Convenient Home Health

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to have a written emergency preparedness and response plan that comprehensively described its approach to a disaster that could affect the need for its services or its ability to provide those services for.1 of 1 Emergency Preparedness plan reviewed, in that there . no review of the plan This failure placed the agency clients at risk of harm due to staff’s unawareness of their roles and responsibilities to the clients in actual disaster or emergency situations. Findings include: Record reviews of undated binder provided by the administrator showed emergency preparedness plan for 2020 and previous years but did not show the emergency preparedness plans were reviewed and or revised. During an interview on 3/12/26 at approximately 10:30 am, the Administrator was asked if the agency had an emergency preparedness plan written for the years 2023,2024 and 2025, the administrator handed over to the surveyor the EPP binder and said, “We should have the plan here.”(referring to the binder) The surveyor showed the administrator that there was no emergency preparedness plan written in the EPP binder. The Administrator said that they did not realize that they still had to do emergency preparedness planning and reviews since the agency had no patients and they were so focused on cleaning up a lot of other things. Surveyor asked the administrator who was the Disasters Coordinator and he said “is me” During an interview on 3/12/26 at approximately 10:51 am, surveyor asked Who was responsible for making sure that the agency did have an EPP plan? Why didn’t you follow your policy/plan? the Administrator said they did not have the emergency preparedness plan because their attention was on the “marketing” to be able to accept patient in the future. I am responsible for everything now” Record review of the agency’s policy titled undated “Emergency Preparedness Policy and Plan” revealed in part… “Purpose: To provide planning, training and establish preparedness to respond to emergencies/disasters whether they are man-made or natural disasters…. C. Agency will develop and maintain an Emergency Preparedness Plan that utilized in the event a situation occurs that could potentially affect the needs for its services…...D. The effectiveness of the Emergency Preparedness Plan will be reviewed, evaluated, and updated at least annually…...E. An annual review of the Emergency Plan will be documented to include the date of the review and any updates made to the emergency preparedness plan based on the review…N. The agency will conduct one exercise to test the emergency plan at least annually…””

“Physical Therapist CFR(s): 484.115(h) Standard: Physical therapist. A person who is licensed, if applicable, by the state in which practicing, unless licensure does not apply and meets one of the following requirements: (1)(i) Graduated after successful completion of a physical therapist education program approved by one of the following: (A) The Commission on Accreditation in Physical Therapy Education (CAPTE). (B) Successor organizations of CAPTE. (C) An education program outside the United States determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR 212.15(e) as it relates to physical therapists. (ii) Passed an examination for physical therapists approved by the state in which physical therapy services are provided. (2) On or before December 31, 2009- (i) Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or (ii) Meets both of the following: (A) Graduated after successful completion of an education program determined to be substantially equivalent to physical therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR 212.15(e) as it relates to physical therapists. (B) Passed an examination for physical therapists approved by the state in which physical therapy services are provided. (3) Before January 1, 2008 graduated from a physical therapy curriculum approved by one of the following: (i) The American Physical Therapy Association. (ii) The Committee on Allied Health Education and Accreditation of the American Medical Association. (iii) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association. (4) On or before December 31, 1977 was licensed or qualified as a physical therapist and meets both of the following: (i) Has 2 years of appropriate experience as a physical therapist. (ii) Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service. (5) Before January 1, 1966- (i) Was admitted to membership by the American Physical Therapy Association; (ii) Was admitted to registration by the American Registry of Physical Therapists;or (iii) Graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education. (6) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of fulltime experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy. (7) If trained outside the United States before January 1, 2008, meets the following requirements: (i) Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy. (ii) Meets the requirements for membership in a member organization of the World Confederation for Physical Therapy. This Standard is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that Therapy services were initiated and/ or on time for the recertification for 1 of 7 patients (1) with orders for recertification therapy, in that; 1. Patient #1 PT Re Evaluation was conducted 2/18/26 following the Recertification 1/18/26 The PT reevaluation was performed 30 days after recertification. This failure to ensure that physical therapy was performed on time after recertification was ordered with could place Patient #1 and other patients at risk of deterioration in their level of functioning and at risk of an increase in pain and immobility from failing to receive ordered therapy services on time. Findings include: Patient #1 Review of active Patient #1’s clinical record included a plan of care for certification period 1/18/2026 - 3/18/20216 with a start of care date of 1/29/2014. The POC listed diagnoses of, chronic kidney disease, state 4. Abnormalities of gait and mobility essential primary hypertension. The POC listed orders for Skilled nursing 1w9 (once a week for nine weeks); Physical Therapy (PT) to evaluate and treat. HHA: 3W8. Clinical record review revealed PT ReEvaluation was completed on 2/18/2026, twenty (30) days after it was ordered on the plan of care. Clinical records reveal that the patient was not scheduled regular PT Visits, no documentation was found in the electronic medical record. During an interview with Client #1 at Home Visit on 3/13/26, patient stated that PT visits had been very inconsistent, and they missed mostly every visit. Client stated that she was not very happy with PT services, other than that the agency was overall well. Surveyor asked client if she called the agency to inform them about the issue with PT services and she said, yes multiple times. Patient stated that she does not know the name of the PT, because every time is a different person. During an interview on 3/14/2026 at 12:12 PM., Administrator was asked why the PT evaluation was done late. The Administrator stated that she/he did not know why and did not know there was no regular PT visit for client # 1. The admin stated that this was an oversight and the agency did not send the referral to the PT company. The Adm further stated that she/he did not know why. Additionally, the Administrator stated that he called the PT company and sent emails about this patient, but he did not get an answer from the PT company. The agency did not provide additional information by the time of exit. Review of the agency’s written policy on Timeline for Initiation of Services, undated, read in part, “PT, OT, MSW should commence service within 10 business days of service request.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patients’ current medications for 1 of 3 (#1) active patients whose clinical records were reviewed, and a home visits conducted. This failure could place patients at risk of harm and poor health results resulting from potential adverse drug effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Findings include: Patient #1 Review of the SOC assessment dated 01/29/2024 showed the diagnoses of unspecified, essential hypertension, hypertension (high blood pressure), chronic kidney disease stage 4, and others Further review of the SOC assessment RN B documented under drug regimen review “no issues found during review.” And the patient/caregiver received instruction on special precautions for all high-risk medications and how and when to report problems. Review of the POC signed by RN B for Certification Period 01/18/2026 - 03/18/2026 showed a SOC of 06/24/2022 and included the following information: 1) medications: Nefedipine ER Oral 30 mg 1 tab (a tab twice daily) Oxybutynin chloride ER oral 10 mg 1 tab (1tab daily) Donepezil Ncl Oral 10 mg tab (1 Tab daily) Menantine HCL oral 10 mg tab ( 1 tab twice a day) Ferrous Gluconatte Oral 324 (38 fe) mg (1tab daily) Valsartan oral 160 mg 1 tab daily Metoprolol Succinate ER 25 mg tab (1 tab daily) 2) Orders and Treatments: SN: 1wk9 (1 time a week for 9 weeks) with 2 PRN visits for falls/disease exacerbations HHA 3WK 9 PT/CG were informed of ne frequency , disciplines POC , Medication profile for new episode. 3) Goals and Outcomes The patient will have no hospitalizations during the certification period. Patients will remain free of adverse medication reactions during the episode. Patient/Caregiver will verbalized understanding of medication regiment , dose, frequency , indication and side effect Record review revealed no medication profile list nor medication reconciliation. . Review of Patient #1’s current medication record for the certification period from 11/19/2025 to 01/17/2026 revealed that the patients were taking the same medications listed in the above POC. Observation during a home visit on 3/13/2026 at 10: 26 a.m. revealed that Patient #1 lives with a family member. Home Concurrent medication reviewed and the following medications that Patient #1 was taking but were not listed in the patient’s medication list or POC: Lunigan Glu 234 tab ( 2 tabs daily) Not a new medication, client cannot remember start date Allppurinol 100 mg (1 tab daily) Not a new medication, client cannot remember start dateCephalexin 500 mg (2 tab a day) Prescribed by emergency room on 3/3/26Sulindac 150 mg (1 tab every 12 hours) Not a new medication, client cannot remember start date During interview with the Administrator on 03/14/26 at 3:35 p.m. the above findings were presented, and he stated that DON informed him that the POC and medication profile was not created. He stated that DON usually creates the medication profile list. The Administrator stated that this was not acceptable, the administrator was asked what harm can cause if the nurses don’t monitor the patient’s mediation and update the mediation profile. The ADM stated, “from no harm to death.” Surveyor asked the Supervising to ask additional clinical questions, the Adm. stated that she was not available because she was on vacations, alternate supervising nurse was not available as well, she was very new and was not fully onboard. The Administrator stated that he had let go the previous supervisor”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on record review and interview, the agency failed to enforce the agency’s discharge policy for 4 of 4 patients (Patients #4 ,#5 #6 and #7) without communicating to the clients, the clients’ responsible party, all physician’s or allowed practitioners who will be responsible for providing care and services to the patient after discharge at least five days before the date of discharge. Failure of the agency to not communicate plans of care prior to discharge could result in an inadequate physician oversight for the patients ongoing needs after discharge. Findings include: Review of the agency policy titled, “Patient Discharge”, reads in part; “Agency will ensure delivery of the written notification no later than 5 days before the date on which the patient will be discharged.” Client # 4: Review of the clinical record for Client #4 revealed a plan of care (POC) for certification period 5/13/2025 - 7/11/2025 with a start of care date of 5/13/2025. The primary diagnosis is Type 2 diabetes mellitus (sugar in blood); and other pertinent Diagnosis of hypertensive heart disease The orders for discipline and treatments included: Skilled Nurse (SN) Frequency: 1 WK 9; Physical Therapy: To Evaluate and Treat ,Occupational Therapy : to evaluate and treat Review of clinical record for Client #4 revealed the Client was discharged on 7/8/2025; reason for discharge was “goals met.” Further review of the clinical record for Client #5 did not contain any documentation indicating that, a written 5 days discharge notice was given to the client or the client’s responsible party at least five days before the date of discharge. The agency failed to ensure that a written notification was given to the Client #4 or the Client #5’s responsible party at least five days before the date of discharge. Client #5: Review of the clinical record for Client # 5 revealed a plan of care (POC) for Treatment period 9/24/2025 - 11/22/2025 with a start of care date of 7/26/205. The primary diagnosis is primary osteoarthritis; and other pertinent Diagnosis of type 2 diabetes (sugar in the blood) mellitus, atherosclerotic heart disease and essential primary hypertension. Skilled Nurse (SN) Frequency: 1 WK 9 (one visits a week for 9 weeks), Physical Therapy: to evaluate and treat. Review of clinical record for Client #5 revealed the Client was discharged on 1/2/2026; reason for discharge was “goals met.” Further review of the clinical record for Client #5 did not contain any documentation indicating that, a written 5 days discharge notice was given to the client or the client’s responsible party at least five days before the date of discharge. The agency failed to ensure that a written notification was given to the Client #5 or the Client #5’s responsible party at least five days before the date of discharge. Client #6: Review of the clinical record for Client # 6 revealed a plan of care (POC) for Treatment period 2/20/2025 -4/20/2025 with a start of care date of 2/20/2025. The primary diagnosis Cellulitis (inflammation of cells) of the right lower leg . Skilled Nurse (SN) Frequency: 1 WK 9 (one visits week for 9 weeks), Physical Therapy: to evaluate and treat, Occupational Therapy: to evaluate and treat. Review of clinical record for Client #6 revealed the Client was discharged on 3/25/2025; reason for discharge was “goals met.” Further review of the clinical record for Client #6 did not contain any documentation indicating that, a written 5 days discharge notice was given to the client or the client’s responsible party at least five days before the date of discharge. The agency failed to ensure that a written notification was given to the Client #6 or the Client #6’s responsible party at least five days before the date of discharge. Client #7: Review of the clinical record for Client # 7 revealed a plan of care (POC) for Treatment period 9/17/2025 - 11/15/2025 with a start of care date of 12/2/2022. The primary diagnosis is primary osteoarthritis; and other pertinent Diagnosis of type 2 diabetes mellitus, atherosclerotic heart disease and essential primary hypertension Skilled Nurse (SN) Frequency: 2-3 PRN)(as need it), Physical Therapy: to evaluate and treat. Review of clinical record for Client #7 revealed the Client was discharged on 1/16/2026; reason for discharge was “goals met.” Further review of the clinical record for Client #7 did not contain any documentation indicating that, a written 5 days discharge notice was given to the client or the client’s responsible party at least five days before the date of discharge. The agency failed to ensure that a written notification was given to the Client #7 or the Client #7’s responsible party at least five days before the date of discharge. During an interview 03/14/2026 at 12:34 PM, the Administrator was asked why 5 days discharge notice was not given to the patient #4. #5, # 6 and #7 or their responsible parties before they were discharged from the agency. Administrator stated, the discharge records may had been saved in the computer, but I am not sure where. The Administrator further stated that he/she had already looked for them, but he said I could not find anything. , Surveyor asked who was responsible for maintaining medical records in order, the Administrator stated that it was her previous supervising nurse, but she let her go because she was not doing anything. The Administrator added “probably, the nurses were not doing the 5 days discharge notification., No additional document was received. Surveyor asked to speak to the current supervising nurse and administrator stated that she was not available, she was on vacation. The Alt Sup was not available, also she was a new employee.”