Health Watch Health Care of Duncan, LLC

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a phone list had contact information for current employees for all 185 patients and employees. Findings: A review of the Emergency Preparedness Program showed a list of staff names and telephone numbers. The current administrator and alternate administrator’s names and telephone numbers did not appear on the list. On 01/22/26 at 11:00 a.m., Staff B stated the administrator, and alternate administrator’s names and telephone numbers did not appear on the list.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial start of care assessments were completed within 48 hours of referral for two (Pt #5 and 10) of thirteen patients. Findings: Pt #5 A physician’s order dated 11/10/25 ordered the start of care effective 11/12/25. Clinical documentation showed the start of care assessment completed 11/13/25. The clinical record showed no refusal by the patient or caregiver for a start of care within 48 hours of referral, no physician’s order for a delayed start of care, and no coordination note why the admission was completed three days after the referral and a day after the ordered start of care. Pt#10 Clinical documentation showed a referral received 07/30/25 and no initial start of care assessment until 08/02/25. The clinical record showed no refusal by the patient or caregiver for a start of care within 48 hours of referral, no physician’s order for a delayed start of care, and no coordination note why the admission was completed three days after the referral. On 01/22/26 at 11:52 a.m., Staff be stated there is no reason documented for the start of care assessments not being completed within 48 hours of referral.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current POC was provided assisted living facilities for three (Pt #4, 5, and 6) of six patients residing in an assisted living facilities. Findings: Pt #4 A review of the home health agency record at the assisted living showed no current plan of care for the certification period of 01/13/26 - 03/13/26. The only plan of care available was dated 09/14/25 - 11/12/25. Pt #5 A review of the home health agency record at the assisted living showed no plan of care for the certification period of 01/11/26 - 03/11/26. Pt #6 A review of the home health agency record at the assisted living showed no current plan of care for the certification period of 12/14/25 - 02/11/26. The only plan of care available was dated 10/15/25 - 12/13/25. On 01/22/26 at 08:50 a.m., Assisted Living Staff E stated we do not have a current plan of care for Pt # 6. On 01/22/26 at 09:30 a.m., Assisted Living Staff D stated we do not have a current plan of care for Pt #4 and 5.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the CHHA supervisory visits were completed for one (Pt # 6) of 5 patients receiving CHHA services. Findings: Pt #6 A plan of care dated 12/14/25 - 02/11/26 showed orders for a CHHA once a week for nine weeks. Documentation showed an RN supervisory visit completed 12/29/25. No other supervisory visits were completed through 01/22/26 (one should have been completed 01/12/26). On 01/22/26 at 12:00 p.m., Staff A stated only one supervisory visit had been completed since 12/14/25.”