Venerate Home Health Express, LLC

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the Emergency Preparedness Plan had policies and procedures for patient data management and information sharing for all patients and employees. Findings: A review of emergency preparedness records showed no Emergency Preparedness Plan policies and procedures for patient data management and information sharing On 03/26/26 at 9:40 a.m., Staff A stated the agency had no emergency preparedness policy for patient information sharing.”

“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 its Emergency Preparedness communication plan included current employee and physician contact information for all patients and employees. Findings: A review of emergency preparedness records showed no communication plan which included current employee and physician contact information. On 03/26/26 at 9:40 a.m., Staff A stated the emergency preparedness plan did not include contact information for current employees and the patient’s physicians.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency preparedness training program was developed, implemented and reviewed at least annually for all employees. Findings: A review of emergency preparedness records showed no emergency preparedness plan training program for employees. On 03/26/26 at 9:40 a.m., Staff A stated the agency had no emergency preparedness training program.”

“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 reviews and interviews, the agency failed to ensure transfer or discharge summaries were completed for two (Patients #3 and #4) of nine patients. Findings: An agency policy titled, “Discharge, Transfer of Patients” stated any discharge or transfer of patients shall occur ensuring that information is communicated to promote positive patient outcomes. Within 48 hours of transfer to in patient care or with discharge a summary will be completed and sent to the physician ordering care and to the receiving service provider. Patient #3 A review of the clinical record showed the patient was transferred to in-patient hospital services on 03/05/26 and showed no transfer summary was completed. On 03/26/26 at 9:23 a.m., Staff B stated a transfer summary was not completed. Patient #4 A review of the clinical record showed the patient was discharged from agency services on 05/14/24 and showed no discharge. On 03/26/26 at 9:35 a.m., Staff B stated a discharge summary was not completed.”

“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 the QAPI Program included patient indicator data for all patients and employees. Findings: An agency policy, titled “Organizational Performance Improvement Plan” stated the agency organizational plan will continually improve performance of key functions and processes relative to patient care by collecting data to monitor performance and utilize reports generated from OASIS data. A review of QAPI program records showed no patient indicator data was utilized in the QAPI program for calendar years 2024 and 2025. On 03/26/26 at 9:45 a.m., Staff B stated the QAPI program did not use patient OASIS data in 2024 and 2025.”

“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 baseline and goal measurements of the QAPI performance improvement projects for all patients and employees. Findings: A review of QAPI records showed no PIP baseline and goal measurements in calendar years 2024 and 2025. On 03/26/26 at 9:45 a.m., Staff A stated the PIPs in 2024 and 2025 showed no measurable goals.”

“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 patient centered QAPI Program activities for all patients and employees. Findings: An agency policy, titled Quality Assessment and Performance Improvement, stated the governing body is responsible for ensuring ongoing QAPI program efforts address priorities for improved quality of care and patient safety and improvement actions are evaluated. A review of governing body meeting minutes showed no oversite in the conduction of QAPI Program for calendar years 2024 and 2025. On 03/26/26 at 9:45 a.m., Staff A stated the governing body did not oversee the QAPI Program.”

“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 a POC included a SN visit frequency duration for four (Patients #1, 2, 3 and #4) of nine patients. Findings: Patient #1 A review of a POC dated 03/04/26 to 05/02/26 showed a SN visit frequency of one time a week and showed no duration of service. On 03/26/26 at 9:20 a.m., Staff B stated the POC did not include the length of time the patient was going to have SN visits. Patient #2 A review of a POC dated 01/31/26 to 03/31/26 showed a SN visit frequency of one time a week and showed no duration of service. On 03/26/26 at 9:22 a.m., Staff B stated the POC did not include the length of time the patient was going to have SN visits. Patient #3 A review of a POC dated 01/13/26 to 03/13/26 showed a SN visit frequency of one time a week and showed no duration of service. On 03/26/26 at 9:23 a.m., Staff B stated the POC did not include the length of time the patient was going to have SN visits. Patient #4 A review of a POC dated 03/16/24 to 05/14/24 showed a SN visit frequency of one time a week and showed no duration of service. On 03/26/26 at 9:35 a.m., Staff B stated the POC did not include the length of time the patient was going to have SN visits.”

“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 a transfer or discharge summary was provided to the receiving service providers for two (Patients #3 and #4) of nine patients. Findings: An agency policy titled, “Discharge, Transfer of Patients” stated any discharge or transfer of patients shall occur ensuring that information is communicated to promote positive patient outcomes. Within 48 hours of transfer to in patient care or with discharge a summary will be completed and sent to the physician ordering care and to the receiving service provider. Patient #3 A review of the clinical record showed a transfer from the agency on 03/05/26 to inpatient hospital services and showed no coordination of care and no transfer summary was provided to the hospital provider or to the ordering physician. On 03/26/26 at 9:23 a.m., Staff B stated no transfer summary was provided to the hospital or the physician. Patient #4 A review of the clinical record showed a discharge from the agency on 05/14/24 and showed no coordination of care and no discharge summary was provided to the physician. On 03/26/26 at 9:35 a.m., Staff B stated the discharge summary was not provided to the physician.”