Confidential Health Services LLC

“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 observation, record review, and interview, the agency failed to ensure care plans and goals were individualized for patients. This affected three (Patients #11, #15 and #19) of seven patients reviewed. This could affect all patients receiving services from the agency. The active census was 19. See G572”

“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 CMS iQIES summary of Error Report and interview, the facility failed to transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment. This had the potential to affect all 19 patients. Findings include: Review of the CMS iQIES Summary of Error Report revealed between 01/01/24 and 12/31/24 error number 3330 triggered. The facility had mid/late submission OASIS of more than 30 days based on the information contained on question M0090. Information completed revealed 23 errors for 16.79 percent error rate out of 137 assessments. During an interview 04/29/25 at 11:18 A.M., the Director of Nursing verified he had some late submissions last year. He stated he submitted the OASIS assessments twice a month.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review, observation and interview, the facility failed to ensure encoded OASIS data accurately reflected the patient’s status at the time of assessment. This affected three (Patients #11, #15, and #19) of three patients reviewed with a home visit. This had the potential to affect all 19 patients. Findings include: 1. Record review revealed Patient #11 started care on 01/27/17. Diagnoses included including multiple sclerosis, muscle weakness, epilepsy and seizures. Review of the OASIS Assessment for the certification period of 04/15/25 to 06/13/25 revealed the assessment was completed 04/14/25. The Recertification Assessment included care plans for teaching oxygen safety, tracheotomy care, suctioning technique, nebulizer care, urostomy care, and enteral/parental feeding complications. During a home visit on 04/22/25 at12:47 P.M., Patient #11 was observed sitting in a recliner with her legs elevated. Patient #11 was not using oxygen. Her neck was visible with no evidence of a tracheostomy. She ate a hamburger and French fries during the visit. Review of her medication list revealed the patient was not ordered a medication to utilize a nebulizer. During an interview 04/22/25 at 1:40 P.M., Patient #11 stated she never had a tracheostomy and had no oxygen therapy in the house, She stated she did not have a suction or nebulizer machine. She did not have a gastrostomy tube for tube feeding and ate by mouth. She stated she never had a feeding tube and did not have a urostomy tube. During an interview with the Director of Nursing (DON) during the home visit verified the patient never had a tracheostomy, urostomy, feeding tube, or suction machine. The DON verified the patient did not use oxygen or a nebulizer. The DON stated he check marked sections on the OASIS and did not uncheck items in the subgroups that were non applicable, resulting in errors. 2. Record review revealed Patient #15 revealed a 01/16/16 Start of Care with diagnoses including hypertension and osteoarthritis. Review of the OASIS Assessment for the certification period of 03/29/25 to 05/27/25 revealed the assessment was completed 03/28/25. The Recertification Assessment included care plans for teaching seizure precautions, tracheotomy care, suctioning technique, oxygen care, nebulizer care, bladder irrigation, urostomy care, catheter and drainage bag monitoring, insulin administration, tube feeding techniques and flushing, and enteral/parental feeding complications. During a home visit on 04/22/25 at 2:19 P.M. Patient #15 answered the door without a walking device. He then sat on the couch and was not using oxygen. His neck was visible with no evidence of a tracheostomy or suction machine. There was no observation of a urostomy drainage bag or feeding tube. Review of his medication list revealed the patient was not ordered a medication to utilize a nebulizer. The patient was not on insulin During an interview 04/22/25 at 2:00 P.M., Patient #15 stated he never had a tracheostomy and had no oxygen therapy in the house. He did not have a suction or nebulizer machine. He did not take insulin. He did not have a gastrostomy tube for tube feeding and ate by mouth. He stated he never had a feeding tube, did not have a urostomy tube for urine drainage, and did not need bladder irrigation. Patient #15 denied having seizures. During an interview on 04/22/25 at 2:09 P.M. with Staff L, the home health aide, stated she has taken care of Patient #15 before he started with the agency. She verified the patient did not have seizures, a tracheotomy, oxygen, need for suctioning, oxygen care, or utilize a nebulizer. He did not have a need for bladder irrigation, did not have a urostomy, or the need for catheter and drainage bag monitoring. The patient did not take insulin or have a feeding tube. During an interview on 04/22/25 at 4:02 P.M., the DON verified there were areas marked on the OASIS plan of care that did not pertain to the patient. He stated he marked those areas in error and they have continued to carry over without revision. 3. Record review revealed Patient #19 started care on 01/30/19. Diagnoses included type 2 diabetes, hypertension and neuromuscular dysfunction. Review of the OASIS Assessment for the certification period of 02/27/25 to 04/27/25 revealed the assessment was completed 02/26/25. The Recertification Assessment included care plans for teaching nebulizer care, urostomy care, foley care, bladder irrigation, seizures, weight monitoring, glucose monitoring, percutaneous endoscopic gastrostomy (PEG ) tube care, and enteral/parental feeding complications. During a home visit on 04/22/25 at 10:41 A.M., Patient #19 was sitting at the dining room table then in an upholstered chair in the living room. There was no evidence of a urostomy, PEG tube or foley catheter. Review of her medication list revealed the patient was not ordered a medication to utilize a nebulizer. During an interview 04/22/25 at 11:40 A.M., Patient #15, Registered Nurse Staff O, and Home Health Aide Staff V stated Patient #15 did not have a nebulizer treatment, a history of seizures, a urostomy and need for care, a foley catheter or need for care such as bladder irrigation, or bladder irrigation. The staff did not monitor weight or glucose. The patient did not have a PEG tube, or enteral/parental feeding. Staff O verified the OASIS plan of care was inaccurate.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on record review and interview, the facility failed to ensure the patient and/or representative were informed of the patient’s rights including transfer and discharge from the Home Health Agency. This affected all 19 residents of the facility. Findings include: Review of the Admission packet revealed no evidence of the patient and/or representative being informed of rights and how to exercise them related to transfer and discharge from the facility. Interview 04/21/25 at 5:42 P.M. with Director of Nursing and the Agency Owner verified the patients were not informed of the patient rights including transfers and discharge policies.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to provide discharge summaries to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This affected two (Patient’s #20 and #23) of two patients reviewed for discharge. Findings include: 1. Record review revealed Patient #20 started care on 01/27/16. Diagnoses included type 2 diabetes, hypertension and wrist pain. Patient #20 received skilled nurse visits twice a day for blood glucose monitoring and insulin administration. She received 42 hours of aide services per week. Patient #20 was sent a 30 day discharge notice 12/02/24 due to the patient’s long term home health aide (HHA) finding another position. The facility was unable to find staff to provide her care due to her distance from the facility. The last day services were provided was 12/30/24. A discharge OASIS was completed 12/31/24. There was not a discharge summary developed. There was no evidence of a discharge summary being sent to the Home Health Agency who took over the care of Patient #20. 2. Record review revealed Patient #23 started care on 10/12/20. Diagnoses included chronic migraine, hypertension, sleep apnea, and neurofibromatosis. Patient #23 received 27.5 hours of aide services per week with an order through 02/01/25. On 02/07/25 the facility was sent a message from Patient #23’s case manager stating services ended 02/01/25. The patient went to another agency. There was not a discharge summary developed. There was no evidence of a discharge summary being sent to the Home Health Agency who took over the care of Patient #23. During an interview on 04/29/25 at 2:42 P.M., the Director of Nursing (DON) stated a discharge summaries were not completed and sent to the admitting agencies. Review of the policy titled “Discharge Summary”, dated 2013, did not include a discharge summary would be sent to the admitting agency upon discharge.”

“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 observation, record review, and interview, the agency failed to ensure care plans and goals were individualized for patients. This affected three (Patients #11, #15 and #19) of seven patients reviewed. This could affect all patients receiving services from the agency. The active census was 19. Findings include: Record review revealed Patient #11 started care on 01/27/17. Diagnoses included including multiple sclerosis, muscle weakness, epilepsy and seizures. Review of the OASIS Assessment for the certification period of 04/15/25 to 06/13/25 revealed the assessment was completed 04/14/25. The Recertification Assessment included care plans for teaching oxygen safety, tracheotomy care, suctioning technique, nebulizer care, urostomy care, and enteral/parental feeding complications. During a home visit on 04/22/25 at12:47 P.M., Patient #11 was observed sitting in a recliner with her legs elevated. Patient #11 was not using oxygen. Her neck was visible with no evidence of a tracheostomy. She ate a hamburger and French fries during the visit. Review of her medication list revealed the patient was not ordered a medication to utilize a nebulizer. During an interview 04/22/25 at 1:40 P.M., Patient #11 stated she never had a tracheostomy and had no oxygen therapy in the house, She stated she did not have a suction or nebulizer machine. She did not have a gastrostomy tube for tube feeding and ate by mouth. She stated she never had a feeding tube and did not have a urostomy tube. During an interview with the Director of Nursing (DON) during the home visit verified the patient never had a tracheostomy, urostomy, feeding tube, or suction machine. The DON verified the patient did not use oxygen or a nebulizer. The DON stated he check marked sections on the OASIS and did not uncheck items in the subgroups that were non applicable, resulting in errors. 2. Record review revealed Patient #15 revealed a 01/16/16 Start of Care with diagnoses including hypertension and osteoarthritis. Review of the OASIS Assessment for the certification period of 03/29/25 to 05/27/25 revealed the assessment was completed 03/28/25. The Recertification Assessment included care plans for teaching seizure precautions, tracheotomy care, suctioning technique, oxygen care, nebulizer care, bladder irrigation, urostomy care, catheter and drainage bag monitoring, insulin administration, tube feeding techniques and flushing, and enteral/parental feeding complications. During a home visit on 04/22/25 at 2:19 P.M. Patient #15 answered the door without a walking device. He then sat on the couch and was not using oxygen. His neck was visible with no evidence of a tracheostomy or suction machine. There was no observation of a urostomy drainage bag or feeding tube. Review of his medication list revealed the patient was not ordered a medication to utilize a nebulizer. The patient was not on insulin During an interview 04/22/25 at 2:00 P.M., Patient #15 stated he never had a tracheostomy and had no oxygen therapy in the house. He did not have a suction or nebulizer machine. He did not take insulin. He did not have a gastrostomy tube for tube feeding and ate by mouth. He stated he never had a feeding tube, did not have a urostomy tube for urine drainage, and did not need bladder irrigation. Patient #15 denied having seizures. During an interview on 04/22/25 at 2:09 P.M. with Staff L, the home health aide, stated she has taken care of Patient #15 before he started with the agency. She verified the patient did not have seizures, a tracheotomy, oxygen, need for suctioning, oxygen care, or utilize a nebulizer. He did not have a need for bladder irrigation, did not have a urostomy, or the need for catheter and drainage bag monitoring. The patient did not take insulin or have a feeding tube. During an interview on 04/22/25 at 4:02 P.M., the DON verified there were areas marked on the OASIS plan of care that did not pertain to the patient. He stated he marked those areas in error and they have continued to carry over without revision. 3. Record review revealed Patient #19 started care on 01/30/19. Diagnoses included type 2 diabetes, hypertension and neuromuscular dysfunction. Review of the OASIS Assessment for the certification period of 02/27/25 to 04/27/25 revealed the assessment was completed 02/26/25. The Recertification Assessment included care plans for teaching nebulizer care, urostomy care, foley care, bladder irrigation, seizures, weight monitoring, glucose monitoring, percutaneous endoscopic gastrostomy (PEG ) tube care, and enteral/parental feeding complications. During a home visit on 04/22/25 at 10:41 A.M., Patient #19 was sitting at the dining room table then in an upholstered chair in the living room. There was no evidence of a urostomy, PEG tube or foley catheter. Review of her medication list revealed the patient was not ordered a medication to utilize a nebulizer. During an interview 04/22/25 at 11:40 A.M., Patient #15, Registered Nurse Staff O, and Home Health Aide Staff V stated Patient #15 did not have a nebulizer treatment, a history of seizures, a urostomy and need for care, a foley catheter or need for care such as bladder irrigation, or bladder irrigation. The staff did not monitor weight or glucose. The patient did not have a PEG tube, or enteral/parental feeding. Staff O verified the OASIS plan of care was inaccurate.”

“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 record review and interview, the facility failed to conduct a performance improvement project. This affected all current 19 patients. Findings include: Review of the Quality Assessment and Performance Improvement (QAPI) documentation revealed the last meeting was held on 12/09/24. The agenda included review of patient care, clinical agency updates, and quality assurance, performance and improvement plan. The meeting began at 4:00 P.M. and adjourned at 4:05 P.M. The notes included for QAPI a high level of satisfaction and no complaints in the following areas: no patient injuries, no patient neglect, 100 percent satisfaction for patient observation, and 100 percent infection control and training. There was no evidence the facility identified an area to work on for improvement. There was no evidence of a QAPI plan for any area current or past. There was no evidence of the facility conducting at least one performance improvement project either in development, on-going or completed each calendar year. There were no past projects identified in the QAPI binder or presented for inspection. During an interview on 04/29/25 at 2:47 P.M., the Director of Nursing verified there was not a QAPI plan in place. There was not an area identified for improvement with a plan in place, what data would be collected and what measures would be taken to improve an identified area in need of improvement.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on record review and interview, the facility failed to ensure the patient and/or representative were informed of the patient’s rights including Federally-funded and state-funded entities as regulated. This affected all 19 residents of the facility. Findings include: Review of the Admission packet revealed no evidence of the patient and/or representative being informed of rights and how to exercise them related to Federally-funded and state-funded entities. There was no evidence of the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization. During an interview 04/21/25 at 5:42 P.M., the Director of Nursing and Agency Owner verified the patients were not informed or provided the names, addresses, and telephone numbers of the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization as required.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure the patient’s clinical record accurately identify all medications the patient was taking. This affected three (Patient’s #11, #15 and #19) of three patients who had home visits conducted. Findings include: 1. Record review revealed Patient #11 started care on 01/27/17. Diagnoses included multiple sclerosis, muscle weakness, epilepsy and seizures. During a home visit on 04/22/25 at 12:47 P.M., Patient #11’s medications were in a basket on the table with a medication profile list. Reconciliation with the Director of Nursing (DON), who was present during the home visit, revealed Basaglar Kwikpen 30 units twice a day was listed. The DON stated the insulin was changed to three times a day approximately three months ago and not updated on the profile list. Glipizide 5 milligrams (mg) daily had been changed to twice a day 02/28/25 and not updated on the profile. Meclizine 25 mg three times a day was listed on the profile. Patient #11 stated she only takes the medication as needed. Quetiapine Fumarate 100 mg three times a day was included on the profile. Patient #11 said the medication was changed to “up to” three times a day on 02/21/25. Tizanidine 4 mg three times a day listed on the profile sheet. Patient #11 stated she takes the medication twice a day. Valsartan-hydrochlorothiazide 160/25 mg was listed two times a day. Patient #11 said she takes it once a day. Glucophage 500 mg one tablet twice a day was not on the medication profile. The prescription was filled 02/28/25. The DON verified the medication profile was not up to date. 2. Record review revealed Patient #15 started care on 01/16/16. Diagnoses included hypertension and osteoarthritis. During a home visit on 04/22/25 at 2:19 P.M., Patient #15 had a medication profile on his table next to his medications. Review of his medication list revealed potassium 10 mg once a day starting on 03/18/25. Observation 04/22/25 at 2:00 P.M. of the prescription bottle revealed the prescription bottle contained potassium 10 milliequivalents (meq), not milligrams as listed on the medication profile. During an interview on 04/22/25 at 2:09 P.M., Patient #15 and Staff L, the home health aide, verified the prescription read milliequivalents, not milligrams. 3. Record review revealed Patient #19 started care on 01/30/19. Diagnoses included type 2 diabetes, hypertension and neuromuscular dysfunction. During a home visit on 04/22/25 at 10:41 A.M., Registered Nurse (RN) Staff O placed the patients prescriptions on the table with the medication profile sheet the staff and patient had in the home. Reconciliation with RN Staff O revealed Acetaminophen 500 mg every eight hours as needed was on Patient #19’s list, but not the agency’s list. Advair Diskus inhalation one puff twice a day was on the medication profile, but Patient #19 did not have the medication. The patient had Fluticasone Propionate 250/50 once a day instead. Staff O indicated the insurance would not pay for the Advair. Albuteral inhalation aerosal solution 90 mcg/activation two puffs four times a day for shortness of breath was on the list. RN Staff O stated Patient #19 takes the medication twice a day. Atorvastatin Calcium 40 mg daily, Donepezil 10 mg two tablets a day and Luvox 50 mg two pills in the morning and one pill in the evening were not on the patient’s copy of the medication list. Guaifenex SR oral extended release 12 hours 400mg twice a day was on the list, but RN Staff O stated the medication was given as needed, not twice a day, The medication was not on the patient’s copy of the medication list. There was a prescription for Lasix 80 mg tablet one daily. RN Staff O said he administers 40 mg a day. Staff O indicated the dosage had been changed. The medication was not on either medication list. Hydrochlorothiazide was on the medication list provided. Staff O stated the medication had been discontinued. Jardiance 10 mg daily was on the agency’s list, but was not on the patient’s copy of the medication list. Melatonin 3 mg every night was on the medication list provided. RN Staff O stated the medication was administered as needed. Polyethylene glycol 3350 oral powder 17 Grams daily was listed. Staff O stated the medication was administered as needed, not daily. RN Staff O stated the Spiriva Handihaler inhalation capsule 18 mcg two inhalations on the medication lust had been discontinued. Trazamine 100 mg nightly listed on the medication list was discontinued per RN Staff O. Tamsulosin 0.4 mg one capsule a day, filled on 02/18/25, was not on either medication profile list. Ventolin HFA inhalation two puffs twice a day listed on the medication profile was discontinued per RN Staff O. The medication profile list included Vitamin B12 1000 mcg one daily. The bottle of Vitamin B12 in the home was 5000 iniernational units (iu). The medication was not on the patient’s copy of the medication list. Vitamin D2 50 mcg/2000 iu daily was on the provided medication list. RN Staff O stated the patient did not take Vitamin D2, he takes Vitamin D3. Vitamin E Blend 200 units per day was on the medication list. Staff O stated the patient does not take Vitamin E. Patient #19 had prescriptions for Azelastane nasal spray twice a day, Omeprazole 40 mg a day, Vitamin D3 2000iu one a day and Carvedilol 6,25 mg twice a day that were not on the provided medication profile. During an interview 04/22/25 at 11:40 A.M., Registered Nurse Staff O verified the medication lists were not up to date.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge. This affected two (Patient’s #20 and #23) of two patients reviewed for discharge. Findings include: Record review revealed Patient #20 started care on 01/27/16. Diagnoses included type 2 diabetes, hypertension and wrist pain. Patient #20 was sent a 30 day discharge notice 12/02/24 due to the patient’s long term home health aide (HHA) finding another position. The facility was unable to find staff to provide her care due to her distance from the facility. The last day services were provided was 12/30/24. A discharge OASIS was completed 12/31/24. There was not a discharge summary developed. There was no evidence of the physician being sent a discharge summary. 2. Record review revealed Patient #23 started care on 10/12/20. Diagnoses included chronic migraine, hypertension, sleep apnea, and neurofibromatosis. On 02/07/25 the facility was sent a message from Patient #23’s case manager stating services ended 02/01/25. The patient went to another agency. There was not a discharge summary developed. There was no evidence of the physician being sent a discharge summary. During an interview on 04/29/25 at 11:42 A.M., the Director of Nursing stated a discharge summary was not completed and sent to the physician.”