patients and staff. The census was six. A record review of the emergency preparedness plan provided by the provider via email on 03/26/25 at approximately 5:09 P.M. revealed there was no documentation the provider reviewed and updated the plan every two years. No additional documentation was provided at the time of survey to validate the plan was updated, as required by the applicable code. An interview with the Chief Medical Information Officer verified they haven’t updated the plan since 2020.”

“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 the record review and staff interview, the provider failed to train their staff on the emergency preparedness plan. This had the potential to affect all patients and staff. The census was six. A record review of the emergency preparedness plan provided by the provider on 03/26/25 at approximately 5:09 P.M. revealed there was no documentation the provider had trained their staff on the emergency preparedness plan at least every two years. An interview with the Chief Medical Information Officer verified they haven’t trained their staff on the plan since 2020.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on the record review and staff interview, the provider failed to conduct exercises to test their emergency plan at least annually. This had the potential to affect all patients and staff. The census was six. A record review of the emergency preparedness plan provided by the provider on 03/26/25 at approximately 5:09 P.M. revealed no documentation the provider had tested the emergency preparedness plan at least every two years. An interview with the Chief Medical Information Officer verified they haven’t tested the plan since 2020.”

“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, staff interview, and policy review, the agency failed to ensure all OASIS submissions were within 30 days of completion. This could affect all patients at this agency. The census was six. Review of the OASIS Agency Final Validation report from January and February of 2025 revealed 13 late submissions with the warning code 3330 “Submission date is more than 30 days from the completion date.” Review of the undated agency policy titled “Reporting of OASIS Information” revealed the Agency must encode and have the capability of transmitting OASIS data for each patient within thirty (30) days of completing any required OASIS data set assessment. Interview on 03/25/26 at 12:48 PM Staff B confirmed there were 13 late OASIS submissions.”

“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 record review, policy review, and staff interviews, the agency failed to ensure all patients had an individualized physician’s plan of care. This affected three (#4, #5 and #7) out of three patients with Department of Developmental Disabilities (DODD) payor source. The agency failed to notify the physician of all missed visits for two (#1 and #3) out of five patient records with visits reviewed. The census was six. 1. A. Review of the medical record for Patient #4 revealed no plan of care. B. Review of the medical record for Patient #5 revealed no plan of care. Interview on 03/24/25 at 4:30 PM Staff B confirmed there were no physician plan of care for Patient #4 or Patient #5. Staff B stated they get the instructions for the service from DODD. They tell the agency when to go and what services to provide. C. Review of the medical record for Patient #7 revealed no plan of care. Interview on 03/26/27 at 10:12 AM Staff A confirmed there was no physician plan of care for Patient #7. Review of the undated agency policy titled “Plan of Care-CMS #485 and Physician Orders” revealed each patient must receive an individualized written plan of care. The plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment Review of the agency’s policy titled “Coordination of Patient Care” revised 03/2018 revealed coordination of agency’s resources included notifying the physician and making sure that they are aware of the missed visits and must document it. 2. A. Review of the medical record for Patient #1 and the plan of care dated 01/28/25 to 03/28/25 revealed the skilled nurse (SN) was to provide care twice a week. The SN had missed visits on 02/11/25, 02/25/25, 03/13/25 and 03/18/25. There was no documentation the physician had been notified of the missed visits. B. Review of the medical record for Patient #3 and the plan of care dated 02/14/25 to 04/14/25 revealed the SN was to provide wound care three times a week. The SN had missed visits on 03/12/25 and 03/19/25. There was no documentation the physician had been notified of the missed visits. Interview on 03/24/25 at 2:33 PM Staff A confirmed the physician was not notified of the missed visits. Staff A stated they were understaffed. Review of the agency policy titled “Coordination of Patient Care,” revised 03/2018, revealed coordination of agency’s resources included notifying the physician and making sure that they are aware of the missed visits and must document it.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on policy review and staff interview the agency failed to develop, implement, evaluate, and maintain Quality Assessment and Performance Improvement (QAPI) program. This had the potential to affect all patients admitted to the agency. The census was six. Review of the agency policy titled “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” revised 03/2018, revealed the Agency will establish an ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program. Interview on 03/25/25 at 4:03 PM Staff A and B both confirmed the agency had no QAPI program.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on policy review and staff interview, the agency failed to conduct performance improvement projects. This could potentially affect all patients and staff at this agency. The census was six. Review of the agency policy titled “Performance Improvement Projects,” revised 03/2018 revealed the agency will conduct performance improvement projects. Interview on 03/25/25 at 4:03 PM Staff A and B both confirmed the agency was not conducting any Performance Improvement Projects.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to ensure a home health aide (HHA) care plan was written by the registered nurse for every HHA providing care. This affected three (#4, #5, and #7) out of three patients reviewed with HHA services. The census was six. 1. Review of the medical record for Patient #4 and the home health aide (HHA) time sheets from 03/02/25 to 03/15/25 revealed the HHA provided care five times a week. There was no documented evidence of an HHA care plan written by the registered nurse. 2. Review of the medical record for Patient #5 and the home health aide (HHA) time sheets from 03/02/25 to 03/15/25 revealed the HHA provided care five times a week. There was no documented evidence of an HHA care plan written by the registered nurse. 3. Review of the medical record for Patient #7 and the home health aide (HHA) time sheets from 12/08/24 to 12/20/24 revealed the HHA provided care five times a week. There was no documented evidence of an HHA care plan written by the registered nurse. Review of the undated agency policy titled “Care Planning Process” revealed the HHA care plan will be developed by a registered nurse prior to HHA rendering care. Interview on 03/25/25 at 4:31 PM Staff A confirmed there were no HHA care plans written by the registered nurse.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on policy review and staff interview, the agency failed to establish a Governing Body. This could potentially affect all patients and staff at this agency. The census was six. Review of the undated agency policy titled “Governing Body” revealed the Governing Body assumes full legal authority and responsibility for the Agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the Agency’s budget and its operational plans and its quality assessment and performance improvement program. The Governing Body will have bylaws which will be reviewed and revised annually and as needed. The Governing Body is responsible for assuring that an ongoing program for Quality Assessment/Performance Improvement and patient safety is defined, implemented and maintained. Interview on 03/24/25 at 3:45 PM Staff A and B both confirmed there was no Governing Body. Staff B stated, “There is only me.””

“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 observations, record review, staff interviews, patient interviews, family interviews, and policy review, the agency failed to ensure the medications taken by the patients match the medication profile in the medical record. This affected two (#1 and #2) out of two patients with medications reviewed in the home. The census was six. 1.Observations on 03/25/25 at 8:00 AM during a home visit for Patient #1, with Staff B present, included a review of the medications the patient takes in the home. Review of the medical record for Patient #1 and the current medication profile did not match these medications taken in the home. The medication profile revealed the blood pressure medication isosorbide mononitrate 30 milligrams (mg) was taken daily. Observation of the medication bottle revealed isosorbide mononitrate 60 mg was actually taken daily and was last filled on 02/05/25. The medication profile revealed the blood pressure medication carvedilol 25 mg was taken three times a day. Observation of the medication bottle revealed carvedilol 25 mg was actually taken twice a day and last filled on 09/11/24. Interview of 03/25/25 at 8:26 AM with Patient #1’s family member confirmed Patient #1 took it the carvedilol 25 mg twice a day per the medication list from the hospital dated 01/22/25. The medication profile revealed the blood pressure medication hydralazine 100 mg was taken three times a day. Observations of the medication bottle revealed hydralazine 25 mg was taken three times a day and last filled on 02/05/25. Observation of the medication bottle revealed the antidepressant mirtazapine 15 mg to take half a tablet at bedtime and last filled on 11/24/24. The medication profile did not reflect Patient #1 was taking mirtazapine 15 mg. Interview on 03/25/25 at 8:38 AM Staff B confirmed the medications taken in the home by Patient #1 did match the medication list from the hospital dated 01/22/25. Staff B confirmed the medications the patient was taking did not match the medication profile in the medical record. 2. Observations during a home visit on 03/25/25 at 9:30 AM for Patient #2, with Staff C present, included a review of the medications the patient takes in the home. Review of the medical record for Patient #2 and the current medication profile did not match these medications taken in the home. Review of the medication profile revealed Patient #2 was on 2 liters of oxygen as needed. Interview on 03/25/25 at 9:46 AM Patient #2 stated they use 4 liters of oxygen at night. Patient #2 stated it was increased “Months ago.” Review of the medication profile revealed Patient #2 used diclofenac 3% topical gel twice a day. Interview on 03/25/25 at 9:48 AM Patient #2 stated they only use the diclofenac gel as needed. Patient #2 stated this was changed last month. Interview on 03/25/25 at 9:50 AM Staff C confirmed the medications taken in the home by Patient #2 did not match the medication profile in the medical record. Review of the agency policy titled “Medication Orders,” revised 03/2018, revealed the medication profile will be accurate. Review of the agency policy titled “Medication Reconciliation,” revised 03/2018, revealed the Agency will reconcile patient’s medications at time of admission and on an ongoing basis 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. Medications ordered while the patient is receiving care will be compared to the medication profile. The medication profile will be updated with each new or changed medication.”

“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, staff interview, and policy review, the agency failed to ensure the services provided were per physician orders. This affected seven out of seven patients reviewed. (#1, # 2, #3, #4, #5, #6 and #7) The census was six. 1. Review of the medical record for Patient #1 did not reveal a physician’s order for services provided. Review of the skilled nurse (SN) visit notes from 02/02/25 to 02/15/25 revealed the SN provided care twice a week to Patient #1. 2. Review of the medical record for Patient #2 did not reveal a physician’s order for services provided. Review of the SN visit notes from 02/23/25 to 02/15/25 revealed the SN provided care once a week to Patient #2. 3. Review of the medical record for Patient #3 did not reveal a physician’s order for services provided. Review of the SN visit notes from 02/16/25 to 02/22/25 revealed the SN provided care three times a week to Patient #3. 4. Review of the medical record for Patient #4 did not reveal a physician’s order for services provided. Review of the home health aide visit notes from 03/02/25 to 03/15/25 revealed home health aide services were provided seven days per week to assist Patient #4 with personal care. 5. Review of the medical record for Patient #5 did not reveal a physician’s order for services provided. Review of the home health aide visit notes from 03/02/25 to 03/14 25 revealed home health aide services were provided five days per week to assist Patient #5 with personal care. 6. Review of the medical record for Patient #6 did not reveal a physician’s order for services provided. Review of the SN visit sheets from 01/20/25 to 02/10/25 revealed the SN visited twice a week. 7. Review of the medical record for Patient #7 did not reveal a physician’s order for services provided. Review of the home health aide visit notes from 12/08/24 to 12/21/24 revealed home health aide services were provided Monday through Friday to assist Patient #7 with personal care. Review of the undated agency policy titled “Plan of Care-CMS #485 and Physician’s Orders” revealed care and services will be provided according to physician orders. Interview on 03/27/25 at 12:36 PM Staff A confirmed there was no physician’s orders for the services provided to Patient #1, #2, #3, #4, #5, #6, and #7.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review, staff interview and policy review, the agency failed to ensure the physician’s plan of care was reviewed and signed every 60 days. This affected four (#1, #2 #3 and #6) out of four patients reviewed with a plan of care. The census was six. 1. Review of the medical record for Patient #1 and physician plan of care, dated 01/28/25 to 03/28/25, revealed the physician did not sign this plan of care for this 60 day period. 2. Review of the medical record for Patient #2 and physician plan of care dated 12/25/24 to 02/22/25 revealed the physician did not sign this plan of care for this 60 day period. 3. Review of the medical record for Patient #3 and physician plan of care dated 12/16/24 to 02/13/25 revealed the physician did not sign this plan of care for this 60 day period. Interview on 03/24/25 at 12:43 PM Staff A confirmed the physician plan of cares were not signed for Patient #1, #2, and #3. Staff A provided the last signed physician’s plan of care for Patient #3 which was dated 04/10/24 to 06/08/24 and signed on 06/05/24. Staff A confirmed there was no other signed plan of care for Patient #3. 4. Review of the medical record for Patient #6 and physician plan of care dated 01/20/25 to 03/20/25 revealed the physician did not sign this plan of care for this 60 day period. Interview on 03/26/25 at 10:10 AM Staff A confirmed the plan of care was not signed within the 60 day certification period. Review of the undated agency policy titled “Plan of Care-CMS #485 and Physician’s Orders” revealed each Plan of Care must be signed and dated by the physician. The physician who establishes the Plan of Care must sign and date the recertification. The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and no less frequently than once every 60 days.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on record review, policy review, and staff interview the agency failed to ensure the physician had been notified of a discharge. This affected two (#6 and #7) out of two discharged patients reviewed. The census was six. 1. Review of the medical record for Patient #6 revealed start of care 01/20/25. Review of the discharge summary revealed Patient #6 was discharged 02/12/25. There was no documentation the physician had been notified of the discharge. Interview on 03/26/25 at 3:33 PM Staff A confirmed the physician had not been notified of the discharge. 2. Review of the medical record for Patient #7 revealed a start of care 02/18/24. Review of the discharge summary revealed no discharge date, no physical or psychological status, no care summary and no registered nurse signature and date. There was no documentation the physician had been notified of the discharge. Review of the discharged patient list revealed Patient #7 was discharged 12/26/24. Interview on 03/25/25 at 4:56 PM Staff A confirmed the discharge summary was incomplete and confirmed there was no documentation the physician had been notified. Review of the agency policy titled “Discharge Summary,” revised 03/2018, revealed a Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist. A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to ensure the registered nurse made an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to assess the quality of care and services provided by the home health aide (HHA). This affected two (#4 and #5) out of two patients reviewed with HHA services. The census was six. 1. Review of the medical record for Patient #4 revealed start of care 07/16/2019. Patient #4 was an active patient with home health aide (HHA) services Monday through Friday. The record contained no evidence of supervisory visits of the HHA every 60 days. Interview on 03/25/25 at 4:31 PM Staff A confirmed there were no supervisory visits of the HHA since 03/2024. 2. Review of the medical record for Patient #5 revealed start of care 03/26/19. Patient #5 was an active patient with home health aide services Monday through Friday. The record contained no evidence of supervisory visits of the HHA every 60 days. Interview on 03/25/25 at 3:30 PM Staff B stated there had been no supervisory visits of the HHA since the skilled care was discontinued. The last supervisory visit for Patient #5 was 01/13/23. Review of the agency policy titled “Home Health Aide Supervision,” revised 03/2018, revealed if Home Health Aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse will make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care.”