Community Home Health Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of agency policy, an observation (OBS), clinical record (CR) reviews, and an interview with the Administrator/Director of Nursing and the Alternate administrator/Alternate director of nursing, the agency failed to ensure care was provided in accordance with the established plan of care and physician orders for one (1) of seven (7) CR reviewed (CR #3). Findings include: A review of agency’s policies and procedures conducted on March 23, 2026, at approximately 9am revealed the following: A review of agency policy titled “Home Health Plan of Care (CMS-485) Policy” stated … “Policy All patients admitted to home health services must have a written Plan of Care (POC)… All care provided must be consistent with the approved Plan of Care. Any deviations require a physician order… “ OBS#3 On March 19, 2026, at approximately 12:40 PM, within the home of the patient (CF#3), I observed the Physical Therapist Assistant (PTA) (PF#5) administered a blue gel (Biofreeze) and a yellowish substance (massage oil) to the patients (CF#3) leg. The substances were not the patient’s personal containers. The PTA (PF#5) pulled the containers out of her bag. The containers were unlabeled. The PTA (PF#5) reported that it was Biofreeze and Massage oil. These interventions were not included in the plan of care. These interventions were not listed on the medication profile. There were no physician orders authorizing their use. Reviewed CR #3 conducted on March 18, 2026, at approximately 11:15 am revealed, the start of care date is 2/26/26. Certification period 2/26/26 to 4/26/26. Primary Diagnosis Primary generalized (osteo)arthritis. Frequency Physical therapy 1 visit x wk1, 2 visits weekly x wks8. Medication list did not contain Biofreeze. No physician orders in the file for this medication or treatment. An interview conducted on March 20, 2026, at approximately 5pm with the Administrator/Director of nursing and the Alternate administrator/Alternate director of nursing, confirmed the above findings.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based upon review of agency policy, observation of agency’s staff during home visits, and interview with the Administrator/Director of nursing and the Alternate administrator, the employee failed to follow basic infection control practices for one (1) of three (3) observations (OBS). (OBS # 3). Findings include: A review of agency’s policies and procedures conducted on March 23, 2026, at approximately 9am revealed the following: Agency policy titled, “Bag Technique Procedure” stated, …PROCEDURE To prevent contamination… 8. …If additional equipment or supplies are needed from the bag during the home visit, the hand washing procedure must be repeated. Never enter the clean area of the bag without cleansing hands…”Agency policy titled “Hand washing Policy” stated, “Purpose Prevents the transmission of infectious agents between patients, caregivers, and family members. Reduces healthcare-associated infections (HAIs) in the home environment…When to Wash Hands 1. Before and after patient contact…4. After contact with contaminated surfaces…” An observation during the home visit conducted March 19, 2026 from approximately 12:40 pm to 1 pm revealed the following: OBS#3 On March 19, 2026, at approximately 12:40 PM, within the home of the patient (CF#3), I observed the Physical Therapist Assistant (PTA) (PF#5) donning gloves to assist the patient in ambulating. Following this, the PTA measured the patient’s blood pressure and proceeded to clean the blood pressure machine while still wearing the same gloves. Subsequently, she retrieved a ziplock bag containing two containers from her bag, keeping the gloves on throughout the process. The PTA then applied a blue substance from the first container onto her gloved hands, which she used to massage the patient’s lower left leg. Afterward, she opened the second container, inserted her gloved finger into the substance, and applied it to the patient’s leg. Upon inquiring about the contents of the containers, she identified them as “Biofreeze and Massage oil.” An interview conducted on March 20, 2026, at approximately 5pm with the Administrator/Director of nursing and the Alternate administrator/alternate director of nursing, confirmed the above findings.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on a review of agency policy, personnel file (PF) reviews, and interview with the Administrator/Director of nursing and the Alternate administrator/Alternate director of nursing, the agency failed to ensure initial and annual clinical staff competency evaluations were documented for three (3) of the nine (9) PFs reviewed (PF#4-5, PF#8); failed to ensure initial and annual skills assessments evaluations were documented for seven (7) of nine (9) PFs reviewed. (PF#1, PF#3-8) Findings include: A review of agency’s policies and procedures conducted on March 23, 2026, at approximately 11 am revealed the following: Agency policy titled “PERFORMANCE EVALUATIONS/SKILLS COMPETENCY EVALUATIONS” stated, “General Statement Performance evaluations are required for every employee and skills competency evaluations are required for all direct and contracted field staff... Skills competency evaluations are required for all Field Staff, on hire…Both types of evaluations are next required 12 months after the employees hire date, and then annually…”Agency policy titled “SUPERVISION AND EVALUATIOON OF STAFF” stated, “…Annual Direct Observation Visit of Staff Each clinical staff member, including members that have been contracted on an individual basis, must be supervised on-site at least annually by an appropriate supervisor.”Agency policy titled “Orientation and Education Policy” stated, “Purpose: …To provide opportunity for professional growth for all levels of staff. Policy: Community Home Health provides comprehensive orientation, education programs and continuing education for all employees…Education is fostered through…competency evaluations for all field staff conducted at orientation and annually…6. All direct care staff must have a minimum of 12 hours of in-services per year.” A personnel review conducted on March 18, 2026, between approximately 2 pm to 3:30 pm, then again on March 19 at approximately 10:45am revealed the following: PF#1 Date of hire (DOH) 2/4/01: Position is Alternate Administrator/Alternate director of nursing. Did not contain documentation of annual skills evaluations for 2023, 2024, 2025 and 2026. PF#3 DOH 6/27/24: Position is Registered Nurse. Did not contain documentation of an initial skills assessment in 2024. Also did not contain documentation of an annual skills assessment in 2025. PF#4 DOH 12/24/24: Position is Physical Therapist. Did not contain documentation of an initial competency evaluation and initial skills assessment. Additionally, it did not contain documentation of an annual competency and skills evaluation in 2025. PF#5 DOH 6/24/15: Position is Physical Therapist Assistant. Did not contain documentation of an initial competency evaluation and initial skills assessment. Additionally, it did not contain documentation of annual competency and skills evaluations in 2023, 2024, and 2025. PF#6 DOH 8/25/22: Position is Registered Nurse. Did not contain documentation of an initial skills assessment. Additionally, it did not contain documentation of annual competency evaluations and skills assessments for 2024, 2025 and 2026. PF#7 DOH 2/28/24: Position is Registered Nurse. Did not contain documentation of an initial skills assessment. Additionally, it did not contain documentation of annual competency and skills assessments for 2025 and 2026. PF#8 DOH 4/18/25: Position is Speech Therapist. Did not contain documentation of initial competency evaluation and initial skills assessment. A An interview conducted on March 20, 2026, at approximately 5pm with the Administrator/Director of nursing and the Alternate administrator/Alternate director of nursing, confirmed the above findings.”