Heart Care at Home, LLC

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of patient rights and responsibilities were available for review for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect the ability of all patients, caregivers and family members to effectively understand their rights and responsibilities while receiving home care services. See tag G418. Based on record reviews and interviews, the agency failed to ensure patient consent for the provision of agency care and services were obtained for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to violate the patient right to informed consent in the planning of and participation in services and care for all patients. See tag G434. Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to five (Patients #1, 2, 3, 5 and #7) of seven patients. The failed practice had the potential to violate the patients’ right to informed notice of discharge from home health care prior to their discharge from agency services for all patients. See tag G456. Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to five (Patients #1, 2, 3, 5 and #7) of seven patients. The failed practice had the potential to violate the patients’ right to informed notice of discharge from home health care prior to their discharge from agency services for all patients. See tag G464. See deficient practice statements for tags G418, G434, G456, G464”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive assessment (OASIS) was conducted at SOC for one (Patients #1) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs for all patients. See Tag G528. Based on record review and interview, the agency failed to ensure a medication profile was completed for ordered medications for two (Patients #1 and #2) of seven patients. The failed practice had the potential to impact the patient’s safety by not identifying and cross-referencing medications for allergies, duplications and contraindications services for all patients. See Tag G536. Based on record review and interview, the agency failed to ensure a discharge assessment (OASIS) was completed for four (Patients #1, 2, 6 and #7) of seven patients. The failed practice had the potential to impact the coordination of follow up care affecting patient outcomes for all patients. See Tag G550. See deficient practice statements for tags G528, G536, G550”

“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 and interview, the agency failed to ensure development of an episodic certification Plan of Care for three (Patients #1, 2 and #6) of seven patients. The failed practice had the potential to affect the ability of the agency to identify and address a patient’s health care needs and interventions to achieve health improvements and outcomes for all patients. See tag G572. Based on record review and interview, the agency failed to ensure individualized patient POC for four (Patients #3, 5, 6 and #7) of seven patients. This failed practice had the potential to affect the health and health care outcomes of patients that required skilled care interventions to improve their health status. See tag G574. Based on record review and interview, the agency failed to ensure a physician order for wound site care interventions as a part of the patient’s plan of care for one (Patient #2) of seven patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve management of health conditions for all patients. See tag G576. Based on record review and interview, the agency failed to ensure timely notification and physician opportunity to review and revise individualized POCs every 60 days for four (Patients #3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect timely implementation of physician orders of skilled care interventions that improve the health status for all patients. See tag G588. See deficient practice statements for tags G572, G574, G576 and G588.”

“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 record review and interview, the agency failed to ensure evidence of a patient centered QAPI program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G642. Based on record review and interview, the agency failed to ensure utilization of QAPI data in calendar years 2023 and 2024 and from 01/01/25 to 11/24/25 to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See tag G644. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI activities included follow-up for self-monitoring for outcomes, improved care, services and operations for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. See tag G646. Based on record review and interview, the agency failed to ensure a performance improvement project for the agency from 07/02/23 to 12/31/23, calendar year 2024 and 01/01/25 to 11/24/25 for all patients and employees. This failed practice had the potential to place the agency, its patients and all employees at risk for stagnated efforts for improvement because of unidentified problematic clinical, administrative, infection control or personnel problems. See tag G658. Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program for 09/05/24 to 12/31/24 and 01/01/25 to 11/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See tag G660. See deficient practice statements for tags G642, G644, G646, G658 and G660.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were maintained in their entirety and accessible for two (Patients #1 and #2) of seven patients. This failed practice had the potential to affect the care and safety of services delivered to the patients. See tag G1012. Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for one (Patient #7) of seven patients. The failed practice had the potential to affect the care of service discipline interventions delivered to the patients. See tag G1014. Based on record reviews and interview, the agency failed to ensure a completed transfer with discharge summary was provided to the receiving service provider for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect care transition outcomes for all patients. See tag G1022. See deficient practice statements for tags G1012, G1014 and G1022.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was updated for the agency for all patients and employees. Findings: A review of emergency preparedness records showed a community-based risk assessment for the agency dated 06/27/22. On 11/24/25 at 11:00 a.m., Staff A stated the agency did not update the community based all hazards risk assessment.”

“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 an Emergency Preparedness Communication Plan included current employee contact information for the agency for all patients and employees. Findings: A review of emergency preparedness records showed a communication plan with contact information of people no longer employed by the agency. On 11/24/25 at 11:00 a.m., Staff A stated the emergency preparedness communication plan had not been updated with contact information for current employees of the agency.”

“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 agency failed to ensure completion of a discharge summary for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. Findings: Patient #1 At 11:00 a.m., a review of the patient roster for the agency showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the clinical record showed a start of care date of 10/26/24. The clinical record showed no discharge from agency services; no discharge OASIS assessment and no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. No discharge summary was completed. Patient #3 A review of the clinical record showed a start of care date of 06/02/25 and a discharge date of 06/27/25. The clinical record showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was completed. Patient #5 A review of the clinical record showed a start of care date of 03/18/25 and a discharge date of 03/31/25. The clinical record showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was completed. Patient #6 A review of the clinical record showed a start of care date of 04/19/19. The clinical record showed the patient was transferred to in-patient facility services on 10/07/24 but showed no transfer with discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no transfer with discharge summary was completed. Patient #7 A review of the clinical record showed a start of care date of 08/10/24. The clinical record showed that the patient was discharged to other home health provider on 10/08/24 but showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was completed.”

“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 and interview, the agency failed to ensure development of a Plan of Care for three (Patients #1, 2 and #6) of seven patients. The failed practice had the potential to affect the ability of the agency to identify and address a patient’s health care needs and interventions to achieve health improvements and outcomes for all patients. Findings: Patient #1 A review of the patient roster for the agency showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the clinical record showed no POC for certification period of 10/26/24 to 12/24/24. The clinical record showed no physician notifications or communication notes and no eMR entries of physician orders. On 11/24/24 at 11:45 a.m., Staff A stated: 1. The patient did not have a plan of care. 2. The agency received faxed orders from the wound clinic in Fort Smith, Arkansas. Patient #6 A review of the clinical record showed a blank POC for certification period of 09/19/24 to 11/17/24. The clinical record showed no physician notifications or communication notes and no eMR entries of physician orders. On 11/24/24 at 11:45 a.m., Staff A stated the patient did not have a plan of care.”

“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 record review and interview, the agency failed to ensure evidence of a patient centered QAPI program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: A review of QAPI program records showed no QAPI program activities which showed measurements, analysis, tracking or evaluation of data (scope) for the agency’s improvement in calendar years 2023 and 2024 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff A stated: 1. The agency prepared quarterly reports for the calendar year 2023, 2024 and 01/01/25 to 11/24/25. 2. The QAPI meeting minutes showed no improvement measurements, analysis, tracking or evaluation of the data by the agency. 3. The agency had no QAPI activity from 09/06/24 to 12/31/24 and 01/01/25 to 11/24/25.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization of QAPI data in calendar years 2023, 2024 and 01/01/25 to 11/24/25 to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of QAPI records showed no data collection sources or activities utilized in the analysis of data in the agency’s QAPI Program for calendar years 2023, 2024 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff A stated: 1. All QAPI program records were provided. 2. The records showed no program improvement data sources or analysis of the data.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI activities included follow-up for self-monitoring for outcomes, improved care, services and operations for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. Findings: A review of QAPI records for calendar year 2023, 2024 and 01/01/25 to 11/24/25 showed no patient centered QAPI program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services, and operations. On 11/24/25 at 11:30 a.m., Staff A stated: 1. All QAPI program records were provided. 2. The records did not have patient centered activities that included follow up of identified problems or outcomes.”

“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 agency failed to ensure a performance improvement project for the agency from 07/02/23 to 12/31/23, calendar year 2024 and 01/01/25 to 11/24/25 for all patients and employees. This failed practice had the potential to place the agency, its patients and all employees at risk for stagnated efforts for improvement because of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI records showed no performance improvement project for the agency from 07/02/23 to 12/31/23, calendar year 2024 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff A stated the agency did not have a QAPI PIP since concluding the project on urinary tract infections on 07/01/23.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program from 09/05/24 to 12/31/24 and 01/01/25 to 11/24/25 for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: A review of governing body meeting minute records showed no governing body oversite of a patient centered QAPI program for the agency from 09/05/24 to 12/31/24 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff A stated governing body meeting minute records did not show oversite of the QAPI program from 09/05/24 to 12/31/24 and 01/01/25 to 11/24/25.”

“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 record review and interview, the agency failed to ensure the Infection Control program surveillance data was included in QAPI program activities for all patients and employees. Findings: A review of QAPI records showed no infection control surveillance data through the QAPI program for calendar years 2023, 2024 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff B stated infection surveillance activities were not reported through the agency’s QAPI program.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of patient rights and responsibilities were available for review for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect the ability of all patients, caregivers and family members to effectively understand their rights and responsibilities while receiving home care services. Findings: On 11/24/25 at 9:00 a.m., an agency admission packet with client forms was requested. No admission packet was provided. At 11:00 a.m., the eMR for patients #1, 2, 3, 5, 6 and #7 were reviewed. No patient rights and responsibilities signature form were present. At 11:45 a.m., patient rights and responsibilities signature form for patients #1, 2, 3, 5, 6 and #7 were requested. No forms were provided. Staff A stated: 1. The admission records which showed patient receipt/acknowledgement of rights and responsibilities should have been attached to the patients’ electronic records after the start of care was completed. 2. The paper records of patients #1, 2, 3, 5, 6 and #7 were not available for survey.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure patient consent for the provision of agency care and services were obtained for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to violate the patient right to informed consent in the planning of and participation in services and care for all patients. Findings: On 11/24/25 at 11:00 a.m., the eMR for patients #1, 2, 3, 5, 6 and #7 were reviewed. No consent signature forms were present. At 11:45 a.m., patient consent signature forms for patients #1, 2, 3, 5, 6 and #7 were requested. No forms were provided. Staff A stated: 1. The admission records which showed patient consent for care and services should have been attached to the patients’ electronic records after the start of care was completed. 2. The paper records of patients #1, 2, 3, 5, 6 and #7 were not available for survey.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to five (Patients #1, 2, 3, 5 and #7) of seven patients. The failed practice had the potential to violate the patients’ right to informed notice of discharge from home health care prior to their discharge from agency services for all patients. Findings: Patient #1 A review of the patient roster for the agency showed the patient had a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the clinical record showed no advance notice of discharge or home health change of care notice and no physician communications prior to discharge from the agency on 12/07/24 for no additional orders for services. On 11/24/25 at 11:45 a.m., Staff A stated the patient did not receive notice of discharge prior to being discharged from the agency for no additional orders for services. Patient #3 A review of the clinical record showed no advance notice of discharge or home health change of care notice and no physician communications prior to discharge from the agency on 06/27/25 for no payer source for services. On 11/24/25 at 11:45 a.m., Staff A stated the patient did not receive a notice of discharge prior to being discharged from the agency for no payer source for services (no insurance authorization). Patient #5 A review of the clinical record showed no advance notice of discharge or home health change of care notice and no physician communications prior to discharge from the agency on 03/31/25 for no payer source for services. On 11/24/25 at 11:45 a.m., Staff A stated the patient did not receive a notice of discharge prior to being discharged from the agency for no payer source for services (no insurance authorization). Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice and no physician communications prior to discharge from the agency on 10/08/24 for no payer source for services. On 11/24/25 at 11:45 a.m., Staff A stated the patient did not receive a notice of discharge prior to being discharged from the agency for no payer source for services (no insurance authorization).”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive assessment (OASIS) was conducted at SOC for one (Patients #1) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs for all patients. Findings: Patient #1 At 11:00 a.m., the patient showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review.”

“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 and interview, the agency failed to ensure a medication profile was completed for ordered medications for two (Patients #1 and #2) of seven patients. The failed practice had the potential to impact the patient’s safety by not identifying and cross-referencing medications for allergies, duplications and contraindications services for all patients. Findings: Patient #1 At 11:00 a.m., the patient showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the Plan of Care dated 10/26/24 to 12/24/24 showed no medication profile and no list of medications were cross-referenced for allergies and/or drug incompatibilities by an RN. The eMR showed no medication profile (list), no patient refusal of medication assessment, no physician notifications, and no change in orders. On 11/24/25 at 11:45 a.m., Staff A stated: 1. The eMR showed no medication profile and no list of medication. 2. A list of medications should have been collected and cross referenced for allergies and/or drug incompatibility by an RN at the SOC.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge assessment (OASIS) was completed for four (Patients #1, 2, 6 and #7) of seven patients. The failed practice had the potential to impact the coordination of follow up care affecting patient outcomes for all patients. Findings: Patient #1 At 11:00 a.m., a review of the active patient roster for the agency showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the clinical record showed a start of care date of 10/26/24. The clinical record showed no discharge from agency services; no discharge OASIS assessment was conducted and no change in orders. On 11/24/25 at 11:45 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. No discharge OASIS was completed. Patient #6 A review of the clinical record showed a start of care date of 04/19/19. The clinical record showed the patient was transferred to in-patient facility services on 10/07/24 but showed no transfer with discharge from agency services; no transfer/discharge OASIS assessment was conducted and no change in orders. On 11/24/25 at 11:45 a.m., Staff A stated no transfer with discharge OASIS was completed. Patient #7 A review of the clinical record showed a start of care date of 08/10/24. The clinical record showed that the patient was discharged to other home health provider on 10/08/24 but showed no discharge from agency services; no discharge OASIS assessment was conducted and no change in orders. On 11/24/25 at 11:45 a.m., Staff A stated no discharge OASIS was completed.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC for four (Patients #3, 5, 6 and #7) of seven patients. This failed practice had the potential to affect the health and health care outcomes of patients that required skilled care interventions to improve their health status. Findings: Patient #3 A review of the POC dated 06/02/25 to 07/31/25 showed no diagnoses, no skilled intervention treatment due date for Vitamin B12 injection medication administration, no pain reporting parameters and no goals. On 11/24/25 at 11:45 a.m., Staff A stated the POC did not include diagnoses, intervention treatment due dates, pain reporting parameters or patient goals. Patient #5 A review of the POC dated 03/18/25 to 05/16/25 showed no patient goals. On 11/24/25 at 11:45 a.m., Staff A stated the POC did not include goals. Patient #6 A review of the POC dated 09/19/24 to 10/07/24 showed no diagnoses, no orders, no medications and no goals. On 11/24/25 at 11:45 a.m., Staff A stated the POC did not include diagnoses, no orders, no medications and no patient goals. Patient #7 A review of the POC dated 08/10/24 to 10/08/24 showed no diagnoses, no skilled intervention treatment due dates for urinary catheter management, no pain reporting parameters and no goals. On 11/24/25 at 11:45 a.m., Staff A stated the POC did not include diagnoses, intervention treatment due dates, pain reporting parameters or patient goals.”

“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 record review and interview, the agency failed to ensure a physician order for wound site care interventions as a part of the patient’s plan of care for one (Patient #2) of seven patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve management of health conditions for all patients. Findings: Patient #2 A review of the POC dated 10/26/24 to 12/24/24 showed no orders for wound care interventions. The clinical record showed wound care orders were sent to the agency from a wound clinic in Fort Smith, Arkansas. The orders were not entered into the patient’s eMR. On 11/24/25 at 11:45 a.m., Staff A stated the POC for patient #2 showed no physician order transcription into the clinical record, no physician notifications, and no changes in orders.”

“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 and interview, the agency failed to ensure timely notification and physician opportunity to review and revise individualized POCs every 60 days for four (Patients #3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect timely implementation of physician orders of skilled care interventions that improve the health status for all patients. Findings: Patient #3 A review of the clinical record showed a SOC date of 06/02/25 with a POC of 06/02/25 to 07/31/25. The POC showed no attempts to send to the physician for signature, no communication notes and no physician notification. On 11/24/25 at 11:45 a.m., Staff A stated there was no POC signed by the physician for patient #3. Patient #5 A review of the clinical record showed an SOC date of 03/18/25 with a POC of 03/18/25 to 05/16/25. The POC showed no attempts to send to the physician for signature, no communication notes and no physician notification. On 11/24/25 at 11:45 a.m., Staff A stated there was no POC signed by the physician for patient #5. Patient #6 A review of the clinical record showed a SOC date of 04/19/19 with a POC of 09/19/24 to 10/07/24. The POC showed no attempts to send to the physician for signature, no communication notes and no physician notification. On 11/24/25 at 11:45 a.m., Staff A stated there was no POC signed by the physician for patient #6. Patient #7 A review of the clinical record showed a SOC date of 08/10/24 with a POC of 08/10/24 to 10/08/24. The POC showed no attempts to send to the physician for signature, no communication notes and no physician notification. On 11/24/25 at 11:45 a.m., Staff A stated there was no POC signed by the physician for patient #7.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: PT evaluation was conducted as ordered for one (Patient #5) of seven patients. OT evaluation was conducted for one (Patient #5) of seven patients. SN conducted urinary catheter change every month as ordered for one (Patient #7) of seven patients. Findings: Patient #5 A review of the POC dated 03/18/25 to 05/16/25 showed orders for PT to evaluate and treat one time for one week, OT to evaluate and treat one time for one week. The clinical record showed a PT and OT evaluation were due during the week of 03/18/25 to 03/22/25 (two visits ordered, no visits conducted) and showed no patient/caregiver refusal of visits, no physician notification, and no changes in orders. The clinical record showed a PT evaluation was conducted on 03/26/25 and showed no OT evaluation during the episodic period. On 11/24/25 at 11:45 a.m., Staff A stated the PT and OT evaluations should have been conducted as ordered on the POC. Patient #7 A review of the POC dated 08/10/24 to 10/08/24 showed orders for SN to change urinary catheter every month with a SN visit frequency of one time a week for two weeks, then once every two weeks times seven days. The clinical record showed no urinary catheter changes during SN visits conducted on 09/12/24 and 10/08/24 and showed no patient/caregiver refusal, no physician notifications, and no change in orders. On 11/24/25 at 11:45 a.m., Staff A stated the SN should have changed the urinary catheter during the SN visits on 09/12/24 and 10/08/24.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of QAPI records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2023, 2024 and 01/01/25 to 11/24/25. On 11/24/25 at 11:30 a.m., Staff A stated QAPI program activities had no multi-disciplined skilled professional staff participation.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were maintained in their entirety and accessible for two (Patients #1 and #2) of seven patients. This failed practice had the potential to affect the care and safety of services delivered to the patients. Findings: Patient #1 A review of a patient roster for the agency showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of a patient roster for the agency showed a start of care date of 10/26/24. A clinical record for patient #2 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:05 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for one (Patient #7) of seven patients. The failed practice had the potential to affect the care of service discipline interventions delivered to the patients. Findings: Patient #7 A review of the POC dated 08/10/24 to 10/08/24 showed orders for SN to change urinary catheter every month with a SN visit frequency of one time a week for two weeks, then once every two weeks times seven days. The clinical record showed no SN visit notes for visits conducted on 09/12/24 and 10/08/24 and showed no urinary catheter change was conducted. On 11/24/25 at 11:45 a.m., Staff A stated the SN should have completed SN visit notes on 09/12/24 and 10/08/24.”

“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 reviews and interview, the agency failed to ensure a completed transfer with discharge summary was provided to the receiving service provider for six (Patients #1, 2, 3, 5, 6 and #7) of seven patients. The failed practice had the potential to affect care transition outcomes for all patients. Findings: Patient #1 A review of a patient roster for the agency showed a start of care date of 11/22/24. A clinical record for patient #1 was requested. No electronic or paper clinical record was accessible for review. On 11/24/25 at 11:00 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. The agency had no current patients on services. 3. The patient had no electronic or paper clinical record accessible for review. Patient #2 A review of the clinical record showed a start of care date of 10/26/24. The clinical record showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated: 1. The patient showed up as an active patient on the agency roster but was discharged some time ago. 2. No discharge summary was provided to the physician. Patient #3 A review of the clinical record showed a start of care date of 06/02/25 and a discharge date of 06/27/25. The clinical record showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was provided to the physician. Patient #5 A review of the clinical record showed a start of care date of 03/18/25 and a discharge date of 03/31/25. The clinical record showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was provided to the physician. Patient #6 A review of the clinical record showed a start of care date of 04/19/19. The clinical record showed the patient was transferred to in-patient facility services on 10/07/24 but showed no transfer with discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no transfer with discharge summary was provided to the physician or in-patient facility. Patient #7 A review of the clinical record showed a start of care date of 08/10/24. The clinical record showed that the patient was discharged to other home health provider on 10/08/24 but showed no discharge summary was completed. On 11/24/25 at 11:45 a.m., Staff A stated no discharge summary was provided to the physician or receiving home health service provider.”