West Winds Health Services, Inc.

“Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This Element is not met as evidenced by: Based on record review, interview, and policy review the provider failed to ensure a structured home health training program, which included 16 hours of classroom training, was completed for two of two (E and F) newly employed home health aides prior to in-home training. Findings included: Review of home health aide E’s personnel file revealed that she was hired on 5/1/24. There was no documentation that she completed the classroom training. She had home health aide evaluation forms completed on 6/26/24 and 5/20/25 for the in-home training.Review of home health aide F’s personnel file revealed that she was hired on 8/25/25. There was no documentation that she completed the classroom training. She did not have any home health aide evaluation forms completed for the in-home training.Interview on 1/21/26 with registered nurse (RN)/owner A revealed that before the home health aides would leave for the in-home training she would spend approximately an hour with each home health aide reviewing infection control, vital sign parameters (measurements of body’s basic functions, such as temperature, blood pressure, pulse, and respiration rate), required home health aides paperwork, proper use of gait belts, and situations that must be report to nursing staff. Following this review, home health aides were required to watch a video addressing elder abuse and neglect and reporting requirements. RN/owner A stated the home health aides completed a minimum of 40 hours and up to 120 hours in-home training under the supervision of the nurse. She indicated that not all nurses completed a written home health aide form; instead, most nurses provide real-time feedback to the home health aides during the in-home training. Review of the provider’s March 2018 Home Health Aide Services and Training Program policy revealed: Policy: “All Home Health Aides employed or contracted by the Agency will satisfactorily complete a home health aide training program and competency evaluation program prior to performing patient care. Home Health Aides are selected on the basis of such factors as sympathetic attitude toward the care of the sick, ability to write, read and carry out directions, and maturity and ability to deal effectively with the demands of the job.” Procedure: “4. A minimum of 16 hours of classroom training must precede a minimum of 16 hours of supervised practical training as part of the 75 hours.” “7. The Agency must maintain documentation that demonstrates the requirements of this standard have been met.””

“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 record review, and interview, the provider failed to notify the physician within five business days following discharge for two of two patients (4 and 5) who discharged from the home health agency (HHA). Findings included: Review of patient 4’s medical record revealed he was admitted on 6/4/25. His admitting diagnoses included type 2 diabetes, heart failure, non-pressure chronic ulcer(skin tissue breakdown), end stage renal disease (chronic kidney disease), and hypertension (high blood pressure). Patient was discharged from the HHA on 9/3/25 with goals met. The discharge summary report was signed by registered nurse (RN) C on 9/8/25 and “Faxed 9/9/25” was written on the discharg summary. 2. Review of patient 5’s medical record revealed she was admitted on 8/28/25. Her admitting diagnoses included hypertensive heart and chronic kidney disease without heart failure, chronic kidney disease, anxiety disorder, major depressive disorder and rheumatoid arthritis (autoimmune disease that attacks the joint lining causing painful, swollen, warm joints). Patient was discharged from the HHA on 11/25/25 with goals met. The discharge summary report was signed by RN D on 12/8/25 and “Faxed 12/9/25” was written on the discharged summary. 3. Interview on 1/20/26 at 4:53 p.m. with office manager B revealed she was not aware that the discharge summary was required to be sent to the physician within five business days of the patient’s discharge date. She stated that she was responsible for sending the discharge summary to the physician once the clinician had completed it. 4. Interview on 1/21/26 at 8:29 a.m. with RN/owner A revealed she was aware the discharge summary must be sent to the physician within five business days following a patient’s discharged from the HHA. RN/owner A reported that during a staff meeting in March 2024, she reviewed the required, “Discharge Summary sent within 5 days” and RN D attended that staff meeting. RN C had not yet begun employment with the HHA at that time that meeting was held.. RN/owner A stated that she reviewed the five-day discharge summary requirement with RN C upon RN C’s hire. RN/owner A confirmed that the agency did not have a written policy addressing completion of the discharge summary and notification of the physician within five business days.”