Welcome Back Home Care, Inc.

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and contact information for an integrated emergency preparedness response with Federal, State, Tribal and Regional emergency management officials for all patients and employees. Findings: A review of emergency preparedness records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal and Regional emergency management officials for the agency. On 09/30/25 at 10:30 a.m., Staff A stated the agency did not have processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal and Regional emergency management officials for the agency.”

“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 no communication plan with current employee contact information for the agency. On 09/30/25 at 10:30 a.m., Staff A stated the emergency preparedness communication plan did not include contact information for current employees of the agency.”

“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 a performance improvement project for the agency in calendar years 2024 and 01/01/25 to 08/31/25 for all patients and employees. Findings: A review of QAPI Program records showed no performance improvement project for the agency in calendar years 2024 and 01/01/25 to 08/31/25. On 09/30/25 at 10:45 a.m., Staff A stated: 1. The agency did not have a QAPI performance improvement project in calendar year 2024 and from 01/01/25 to 08/31/25. 2. A performance improvement project was put into place on 09/02/25 when the current administration took over the agency.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the agency’s program evaluation, budget and capital expenditure authorization, and QAPI plan approval from the agency’s acquisition date of 09/01/25 for all patients and employees. Findings: A review of governing body meeting records showed no governing body oversite of the sale of the agency effective 09/01/25 and showed no program evaluation, budget and capital expenditure authorization or QAPI plan approval from the agency’s acquisition date of 09/01/25. On 09/30/25 at 10:25 a.m., Staff A stated: 1. The governing body meeting minutes showed no governing body oversite of the agency’s sale prior to 09/01/25. 2. The agency had no governing body meeting minutes that showed governing body oversite for the agency from the acquisition date of 09/01/25.”

“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 POCs for SN treatment interventions for urinary catheter management included last changed or due date of treatment interventions for two (Patients #2 and #3) of eight patients. Findings: Patient #2 A review of the POC dated 08/13/25 to 10/11/25 showed orders for SN to perform urinary management intervention of 18 French /10 cubic centimeter catheter change every two weeks. The POC did not identify a last changed or due date of the intervention and showed no physician notifications and no change in orders. On 09/30/25 at 11:17 a.m., Staff H stated the POC did not identify a last changed date or due date for the catheter change. Patient #3 A review of the POC dated 08/09/25 to 10/07/25 showed orders for SN to perform urinary management intervention of 16 French /10 cubic centimeter catheter change every four weeks. The POC did not identify a last changed or due date of the intervention and showed no physician notifications and no change in orders. On 09/30/25 at 11:32 a.m., Staff H stated the POC did not identify a last changed date or due date for the catheter change.”

“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 physician orders were a part of the patient POC for one (Patient #4) of eight patients. Findings: Patient #4 A review of the POC dated 07/25/25 to 09/22/25 showed orders for SN to conduct wound site care interventions to: 1. Right and left great toes, and left heel: cleanse with normal saline and VASHE cleanser, apply Santyl and hydrofera blue, and cover with an ABD pad and Kerlex dressing material. 2. Right heel: cleanse with normal saline and VASHE cleanser, apply betadine solution and cover with an ABD pad and Kerlex dressing material. · SN visit notes dated 07/25/25, 08/01/25, 08/04/25, 08/08/25, 08/15/25, 08/22/25, 08/26/25, 08/29/25, 09/05/25, 09/08/25, 09/12/25 and 09/19/25 showed no wound site care interventions to the right and left great toes. · SN visit notes dated 07/28/25, 08/04/25, 08/08/25, 08/15/25, 08/22/25, 08/26/25 and 08/29/25 showed no documentation that Santyl was applied to the wound site to the left heel. · A SN visit note dated 08/01/25 documented Medi-honey and alginate were applied to the wound site to the right heel. The POC showed no physician notifications and no changes in orders. On 09/30/25 at 11:36 a.m., Staff H stated: 1. The agency received orders from the Wound Clinic on 07/23/25 to discontinue the Santyl and to the left and right heel, discontinue the hydrofera blue to the left heel and apply Medi-honey and alginate to the right heel. 2. The agency did not receive orders to discontinue the wound site intervention to the right and left great toes. 3. The wound clinic orders were attached to the EMR but were not entered into the patient’s POC.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for two (Patients #2 and #4) of eight patients. Findings: Patient #2 A review of a plan of care dated 08/13/25 to 10/11/25 showed a primary diagnosis of neuromuscular dysfunction of the bladder and showed a SN visit frequency of once every other week for eight weeks to manage and change the urinary catheter. SN visit notes dated 08/21/25, 09/04/25 and 09/16/25 showed no urinary catheter change was conducted during the SN visits. The clinical record showed no physician notifications and no changes in the orders. On 09/30/25 at 11:17 a.m., Staff H stated: 1. The patient had a suprapubic catheter placed on 08/20/25 and the urologist was changing out the catheter. 2. The agency did not receive orders to discontinue the catheter changes, and the physician was notified to discontinue the orders on the POC. Patient #4 A review of the POC dated 07/25/25 to 09/22/25 showed a primary diagnosis of Diabetes Mellitus Type II with a foot ulcer and showed a SN visit frequency of two times a week for nine weeks for SN to conduct wound site care interventions to the right and left great toes, left heel and right heel. SN visit notes dated 07/25/25, 08/01/25, 08/04/25, 08/08/25, 08/15/25, 08/22/25, 08/26/25, 08/29/25, 09/05/25, 09/08/25, 09/12/25 and 09/19/25 showed no wound site care interventions to the right and left great toes and showed no physician notifications and no changes in orders. On 09/30/25 at 11:36 a.m., Staff H stated: 1. The agency received orders from the Wound Clinic on 07/23/25 to change the wound care interventions to the left and right heel. 2. The agency did not receive orders to discontinue the wound site interventions to the right and left great toes. 3. The Wound Clinic was not contacted to verify orders to discontinue the wound site interventions to the right and left great toes.”

“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 the SN reported to the physician blood sugar readings outside of reporting parameters for one (Patient #1) of eight patients. Findings: Patient #1 A review of the POC dated 08/11/25 to 10/09/25 showed orders for SN to assess and report the patient’s blood sugar levels less than 60 every visit. A SN visit note dated 09/09/25 showed that the patient reported blood sugar levels from 52 to 300 over a week’s period with symptoms of lightheadedness. A communication note to the physician dated 09/09/25 showed the patient was experiencing audible respiratory wheezing but did not report the blood sugar levels of 52 to 300 with symptoms of lightheadedness. The clinical record showed no follow-up physician notification and no change in orders. On 09/30/25 at 11:04 a.m., Staff H stated the patient’s reported blood sugar levels were not reported to the physician.”

“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 #3) of eight patients. Findings: Patient #3 A review of the POC dated 08/09/25 to 10/07/25 showed orders for SN to perform a venipuncture lab draw and collect a urine specimen for urinalysis. The clinical record showed no SN visit note for the 08/28/25 visit date. A communication note dated 08/28/25 stated the nurse performed a venipuncture for the lab draw, collected the urine specimen and delivered the specimens to a laboratory. The communication note did not document the SN patient assessment, venipuncture procedure or patient response of the intervention. On 09/30/25 at 11:32 a.m., Staff H stated: 1. There was not a SN visit note for 08/28/25. 2. Visits for lab draws are not billable. 3. We do not document non-billable visits as SN visits.”