Companion Home Health, LLC

“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 interviews, the agency failed to ensure performance improvement project for the agency in calendar year 2024 and 01/01/25 to 06/03/25 showed baseline or threshold measurements to identify measurable outcomes in PIP activity for 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and #11) and all employees. Findings: A review of QAPI Program documentation showed no performance improvement project measurable goals (baseline or threshold levels) for calendar year 2024 and 01/01/25 to 06/03/25 QAPI activities. On 06/04/25 at 1:15 p.m., Staff B stated the agency had no QAPI PIP documentation which showed baseline or threshold measurements for calendar year 2024 and 01/01/25 to 06/03/25 QAPI activities.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information for complaint and grievance procedures was a part of the admission packet information for three (Patients #2, 3 and #6) of 11 patients. Findings: A review of start of care packets showed no agency administrator’s name and contact information for complaint and grievance procedures for the agency. Patient #2 On 06/04/25 at 8:30 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #3 On 06/04/25 at 8:45 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #6 On 06/04/25 at 9:00 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. On 04/04/25 at 1:20 p.m., Staff B reviewed the start of care patient information and stated the administrator’s name and contact information was not in the information given to patients at the time of admission to the agency for patients #2, 3 and #6.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Physician notification the agency could no longer meet the patient needs prior to discharge for three (Patients #9, 10 and #11) of 11 patients. 2. Arrange transfer of care to another care entity for three (Patients #9, 10 and #11) of 11 patients. Findings: Patient #9 A review of a POC for 11/30/24 to 01/20/25 showed a SN visit frequency of one time a week for one week, effective 11/30/25 and one time a day for one day, effective 01/22/25 for assessment, monitoring and teaching of blood sugar and pain management. The POC showed orders for SN to conduct foley catheter change 18 French/10 cubic centimeters every month due week of 01/31/25. The POC showed a physical therapy visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week for physical therapy evaluation and treatment. A review of a communication note dated 01/22/25 stated the patient was being discharged to hospice care services. A review of clinical documentation showed no communication with the ordering provider of discharge from home care services and showed no coordination of care with the hospice to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. On 06/04/25 at 1:48 p.m., Staff C stated: 1. The SN did not communicate with the ordering provider that the patient was being discharged from the agency to hospice services. 2. The agency showed no coordination of care with the hospice to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. Patient #10 A review of a POC for 02/19/25 to 04/04/25 showed a SN visit frequency of one time a week for one week, then one time a week for eight weeks for assessment, monitoring and teaching of blood sugar and pain management; and physical therapy visit frequency of one time a week for one week, two times a week for four weeks, one time a week for one week, then two times a week for two weeks for physical therapy evaluation and treatment. Documentation showed a discharge reason as “other”, showed no communication with the ordering medical provider to notify the patient was being discharged from home care services and showed no arrangement with another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 04/04/25. On 06/04/25 at 1:56 p.m., Staff C stated: 1. The SN did not communicate with the physician that the patient was being discharged from the agency. 2. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 04/04/25. Patient #11 A review of a POC for 11/08/24 to 01/06/25 showed a SN visit frequency of one time a week for three weeks, then one to two times a month for two months for assessment, monitoring and teaching of pain management; and physical therapy visit frequency of one time a week for five weeks for physical therapy evaluation and treatment. A review of a quick note (a communication note) dated 01/02/25 stated the patient was being discharged due to a change in payor source. Documentation showed no communication with the ordering medical provider to notify the patient was being discharged from home care services and showed no arrangement with another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 01/02/25. On 06/04/25 at 2:00 p.m., Staff C stated: 1. The SN did not communicate with the physician that the patient was being discharged from the agency. 2. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 04/04/25.”

“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 included: 1. A a specific SN visit frequency and duration for one (Patient #2) of 11 patients. 2. Blood sugar reporting parameters for one (Patient #5) of 11 patients. 3. pain reporting parameters for one (Patients #5, 6, 7 and #11) of 11 patients. 4. wound site goals for one (Patient #6) of 11 patients. 5. SN catheter treatment/interventions or last changed/treatment due date for urinary catheter management for one (Patient #7) of 11 patients. Findings: Patient #2 A review of the POC dated 03/28/25 to 05/26/25 showed orders for SN to conduct assessment and teaching of patient health conditions and medications every visit. A review of clinical documentation showed a SN visit range with a frequency and duration of one to two times a month times two months on the POC. Documentation showed SN visits were conducted on 04/24/25 (SOC) and on 05/21/25. Documentation showed no patient refusal of visits, no physician notifications and no change in orders. On 06/04/25 at 11:55 a.m., Staff C stated the POC for patient #2 should have included an individualized SN visit frequency and duration to meet the patient’s care needs. Patient #5 A review of the POC dated 04/06/25 to 06/04/25 showed orders for SN one time a week for nine weeks to conduct assessment, monitoring and teaching of patient blood sugar and pain levels every visit. A review of clinical documentation showed no blood sugar or pain physician reporting parameters on the POC. Documentation showed SN visits were conducted on 04/11/25, 04/16/25, 04/29/25, 05/06/25, 05/12/25, 05/20/24 and on 05/27/25 and showed no patient blood sugar monitoring results and no reported pain levels. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s blood sugar or pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 12:07 p.m., Staff C stated the POC for patient #5 should have included blood sugar and pain physician reporting parameters. Patient #6 A review of the POC dated 04/13/25 to 06/11/25 showed orders for SN one time a week for eight weeks to conduct assessment, monitoring, intervention and teaching of patient pain levels and wound site care every visit. A review of clinical documentation showed no pain physician reporting parameters or wound site goals on the POC. Documentation showed SN visits were conducted on 04/14/25, 04/30/25, 05/06/25, 05/13/25, 05/21/24 and on 05/28/25 showed no patient reported pain levels and showed the patient complained of increased pain. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:05 p.m., Staff C stated the POC for patient #6 should have included pain physician reporting parameters and wound site goals for patient #6. Patient #7 A review of the POC dated 05/10/25 to 07/08/25 showed orders for SN one time a day for one day, one time a week for two weeks then one to two times a week for eight weeks to conduct assessment, monitoring, intervention and teaching of patient pain levels every visit and SN to conduct foley catheter 16 French/10 cubic centimeters every month. A review of clinical documentation showed SN visits were conducted on 05/13/25, 05/15/25, 05/19/25, 05/23/25 and on 05/28/25 showed no patient reported pain levels and no foley catheter intervention was conducted. Documentation showed no pain physician reporting parameters or foley catheter intervention last changed or monthly change due date on the POC. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:08 p.m., Staff C stated the POC should have included pain physician reporting parameters and foley catheter intervention last changed or monthly change due date for patient #7. Patient #11 A review of the POC dated 11/08/24 to 01/06/25 showed orders for SN to conduct assessment and teaching of patient pain management every visit. A review of clinical documentation showed no physician pain management reporting parameters on the POC. Documentation showed SN visits were conducted on 11/12/25, 11/20/24, 12/06/24 and on 12/19/24 showed no patient reported pain levels. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:10 a.m., Staff C stated the POC should have included physician pain management reporting parameters for patient #11.”

“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: 1. SN monitored the patient’s blood pressure every visit as ordered for one (Patient #1) of 11 patients. 2. SN monitored a patient’s blood sugar every visit as ordered for one (Patient #1) of 11 patients. 3. PT conducted visits as ordered for one (Patient #2) of 11 patients. 4. SN conducted visits as ordered for three (Patients #5, 6 and #8) of 11 patients. 5. MSW conducted a visit as ordered for one (Patient #7) of 11 patients. 6. SN conducted foley catheter change intervention as ordered for one (Patient #9) of 11 patients. Findings: Patient #1 A review of the POC dated 03/28/25 to 05/26/25 showed orders for SN one time a week for eight weeks to assess and instruct the patients’ blood pressure and blood sugar every visit. SN to report to physician blood pressure of greater than 160/90. · A review of SN visits on 04/02/25, 04/03/25, 04/08/25, 04/15/24, 04/22/25, 04/29/25, 05/06/25 and on 05/13/25 showed no blood sugar monitoring interventions. · 04/08/25 blood pressure reading of 174/80, 04/10/25 blood pressure reading of 178/72 and on 04/17/25 blood pressure reading of 162/70 were not reported to the physician. Documentation showed no patient or caregiver refusal of blood pressure result reporting or blood sugar monitoring, no physician notification and no changes in orders. On 06/04/25 at 11:42 a.m., Staff C stated: 1. The SN visit notes dated 04/02/25, 04/03/25, 04/08/25, 04/15/24, 04/22/25, 04/29/25, 05/06/25 and 05/13/25 showed no blood sugar monitoring interventions. 2. The SN visit notes dated 04/08/25 blood pressure reading of 174/80, 04/10/25 blood pressure reading of 178/72 and 04/17/25 blood pressure reading of 162/70 were not reported to the physician. Patient #2 A review of the POC dated 04/24/25 to 06/22/25 showed orders for PT to evaluate and treat with a frequency and duration of two times a week for five weeks. A review of visit notes for the week of 05/18/25 to 05/24/25 showed a missed PT visit on 05/23/25 (two visits ordered, no visit conducted) and during the week of 05/25/25 to 05/31/25 no PT visits were conducted (two visits ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 06/04/25 at 11:55 a.m., Staff A stated the PT visits should have been conducted as ordered on the POC. Patient #5 A review of the POC dated 04/06/25 to 06/04/25 showed orders for SN one time a week for nine weeks. A review of visit notes for the week of 04/20/25 to 04/26/25 showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 12:07 p.m., Staff C stated the SN visits should have been conducted as ordered on the POC. Patient #6 A review of the POC dated 04/13/25 to 06/11/25 showed orders for SN one time a week for eight weeks. A review of visit notes for the week of 04/20/25 to 04/26/25, showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:05 p.m., Staff D stated the SN visits should have been conducted as ordered on the POC. Patient #7 A review of the POC dated 05/10/25 to 07/08/25 showed orders for MSW one time a day for one day on 05/20/25. A review of visit notes showed no MSW visit on 05/20/25 (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:37 p.m., Staff A stated no MSW visits had been conducted for patient #7. Patient #8 A review of the POC dated 01/24/25 to 03/24/25 showed orders for SN one time a week for nine weeks. A review of visit notes for the week of 03/02/25 to 03/08/25, showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:44 p.m., Staff C stated the SN visits should have been conducted as ordered on the POC. Patient #9 A review of the POC dated 11/30/24 to 01/28/25 showed orders for SN to conduct foley catheter intervention monthly, due on 01/31/25 (two months). A SN visit note dated 12/02/24 stated the monthly foley catheter change was completed. SN visit notes dated 12/10/24, 12/16/24, 12/24/24, 12/31/24, 01/07/25, 01/13/25, and 01/21/25 showed no foley catheter change was conducted. Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 06/04/25 at 1:48 p.m., Staff C stated monthly foley catheter change should have been conducted by the SN as ordered on the POC.”

“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 interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving providers for two (Patients #8 and #9) of 11 patients. Findings: Patient #8 A review of the clinical record showed transfer from the agency on 03/19/25 to inpatient hospital services with subsequent discharge from the agency on 03/23/25. A review of clinical documentation showed no transfer and/or discharge summary was provided to the receiving inpatient hospital service provider. Patient #9 A review of the clinical record showed discharge from the agency on 01/22/25 to hospice services. A review of clinical documentation showed no discharge summary was provided to the receiving hospice provider and no discharge summary was provided to the ordering physician. On 06/04/25 at 1:48 p.m., Staff C stated no transfer or discharge summaries for patients #8 and #9 were sent to the receiving providers or the ordering physician.”