Conemaugh Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on review of agency policies/procedures, medical records, and an interview with the agency administrator, it was determined that the agency failed to ensure patient’s received appropriate care planning, coordination of services, and quality of care. This Condition is not met as evidenced under the following standards: Cross Reference: 0570 Care Planning, Coordination, Quality of Care-484.60 0574 Plan Of Care Must Include The Following -484.60(a)(2)(i-xvi) 0576 All Orders Recorded In Plan of Care -484.60(a)(3) 0590 Promptly Alert Relevant Physician of Changes -484.60(c)(1) 0606 Integrate All services – 484.60 (d)(3)”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on a review of agency complaint documentation, plan of care and staff (EMP) interview it was determined that the agency did not report safety issues timely to the Department of Health Event Reporting System (ERS) related for two (2) of two (2) events reviewed (MR1 and MR2). Findings Included: Focused review of the agency policy 7/2/2025 at approximately 10:28 AM revealed, “PATIETN ABUSE, ESXPLOITATION, AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING…PURPOSE: To identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect. POLICY: By law, health care providers are mandated to report cases of actual or suspected abuse an/or neglect. Agency employees/contracts will be aware of signs and symptoms indicating possible abuse, neglect, and/or exploitation. Staff/contractors identify and assess patients for actual or suspected abuse and/or neglect and report such incidents to agency supervisor and the appropriate community/state agency. DEFFINITIONS: A. Adult Abuse The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish to elderly or disabled person. Abuse may be verbal, mental, sexual, or physical and includes abuse facilitated or enabled through the use of technology…E. Misappropriation of Property, Theft or stealing of items from a patient’s home…J. Child Abuse * Mental or emotional injury to a child that results in observable and material impairment in a child’s growth, development or psychological functioning; Causing or permitting the child to be in a situation in which the child sustains a mental or emotional injury that results in an observable and material impairment in the child’s growth, development, or psychological functioning; physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from physical injury to the child, including an injury that is at variance with the history are explanation given and excluding an accident or reasonable discipline by a parent, guardian, or managing possessory conservator that does not expose the child to a substantial risk of harm; * Failure to make reasonable effort to prevent an action by another person that results in substantial harm to the child; * Sexual conduct harmful to the child’s mental, emotional, or physical welfare; failure to make reasonable effort to prevent sexual conduct harmful to a child; obscene photograph, film, or depiction of the child *Compelling or encouraging a child to engage in sexual conduct *Causing, permitting, encouraging, engaging in, or allowing the photographing, filming, or depiction of the child as obscene or pornographic; * The current use by a person of a controlled substance in a manner or to the extent that the use results in physical, mental, or emotional injury to a child *Causing, expressively permitting, or encouraging a child to use a controlled substance K. Child Neglect: *Leaving a child in a situation where the child would be exposed to a substantial risk of physical or mental harm, without arranging for necessary care for the child, and the demonstration of intent not to return by a parent, guardian, or managing or possessor conservation of the child; the following acts or omissions by a person; *Placing a child in or failing to remove a child from a situation that a reasonable person would realize requires judgment or actions beyond the child’s level of maturity, physical condition, or mental abilities and that results in bodily injury or substantial risk of immediate harm to the child; *Failing to seek, obtain, or follow through with medical care for a child, with the failure resulting in or presenting a substantial risk of death, disfigurement, or bodily injury or with the failure result in in an observable and material impairment to the growth, development, or functioning of the child; * Failing to provide a child with food, clothing or shelter necessary to sustain life or health of the child, excluding failure cause primarily by financial inability unless relief services had been offered and refused; or *Placing a child in or failing to remove that child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child; or * The failure by the person responsible for a child’s care, custody, or welfare to permit the child to return to the child’s home without arranging for the necessary care for the child after the child has been absent from the home for any reason, including having been in residential placement or having run away…PROCEDURE: 1. Agency staff/contractor/volunteer will immediately report and document the assessment of the patient’s condition which might indicate abuse, neglect, and/or exploitation to state agency supervisor and appropriate community agency. The agency or staff members will not implement retaliatory action against any individual who reports suspected patient abuse, neglect, and/or exploitation. Focused review of the agency policy on 7/2/2025 at approximately 10:25 AM revealed, “Sentinel Event…POLICY: The agency shall review all unexpected patient events in accordance with the agency’s ongoing performance improvement program, and in conjunction with current state regulations and The Joint Commission Standards. In the course of this process, when a potential Sentinel Event or an event at high risk for causing a Sentinel Event (near miss) is identified, a Sentinel Event review will be initiated under the direction of management. In Pennsylvania, events which seriously compromise quality assurance or patient safety, will be reported by the Executive Director/Clinical Director to the Department of Health at https://sais.hnelath.pa.gov/Incidents/Facilitylogin.asp within 24 hours of occurrence or discovery. Events compromising quality assurance or patient safety may include, but are not limited to: *Deaths due to injuries (if agency staff were on the premise at time of injury), suicide or unusual circumstances *Death due to malnutrition, dehydration, or sepsis *Elopement *Transfer to a hospital as a result of an injury or accident (if agency staff were on the premises at time of injury or accident)*Complaint of patient abuse, whether or not confirmed by the facility*Rape *Hemolytic transfusion reaction *Significant disruption of service due to disaster such as fire, storm, flood, or other occurrence * Notification of termination of any services vital to the continued safe operation of the facility or the health and safety of its patients and personnel, including but not limited to actual termination of electric, gas, steam heat, water, sewer and local exchange telephone service *Unlicensed practice of a regulated profession…” Focused review of the State reporting procedures on 7/15/2025 at approximately 11:00 AM revealed, “Report Child Abuse or Neglect as a Mandated Reporter | Commonwealth of Pennsylvania When must a mandated reporter make a report? A mandated reporter must make a report of suspected child abuse or neglect through the Child Welfare Portal or by calling ChildLine at 1-800-932-0313 if they have reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances: The mandated reporter comes into contact with the child in the course of employment, occupation and practice of a profession or through a regularly scheduled program, activity or service;The mandated reporter is directly responsible for the care, supervision, guidance or training of the child, or is affiliated with an agency, institution, organization, school, regularly established church or religious organization or other entity that is directly responsible for the care, supervision, guidance or training of the child;A person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse. This specific circumstance includes when a mandated reporter is “on” or “off” the clock; or,An individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse.Mandated reporters must make this report even if the child themselves did not disclose the suspected abuse. You do not have to have direct contact with the child to make a report.” A review of MR1 was conducted on 7/2/2025 at approximately 2:05 PM, start of care 4/12/2025 which revealed the following. An ERS Report was submitted to the Pennsylvania Department of Health Event Reporting System on 5/21/2025 relating to MR1 pertaining to misappropriation of patient/resident property. Within the report a minor was identified with possible suspected abuse. The report was submitted to county Office of aging APS (Adult Protective Services) on 5/21/2025. A report was not made to ChildLine services until 6/17/2025. The agency policy reviewed on 7/2/2025 at approximately 10:28 AM list staff “will immediately report and document the assessment of the patient’s condition which might indicate abuse, neglect, and/or exploitation to state agency supervisor and appropriate community agency.” Upon review of the agency policy and procedures the surveyor could not identify a listing or resource for agency staff to identify and report to the appropriate state agency supervisor or community agency related to minors. A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. An ERS Report was submitted to the Pennsylvania Department of Health Event Reporting System on 4/17/2025 pertaining to MR2. The report was identified as a sentinel event. The report was submitted by the agency on 4/22/2025. Per agency policy “In Pennsylvania, events which seriously compromise quality assurance or patient safety, will be reported by the Executive Director/Clinical Director to the Department of Health at https://sais.hnelath.pa.gov/Incidents/Facilitylogin.asp within 24 hours of occurrence or discovery.” EMP1 confirmed on 7/3/2025 at approximately 10:55 AM a report was not submitted to the Department’s Event Reporting System (ERS) within 24 hours. An interview was conducted on 7/8/2025 at approximately 1:20 PM with the executive director, confirmed the above information.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to maintain an accurate medication profile and to ensure review of potential adverse effects for two (2) of four (4) MR reviewed (MR1 and MR2). Findings included: Focused review of the department policy on 7/15/2025 at approximately 9:05 AM revealed, “MONITORING MEDICATIONS…POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manger…The physician is contacted immediately if any discrepancies between agency information and patient medications are found. All clinicians will have immediate access to current drug books and/or current web based programs. PROCEDURES: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana (in states where legalized)…c. The clinician will notify the physician of any of the above as warranted. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies; ii. Collaborate with Patient Care Manager/care manager as needed…4. The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization. The agency will provide the patient or the transferring or accepting organization a complete reconciled medication list upon discharge or transfer…” A review of MR1 was conducted on 7/2/2025 at approximately 2:05 PM, start of care 4/12/2025 which revealed the following. Certification period 4/12/2025 to 6/10/2025 with a primary diagnosis aftercare following joint replacement surgery. A second certification period for MR1 was started 5/28/2025 to 7/26/2025. Upon review of the two plans of care, under the plan of care starting 4/12/2025 listed “Allergies: HYDROMORPHONE…” The plan of care starting 5/28/2025 listed under section “Allergies: NKA…” and listed on the “Client Medication Report…Client Allergies NKA…” The allergy information did not transfer from the original plan of care to the next certification period. A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. Certification period 4/10/2025 to 6/8/2025 with a primary diagnosis displaced bimalleolar fracture of right lower leg, subsequent encounter for a closed fracture with routine healing. MR2 also had the following diagnosis “…END STAGE RENAL DISEASE, DEPENDENCE ON RENAL DIALYSIS…LONG TERM (CURRENT) USE OF ANTIHROMBOTICS/ANTIPLATELETS…” Review of the plan of care was conducted on 7/2/2025 at approximately 2:20 PM revealed, “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Orders of discipline and Treatments…PRESENCE OF PERITONEAL DISALYSIS CATHETER, PATIENT PERFORMS OWN PERITONEAL DIALYSIS 4 TIMES PER WEEK, HAS BEEN DOING FOR APPROXIMATELY ONE YEAR.” Focused review of the agency investigation was conducted on 7/3/2025 approximately 10:22 AM revealed, Per investigation findings “Patient was scheduled to follow up with her kidney doctor on 4/17/2025 for an injection to increase RBC production.” Per review of the “Client Medication Report” (dated 7/2/2025) the surveyor could not confirm what injectable medication was to be provided to the patient. An interview was conducted on 7/8/2025 at approximately 1:20 PM with the executive director, confirmed the above information.”

“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 a review of agency policy, medical record (MR) and staff (EMP) interview the agency failed to ensure the patient’s plan of care included medication potential adverse effects and services for two (2) of four (4) MR reviewed, (MR1 and MR2). Findings included: Focused review of the department policy on 7/15/2025 at approximately 9:05 AM revealed, “MONITORING MEDICATIONS…POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manger…The physician is contacted immediately if any discrepancies between agency information and patient medications are found. All clinicians will have immediate access to current drug books and/or current web-based programs. PROCEDURES: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana (in states where legalized)…c. The clinician will notify the physician of any of the above as warranted. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies; ii. Collaborate with Patient Care Manager/care manager as needed…4. The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization. The agency will provide the patient or the transferring or accepting organization a complete reconciled medication list upon discharge or transfer…” Focused review of the department policy on 7/9/2025 at approximately 3:00 PM revealed, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE…POLICY: The agency provides care and services within an integrated continuum or care system. This is accomplished by: *Identifying patient needs through assessment and communication with other health care providers…5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: a. Avoidance of duplication of services b. Complementary goal between various disciplines c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these…6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual’s care is coordinated to ensure that patient’s needs are met efficiently, without duplication of services, including: a. Staff understanding the role and responsibilities of these healthcare providers b. Communication with other health care providers when there are significant changes in patient care and/or condition c. If and when conflicts and/or duplications arise, attempts are made to correct and reduce these situations…8. Coordination of Care for Updates to the Plan of Care: a. Revisions to the plan of acre due to a change in patient’s condition will be communicated to: i. Patient ii. Patient’s representative, if any iii. Caregiver iv. All physicians/authorized practitioner issuing orders, as applicable. The responsible physician/authorized practitioner will be notified of any orders from other physicians/authorized practitioner.” Focused review of the department policy on 7/17/2025 at approximately 12:40 PM revealed, “PLAN OF CARE (POC) PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. POLICY: Each patient has a individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: 1. A POC is developed for all patients and updated no less than every 60 days with the exception of some waiver patients that allow Plan of Care updates greater then 60 days. 2. The POC includes…b. Types, frequency, and duration of services required which may include virtual services…f. Medications and treatments…j. Required equipment and supplies…n. All patient care orders…3.The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior to providing services…6. Physician/authorized practitioner’s orders are obtained to update the POC and may include problems and goals. 7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. 8. Alterations to the POC are made only with the physician/authorized practitioner’s approval. A review of MR1 was conducted on 7/2/2025 at approximately 2:05 PM, start of care 4/12/2025 which revealed the following. Certification period 4/12/2025 to 6/10/2025 with a primary diagnosis aftercare following joint replacement surgery. A second certification period for MR1 was started 5/28/2025 to 7/26/2025. Upon review of the two plans of care, under the plan of care starting 4/12/2025 listed “Allergies: HYDROMORPHONE…” The plan of care starting 5/28/2025 listed under section “Allergies: NKA…” and listed on the “Client Medication Report…Client Allergies NKA…” The allergy information did not transfer from the original plan of care to the next certification period plan of care. A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. Certification period 4/10/2025 to 6/8/2025 with a primary diagnosis displaced bimalleolar fracture of right lower leg, subsequent encounter for a closed fracture with routine healing. MR2 also had the following diagnosis “…END STAGE RENAL DISEASE, DEPENDENCE ON RENAL DIALYSIS…LONG TERM (CURRENT) USE OF ANTIHROMBOTICS/ANTIPLATELETS…” Review of the plan of care was conducted on 7/2/2025 at approximately 2:20 PM revealed, “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Orders of discipline and Treatments…PRESENCE OF PERITONEAL DISALYSIS CATHETER, PATIENT PERFORMS OWN PERITONEAL DIALYSIS 4 TIMES PER WEEK, HAS BEEN DOING FOR APPROXIMATELY ONE YEAR.” Focused review of the agency investigation was conducted on 7/3/2025 approximately 10:22 AM revealed, Per investigation findings “Patient was scheduled to follow up with her kidney doctor on 4/17/2025 for an injection to increase RBC production.” Per review of the “Client Medication Report” (dated 7/2/2025) the surveyor could not confirm what injectable medication was to be provided to the patient or who the “kidney doctor” was providing services. A review of the plan of care was conducted 7/2/2025 at approximately 2:20 PM, under diagnoses section listed dependence on renal dialysis. The surveyor was unable to identify the dialysis provider from the documentation provided. An interview conducted with EMP1 the executive director on 7/3/2025 at approximately 1:00 PM confirmed the agency did not contact the dialysis center or nephrologist providing services to MR2. An interview was conducted on 7/8/2025 at approximately 1:20 PM with the executive director, confirmed the above information.”

“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 a review of agency policy, medical record (MR) and staff (EMP) interview the agency failed to the agency failed to ensure complete medication and treatment orders were included on initial “Home Health Certification and Plan of Care” for one (1) of four (4) MR reviewed, (MR2). Findings included: Focused review of the department policy on 7/17/2025 at approximately 12:40 PM revealed, “PLAN OF CARE (POC) PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. POLICY: Each patient has a individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: 1. A POC is developed for all patients and updated no less than every 60 days with the exception of some waiver patients that allow Plan of Care updates greater then 60 days. 2. The POC includes…b. Types, frequency, and duration of services required which may include virtual services…f. Medications and treatments…j. Required equipment and supplies…n. All patient care orders…3.The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior to providing services…6. Physician/authorized practitioner’s orders are obtained to update the POC and may include problems and goals. 7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. 8. Alterations to the POC are made only with the physician/authorized practitioner’s approval. Focused review of the department policy on 7/17/2025 at approximately 12:40 PM revealed, “PHYSICIAN ORDERS…POLICY: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner, or as designated by state practice Acts and that order be reduced to writing and signed/dated by the ordering physician. PROCEDURE: 9. If there are questions regarding an order or the order is not legible, it is the responsibility of the licensed clinician to seek clarification from the physician/authorized practitioner…” Focused review of the department policy on 7/9/2025 at approximately 3:00 PM revealed, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE…POLICY: The agency provides care and services within an integrated continuum or care system. This is accomplished by…6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual’s care is coordinated to ensure that patient’s needs are met efficiently, without duplication of services, including: a. Staff understanding the role and responsibilities of these healthcare providers b. Communication with other health care providers when there are significant changes in patient care and/or condition c. If and when conflicts and/or duplications arise, attempts are made to correct and reduce these situations…8. Coordination of Care for Updates to the Plan of Care: a. Revisions to the plan of acre due to a change in patient’s condition will be communicated to: i. Patient ii. Patient’s representative, if any iii. Caregiver iv. All physicians/authorized practitioner issuing orders, as applicable. The responsible physician/authorized practitioner will be notified of any orders from other physicians/authorized practitioner.” A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. Certification period 4/10/2025 to 6/8/2025 with a primary diagnosis displaced bimalleolar fracture of right lower leg, subsequent encounter for a closed fracture with routine healing. MR2 also had listed the following diagnosis “…END STAGE RENAL DISEASE, DEPENDENCE ON RENAL DIALYSIS…LONG TERM (CURRENT) USE OF ANTIHROMBOTICS/ANTIPLATELETS…” Review of the plan of care was conducted on 7/2/2025 at approximately 2:20 PM revealed, “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Orders of discipline and Treatments…PRESENCE OF PERITONEAL DISALYSIS CATHETER, PATIENT PERFORMS OWN PERITONEAL DIALYSIS 4 TIMES PER WEEK, HAS BEEN DOING FOR APPROXIMATELY ONE YEAR.” Focused review of the agency investigation was conducted on 7/3/2025 approximately 10:22 AM revealed, Per investigation findings “Patient was scheduled to follow up with her kidney doctor on 4/17/2025 for an injection to increase RBC production.” Per review of the “Client Medication Report” (dated 7/2/2025) the surveyor could not confirm what injectable medication was to be provided to the patient or who the “kidney doctor” was providing services. A review of the plan of care was conducted 7/2/2025 at approximately 2:20 PM, under diagnoses section listed dependence on renal dialysis. The surveyor was unable to identify the dialysis provider from the documentation provided. An interview conducted with EMP1 the executive director on 7/3/2025 at approximately 1:00 PM confirmed the agency did not contact the dialysis center or nephrologist providing services to MR2. An interview was conducted on 7/8/2025 at approximately 1:20 PM with the executive director, confirmed the above information.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of agency policy, medical record (MR) review and staff (EMP) interview the agency failed to ensure the physician was notified of changes in the patient’s condition for one (1) of four (4) MR reviewed. (MR2) Findings included: Focused review of the department policy on 7/9/2025 at approximately 3:00 PM revealed, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE…POLICY: The agency provides care and services within an integrated continuum or care system. This is accomplished by: *Identifying patient needs through assessment and communication with other health care providers. *Admitting only those patients whose health care needs can be met by the agency and making appropriate referrals to other organizations capable of meeting patient needs when the agency is unable to do so. Coordination patient care among various disciplines and between in-person and virtual clinicians to ensure that services are continuous and coordinated from admission through discharge. 2. During the course of care and services: a. The executive Director and Clinical Director coordinate patient care and services. b. To the greatest extent possible, patients receive care from a limited number of staff…4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment…d. When results of laboratory and other tests become available e. When there is a need to change the patient’s plan of care f. And at least every 60 days to review, revise, update, and/or continue the plan of care…In the event that a physician cannot be reached to communicate the status of a patient the following will occur: *Medical Director and/or Supervisor will be contacted for assistance with contacting physician/authorized practitioner *Patients with critical needs as determined by the clinician will be advised to seek emergency medical treatment 5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: a. Avoidance of duplication of services b. Complementary goal between various disciplines c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these…6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual’s care is coordinated to ensure that patient’s needs are met efficiently, without duplication of services, including: a. Staff understanding the role and responsibilities of these healthcare providers b. Communication with other health care providers when there are significant changes in patient care and/or condition c. If and when conflicts and/or duplications arise, attempts are made to correct and reduce these situations…8. Coordination of Care for Updates to the Plan of Care: a. Revisions to the plan of acre due to a change in patient’s condition will be communicated to: i. Patient ii. Patient’s representative, if any iii. Caregiver iv. All physicians/authorized practitioner issuing orders, as applicable. The responsible physician/authorized practitioner will be notified of any orders from other physicians/authorized practitioner.” Focused review of the department policy on 7/2/2025 at approximately 10:28 AM revealed, “ON-CALL PORCESS (TO INCLUDE DUREING AND AFTER HOURS CARE)…POLICY: The agency ensures that patients, caregivers, and/or their physicians, as well as referral sources and other health care providers, have access to a staff clinician 24 hours-a-day by means of providing an on-call nurse during and after office hours. A RN will be available at least by telephone while any services are provided. The leaders provide the framework for planning, direction, coordination, providing, and improving health care and services that respond to patient and community needs to improve patient health outcomes. PROCEDURE: 1. The agency will provide each client, upon admission to services, a designated on-call telephone number and will instruct each client to call this number to access care from the agency after regular business hours. 2. The agency shall identify the operating hours by posting contact information on the front door or applicable signage such that the public will know how and who to reach if no one is in the agency. 3. To ensure that a clinician can be contacted by telecommunications, during and after office hours, each agency will establish a call schedule for their offices. 4. The respective answering services will contact the on-call clinician immediately after the patient related call is received. The total response time for patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes. *For calls to answering services made (Agency) Personal Emergency response System (PERS), that are not emergent, (Agency)-PERS will: *Contact (Agency) office/answering service and leave message for clinician, to include patient name, phone number, and reason for button push. Answering service will be responsible for contacting on-call nurse for follow-up. *Inform subscriber/patient that if return call is not received by on-call nurse within 30 minutes, the Personal Help Button should be pressed again. 5. Clinicians will provide follow-up appropriate to the call via: *Telephonic intervention with the patient/caregiver *Perform onsite visit to the patient, if necessary *Obtain physician orders, as needed 6. A home visit from the clinician may be indicated when: *New onset of symptoms are reported *Exacerbation of symptoms are reported *Issue cannot be resolved via telephonic intervention *As ordered by the physician * If emergent care is deemed necessary and appropriate during he in-person visit, the nurse will remain with the patient until emergency services arrive and assume care of the patient. 7. Clinicians will document responses and outcomes of appropriate calls on the On-Call Coordination note. 8. Clinicians will submit the On-Call Coordination Note and any supporting patient documentation by next business day and verbally communicate all on-call issues to appropriate Executive Director/Clinical Director and/or Patient Care Manager. 9. The Executive Director/Clinical Director will assure that appropriate follow-up-visits are scheduled if needed. 10. On-call clinicians shall maintain an adequate car stock. 11. On-call clinicians shall utilize back-up administrator on-call as needed for questions, problems, or concerns. 12. The agency shall ensure that every opportunity shall be made for the live exchange or person to person exchange of on-call or patient information. This exchange of information can occur during report, at end or beginning of shift, or at any time the information is requested or needed.” Focused review of the agency job description on 7/2/2025 approximately 10:45 AM revealed, “Job Description Job Title: REGISTERED NURSE-HOME HEALTH…Job Summary: The Registered Nurse in Home Health Provides and directs provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations, and agency policies. The Registered Nurse coordinates total plan of care with other health care professionals involved in care and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. All done within a Point of care Setting. Essential Functions: 1. Clinical Competence *Initiates, develops, implements, and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care…3. Makes the initial and/or comprehensive nursing evaluation visit, ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source, accurately determines primary focus of care, develops the plan of care within State specific guidelines with the physician, and submits accurate documentation. Communicates relevant information timely and effectively with appropriate agency staff including but not limited to: any patient care issues or needs, visit assignments, dates of scheduled visits, and schedule changes to scheduler, orders and OASIS data sets, coding requests, schedule home visits, to coordinate care with other clinicians, Communicates timely and effectively with physicians, patients, and family members to ensure quality care and service excellence…” Focused review of the vendor service agreement was conducted on 7/3/2025 approximately 9:15 AM revealed, “EXHIBIT A (Vendor) ANSWERING SERVICE AND WEB PORTAL The following are the Terms and Conditions for RN Triage, also referred to as Clinical Answering Services…During the Term of this Agreement, Vendor shall provide patient/customer experience services, call routing, applications, and clinical answering services with the express authorization of designated client personnel. Vendor, if applicable, will consult and advise callers and/or caregivers (i.e., patients, customers, families, and/or staff at an outside facility where a patient may reside) per protocols established by Client and Vendor during implementation set up, as well as the ongoing needs of Client regarding same during the term…” A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. Certification period 4/10/2025 to 6/8/2025 with a primary diagnosis displaced bimalleolar fracture of right lower leg, subsequent encounter for a closed fracture with routine healing. MR2 also had listed the following diagnosis “…END STAGE RENAL DISEASE, DEPENDENCE ON RENAL DIALYSIS…LONG TERM (CURRENT) USE OF ANTIHROMBOTICS/ANTIPLATELETS…” Per lab results reviewed on 7/22/2025 at approximately 2:35 PM revealed MR2 results, “…CBC with Auto Differential reflex to Manual Differential, if abnormal…Hemoglobin Value 6.4 (LL) Ref Range 11.5-16.0 g/dl, Hematocrit Value 22 (L) Ref. Range 37-47%...Communication Logs CBC with Auto Differential reflex to Manual Differential, if abnormal 4/16/2025 1907 (EMP3) called by…Comment: The following critical results were read back and acknowledged. HGB 6.4 g/dL Low Critical (ref. Range: 11.5-16.0)…” Focused review of the agency investigation was conducted on 7/3/2025 approximately 10:22 AM revealed, On 4/16/25 at 19:31 on call nurse 2nd attempt made to contact patient…stated that…has had issues with…Hgb before, but it has never been that low…Instructed the patient to call back if…has any changes in symptoms or has any bright red bleeding. Patient did state that on 4/15/2025…started having black stools…denied iron supplements. Patient was scheduled to follow up with…kidney doctor on 4/17/2025 for an injection to increase RBC production and stated…would speak with MD then. On- call triage nurse instructed the patient to call back if…had any change in symptoms or has any bright red bleeding…” “On-call triage nurse did not phone PCP (primary care provider) office or the (Agency) nurse on call, with critical hemoglobin of 6.4 or recommended patient go to the emergency room or call 911…” A review of the findings was reviewed with the executive director, (via conference call) high impact quality and patient experience coordinator and survey and performance improvement manger on 7/8/2025 at approximately 1:11 PM confirmed the above information.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on review of agency policy, medical record (MR) review and staff (EMP) interview the agency failed to coordinate care of the patient related to services and medication(s) for one (1) of four (4) MR reviewed. (MR2) Findings Included: Focused review of the department policy on 7/9/2025 at approximately 3:00 PM revealed, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE…POLICY: The agency provides care and services within an integrated continuum or care system. This is accomplished by: *Identifying patient needs through assessment and communication with other health care providers. *Admitting only those patients whose health care needs can be met by the agency and making appropriate referrals to other organizations capable of meeting patient needs when the agency is unable to do so. Coordination patient care among various disciplines and between in-person and virtual clinicians to ensure that services are continuous and coordinated from admission through discharge. 2. During the course of care and services: a. The executive Director and Clinical Director coordinate patient care and services. b. To the greatest extent possible, patients receive care from a limited number of staff…4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment…d. When results of laboratory and other tests become available e. When there is a need to change the patient’s plan of care f. And at least every 60 days to review, revise, update, and/or continue the plan of care…In the event that a physician cannot be reached to communicate the status of a patient the following will occur: *Medical Director and/or Supervisor will be contacted for assistance with contacting physician/authorized practitioner *Patients with critical needs as determined by the clinician will be advised to seek emergency medical treatment 5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes: a. Avoidance of duplication of services b. Complementary goal between various disciplines c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these…6. Coordination of services with other organizations and community: When the patient receives services from other organizations and/or individual’s care is coordinated to ensure that patient’s needs are met efficiently, without duplication of services, including: a. Staff understanding the role and responsibilities of these healthcare providers b. Communication with other health care providers when there are significant changes in patient care and/or condition c. If and when conflicts and/or duplications arise, attempts are made to correct and reduce these situations…8. Coordination of Care for Updates to the Plan of Care: a. Revisions to the plan of acre due to a change in patient’s condition will be communicated to: i. Patient ii. Patient’s representative, if any iii. Caregiver iv. All physicians/authorized practitioner issuing orders, as applicable. The responsible physician/authorized practitioner will be notified of any orders from other physicians/authorized practitioner.” Focused review of the department policy on 7/17/2025 at approximately 12:40 PM revealed, “PLAN OF CARE (POC) PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. POLICY: Each patient has a individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: 1. A POC is developed for all patients and updated no less than every 60 days with the exception of some waiver patients that allow Plan of Care updates greater then 60 days. 2. The POC includes…b. Types, frequency, and duration of services required which may include virtual services…f. Medications and treatments…j. Required equipment and supplies…n. All patient care orders…3.The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior to providing services…6. Physician/authorized practitioner’s orders are obtained to update the POC and may include problems and goals. 7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. 8. Alterations to the POC are made only with the physician/authorized practitioner’s approval. Focused review of the department policy on 7/17/2025 at approximately 12:40 PM revealed, “PHYSICIAN ORDERS…POLICY: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner, or as designated by state practice Acts and that order be reduced to writing and signed/dated by the ordering physician. PROCEDURE: 9. If there are questions regarding an order or the order is not legible, it is the responsibility of the licensed clinician to seek clarification from the physician/authorized practitioner…” Focused review of the department policy on 7/2/2025 at approximately 10:28 AM revealed, “ON-CALL PORCESS (TO INCLUDE DUREING AND AFTER HOURS CARE)…POLICY: The agency ensures that patients, caregivers, and/or their physicians, as well as referral sources and other health care providers, have access to a staff clinician 24 hours-a-day by means of providing an on-ca;; nurse during and after office hours. A RN will be available at least by telephone while any services are provided. The leaders provide the framework for planning, direction, coordination, providing, and improving health care and services that respond to patient and community needs to improve patient health outcomes. PROCEDURE: 1. The agency will provide each client, upon admission to services, a designated on-call telephone number and will instruct each client to call this number to access care from the agency after regular business hours. 2. The agency shall identify the operating hours by posting contact information on the front door or applicable signage such that the public will know how and who to reach if no one is in the agency. 3. To ensure that a clinician can be contacted by telecommunications, during and after office hours, each agency will establish a call schedule for their offices. 4. The respective answering services will contact the on-call clinician immediately after the patient related call is received. The total response time for patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes. *For calls to answering services made (Agency) Personal Emergency response System (PERS), that are not emergent, (Agency)-PERS will: *Contact (Agency) office/answering service and leave message for clinician, to include patient name, phone number, and reason for button push. Answering service will be responsible for contracting on-call nurse for follow-up. *Inform subscriber/patient that if return call is not received by on-call nurse within 30 minutes, the Personal Help Button should be pressed again. 5. Clinicians will provide follow-up appropriate to the call via: *Telephonic intervention with the patient/caregiver *Perform onsite visit to the patient, if necessary *Obtain physician orders, as needed 6. A home visit from the clinician may be indicated when: *New onset of symptoms are reported *Exacerbation of symptoms are reported *Issue cannot be resolved via telephonic intervention *As ordered by the physician * If emergent care is deemed necessary and appropriate during he in-person visit, the nurse will remain with the patient until emergency services arrive and assume care of the patient. 7. Clinicians will document responses and outcomes of appropriate calls on the On-Call Coordination note. 8. Clinicians will submit the On-Call Coordination Note and any supporting patient documentation by next business day and verbally communicate all on-call issues to appropriate Executive Director/Clinical Director and/or Patient Care Manager. 9. The Executive Director/Clinical Director will assure that appropriate follow-up-visits are scheduled if needed. 10. On-call clinicians shall maintain an adequate car stock. 11. On-call clinicians shall utilize back-up administrator on-call as needed for questions, problems, or concerns. 12. The agency shall ensure that every opportunity shall be made for the live exchange or person to person exchange of on-call or patient information. This exchange of information can occur during report, at end or beginning of shift, or at any time the information is requested or needed.” A review of MR2 was conducted on 7/2/2025 at approximately 2:20 PM, start of care 4/10/2025 which revealed the following. Certification period 4/10/2025 to 6/8/2025 with a primary diagnosis displaced bimalleolar fracture of right lower leg, subsequent encounter for a closed fracture with routine healing. MR2 also had the following diagnosis “…END STAGE RENAL DISEASE, DEPENDENCE ON RENAL DIALYSIS…LONG TERM (CURRENT) USE OF ANTIHROMBOTICS/ANTIPLATELETS…” Review of the plan of care was conducted on 7/2/2025 at approximately 2:20 PM revealed, “HOME HEALTH CERTIFICATION AND PLAN OF CARE…Orders of discipline and Treatments…PRESENCE OF PERITONEAL DISALYSIS CATHETER, PATIENT PERFORMS OWN PERITONEAL DIALYSIS 4 TIMES PER WEEK, HAS BEEN DOING FOR APPROXIMATELY ONE YEAR.” Focused review of the agency investigation was conducted on 7/3/2025 approximately 10:22 AM revealed, Per investigation findings “Patient was scheduled to follow up with her kidney doctor on 4/17/2025 for an injection to increase RBC production.” Per review of the “Client Medication Report” (dated 7/2/2025) the surveyor could not confirm what injectable medication was to be provided to the patient or who the “kidney doctor” was providing services. A review of the plan of care was conducted 7/2/2025 at approximately 2:20 PM, under diagnoses section listed dependence on renal dialysis. The surveyor was unable to identify the dialysis provider from the documentation provided. An interview conducted with EMP1 the executive director on 7/3/2025 at approximately 1:00 PM confirmed the agency did not contact the dialysis center or nephrologist providing services to MR2. An interview was conducted on 7/8/2025 at approximately 1:20 PM with the executive director, confirmed the above information.”