Lotus Home Healthcare Services, PC

“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 record review and interview, the agency failed to conduct exercises to test the emergency plan or to activate the plan after an actual natural or man-made emergency annually and maintain documentation of all drills, tabletop exercise, and emergency events, for two (2023 and 2024) of three years reviewed. The failure placed the agency’s patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster or emergency. Findings include: During the entrance conference at 12:25 p.m. on 06/02/2025, the Alt Admin self-identified as the disaster coordinator and identified the ADON as the alternate disaster coordinator. Record review of the undated emergency preparedness manual revealed the following records: A tabletop exercise for tornado/storms labeled, “Disaster/Drill After Action Review/Critique,” record dated 04/04/2022 and unsigned. Review of the record revealed that the exercise was “called by” Former Admin B. An “Evaluation of Emergency Preparedness…Event,” emergency event (Ice Storm) dated 01/08/2025 and signed by the Alt Admin. Review of the evaluation record read in part: “…Emergency Preparedness Evaluation Plan for [Identifier 100, another HHA under management by the management company that manages the agency). Continued review of the EP records did not reveal any records or documentation to establish that the agency had participated in a full-scale exercise that was community based every 2 years and conducted on the opposite year of the full-scale exercise, a second community-based exercise, mock drill, or tabletop exercise. The agency’s emergency preparedness records also failed to contain documentation that the agency experienced an actual or man-made emergency that required an activation of the emergency plan that would have exempted the agency from a full-scale exercise for the years 2023 and 2024. During an interview on 06/09/2025 at 3:05 p.m. with the Admin/DON and the Alt Admin (disaster coordinator) the surveyor reviewed the findings and asked who at the agency was responsible for the agency’s EP program. The Alt Admin stated that the (Alt Admin) and the Former Admin A/ADON were responsible for the agency’s EP program. The surveyor asked the Alt Admin what the agency’s processes were for the EP program. The Alt Admin stated that the agency watched the “news for anything coming up; alerted the field staff and followed up” with the staff; and then updated the binder. The Admin/DON stated that the agency followed the call tree (called the patients) by triage level. The surveyor asked why the agency had not completed drills, exercises, or activated the plan during emergency events to test the plan, analyzed and maintained documentation of any drills, exercises, and actual events for 2023 and 2024. The Alt Admin replied, “Actually, I didn’t know that (the requirements).” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “They can have a delay in care.” The Alt Admin stated that the patient’s would not know who to call. Record review of agency policy titled “Emergency Preparedness and Response Plan EC.40” last reviewed 05/01/2024 read in part: “Purpose i. To ensure the Agency complies with all applicable federal, state, and local emergency preparedness requirements...POLICY... 2. Testing and Training a. The Agency will conduct exercises to test the emergency plan at least annually. The Agency will: (1) Participate in a full-scale community-based exercise every two years. If participation in a community-based exercise is not possible, a facility-based functional exercise will be conducted every two years. The Agency will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e., date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise). If the Agency experiences an actual natural or manmade emergency that requires activation of the emergency plan, the Agency is exempt from engaging in its next required full-scale community-based or facility-based functional exercise for one year following the onset of the emergency event. (2) Conduct an additional exercise every two years, opposite the year the full-scale community-based or facility-based functional exercise is conducted, that may include, but is not limited to the following: (a) A second full-scale community-based or facility-based functional exercise, or (b) A mock disaster drill, or (c) A tabletop exercise or workshop that includes 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 (3) The Agency will analyze the Agency’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, assess staff knowledge of emergency procedures and revise the emergency plan, as needed. (4) The Agency will document the lessons learned following their tabletop and full-scale exercises and real life emergencies and demonstrate that they have incorporated any necessary improvements in their emergency preparedness program...””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system regarding each beneficiary (patient), within 30 days of completing the OASIS assessment, in that; for report period 06/01/2025 to 06/01/2025 (82.22 percent) of OASIS assessments had submission dates that were more than 30 days after the M0090 date (date OASIS assessment completed). The failure prevented the patients’ data from being available to CMS for timely analysis to identify agency performance levels in the provision of patient care and treatment. Findings include: Review of iQIES (an internet-based system used by CMS to manage provider and patient information) on 06/02/2025 revealed the Agency’s OASIS error summary report for the report period 06/01/2025 to 06/01/2025. Review of the report revealed the following: error description “Record Submitted Late: The submission date was more than 30 days after the M0090 date on this new record; [The number] of assessments processed 45; [The number] of assessments with [a late submission] error 37; [and the percentage] of assessment with [a late] error [82.22 percent].” During an interview with the Admin/DON and Alt Admin on 06/09/2025 at 2:50 p.m., the surveyor asked who at the agency was responsible for submitting the agency’s OASIS assessments. The Alt Admin replied, “That’s me.” The surveyor asked what the agency’s process was for submitting the agency’s OASIS assessments. The Alt Admin replied, “I will submit every day if completed. If not, we call the RN.” The surveyor reviewed the findings and asked why the OASIS assessments were not submitted timely (within 30 days of the completion date). The Alt Admin replied, “When we took over (management of the agency) last October and saw that they (previous owners) had so many late (submissions), we called them (previous owners and RNs). They have another business now. That is why we are the management company.” The surveyor asked how the failure could adversely affect the agency’s’ patients. The Alt Admin stated that the patient would not get a plan of care, could have missed visits, and the agency would not be able to bill. Review of agency policy titled, “Timelines” last reviewed 08/01/20 read in part: “…Policy The Agency will ensure timely provision of services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure… C. A registered nurse, physical therapist, or speech therapist will complete the Initial Comprehensive Assessment no later than five calendar days after the start of care (SOC) for all patients/clients in a licensed and certified agency… E. Recertifications/comprehensive reassessments will be completed no earlier than five days prior to end of the episode and no later than the last day of the episode (the 56th through the 60th day… II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard…from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2022 and 2023 that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings included: During the entrance conference on 06/02/2025 at 12:25 p.m., the surveyor requested all agency QAPI documents/reports/manuals. During an interview with the Alt Admin on 06/02/2025 at 3:15 p.m. the surveyor again requested the agency’s QAPI records. The Alt Admin stated that the agency had “moved several times. I think it is in storage. I have someone there looking right now.” The surveyor requested the agency’s QAPI records and client satisfaction surveys for 2022, 2023, and 2024 be available for review on 06/03/2024. The surveyor received and reviewed the agency QAPI records for quarter one 2025 on 06/04/2025 at 10:00 a.m. At 10:18 a.m. the Alt Admin provided a QAPI records for quarter four of 2024. Review of agency’s undated and unsigned QAPI records revealed the following: 2024 records included: two patient clinical record audit (review) for Patients # 5 and 11, a patient indicators report, three performance improvement plans, and a “QA/PI Quarterly Report for the fourth quarter of 2024. 2025 records included: a patient clinical record audit (review) for Patient # 11, a patient indicators report, and two performance improvement plans. Continued review of the agency’s QAPI records did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for each calendar year of 2022 and 2023. During an interview on 06/09/2025 at 3:07 p.m. with the Admin/DON and Alt Admin, the surveyor asked who at the agency was responsible for the agency’s QAPI program. The Admin/DON stated that (the Admin/DON) was responsible. The surveyor asked what the agency processes were for implementing the program. The Admin/DON stated that the agency contracted with a consultant to compile the agency’s trends then the Admin/DON followed up with staff training and needed corrective actions. The surveyor reviewed the findings and asked why the agency had not conducted PIP(s) for 2022 and 2023. The Admin/DON replied, “I would not know before 2025 (was not the Admin/DON prior to 01/10/2025).” The Alt Admin replied, “we were moving, and we did not get it from the other owners.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON stated that the failure could cause the agency to not know how to properly care for the patients if the agency was not aware of the tracts and trends (to collect data, organize, and analyze it for improvement) in providing patient care and services. The surveyor asked if not knowing the tract and trends cause harm to the patients. The Admin/DON replied, “Of course.” Review of agency policies titled, “Quality Assessment Performance Improvement Program QAPI.5” last reviewed 01/13/18 revealed the following, “...Policy…III The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS…Procedure…E. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…””

“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 record review, observation, and interview the agency failed to ensure that all entries in the patients’ clinical records were completed and appropriately authenticated, dated, and timed with a primary author’s signature and title, who had reviewed and approved the entry, in one (Patients # 3) of two patient records reviewed who received a home visit. The failure placed the patients at risk of harm if care and treatment were not reviewed, approved, and authenticated by the primary author. Findings included: Clinical Record # 3: Patient # 3: Review of Patient # 3’s clinical record revealed a POC with a SOC of 05/19/2025 for the certification period of 05/19/2025 to 07/17/2025. Review of the POC revealed a primary diagnosis of encounter for orthopedic (treatment related to bones or muscles) aftercare following surgical amputation of one left toe. the POC was not signed or dated by an agency RN (15 days after the order was written). Continued review of the POC revealed the following: an order for SN visits for one time per week for one week, three times per week for four weeks, and two times per week for five weeks; an order for physical therapy to evaluate and treat. Further review of the record did not reveal that he POC was authenticated by an agency RN (was not signed, dated, timed, or titled by the primary author (RN B). During a home visit on 06/05/2025 at 10:00 a.m. with Patient # 3 and RN B, (Patient # 3) stated that the agency took 10 days after return home from the hospital to begin nursing services. During the visit, the surveyor observed RN B perform wound care. The surveyor observed and reviewed the patient’s admission records. The records did not include a plan of care. The surveyor observed RN B place a plan of care with a SOC of 05/19/2025 for the certification period of 05/19/2025 to 07/17/2025 in the admission folder. Review of the plan of care revealed that RN B. had signed it (after the surveyor reviewed the electronic clinical record on 06/03/2025). During an interview on 06/09/2025 at approximately 4:00 p.m. with the Admin/DON and Alt Admin the surveyor reviewed the findings and asked why the POC for Patient # 3 had not been authenticated by an agency RN, at least 15 days after the plan of care was written. The Admin/DON called RN B by phone. During the phone interview with RN B, the surveyor asked why RN B had not authenticated the current POC, prior to service initiation. RN B replied, “Most likely, it was sent back to me, and I forgot to sign. It was an oversight.” Review of agency policy titled, “Authorization and Authentication of Medical Record Entries IM.30” last reviewed 05/01/24 read in part: “Purpose [:] To identify the authors of medical record entries…Policy [:] All medical record entries whether paper, electronic, or a combination format will be legible, clear, complete, made by appropriate staff, and authenticated as true and accurate by the author of the entry. Procedure…IV Each medical record entry will be dated, timed, and signed with the complete name and title of the person making the entry…””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in five (Patients # 4, 6, 7, 8, and 10) of five inactive patient records reviewed, who required a written notice. The agency failed to provide Patients # 4, 6, 7, 8, and 10 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. The failure caused the clients to not have written advance notice to appeal the discharge decision if desired. Findings include: Patient # 4: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 4 as 06/16/2023. Record review of the clinical records for Patient # 4 revealed a POC for the certification period of 04/18/2023 to 06/16/2023. Review of the POC revealed a start of care date of 04/18/2023 with a principal diagnosis of type 2 diabetes mellitus (a condition where the body cannot use insulin properly or does not produce enough insulin to maintain healthy blood glucose or sugar levels) with complications. The POC was dated 04/18/2023 and electronically signed by RN C. The POC contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the records revealed a discharge OASIS with summary signed by the ADON and dated 06/16/2023. Review of the discharge summary revealed a discharge date of 06/16/2023. Review of the discharge OASIS read in part: “…Written notice of discharge provided to patient…” The area provided to indicate that the agency provided written notice to Patient # 4 was not checked. Further review of Patient # 4’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 06/16/2023. The record did not include a written NOMNC. Patient # 6: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 6 as 04/20/2024. Record review of the clinical records for Patient # 6 revealed a POC for the certification period of 02/21/2024 to 04/20/2024. Review of the POC revealed a start of care date of 02/21/2024 with a principal diagnosis of paroxysmal atrial fibrillation (short-lived and intermittent irregular heart rhythm). The POC was dated 02/21/2024 and electronically signed by RN D. The POC contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the records revealed a discharge OASIS with summary signed by the ADON and dated 04/20/2024. Review of the discharge summary revealed a discharge date of 04/20/2024. Review of the discharge OASIS read in part: “…Written notice of discharge provided to patient…” The area provided to indicate that the agency provided written notice to Patient # 6 was not checked. Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 04/20/2024. The record did not include a written NOMNC. Patient # 7: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 7 as 07/02/2023. Record review of the clinical records for Patient # 7 revealed a POC for the certification period of 05/04/2023 to 07/02/2023. Review of the POC revealed a start of care date of 05/04/2023 with a principal diagnosis of hyperlipidemia (elevated levels of cholesterol in the blood). The POC was dated 05/04/2023 and electronically signed by RN C. The POC contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the records revealed a discharge OASIS with summary signed by the ADON and dated 07/02/2023. Review of the discharge summary revealed a discharge date of 07/02/2023. Review of the discharge OASIS read in part: “…Written notice of discharge provided to patient…” The area provided to indicate that the agency provided written notice to Patient # 7 was not checked. Further review of Patient # 7’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 07/02/2023. The record did not include a written NOMNC. Patient # 8: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 8 as 06/19/2024. Record review of the clinical records for Patient # 8 revealed a POC for the certification period of 05/15/2024 to 07/13/2024. Review of the POC revealed a start of care date of 03/22/2023 with a principal diagnosis of primary lateral sclerosis (a neurological of the neurons in the brain and spinal cord). The POC was dated 05/10/2024 and electronically signed by the ADON. The POC contained an order for skilled nursing three times in 60 days: home health aide visits three times per week for eight weeks, and one time per week for one week. Continued review of the records revealed a discharge OASIS with summary signed by the ADON and dated 06/19/2024. Review of the discharge summary revealed a discharge date of 06/19/2024. Review of the discharge OASIS read in part: “…Written notice of discharge provided to patient…” The area provided to indicate that the agency provided written notice to Patient # 8 was not checked. Further review of Patient # 8’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 06/19/2024. The record did not include a written NOMNC. Patient # 10: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 10 as 09/23/2023. Record review of the clinical records for Patient # 10 revealed a POC for the certification period of 09/12/2023 to 11/10/2023. Review of the POC revealed a start of care date of 09/12/2023 with a principal diagnosis of cutaneous abscess of back (skin infectious wound to back). The POC was dated 09/12/2023 and electronically signed by RN C. The POC contained an order for skilled nursing visits two times per week for one week and three times per week for eight weeks. Continued review of the records revealed a discharge OASIS with summary signed by the ADON and dated 09/23/2023. Review of the discharge summary revealed a discharge date of 09/23/2023. Review of the discharge OASIS read in part: “…Written notice of discharge provided to patient…” The area provided to indicate that the agency provided written notice to Patient # 10 was not checked. Further review of Patient # 10’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/23/2023. The record did not include a written NOMNC. During an interview on 06/09/2025 at approximately 4:15 p.m. with the Admin/DON and the Alt Admin, the surveyor reviewed the findings and asked who at the agency was responsible for providing the discharge notice. The Admin/DON stated the field nurse. The surveyor asked why the agency had not ensured that the nurse provided a written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for the patients. The Admin/DON stated that (the Admin/DON) had taught on it and the nurses just focused so much on the five-day discharge notice (state regulatory requirement) that they just don’t provide the two-day NOMNC (federal requirement). The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated that the failure could cause a delay in getting the care that the patients needed after discharge. Review of agency policy titled, “Patient/Client Transfer and Discharge Notices” last reviewed 08/01/20 read in part: “ ...Policy… III. The Agency will deliver the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily...Procedure… B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client, or representative (if any) when providing notice of discharge... C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received...””

“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 record review, observation and interviews, the agency failed to advise patients of the name, address, and telephone number of a federally-funded and state-funded entity that service the area where the patients resided, in that: The agency failed to advise two (Patients # 2 and 3) of two patients, who received home visits of the updated name and contact information for the Quality Improvement Organization in their service area. The failure caused the patients to not have current information to appeal any pending discharge from the agency, if needed, and placed them at risk to not receive needed post discharge services. Findings include: Review of the agency’s “Patient Rights” record, dated 01/13/18, that was provided to agency patients read in part: “…Federally and State Funded Resources…(v) Quality Improvement Organization. [Identifier 200] …” Patient # 2: Review of Patient # 2’s clinical record revealed a POC with a SOC of 03/14/2025 for the certification period of 05/13/2025 to 07/11/2025. Review of the POC revealed a primary diagnosis of encounter for change or removal of surgical wound dressing and that RN A signed and dated the POC on 05/10/2025. Continued review of the POC(s) revealed the following: an order for SN visits four times per week for one week and three times per week for nine weeks. During a home visit on 06/05/2025 at 1:00 p.m. with Patient # 2 the surveyor observed and reviewed Patient #2’s home folder. The home folder did not include the name, address, and telephone number of the following federally funded and state-funded entity that served the area where the patient resided: the Quality Improvement Organization (Identifier 300). The surveyor asked Patient #2 if any documents or paperwork had been removed from the home folder. Patient #2 stated the Alt Admin just brought the admission folder “today” and all the paperwork that was provided by the agency was in the folder. Patient # 2 stated that (Patient # 2) did not receive an admission folder at admission. Patient # 3: Review of Patient # 3’s clinical record revealed a POC with a SOC of 05/19/2025 for the certification period of 05/19/2025 to 07/17/2025. Review of the POC revealed a primary diagnosis of encounter for orthopedic (treatment related to bones or muscles) aftercare following surgical amputation of one left toe and that the POC was not signed or dated by an agency RN. Continued review of the POC revealed the following: an order for SN visits for one time per week for one week, three times per week for four weeks, and two times per week for five weeks; an order for physical therapy to evaluate and treat. During a home visit on 06/05/2025 at 10:00 a.m. with Patient # 3 and RN B, the surveyor observed and reviewed Patient # 3’s home folder. The home folder did not include the name, address, and telephone number of the following federally funded and state-funded entity that served the area where the patient resided: the Quality Improvement Organization (Identifier 300). The surveyor asked Patient # 3 if any documents or paperwork had been removed from the home folder. Patient # 3 stated the paperwork that was provided by the agency was in the folder. During an interview on 06/09/2025 at approximately 3:30 p.m. with the Admin/DON and Alt Admin, the surveyor reviewed the findings and asked who at the agency was responsible for written information in the admission paperwork. The Admin/DON stated that (the Admin/DON) was responsible for the written information in the admission paperwork. The surveyor asked why the Quality Improvement Organization had not been updated and current for the patient’s service area. The Admin/DON replied, “That is a work in process. We just started in February. Oversight.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON stated that the patients would not get the correct organization for the appeal process. The surveyor asked what could not having the correct information cause. The Admin/DON replied, “A delay in the services.” Review of agency policy titled, “Rights and Responsibilities RI.5” last reviewed 11/16/22 read in part: “…Procedure…K. Be advised of the names, addresses, and telephone numbers of the following federally-funded and state-funded entity that served the area where the patient resides: 1. Agency on Aging, 2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center and 5. Quality Improvement Organization…” Review of the Center for Medicare Advocacy website, Medicare Quality Improvement Organization Changes Name - Center for Medicare Advocacy, on 06/13/2025 revealed the following: “…Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) help Medicare beneficiaries with their concerns about quality of care, and in filing an appeal if coverage is ending too soon. As of July 1, 2024, the BFCC-QIO formerly known as [Identifier 200] is officially [Identifier 300] ...””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review, observation, and interview the agency failed to coordinate care delivery to meet the patient’s needs and involve the patient in the coordination of care activities, in that: the agency failed to coordinate patient care supply delivery, physical therapy service evaluation, or both for two of two patients (Patients # 2 and 3), who received a home visit. The failure caused a delay in physical therapy service and supply delivery and placed the clients’ health and safety at risk related to increased risk of infections, falls, or both. Findings include: Patient # 2: Review of Patient # 2’s clinical record revealed two POC(s) with a SOC of 03/14/2025 for the certification periods of 03/14/2025 to 05/12/2025 and 05/13/2025 to 07/11/2025. Review of the POC revealed a primary diagnosis of encounter for change or removal of surgical wound dressing and that RN, A signed and dated the POC(s) on 03/14/2025 and 05/10/2025. Continued review of the POC(s) revealed the following: an order for SN visits for one time per week for one week and three times per week for eight weeks for certification period beginning 03/14/2025; an order for four times per week for one week and three times per week for nine weeks for certification period beginning 05/13/2025; and order for wound care to right lower leg; an order for dressing supplies and duoderm (a type of wound dressing), Ace wrap (used to secure a wound dressing), gauze pads (a type of wound dressing) and kerlix rolls (used to secure a wound dressing). Further review of Patient # 2’s record revealed a communication note dated 03/21/2025 and signed by Supply Staff A. Review of the communication note read in part: “03/21/2025, date communication with patient regarding supplies delivery or delay 03/21/2024…expected date of delivery: 2 to 3 business days…” Continued review of the record did not reveal any further communication or coordination of care with Patient # 2 regarding supply delivery or delay. During a home visit on 06/05/2025 at 1:00 p.m. with Patient # 2 the patient stated that (Patient # 2) had not received any wound care supplies since admission to the agency on 03/14/2025, until “this morning.” Patient # 2 stated that the agency delivered a box of wound care supplies and indicated a box sitting on the floor, near the front door, in the dining room. The surveyor observed the box of supplies sitting on the floor. Patient # 2 stated that the admission nurse, RN A stated that the agency would provide wound care supplies. Patient # 2 stated that (Patient # 2) had called the agency and spoke with Supply Staff A to request supplies. Patient # 2 again stated that (Patient # 2) had not received any supplies from the agency since admission and had been using supplies that were provided by a previous home health agency and had to buy supplies. Patient # 2 stated that (the Alt Admin) called “this morning [06/05/2025]” and stated that (the Alt Admin) was “bringing supplies.” Patient # 3: Review of Patient # 3’s clinical record revealed a POC with a SOC of 05/19/2025 for the certification period of 05/19/2025 to 07/17/2025. Review of the POC revealed a primary diagnosis of encounter for orthopedic (treatment related to bones or muscles) aftercare following surgical amputation of one left toe and that the POC was not signed or dated by an agency RN. Continued review of the POC revealed the following: an order for SN visits for one time per week for one week, three times per week for four weeks, and two times per week for five weeks; an order for physical therapy to evaluate and treat an order for SN to perform wound care three times per week; an order for dressing supplies. Further review of the record did not reveal any coordination of care or documentation regarding wound care supply or physical therapy service delivery delays. During a home visit on 06/05/2025 at 10:00 a.m. with Patient # 3 and RN B (Patient # 3) stated that the agency took 10 days after return home from the hospital to begin services. Patient # 3 stated, “I changed my own dressing until then.” Patient # 3 stated that (Patient # 3) had to purchase all the wound care supplies because the agency had not provided any wound care supplies. During the visit, the surveyor observed RN B perform wound care. The surveyor heard Patient # 3 inform RN B that the patient and a family member had to purchase wound care supplies because the agency had not provided any supplies. The surveyor heard RN B ask Patient # 3 if PT had been started. Patient # 3 stated that PT had not started. The client stated that no one from the agency had contacted him about supplies and delay in PT services. During an interview with the Admin/DON and Alt Admin on 06/10/2025 4:33 p.m. the surveyor asked who at the agency was responsible for providing supplies to the agency’s patients. The Alt Admin replied, “That’s me and [Supply Staff A, who orders the supplies].” The surveyor asked what the agency’s process were. The Alt Admin stated that the SOC nurse informed the agency what supplies were needed; The supply coordinator, Supply Staff B received the supply needs request. For Patient # 2: The surveyor reviewed the findings and asked why the agency did not provide and coordinate the delivery of the wound care supplies for Patient # 2. The Alt Admin stated that the agency tried to order the supplies, but the suppliers did not take Patient # 2’s insurance. The surveyor asked who was responsible for the supplies (the agency or the patient). The Alt Admin stated that the agency was responsible for providing the supplies. The surveyor asked why there was no coordination of care with Patient # 2 regarding the delivery of supplies after 03/21/2025 (communication note by Supply Staff A). The Alt Admin stated that (the Alt Admin) did not document coordination of care with Patient # 2. The surveyor asked how the failure could adversely affect the patient. The Admin/DON stated that the failure could cause a delay in care and a delay in improvement. For Patient # 3: The surveyor asked why the agency did not provide and coordinate care for Patient # 3’s supply delivery. The Admin/DON and Alt Admin stated that they were not aware that the supplies had not been delivered. The Admin/DON called RN B and asked how the RN sent requests for patient supplies. RN B stated that (RN B) sent a message request at Patient # 3’s admission. RN B stated that a text message was sent to Supply Staff B. At approximately 4:35 p.m. on 06/10/2025 during an interview with Supply Staff B, (Supply Staff B) stated, “I normally sent it (supply request) to (Supply Staff A).” the surveyor observed Supply Staff B looking at messages on a mobile phone, Supply Staff B stated that (Supply Staff B) could not find where the supply request for Patient # 3 was sent to Supply Staff A. The Alt Admin asked Supply Staff A about the request for supplies. The Alt Admin brought the supply log from Supply Staff A. The Alt Admin reviewed the log and there was no documentation of coordination regarding supply delivery for Patient # 2 or 3. During an interview with the Admin/DON and the Alt Admin on 06/09/2025 at 4:00 p.m. the surveyor reviewed the findings and asked who at the agency was responsible for ensuring PT evaluations were completed. The Alt Admin stated that “intake” (Intake Staff A) was responsible. The surveyor asked why the PT evaluation had not been completed (order received on 05/19/2025 for the PT evaluation). During interview (06/09/2025 approximately 4:00 p.m.) with Intake Staff A the surveyor asked why the PT evaluation had not been completed. Intake Staff A stated that the agency “were trying to find a therapist. We found one that will go this week.” The Surveyor asked why there was no coordination of care with Patient # 3 and the agency staff. Intake Staff A stated that Intake Staff B was the person communicating with Patient # 3. During phone interview with Intake Staff B (06/09/2025 4:00 p.m.) Intake Staff B stated that (Intake Staff B) did not document any communication until a final resolution. The surveyor asked how the failure could adversely affect the patient. The Admin/DON stated that there would be a delay in care and delay in improvement. Review of agency policy titled; “Monitoring Client Care/Coordination of Care” last reviewed 08/01/20 read in part: “Purpose [:] To ensure coordination of patient care/treatment…Policy…Agency will collaborate with other organizations providing services…the patient/client…to ensure appropriate coordination of care for the patient. Procedure…III. Agency Staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care.””