Shalem Home Health Care Inc.

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure that the patient received all home health aide services (hha) as outlined in the plan of care in one (Patient # 2) of three records reviewed in which the patients received a home visit. The failure caused the patient to not receive home health aide services (Personal care tasks: bathing, dressing, shampooing, and assistance with transferring and household tasks: linen change, make bed) as ordered on the POC. The failure placed the patient at risk of decreased mobility, falls, or skin infections. Findings include: Patient Record Review # 2: Review of Patient # 2’s EHR revealed a POC with a start of care date of 09/03/2025 for certification period of 10/28/2025 to 12/26/2025. The POC was signed by the Admin/DON on 10/24/2025. The POC contained a primary diagnosis of chronic congestive heart failure (a heart condition that causes a buildup of fluid in body tissues and the lungs). The POC also included orders for SN visits two times per week for nine weeks and home health aide three times per week for nine weeks. Continued review of the record revealed a physician’s order addressed to physician (Physician # 3) dated 10/28/2025. Review of the physician’s order revealed the Admin/DON signed the order and it included orders for SN visits two times per week for nine weeks and home health aide three times per week for nine weeks. Further review of the record revealed a home health aide care plan dated 10/28/2025. Review of the care plan revealed that Admin/DON signed the care plan and assigned the following tasks: Incontinence (loss of bowel or bladder control) care; assist with mobility (walking and transfer), Household (light housekeeping, change linen, make bed), Personal care (Dressing, back rub, check skin, skin care, comb hair, foot and nail care, oral care, shampoo hair, Shower, and infection precautions). Continued review of home health aide care plan did not reveal a frequency of visits or frequency of assigned tasks. Further review of the record did not have any records that indicated that there was an order to decrease the number of home health aide visits for Client # 2. During a home visit, interview, and observation with Client # 2, Admin/DON, and hha A on 11/25/2025 at 1:00 p.m., the surveyor observed Admin/DON assessing and listening to Client # 2’s, dialysis access site (a surgical connection made to a blood vessel, that allows blood to be drawn and returned during dialysis or cleansing of the blood)., heart, and lungs, and assessing (Client # 2’s) eyes and skin. The surveyor observed hha A assist Client # 2 with a shower. The surveyor asked hha A and Client # 2 how often hha visited. Client # 2 and hha A stated that (hha A) provided home health aide visits two times weekly. Client # 2 was not aware that the agency had an order for home health aide visits three times weekly. Home health aide, hha A stated that (hha A) received a monthly schedule and if it changed, she received a call to update the schedule. The surveyor asked if hha A was aware that the Client’s plan of care listed hha visits three times weekly. She stated that it was on her schedule two times weekly. She stated that she was not aware of the three times per week visit order. During an interview with the Admin/DON, on 12/01/2025 at 3:05 p.m., the surveyor asked how often Patient # 2 received home health aide visits. The Admin/DON stated two times weekly. The surveyor reviewed the findings and asked who was responsible for ensuring that the clients received the services as ordered in the plan of care. The Admin/DON stated that (Admin/DON) was responsible. The surveyor asked why Patient # 2 did not receive the hha visits three times per week as ordered. The Admin/DON stated that the agency recently had a nurse quit and (Admin/DON) had to take on that nurse’s case load. The surveyor asked why there was no frequency of visits or frequency of tasks listed on the home health aide’s care plan. The Admin/DON replied, “Maybe, [the agency staff] didn’t learn how to use the new program [electronic health record system] (to enter the frequency).” The surveyor asked how the failure could adversely affect the patient. Admin/DON stated that the failure could cause loss of mobility, falls, muscle weakness, or possible infection at the new dialysis access site (if patient not receiving showers as assigned). Review of agency policy titled, “Implementing Care and Treatment” dated 05/02/24 read in part, “Purpose To ensure patient/client care and treatment are provided as identified in the care planning process. Policy I. Agency staff providing patient/client care and treatment will be competent to the level of care and treatment needed, and the care provided will be within the frequency parameters established on the care planning document(s)… V. Home health aides are members of the interdisciplinary team and are assigned to a specific patient/client by a registered nurse (RN)… within a time frame to meet the patient’s/client’s identified needs and per physician… orders. The home health aide will be provided with written patient/client care instructions prepared by that RN…A. The home health aide provides services that are ordered by the physician…included in the Plan of Care, permitted under state law, and consistent with the home health aide training...””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the patient’s individualized plan of care (POC) had been reviewed and revised by the patient’s physician no less frequently than once every 60 days, in one (Patients # 1) of three sampled skilled patient records reviewed who received wound care. The failure placed the patients at risk of harm due to lack of physician oversight if there were changes in the patient’s condition or if there was a need for additional care and services. Findings Included: Patient # 1: Review of the clinical record for Patient # 1 revealed a POC with a SOC date of 04/07/2025. The POC contained a certification period of 08/05/2025 to 10/03/2025 dated and signed by the Admin/DON on 08/01/2025. Review of the POC revealed a primary diagnosis of open wound to buttocks (lower rear area of the human back). The POC contained orders for SN visits one time per week for one week, two times per week for eight weeks, and one time per week for one week. Continued review of the record did not reveal that Patient # 1’s individualized plan of care had been reviewed and revised by the patient’s physician no less frequently than once every 60 days (review was due by 10/04/2025). Continued review of the EHR revealed a physician’s order dated 10/04/2025 that read in part, “…Recertify patient for Home Health Episode 10/4/25-12/2/25 SN Frequency: [two time per week for eight weeks] The estimated time for skilled services is 60 days…” Admin/DON signed the physician’s order on 10/04/2025. Physician # 1 was listed as the ordering physician. Further review of the record revealed that under the “orders” tab the “CMS 485” (Centers for Medicare and Medicaid Services home health certification and plan of care used for certification and recertification of skilled nursing services and must be signed by a primary care physician or designee), was “not started.” The task of completing the 485 or POC was assigned to RN A. During an interview with the Admin/DON and RN A on 12/01/2025 at 3:18 p.m. the surveyor reviewed the findings and asked why the POC had not been started during record review on 11/24/2025 and still had not been completed on 12/01/2025. RN A replied, “Possibly because the recert was not completed, but I would have to look at it.” The surveyor asked if RN A had completed the POC on 11/24/2025. RN A stated that (RN A) would have to look at (RN A’s) phone. The surveyor asked why the POC had not been completed by 10/04/2025 (date next review by physician was due). RN A replied, “To be honest with you it was an oversight on my part.” The surveyor asked how the failure could adversely affect the patient. RN A replied, “If the plan of care for wound care or medication had changed, it could make the wounds worse. It could affect the client’s health and safety.” Review of agency policy titled, “Plan of Care” last reviewed 05/02/24 revealed that it read in part, “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems.…VI. The individualized Plan of Care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health Plan of Care and the Agency as frequently as the patient’s/client’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date…””

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the development of the individualized plan of care for one (Patient # 5) of five sampled active patient records reviewed, in that, after initial assessment (on 11/13/2025) the agency failed to ensure that Patient # 5’s plan of care was completed within three to five days of the initial assessment. The plan of care was not developed or completed until after 11 days of the initial assessment. The failure placed the patient’s health and safety at risk if agency staff overlooked orders for physical therapy treatment, nursing care, or home health aide services. Findings include: Patient # 5: Review of the clinical record for Patient # 5 did not reveal a POC for the initial SOC date of 11/13/2025. Continued review of the EHR revealed a physician’s order dated 11/13/2025 that read in part, “…Admit new patient to Home Health Care Episode 11/13/25 -1/11/26 Frequency: [SN: one time per week for nine weeks HHA: one time per week for one week, three times per week for eight weeks PT to evaluate] The estimated time for skilled services is 60 days…” Admin/DON signed the physician’s order on 11/13/2025. Physician # 2 was listed as the ordering physician. Further review of the record revealed that under the “orders” tab that the “CMS 485 or POC (Centers for Medicare and Medicaid Services home health certification and plan of care used for certification and recertification of skilled nursing services and must be signed by a primary care physician or designee), was “not started.” The task of completing the 485 or POC was assigned to Admin/DON. Further review of the record revealed and initial assessment, OASIS (Outcome and Assessment Information Set, a tool used by CMS to collect a standard set of data that is used to measure quality and outcomes in home health care) dated 11/13/2025. Continued review of the record did not reveal that the agency had completed an individualized plan of care for Patient # 5 within three to five days after the initial assessment on 11/13/2025, according to agency policy. During an interview with the Admin/DON on 12/01/2025 at approximately 3:30 p.m. the surveyor reviewed the findings and asked why the POC for Patient # 5 had not been started during record review on 11/24/2025. The surveyor asked who was responsible for ensuring the POC’s were completed timely. Admin/DON stated (Admin/DON was responsible. The surveyor asked what the agency’s processes were for completing the POC’s timely (within three to five days of the initial assessment according to agency policy). Admin/DON stated that the agency completed the POC’s immediately and at recertification. The surveyor asked why the plan of care for Patient # 1 had not been completed. Admin/DON stated that an agency nurse had left suddenly and (Admin/DON) had to take over the case and it took a few days to complete the POC. The surveyor asked why the Adnin/DON had not followed the agency policy. Admin/DON replied, “Maybe, I overlooked it or something.” Review of agency policy titled, “Plan of Care” last reviewed 05/02/24 revealed that it read in part, “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems… Procedure I. The appropriate licensed professional staff member, with physician and/or non-physician practitioner participation, is responsible for developing the Plan of Care within three to five days of the initial assessment…Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the Plan of Care. The individualized Plan of Care will indicate if the patient/client has an advance directive(s) and if so, what type(s) of advance directive(s) exists. If the patient does not have an advance directive, this should also be listed on the individualized Plan of Care. The individualized Plan of Care must also specify the patient/client and A. The individualized Plan of Care must include the following: 1. All pertinent diagnoses; 2. The patient’s/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; a. The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care. 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors. 13. Patient/client and caregiver education and training to facilitate timely discharge; 14. Patient/client-specific interventions and education; 15. Measurable outcomes and goals identified by the Agency and the patient/client; 16. Information related to any advance directives; and caregiver education and training…””