Materelli Home Health Services, Inc.

“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 review and update of a community-based risk assessment (All Hazards Risk Assessment) every two years for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment dated 04/03/23. On 04/23/26 at 11:15 a.m., Staff A stated the agency had not reviewed and updated the risk assessment since 2023.”

“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 the emergency preparedness communication plan included contact information for Local, State, Regional and Federal resources for the agency for all patients and employees. Findings: A review of emergency preparedness plan records showed no contact information for Local, State, Regional and Federal resources. On 04/23/26 at 11:15 p.m., Staff A stated the communication plan did not include the contact information of resources 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 contact information for employees and physicians that worked with the agency for all patients and employees. Findings: A review of emergency preparedness plan records showed no communication plan that included employee and physician contact information. On 04/23/26 at 11:15 p.m., Staff A stated the active employee call list and the patient information roster that identified the physicians were not included in the communication plan.”

“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 analysis, decision making and follow up monitoring of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative records showed no analysis; decision making and follow up monitoring of QAPI data in the agency’s QAPI program for calendar years 2024 and 2025. On 04/23/26 at 11:45 a.m., Staff A stated the QA reports did not document how the data was reviewed and acted upon 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 the initiation and review of a PIP for all patients and employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar years 2024 and 2025. On 04/23/26 at 11:45 a.m., Staff A stated the agency did not have performance project in 2024 and 2025.”

“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 was included in QAPI activities in 2024 and 2025 for all patients and employees. Findings: A review of QAPI program records showed no infection control surveillance data from 10/15/24 to 12/31/24 and 01/01/25 to 10/20/25. On 04/23/26 at 11:45 a.m., Staff A stated the infection logs were not reported through the agency’s QAPI program for all of 2024 and 2025.”

“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 board oversight for calendar years 2024 and 2025. Findings: A review of the governing board’s records showed no oversight of an operating budget, capital expenditure plan and allocation of resources activities and review and approval of a patient centered QAPI Program in calendar years 2024 and 2025. On 04/23/26 at 11:30 a.m., Staff A stated: 1.The governing board is just the two of us (names withheld, Staff A and B). 2.The last governing board meeting was on 04/04/23.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notices were provided prior to discharge from services to three (Patients #4, 5, and #9) of 10 patients. Findings: Patient #4 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 11/01/25 for no payor source authorization for services. On 04/23/26 at 10:50 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge. Patient #5 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 12/11/25 for no payor source authorization for services. On 04/23/26 at 11:15 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge. Patient #9 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 12/11/25 for no payor source authorization for services. On 04/23/26 at 11:20 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge.”

“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 an evaluation for home care services was conducted within 48 hours of referral for two (Patients #1 and #3) of 10 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 03/03/26 and the evaluation for home care services (SOC assessment) occurred on 03/13/26 (10 days) and showed no patient refusal of evaluation, no physician notification of a delay in evaluation and no change in physician orders. On 04/23/26 at 10:50 a.m., Staff A stated the evaluation was late and there was no documentation of why it was delayed. Patient #3 A review of the clinical record showed the agency received referral information on 09/17/25 and the evaluation for home care services (SOC assessment) occurred on 09/20/25 (three days) and showed no patient refusal of evaluation, no physician notification of a delay in evaluation and no change in physician orders. On 04/23/26 at 11:00 a.m., Staff A stated the evaluation was late and there was no documentation of why it was delayed.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a recertification OASIS was completed every 60 days for two (Patients #2 and #3) of 10 patients. Findings: Patient #2 A review of the clinical record showed the patient was admitted to the agency on 12/29/25 and showed no recertification OASIS for a continued episode of care for the certification period of 02/27/26 to 04/27/26. On 04/23/26 at 10:55 a.m., Staff A stated: 1.The OASIS assessment was not completed. 2.They did not need to do that because they were not billing Medicare. Patient #3 A review of the clinical record showed the patient was admitted to the agency on 09/17/25 and showed no recertification OASIS for a continued episode of care for the certification period of 03/19/26 to 05/17/26. On 04/23/26 at 11:00 a.m., Staff A stated: 1.The OASIS assessment was not completed. 2.They did not need to do that because they were not billing Medicare.”

“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 an individualized patient POC was developed and implemented every 60 days for two (Patients #2 and #3) of 10 patients. Findings: Patient #2 A review of the clinical record showed the patient was admitted to the agency on 12/29/25 and showed no recertification POC was developed and implemented for the certification period of 02/27/26 to 04/27/26. On 04/23/26 at 10:55 a.m., Staff A stated the POC was not completed for the certification period of 02/27/26 to 04/27/26. Patient #3 A review of the clinical record showed the patient was admitted to the agency on 09/17/25 and showed no recertification POC was developed and implemented for the certification period of 03/19/26 to 05/17/26. On 04/23/26 at 11:00 a.m., Staff A stated the POC was not completed for the certification period of 03/19/26 to 05/17/26.”

“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.Physical therapy and Occupational therapy evaluations were conducted as ordered by the physician for one (Patient #6) of 10 patients. 2.SN monitored the weight of patients every visit as ordered by the physician for two (Patients #9 and #10) of 10 patients. 3.SN monitored the fingerstick blood sugar of patient every visit as ordered by the physician for one (Patient #9) of 10 patients. Findings: Patient #6 A review of the clinical record for the certification period of 10/28/25 to 12/26/25 showed a physician order dated 12/11/25 for PT at a frequency of one time a week for one week and OT at a frequency of one time a week for one week to evaluate and establish treatment plans. The clinical record showed no PT and OT evaluations were conducted and showed no refusal of evaluations by the patient, no notification to the physician and no changes in physician orders. On 04/23/26 at 11:15 a.m., Staff A stated the patient did not have the therapy evaluations before the inpatient hospital transfer on 12/22/25. Patient #9 A review of the POC 10/28/25 to 12/26/25 showed orders for the SN to monitor the patient’s weight and finger stick blood sugar results every visit and report readings outside of reporting parameters to the physician. SN visit notes dated 10/29/25, 10/30/25, 11/03/25, 11/05/25, 11/21/25, 11/24/25 and 11/25/25 showed no weight monitoring was conducted during the visits and showed no patient refusal to weigh. SN visit notes dated 11/05/25 showed no finger stick blood sugar monitoring was conducted during the visit and showed no patient refusal of finger stick blood sugar. On 04/23/26 at 11:20 p.m., Staff A stated the SN should have monitored the patient’s weight and finger stick blood sugar every visit. Patient #10 A review of the POC 10/08/25 to 12/06/25 showed orders for the SN to monitor the patient’s weight every visit and report readings outside of reporting parameters to the physician. SN visit notes dated 10/16/25, 10/23/25, 10/31/25, 11/06/25, 11/13/25, 11/20/25 and 11/25/25 showed no weight monitoring was conducted during the visits and showed no patient refusal to weigh. On 04/23/26 at 11:25 p.m., Staff A stated the SN should have monitored the patient’s weight every visit”

“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 complete for three (Patients #1, 2 and #3) of 10 patients. Findings: Patient #1 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 03/19/26, 03/26/26, 04/02/26, 04/09/26 and 04/16/26. On 04/23/26 at 10:50 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits. Patient #2 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 03/04/26, 03/11/26, 03/18/26, 03/25/26, 04/01/26, 04/08/26 and 04/15/26. On 04/23/26 at 10:55 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits. Patient #3 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 01/13/26, 01/20/26, 01/27/26, 02/03/26, 02/10/26, 02/17/26 and 02/24/26. On 04/23/26 at 11:00 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits.”