Marigold Home Healthcare Service

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the individualized emergency preparedness plan for patients failed to identify persons at risk. Seven (7) of seven (7) CR’s did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: The HHA’s Emergency Preparedness Plan, reviewed on January 27, 2025 at approximately 12:00 PM did not address a means to identify patients at risk. The plan did not include a process for classifying and assigning priority based on the complexity and needs of the patient in the event of an emergency. Seven (7) of seven (7) CR’s did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024. The Start of Care/Resumption of Care (SOC/ROC) Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025. The SOC/ROC Nursing Assessment form used by the HHA contained an Emergency Preparedness Care Planning (EPCP) Section. The ECPC Section read in part, “Emergency Priority Code assigned to this patient is ______ based upon the comprehensive assessment of their functional, medical condition, psychosocial situation, cognitive, mental status and any significant care needs. Note: Record the code on the front of this form and other places per agency policy.” A review of the EPCP Section found that a priority code was not assigned to the patient, nor was there documentation of the code on the front of the form, nor in any other documents maintained by the HHA. An interview held with the administrator on January 29, 2025, starting at 3:30 PM confirmed the above findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on a review of the home health agency’s (HHA) emergency preparedness plan (EPP), and an interview with the administrator, the HHA failed to ensure that the EPP included all of the following: (1) Names and contact information for Staff, Entities providing services under arrangement, and Patients’ physicians. Findings include: A review of the HHA’s EPP on January 27, 2025 starting at approximately12:00 PM found that the communication plan contained within the EPP did not include the contact information for staff, entities providing services under arrangement, nor patient’s physicians. There were no other documents provided by the HHA that included the above information. An interview held with the administrator on January 29, 2025 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 a review of clinical records (CR), home health agency (HHA) policies, clinical home visit observations, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for three (3) of three (3) clinical home visits: CR#3, CR#4, and CF#7 Findings include: The HHA’s Bag Technique/Cleaning and Storage of Equipment Policy reviewed on January 28, 2025 at 2:30 PM states in part, “All Marigold Health Bags and their contents (equipment, tools, and supplies) will be cleaned, disinfected and stored properly to prevent the risk of infection or contamination....All reusable equipment (e.g., stethoscopes, blood pressure cuffs, thermometers, etc.) should be cleaned according to the manufacturer’s guidelines after each use. Equipment should be disinfected with approved, hospital-grade disinfectants, especially between uses for different patients. Equipment that is used for multiple patients must be cleaned and disinfected between uses to prevent cross-contamination.” The HHA’s Infection Control Policy reviewed on January 28, 2025 at 2:45 PM reads in part, “All medical equipment used in patient care (e.g., thermometers, blood pressure cuffs, stethoscopes) must be cleaned and disinfected after each use according to the manufacturer’s guidelines and infection control protocols.” An on-site clinical visit was conducted on January 29, 2025 at 10:00 AM at the home of CR#4. The nurse was observed to remove a stethoscope and a blood pressure cuff (contained in a small black case) from the nurses’ bag. The nurse proceeded to use the stethoscope to check the patient’s heart and breath sounds and used the blood pressure cuff to check the patient’s blood pressure. The stethoscope was returned to the nurses’ bag without being disinfected. The blood pressure cuff was rolled up and placed back into the same small black case without being sanitized. All items were returned to the nurses’ bag. An on-site clinical visit was conducted on January 29, 2025 at 10:45 AM at the home of CR#3. The nurse was observed to remove a stethoscope and a blood pressure cuff (contained in a small black case) from the nurses’ bag. The nurse proceeded to use the stethoscope to check the patient’s heart and breath sounds and used the blood pressure cuff to check the patient’s blood pressure. The stethoscope was returned to the nurses’ bag without being disinfected. The blood pressure cuff was rolled up and placed back into the same small black case without being sanitized. All items were returned to the nurses’ bag. An on-site clinical visit was conducted on January 29, 2025 at 11:35 AM at the home of CR#7. The nurse was observed to remove a stethoscope, a blood pressure cuff (contained in a small black case), and a pulse oximeter (contained in a small clear plastic bag) from the nurses’ bag. The nurse proceeded to use the stethoscope to check the patient’s heart and breath sounds and used the blood pressure cuff to check the patient’s blood pressure. The pulse oximeter was placed on the patient’s finger to check the patient’s oxygen level. The stethoscope was returned to the nurses’ bag without being disinfected. The blood pressure cuff was rolled up and placed back into the same small black case without being sanitized. The pulse oximeter was returned to the same clear plastic bag without being disinfected. All items were returned to the nurses’ bag. An interview held with the administrator on January 29, 2025 at 3:30 PM confirmed the above findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the HHA failed to assure that entries into the CR were accurate, authenticated, and/or timed for seven (7) of seven (7) CR’s reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: An interview with the administrator on January 27, 2025 found that the HHA had purchased a package of OASIS-E (Outcome and Assessment Information Set) forms from an outside vendor (Briggs Healthcare). The package was to include the following forms: Comprehensive Adult Nursing Assessment Start of Care/Resumption of Care (SOC/ROC) with OASIS Elements, Recertification/Follow-Up Assessment including OASIS Elements, and the Discharge Assessment including OASIS Elements. The SOC/ROC form is the same form. The surveyor pointed out to the administrator that the HHA was using the SOC/ROC comprehensive assessment form instead of the Recertification/Reassessment form for recertifications/reassessments. The administrator stated that s/he thought that the HHA had received all of the forms that were purchased as part of the package and would need to follow-up with the vendor to obtain the Recertification/Reassessment forms. The HHA’s Documentation Policy reviewed on January 29, 2025 at approximately 8:15 AM reads in part, “Documentation must be legible, accurate, and clearly organized. All entries must be dated, signed, and include the title of the clinician making the entry.” The HHA’s Comprehensive Assessment and Reassessment Policy reviewed on January 27, 2025 at approximately 1:00 PM reads in part, “For patients to whom OASIS applies, the clinician completes the required OASIS format.” A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 contained a CMS 485 Home Health Certification and Plan of Care (POC) that failed to include: 1) the nurses’ signature, and 2) the date that the physician signed the POC. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 07/18/2023. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 12/30/2024. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 11/22/2024. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. The ROC Assessment form was not signed by the nurse completing the reassessment. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 12/06/2024. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 01/04/2025. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025. A SOC/ROC Assessment form instead of a Recertification/Reassessment Form was used for the new certification period beginning 12/10/2024. The ROC Assessment form is to be used when an existing patient returns to the HHA after being hospitalized as an inpatient for twenty-four (24) hours or more. The patient had not been hospitalized. A Reassessment/Recertification form should have been used for the new certification period. An interview held with the administrator on January 29, 2025 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 (HHA) admission documents, and an interview with the administrator, the HHA failed to provide the patients with an OASIS (Outcome and Assessment Information Set) Privacy Notice for seven (7) of seven (7) CR’s reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: The HHA’s Patient Admission Packet reviewed on January 27, 2025 at approximately 10:00 AM found that the packet, which is provided to patients at the time of admission and includes a list of patient rights, did not contain an OASIS Privacy Notice. A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 did not contain evidence that the patient received the OASIS privacy notice. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 did not contain evidence that the patient received the OASIS privacy notice. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025 did not contain evidence that the patient received the OASIS privacy notice. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025 did not contain evidence that the patient received the OASIS privacy notice. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025 did not contain evidence that the patient received the OASIS privacy notice. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 did not contain evidence that the patient received the OASIS privacy notice. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025 did not contain evidence that the patient received the OASIS privacy notice. An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) admission documents, and an interview with the administrator, the HHA failed to provide the patient with information concerning the criteria for transfer and discharge from the HHA for seven (7) of seven (7) CR’s reviewed; CR#1, CR#2, CR#3, CR#4, CR#5, CF#6, and CR#7. Findings include: The HHA’s Patient Admission Packet reviewed on January 27, 2025 at approximately 10:00 AM found that the packet, which is provided to patients at the time of admission and contains a list of patient rights, did not contain information pertaining to the criteria for transfer and discharge from the HHA. A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at approximately 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 found that the patient did not receive the criteria for transfer and discharge from the HHA. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025 found that the patient did not receive the criteria for transfer and discharge from the HHA. An interview held with the administrator on January 20, 2025 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), home health agency (HHA) admission documents, and an interview with the administrator, the HHA failed to provide the patient with the names, addresses and telephone numbers of federally-funded and state-funded entities that service the area where the patient resides for seven (7) of seven (7) CR’s reviewed; CR#1, CR#2, CR#3, CR#4, CR#5, CF#6, and CR#7. Findings include: The HHA’s Patient Admission Packet reviewed on January 27, 2025 at approximately 10:00 AM found that the packet, which is provided to patients at the time of admission and contains a list of patient rights, did not include the names, addresses and telephone numbers of the following federally-funded and state-funded entities that service the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. An interview held with the administrator on January 29, 2025 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), home health agency (HHA) policy, and an interview with the administrator, the home health agency failed to ensure that an initial assessment was conducted within forty-eight (48) hours of the referral for two (2) of seven (7) CR’s reviewed: CR#5 and CR#6. Findings include: The HHA’s Admission Policy and Procedure, reviewed on January 27, 2025 at approximately 12:15 PM reads in part, “All referrals will be seen within 48 hours of receipt of the referral and/or service orders from the referral source.” A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025 contained a referral date of 10/03/2024. The initial assessment was completed on 10/07/2024, four (4) days after receipt of the referral. There was no documentation that the physician otherwise ordered a specific start of care date. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 contained a referral date of 11/04/2024. The initial assessment was completed on 11/07/2024, three (3) days after receipt of the referral. There was no documentation that the physician otherwise ordered a specific start of care date. An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“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 clinical records (CR), home health agency (HHA) policies, and an interview with the administrator, the agency failed to ensure that the individualized plan of care included the services to be provided for two (2) of seven (7) CR’s reviewed: CR#1 and CR#2. Findings include: The HHA’s Admission Policy and Procedure reviewed on January 27, 2025 at approximately 12:15 PM reads in part, “The Plan of Treatment will include:...Type of service and equipment required...” The HHA’s Plan of Treatment/Periodic Review Policy and Procedure reviewed on January 27, 2025 at approximately 11:45 AM states in part, “The plan of treatment shall include but not limited to the following:...type of service and equipment required...” A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 contained a CMS Home Health Certification and Plan of Care (POC) that included a physician order which read, “One visit every 2 weeks for 60 days.” There was no documentation of the discipline intended to provide the care. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 contained a POC that included a physician order which read, “One time a week for 60 days.” There was no documentation of the discipline intended to provide the care. An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator, the HHA failed to ensure that treatment administered was ordered by a physician for one (1) of seven (7) CR’s reviewed: CR#2. Findings include: The HHA’s Admission Policy and Procedure reviewed on January 27, 2025 at approximately 12:15 PM reads in part, “The Plan of Treatment will include:...Medications and Treatment...” and “All services to be rendered must be specified on the Plan of Treatment (485).” The HHA’s Plan of Treatment/Periodic Review Policy and Procedure reviewed on January 27, 2025 at approximately 11:45 AM states in part, “The plan of treatment shall include but not limited to the following:...Medication and Treatment...” A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 found that the reassessment completed on 07/18/2023 by the skilled nurse (SN) noted that the patient had three (3) sacral pressure ulcers (bedsores). A review of the nursing notes for 07/25/2023, 08/01/2023, 08/10/2023, 08/17/2023, and 09/07/2023 found the following documentation: “RN will clean wound with saline, apply Santyl ointment (a medication to aid in wound care), apply foam adhesive weekly.” Wound care was provided by the RN on the above noted dates as per the nursing notes. The wound care orders contained on the Home Health Certification and Plan of Care (POC CMS 485) stated, “Wound Wash Saline 0.9% spray (spray daily and when needed to clean pressure wound.” There were no orders from the physician on the POC CMS 485 for wound care to include the application of Santyl and foam, nor were any physician orders found in the CR for wound care to include Santyl and foam. An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. 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 failed to assure that the patient received written information regarding the patient’s medication regimen based on the results of the drug regimen review for six (6) of seven (7) CR’s reviewed: CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 07/18/2023, the medication profile (“medication log”) contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, had no evidence that the medication profile was reviewed, reconfirmed and/or updated since 05/18/2023. CR#3 SOC 08/28/2024, CP 12/30/2024 to 02/28/2025 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 12/30/2023, the medication profile contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, was incomplete and not reflective of the physician orders on the Home Health Certification and Plan of Care (CMS 485 POC). The medication profile contained the following information: “Amlodipine 10 mg (milligrams) daily, 12/30/2024” (review date); “Atorvastatin 80 mg daily at bedtime” (no review date), “Lantus Solostar U 100 - see 485” (no dose, frequency or review date), “Metformin” (no dose, frequency or review date). The patient did not receive a copy of the “485” nor is the “485” intended to be a substitute for the written instructions to be provided to the patient. In addition, during the home visit on 01/29/2025 at 10:45 AM, the patient’s caregiver administered Furosemide (water pill) and Atenolol (used for high blood pressure) to the patient. Neither the Furosemide or Atenolol were ordered by the physician on the CMS 485 POC, the medications were not listed on the medication profile found in the CR, nor were any verbal orders found in the CR addressing the administration of Furosemide or Atenolol. Upon questioning the caregiver during the home visit as to whether the patient/caregiver received an admission packet with a medication profile, the caregiver stated that s/he had received a packet, but did not use the medication profile as s/he was aware of the medications to be given to the patient. CR#4 SOC 07/27/2024, CP 11/22/2024 to 01/21/2025 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 11/22/2024, the medication profile contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, had no evidence that the medication profile was reviewed, reconfirmed and/or updated since 07/27/2024. Upon questioning the patient during the home visit on 01/29/2025 at 11:35 AM as to whether the patient received an admission packet with a medication profile, the patient stated that s/he had received a packet but was unable to locate it during the visit, CR#5 SOC 10/07/2024, CP 12/06/2024 to 02/04/2025 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 12/06/2024, the medication profile contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, was incomplete and not reflective of the physician orders contained on the POC. All of the listed medications on the medication profile stated to “See 485” (CMS 485 POC). The patient did not receive a copy of the “485” nor is the “485” intended to be a substitute for the written instructions to be provided to the patient. In addition, there was no date on medication profile as to when it was created or last reviewed. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 01/04/2025, the medication profile contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, was incomplete and not reflective of the physician orders contained on the plan of care. All of the listed medications on the medication profile stated to “See 485” (CMS 485 POC). The patient did not receive a copy of the “485” nor is the “485” intended to be a substitute for the written instructions to be provided to the patient. In addition, there was no date on profile as to when it was created or last reviewed. CR#7 SOC 06/22/2024, CP 12/10/2024 to 02/08/2025 found that while a drug regimen review was documented in the nursing reassessment for the period beginning 12/10/2024, the medication profile contained in the CR, intended to be the written instructions provided to the patient regarding their medication regimen, had no evidence that the medication profile was reviewed, reconfirmed and/or updated since 08/17/2024. Upon questioning the patient during the home visit on 01/29/2025 at 10:00 AM as to whether the patient received an admission packet with a medication profile, the patient stated that s/he had received a packet but was unable to locate it during the visit, An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency policies, and an interview with the administrator, the HHA failed to assure that services ordered by the physician were provided to the patient for three (3) of seven (7) CR’s reviewed; CR#1, CR#2, and CR#6. Findings include: The HHA’s Missed Appointments Policy reviewed on January 28, 2025 at 2:00 PM reads in part, “Marigold Home Health recognizes the importance of ensuring that patients receive the appropriate visits as outlined in their individualized plan of care. If a visit is missed, the clinician or care team member must document the reason for the missed visit in the patient’s medical record within 24 hours.” The HHA’s Documentation Policy reviewed on January 29, 2025 at 8:15 AM states in part, “All documentation must be completed on the same day that services are rendered, including visit notes, care plans, and any changes to the patient’s status.” A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 08/24/2024, CP 08/24/2024 to 10/24/2024 contained orders on the Home Health Certification and Plan of Care (POC) for one (1) visit every 2 weeks for 60 days. Skilled Nursing (SN) visits were being provided even though the POC did not specify the discipline. SN visits occurred the week of 08/18/2024 and 09/01/2024. There was no SN visit/no nurses’ note for the week of 09/15/2024, and no missed visit note indicating the reason for the missed visit. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 contained orders on the POC for one (1) visit per week for 60 days. Skilled Nursing (SN) visits were being provided even though the POC did not specify the discipline. SN visits occurred the weeks of 07/16/24, 7/23/24, 7/30/24, 8/6/24, 8/13/24. There were no SN visits/no nurses’ notes for the weeks of 8/20/24 and 8/27/24, and no missed visit notes indicating the reasons for the missed visits. CR#6 SOC 11/07/2024, CP 01/04/2025 to 03/05/2025 contained orders on the POC for SN visits, 1 visit every 3 weeks for 60 days. A visit occurred the week of 12/29/2024. There was no SN visit/no nurses’ note for the week of 01/19/2025, and no missed visit note indicating the reason for the missed visit. An interview conducted with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 (HHA) failed to assure that a discharge summary was sent to the physician within 5 business days of the patient’s discharge for one (1) of two (2) discharge records reviewed: CR#2. Findings include: A review of CR’s was conducted on January 27, 2025 starting at approximately 11:00 AM, and continued at various times on January 28, 2025. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#2 SOC 05/18/2023, CP 07/18/2023 to 09/18/2023 found that the patient was discharged on 09/14/2025. The OASIS-E (Outcome and Assessment Information Set) Discharge Assessment was completed by the skilled nurse (SN) on 09/14/2024. The Section on the OASIS form titled “Complete this Section for Discharge Purposes (unless summary is written elsewhere)” was blank. The Section “Copy of the summary and current medication list” had a check off box noting that information was to be “faxed within 5 days of discharge.” However, the date and the physician to whom information was to be sent was blank. There was no evidence that a discharge summary was sent to the physician within 5 days of discharge, nor was a discharge summary found in the CR. An interview held with the administrator on January 29, 2025 starting at 3:30 PM confirmed the above findings.”