Compass Home Health and Rehab LLC

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure the discharge planning was conducted in accordance with agency policy/procedure for two (2) of two (2) patients discharged from the agency or skilled nursing (SN) services without goals having been met. (Patient #7 and #11) Findings include: On August 8, 2025 at approximately 12:22 PM, review of agency policy 2-024, titled “Discharge Planning Process” revealed the following: Policy...Patients will not be discharged without appropriate preparation. The patient’s continuing care needs will be assessed on an ongoing basis...Information will be provided to assist the patient in planning his/her discharge... Patient #7 (Branch Office-Discharge): Between August 6, 2025 at approximately 1:16 PM and August 8, 2025 at approximately 10:40 PM, review of the clinical record revealed the start of care date was 05/21/2025, that skilled nursing (SN) services were to be provided one (1) time a week, that SN was to provide wound care to the left fourth toe and right shin and that SN goals had been developed as documented on the “Plan of Care” order form for the initial certification period of 05/21/2025 through 07/19/2025. Visit note documentation revealed three (3) SN visits had been performed by the registered nurse (RN-Employee #5) between 05/21 and 05/29/2025. Review of the SN visit note dated 05/27/2025 revealed the patient had developed a reddened area on the buttock and that the patient was applying barrier cream to the area. Visit note documentation dated 05/29/2025 revealed the RN (Employee #5) documented a new pressure area was present on the right buttock. Review of the off-site SN comprehensive discharge visit note dated 06/02/2025 revealed the (RN (Employee #5) documented the patient was being discharged due to non-compliance and having missed a visit with the attending physician. There was no documentation in the clinical record which provided evidence the patient had met the SN goals included on the “Plan of Care” order form for the above referenced certification period. There was no documentation in the clinical record which revealed RN had provided discharge planning prior to the patient’s discharge on 06/02/2025. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12 PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the start of care date was 02/21/2022, the primary diagnosis is Type-2 diabetes mellitus (diabetes), SN services were to be provided one (1) time a week for eight (8) weeks and that SN goals had been established as documented on the “Plan of Care” order form for the recertification period of 06/05/2025 through 08/03/2025. Review of visit note documentation revealed four (4) SN visits were performed by the registered nurse (RN-Employee #2) between 06/04/2025 and 06/24/2025. Review of Home Health Chage of Care Notice (HHCCN) form documentation revealed the patient was being discharged from SN services. Review of the interim verbal order dated 07/03/2025 revealed the patient was being discharged from SN services without goals having been met. There was no documentation in the clinical record which revealed the RN had provided discharge planning between 06/04/2025 and 06/24/2025. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the agency had provided discharge planning in accordance with agency policy/procedure for the above identified patients.”

“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 review of agency policy/procedure, Centers for Disease Control and Prevention (CDC) recommendations and the Pennsylvania Department of Health (PA DOH) tuberculosis screening recommendations and/or requirements, clinical records and personnel files, and based on interview with the administrator/registered nurse (ADM/RN-Employee #8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure TB screening was completed in accordance with agency policy/procedure, CDC and PA DOH recommendations or requirements for two (2) of two (2) agency staff whose date of hire was after October 5, 2022. (Employees #2 and #7) Findings include: On August 8, 2025 at approximately 9:30 AM, review of policy 9-002, titled “Tuberculosis Exposure Control Plan”, revealed the following under “Procedure”: 9. All personnel will be tested for TB...in accordance with federal, state...regulations. On August 8, 2025 at approximately 9:37 AM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html The TB screening process for health care personnel includes: -A baseline individual TB risk-assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On August 8, 2025 at approximately 9:45 AM review the PA DOH webpage ( https://www.pa.gov/agencies/health/diseases-conditions/infectious-disease/tuberculosis/tb-testing-health-care-workers.html ) revealed the following: Tuberculosis Testing Health Care Workers...On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: The updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment(opens in a new tab), a symptom evaluation, and a TB test (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test-). On August 8, 2025 at approximately 9:55 AM, review of the PA DOH TB manual ( https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/diseases-and-conditions/tb/CMHD%20TB%20Manual%202023.pdf ) revealed the following: LAWS PERTAINING TO TB CONTROL...Pennsylvania laws on TB can be found in the Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, 35 P.S. Sec. 521.1 . Under the provisions of the Pennsylvania Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, DOH has the authority to “protect the health of the people of this Commonwealth, and to determine and employ the most efficient and practical means for the prevention and suppression of disease.” Patient #6 (Branch Office): Between August 6, 2025 at approximately 12:44 PM and August 8, 2025 at approximately 12:03 PM, review of the clinical record revealed the physical therapy assistant (PTA) provided PTA services on 08/04/2025. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the RN (Employee #2) provided skilled nursing services between June 4 and June 24, 2025. Between August 6,, 2025 at approximately 2:01 PM and August 9, 2025 at approximately 8:09 AM, review of personnel file documentation revealed the following: Employee #2: The date of hire of the RN was 06/12/2024. There was no documentation in the personnel file which provided evidence a TB individual risk assessment nor a TB symptom screen had been completed prior to the assignment to provide SN services. Employee #7: The date of hire of the PTA was 06/05/2023. There was no documentation in the personnel file which provided evidence a TB symptom screen had been completed prior to the assignment to provide PTA services. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed initial TB screening was not conducted in accordance with agency policy/procedure, CDC and/or PA DOH recommendations/requirements for the above referenced employees.”

“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 review of agency policy/procedure and clinical records and Pennsylvania state licensure regulations, and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure the name of the collaborating or supervising physician was included on the plan of care (treatment) for five (5) of five (5) patients for whom orders for home health services were provided by a nurse practitioner or physician assistant. (Patients #5, #10, #11, #12 and #13) Findings include: On August 8, 2025 at approximately 12:10 PM, review of agency policy 2-018, titled “Care Planning Process” revealed the following under “Procedure”: 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: R. Other appropriate items...and additional items the organization or physician (or other licensed practitioner) may choose to include. On August 8, 2025 at approximately 1:40 PM, review of the Pennsylvania Health Care Facilities Act-Licensure, COVID-19 Regulatory Flexibility Authority and Repeal Act 30 of 2022 revealed the following under Section 806 (d) Licensure: (2) Home health care services may be ordered by nurse practitioners and physician assistants as provided under sections 1814(a) and 1835(a) of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 et seq.), if the nurse practitioner’s or physician assistant’s collaborating or supervising physician is identified in the patient’s written plan of treatment. Patient #5 (Branch Office): On August 6, 2025 at approximately 12:31 PM review of the clinical record revealed the start of care date was 06/04/2025 and that verbal orders for home health services were provided by a certified registered nurse practitioner (CRNP) as documented on the “Plan of Care-Preview” order form for the recertification period of 08/03/2025 through 10/01/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 08/03/2025 through 10/01/2025 included the name of the CRNP’s collaborating physician. Patient #10 (Branch Office--Discharge): Between August 7, 2025 at approximately 1:35 PM and August 8, 2025 at approximately 10:47 AM, review of the clinical record revealed the start of care date was 01/28/2025 and that verbal orders for home health services were provided by a CRNP as documented on the “Plan of Care” order form for the initial certification period of 01/28/2025 through 03/28/2025. The “Plan of Care” for the initial certification period was countersigned by the CRNP on 02/28/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 01/28/2025 through 03/28/2025 included the name of the CRNP’s collaborating physician. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12 PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the start of care date was 02/21/2022 and that verbal orders for home health services were provided by a CRNP as documented on the “Plan of Care” order form for the recertification period of 06/05/2025 through 08/03/2025. The “Plan of Care” for the initial certification period was countersigned by the CRNP on 06/19/2025. There was no documentation in the clinical record which provided evidence the plan of care for the recertification period of 06/05/2025 through 08/03/2025 included the name of the CRNP’s collaborating physician. Patient #12 (Branch Office): Between August 7, 2025 at approximately 2:37 PM and August 8, 2025 at approximately 11:04 AM, review of the clinical record revealed the start of care date was 07/18/2025 and that verbal orders for home health services were provided by a PA-C as documented on the “Plan of Care” order form for the initial certification period of 07/18/2025 through 09/152025. The “Plan of Care” for the initial certification period was countersigned by the PA-C on 08/07/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 07/18/2025 through 09/15/2025 included the name of the PA-C’s supervising physician. Patient #13 (Branch Office): Between August 7, 2025 at approximately 2:54 PM and August 8, 2025 at approximately 11:11 AM, review of the clinical record revealed the start of care date was 07/18/2025 and that verbal orders for home health services were provided by a PA-C as documented on the “Plan of Care” order form for the initial certification period of 07/18/2025 through 09/152025. The “Plan of Care” for the initial certification period was countersigned by the PA-C on 08/07/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 07/18/2025 through 09/15/2025 included the name of the PA-C’s supervising physician. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the name of the CRNP’s or PA-C’s collaborating/supervising physician had been included on the plan of care for the patients for whom home health services were ordered by a CRNP or PA-C.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policy/procedure and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure verbal orders included on the plan of care were countersigned by the primary care provider (PCP) within 30 days of the verbal order date for three (3) of six (6) patients for whom home health services were provided for a minimum of 30 days during the current certification period. (Patients #8, #9 and #10) Findings include: On August 8, 2025 at approximately 12:35 PM, review of agency policy 2-020, titled “Verification of Physician Orders” revealed the following under “Procedure”: 11. Signed orders will be placed in the clinical record within 30 days of initiation of the order... Patient #8 (Branch Office--Discharge): On August 7, 2025 at approximately 10:26 AM, review of the clinical record revealed the start of care date was 06/25/2025 and that verbal orders for skilled nursing (SN) and physical and occupational therapy (PT and OT) services were obtained by the ADM/RN on 06/24/2025 as documented on the “Plan of Care-Preview” order form for the initial certification period of 06/25/2025 through 08/23/2025. There was no documentation in the clinical record which provided evidence the verbal orders included on the “Plan of Care-Preview” for the initial certification period of 06/25/2025 through 08/23/2025 had been countersigned by the attending physician. Patient #9 (Branch Office): On August 7, 2025 at approximately 10:46 AM, review of the clinical record revealed the start of care date was 08/21/2024 and that verbal orders for SN services were obtained by the ADM/RN on 06/13/2025 as documented on the “Plan of Care-Preview” order form for the recertification period of 06/17/2025 through 08/15/2025. There was no documentation in the clinical record which provided evidence that the verbal orders included on the “Plan of Care-Preview” for the recertification period of 06/17/2025 through 08/15/2025 had been countersigned by the attending physician. Patient #10 (Branch Office--Discharge): Between August 7, 2025 at approximately 1:35 PM and August 8, 2025 at approximately 10:47 AM, review of the clinical record revealed the start of care date was 01/28/2025 and that verbal orders for SN and PT services were obtained by the ADM/RN on 01/28/2025 as documented on the “Plan of Care” order form for the initial certification period of 01/28/2025 through 03/28/2025. The initial “Plan of Care” was countersigned by the certified registered nurse practitioner (CRNP) on 02/28/2025 which was more than 30 days after the verbal order date of 01/28/2025. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the PCP had countersigned the verbal orders included on the “Plan of Care-Preview” or “Plan of Care” form within 30 days of the verbal order date for the above identified patients.”