A Path of Care Home Health VI, LLC

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Emergency contacts and resources phone list had updated contact information for all 193 patients and all employees. Findings: A review of the Emergency Preparedness Program showed a list of local, Federal and State emergency personnel with their contact information which showed a date of 05/19/23. On 05/12/26 at 3:30 p.m., Staff A stated the list was printed 05/19/23 and they were unable to provide the current 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 assessment was completed within 48 hours of referral for one (Pt #2) of eight patients. Findings: Pt #2 A review of the clinical record showed the start of care assessment was completed 07/16/24. The physician’s referral was dated 07/11/24. 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 showed why the admission was completed five days after the referral. On 05/13/26 at 1:14 p.m., Staff B stated the start of care assessment was delayed.”

“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 to an assisted living facility for one (Pt #6) of three patients residing in assisted living facilities. Findings: Pt #6 A review of the resident record at the assisted living facility showed no current plan of care for the certification period of 04/30/26 to 06/28/26. On 05/13/26 at 9:30 a.m., Staff #1 (assisted living facility) stated they did not receive a copy of the current plan of care.”

“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 #3) of seven patients receiving CHHA services. Findings: Pt #3 A plan of care dated 03/23/26 to 05/21/26 showed orders for CHHA services twice a week for nine weeks. Documentation showed an RN supervisor visit was completed 12/29/25. No other CHHA supervisory visits were completed through 05/12/26 (42 days since the last CHHA supervisory visit was completed). On 05/13/26 at 1:31 pm, Staff A stated there were no aide supervisory visits after 03/30/26.”