Attentive Care Service Agency, Inc.

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Emergency Preparedness (EP) documents provided by the home health agency (Agency), and an interview with the administrator, the Agency failed to provide evidence that the EP plan was tested annually. Findings Include: A review of the Agency’s emergency preparedness documents on May 13, 2026 at approximately 11:00 AM did not contain any evidence that exercises to test the EP were conducted in 2024. An interview with the administrator on 05/13/2026 at approximately 12:00 PM confirmed the above findings.”

“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 clinical records (CR), Home Health Agency (Agency) policies, and an interview with the administrator, the Agency failed to assure that the plan of care (POC) was followed in accordance with the physician orders for four (4) of seven (7) CR’s reviewed: CR#1, CR#3, CR#4 and CR#5. Findings include: The Agency’s Physician Order Policy, reviewed on May 13, 2026 at approximately 2:40 PM stated in part, “Prescriptions and nonprescription drugs, devices, medications and treatments will be administered by agency staff in accordance with the written orders of the physician.” The Agency’s Plan of Treatment Policy, reviewed on May 13, 2026 at approximately 2:50 PM read in part, “The plan of treatment (485) will cover pertinent diagnoses including but not limited to...types of services, frequency of visits...” The Agency’s Medical Staff Documentation Requirement Policy, reviewed on May 13, 2026 at approximately 2:25 PM stated in part, “All missed visits need to be reported when they occur and a missed visit form must be completed the day the visit is missed if the visit cannot be rescheduled later in the week.” The Agency’s Missed Visit Documentation Policy, reviewed on May 13, 2026 at approximately 2:15 PM read in part, “All missed visits must be documented using the actual date the visit was scheduled to occur. Missed visits may not be backdated, predated, or entered under any alternate service date.” A review of clinical records was conducted on May 11, 2026 at 1:00 PM and continued May 13, 2026 starting at 10:00 AM. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 07/28/2025, CP 03/25/2026 to 05/23/2026 contained a Home Health Certification and Plan of Care (POC) which included OT (Occupational Therapy) orders three (3) times a week for eight (8) weeks. A review of the visit calendar found that an OT re-evaluation/visit occurred on March 31, 2026. After March 31, 2026 through May 10, 2026, there were no OT visits and no missed visit (MV) notes contained in the CR. During the home visit that occurred on May 12, 2026 at approximately 10:30 AM, the patient confirmed that s/he had not been receiving OT visits. The patient stated that the OT informed him/her that s/he was working on a visit schedule. CR#3 SOC 11/11/2025, CP 03/11/2026 to 05/09/2026 contained a POC which included PT (Physical Therapy) and OT orders three (3) times a week for 8 weeks for both disciplines. The visit calendar and missed visit notes in the CR found the following: Week of 03/15/26: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. Week of 3/22/26: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. Week of 04/05/26: 3 PT MV. Three MV notes were present in the CR, but the dates of the MV shown in the notes were not the actual date the visit was scheduled to occur, per Agency policy. Week of 4/19/26: 1 PT MV. There were no MV notes present in the CR.. Week of 4/26: 3 PT MV. There were no MV notes present in the CR. Week of 5/3/26: 3 PT MV and 1 OT MV. There were no MV notes by either PT or OT present in the CR. CR#4 SOC 01/23/2026, CP 01/23/2026 to 03/23/2026 contained a POC which included PT orders three (3) times per week. There was no duration to the order. The patient did not receive any PT throughout the CP. There were no MV PT notes nor was there a physician’s order to discontinue PT. The patient received OT three (3) times per week throughout the CP, but there were no orders for OT in the POC or subsequent to the POC. CR#5 SOC 07/29/2026, CP 01/25/2026 to 03/25/2026 contained a POC which included PT orders one (1) time per week for nine (9) weeks. The visit calendar and missed visit notes in the CR found the following: Week of 01/25/26: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. Week of 02/15/26: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. Week of 02/22/26: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. Week of 03/15/2026: 1 PT MV. A MV note was present in the CR, but the date of the MV shown in the note was not the actual date the visit was scheduled to occur, per Agency policy. An interview with the administrator on May 13, 2026 starting at 3:30 PM 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 on home visit (HV) clinical observations, a review of the Home Health Agency’s (Agency) policies, and an interview with the administrator, the Agency failed to assure that acceptable standards of practice for infection prevention were maintained. Two (2) of two (2) HV observations did not meet the requirement: PF#3 (HV#1), and PF#9 (HV#2). Findings include: The Agency’s Infection Control and Prevention Policy, reviewed on May 13, 2026 at approximately 10:00 AM stated in part, “The Agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.” The Agency’s Medical Staff Equipment Bag Infection Control Policy, reviewed on May 13, 2026 at approximately 10:10 AM read in part, “Placement of Equipment - Medical staff shall place a disposable barrier on a clean, dry surface before placing the equipment bag down. Avoid placing the equipment bag on floors, bathroom surfaces, kitchen counters used for food preparation, beds or upholstered furniture...After Patient Care - Medical staff shall...disinfect reusable patient care equipment before placing back into the bag.” An on-site clinical visit was conducted on May 12, 2026 at approximately 10:30 AM at the home of CR#1 (HV#1). The nurse’s (PF#3) equipment bag was found to be sitting on a pillow that was on top of a chair. There was no barrier beneath the bag. A glucometer and associated supplies were placed on the bed with no barrier underneath the supplies/equipment. An on-site clinical visit was conducted on May 13, 2026 at approximately 1:00 PM at the home of CR#3 (HV#2). A blood pressure (BP) case was noted to be sitting on a chair, with no barrier underneath the case. PF#9 removed the BP cuff from the case, took the patient’s BP, then replaced the BP cuff into the case without sanitizing it. The BP case was placed back on the chair without a barrier beneath it. The surveyor verified that the BP cuff was PF#9’s equipment and not the patient’s equipment. The stethoscope used to take the BP was placed on top of the BP bag. The surveyor did not observe that PF#9 had sanitizing wipes to clean the equipment. An interview conducted with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (Agency) policy, the Agency’s Patient Admission Packet, Center for Medicare and Medicaid Services (CMS) website, and an interview with the administrator, the Agency failed to provide an OASIS (Outcome and Assessment Information Set) privacy notice to all patients for whom OASIS data was collected. Seven (7) of seven (7) CR’s reviewed did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: The Agency’s Patient Rights and Responsibilities Policy, reviewed on May 13, 2026 at approximately 11:10 AM read in part, “ACSA (Attentive Care Service Agency) must comply with Chapter 42 CFR Part 484 section 484.50 pertaining to Patient rights and responsibilities. This notice must be provided to the patient and/or legal representative (if any), the following information during the initial evaluation/start of care (SOC) visit, before providing any patient care....An OASIS privacy notice to all patients for whom the OASIS data is collected. The patient or legal representative must sign the OASIS privacy notice confirming a copy was provided by the agency.” The Agency’s Patient Welcome Packet reviewed on May 13, 2026 at approximately 11:15 AM stated in part, “ACSA (Attentive Care Service Agency) must comply with Chapter 42 CFR Part 484 section 484.50 pertaining to Patient rights and responsibilities. This notice must be provided to the patient and/or legal representative (if any), the following information during the initial evaluation/start of care (SOC) visit, before providing any patient care....An OASIS privacy notice to all patients for whom the OASIS data is collected. The patient or legal representative must sign the OASIS privacy notice confirming a copy was provided by the agency.” A review of CMS website Transition to All-Payer OASIS Data Collection and Submission on May 4, 2026 at 10:00 AM found that effective July 1, 2025, home health agencies must collect and submit OASIS data for all patients with any pay source who are not exempt from OASIS data collection and who begin receiving home health care services with an OASIS SOC M0090 date on or after July 1, 2025. A review of clinical records was conducted on May 11, 2026 at 1:00 PM, and continued on May 12, 2026 at 9:00 AM, and May 13, 2026 at 10:00 AM. The Start of Care (SOC) is indicated below. CR#1 SOC 07/28/2025 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#2 SOC 01/16/2026 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#3 SOC 11/11/2025 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#4 SOC 01/23/2026 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#5 SOC 07/29/2025 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#6 SOC 02/25/2026 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. CR#7 SOC 03/09/2026 did not contain evidence that the patient or the patient’s legal representative received the OASIS privacy notice. An interview held with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on a review of clinical records (CR), the Home Health Agency’s (Agency) patient admission packet, Agency policy, and an interview with the administrator, the agency failed to provide the patient with the addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. Seven (7) of seven (7) CR’s reviewed did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CF#7. Findings include: The Agency’s Patient Rights and Responsibilities Policy, reviewed on May 13, 2026 at approximately 11:10 AM read in part, “Be advised on the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization.” The Agency’s Patient Welcome Packet reviewed on May 13, 2026 at approximately 11:15 AM stated in part, “Be advised on the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization.” The packet did not include the addresses, and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, Quality Improvement Organization. A review of clinical records was conducted on May 11, 2026 at 1:00 PM, and continued on May 12, 2026 at 9:00 AM, and May 13, 2026 at 10:00 AM. The Start of Care (SOC) is indicated below. CR#1 SOC 07/28/2025 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#2 SOC 01/16/2026 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#3 SOC 11/11/2025 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#4 SOC 01/23/2026 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#5 SOC 07/29/2025 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#6 SOC 02/25/2026 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#7 SOC 03/09/2026 did not contain evidence that the patient or the patient’s legal representative received the addresses and telephone numbers of the Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. An interview held with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”

“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 a review of clinical records (CR), and an interview with the administrator, the home health agency (Agency) failed to complete an initial assessment within forty-eight (48) hours of the referral for three (3) of seven (7) CR’s reviewed: CR#3, CR#6 and CF#7. Findings include: A review of clinical records was conducted on May 11, 2026 at 1:00 PM, and continued on May 12, 2026 at 9:00 AM, and May 13, 2026 at 10:00 AM. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#3 SOC 11/11/2025, CP 03/11/2026 to 05/09/2026. An OASIS (Outcome and Assessment Information Set) Start of Care/ Initial-Comprehensive Assessment contained a referral date of 11/04/2025. The initial assessment was completed on 11/11/2025, seven (7) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. The initial assessment was not completed within forty-eight (48) hours of the referral. CR#6 SOC 02/23/2026, CP 02/23/2026 to 04/23/2026. An OASIS Start of Care/Initial-Comprehensive Assessment contained a referral date of 10/14/2024. The initial assessment was completed on 02/25/2026. The referral date contained on the OASIS form was not indicative of the referral date associated with the current SOC. It was unable to be determined if an initial assessment was completed within forty-eight (48) hours of the referral for the SOC 02/23/2026. CR#7 SOC 03/09/2026, CP 03/09/2026 to 05/07/2026. An OASIS Start of Care/Initial-Comprehensive Assessment contained a referral date of 03/04/2026. The initial assessment was completed on 03/09/2026, five (5) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. The initial assessment was not completed within forty-eight (48) hours of the referral. An interview conducted with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”

“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 a review of clinical records (CR), Home Health Agency (Agency) Policy, and an interview with the administrator, the Agency failed to assure that the skilled professional considered each medication the patient was currently taking for possible side effects for one (1) of seven (7) CR’s reviewed: CR#3, and that any changed medications had a physician’s order for the change for one (1) of seven (7) CR’s reviewed: CR#6. Findings include: The Agency’s Medication Reconciliation Policy, reviewed on May 13, 2026 at 3:10 PM read in part, “Purpose - To review all medications a 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.” “Once the new or changed medication is added to the patient’s profile, a medication reconciliation must be performed and submitted to the patient’s physician. When the new or changed medication is discovered, a physician’s order must be submitted for a physician’s signature indicating approval of the new or changed medication. The new order must be submitted to the physician within 5 days and a signature obtained from the physician within 7 days.” A review of clinical records was conducted on May 11, 2026 at 1:00 PM, and continued on May 12, 2026 at 9:00 AM, and May 13, 2026 at 10:00 AM. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#3 SOC 11/11/2025, CP 03/11/2026 to 05/09/2026 contained a POC with a medication order for Eliquis (blood thinner) 5 milligrams (mg) oral tablet, one tablet by mouth twice daily. A review of the medication profile contained the same order. An OASIS (Outcome and Assessment Information Set) Recertification was completed on 03/10/2026. The Medication Status Section of the OASIS form contained several checkboxes which included: Medications Reconciled and Anticoagulant Use. The Medications Reconciled Box was checked, but the Anticoagulant Use Box was not checked, even though the patient was receiving an anticoagulant. CR#6 SOC 02/23/2026, CP 02/23/2026 to 04/23/2026 contained a POC with a medication order for Empagliflozin (used to lower blood sugar) 25 mg one tablet by mouth once daily for diabetes. A review of the medication profile for the CP 02/23/2026 to 04/23/2026 found that the medication had been discontinued on 03/08/2026. Upon interviewing the administrator on May 13, 2026 at approximately 2:00 PM, the administrator stated that the patient discontinued the medication. There was no physician order to discontinue the medication nor was a skilled nursing note present in the CR indicating that the physician had been contacted about the patient’s decision to discontinue the medication. An interview conducted with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of personnel files (PF), home health agency (Agency) policy, CDC (Centers for Disease Control) Guidelines, and an interview with the administrator, the agency failed to demonstrate the presence of one or more of the following: annual competency evaluation, annual performance evaluation, annual infection control education, tuberculosis symptom screen at the time of hire, and annual tuberculosis education for four (4) of seven (7) PF’s reviewed: PF#2, PF#3, PF#4, and PF#8. Findings include: The Agency’s Hiring Procedures of Direct Care Workers, reviewed on May 11, 2026 at 2:30 PM stated in part, “Personnel contents for agency employees may include, but not be limited to: competency evaluations, performance evaluations...Personnel contents for contracted employee may include, but not be limited to: Competency skills checklist...” In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW’s should receive TB screening annually. HCW’s with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf). *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). A review of personnel files was conducted on May 11, 2026 starting at approximately 11:25 AM and continued on May 12, 2026 at approximately 12:00 PM. The date of hire (DOH) is indicated below. PF #2 DOH 04/16/2016 did not contain evidence of annual competency/skills evaluation in 2024 or 2025, annual performance evaluation in 2025, infection control education in 2025, and annual tuberculosis (TB) education in 2025. PF#3 DOH 11/14/2024 did not contain evidence of annual competency/skills evaluation in 2025, infection control training in 2025, annual TB education in 2025. There was no TB symptom screen (SS) evaluation completed upon hire. The only TB SS evaluation contained in the PF was dated 05/11/2026. PF#4 DOH 01/07/2026 did not contain evidence that a TB SS evaluation was completed upon hire. The only TB SS evaluation contained in the PF was dated 05/12/2026. PF#8 DOH 09/26/2025 did not contain evidence that infection control education was completed at the time of hire. The infection control training document contained in the PF was dated 05/02/2022. An interview with the administrator on May 13, 2026 starting at 3:30 PM confirmed the above findings.”