1st Gentlecare Home Health LLC

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure a competency evaluation by observation of the home health aide’s performance of the task with a client was completed in 1 of 3 (Prov A) employee files reviewed in that the agency did not complete home health aide competency for Prov A. This failure could place the clients at risk of harm and receiving inadequate care from improperly trained staff. Findings include: Record review of Prov A’s employee file revealed an application for employment date of 5/18/2026 with a date of hire as 5/18/2026. The employee file contained a document titled “Home Health Aide Skills Competency Checklist”. The subsections of this document included the following: 1. Communication skills 2. Reading and recording temperature, pulse (heart rate) and respirations (number of breaths) Bed BathBathBlood Pressure (force of blood pushing against the walls of your arteries as it is pumped around your body)ShampooNails and Skin CareOral HygieneToileting and EliminationSafe Transfer Techniques and AmbulationNormal Range of Motion and Positioning Other optional skills The document was completely blank with no documentation of observation for any of these tasks being completed. An interview with DON and Alt Admin on 7/28/2026 at 1:00 PM was conducted. Surveyor asked who was responsible for aide competency checkoffs for Prov A. DON stated it would have been the DON or the Sup RN A. Surveyor asked why the competency checks offs were not completed for Prov A. The DON stated that Prov A’s hiring process was not done correctly when she was hired by the previous Admin. DON stated that the required training was not completed by the prior Admin. Review of agency policy titled “Home Health Aide Competency Evaluation” dated 5/1/24, read in part, “The agency will ensure that each home health aide successfully completed a home health aide competency evaluation in accordance with federal and state laws and regulations prior to performing care independently”.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the agency failed to allow the patient to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to any changes in the care to be furnished in 1 of 2 (Pt #1) patient clinical records reviewed. This failure placed the patient at risk of physical or emotional harm and at risk of being uninformed of changes in the care to be furnished. Findings include: Record review of Pt #1’s medical record revealed a start of care date as 1/2/2026 and a certification period 5/02/2026- 6/30/2026. The primary diagnosis for Pt #1 was listed as primary generalized osteoarthritis (joint disease where the cushioning of your bones wears away causing pain). The plan of care had a section titled “Orders for Disciplines and Treatment”. Under this section, skilled nursing care was ordered 1 time per week for 9 weeks and home health aide services were ordered 2 times per week for 8 weeks followed by 1 time per week for 1 week. The patient visit calendar for certification period 5/2/2026-6/20/2026 revealed home health aide visits was completed on 6/9/26, 6/12/26, 6/16/26, 6/19/26, and a missed aide visit was documented for 6/23/26. Review of Pt #1’s plan of care for a certification period of 7/1/2026-8/29/2026 was also reviewed. Under “Orders for Disciplines and Treatment”, skilled nursing services were again ordered 1 time per week for 9 weeks and home health aide services 1 time per week for 1 week followed by 2 times per week for 8 weeks. Review of the visit schedule for the certification period of 7/1/2026-8/29/2026 was reviewed. The patient visit calendar listed skilled nursing visits for the following dates: 7/8/26, 7/15/26, 7/20/26, 8/3/26, 8/10/26, 8/17/26, and 8/24/26. There were no home health aide visits listed on Pt #1’s visit schedule for this certification period. A document titled “Physician Order” was in Pt #1 clinical record. The document had an order that stated, “discontinue Home Health Aide services effective 7/1/2026”. The document contained the digital signature of the DON dated 7/1/2026 with an electronic signature for the MD dated 7/10/2026. A phone interview with Pt #1 on 7/24/2026 at 10:00 AM was conducted. Pt #1 stated she was receiving home health aide services from [agency name] but hasn’t received any aide services since the end of June 2026. Surveyor asked Pt #1 if she knew why she was no longer receiving the aide services and Pt #1 stated she believed it was because Prov A quit because she wasn’t getting paid for the hours that she worked. A phone interview with Prov A on 7/24/2026 at 10:10 AM was conducted. Surveyor asked Prov A if she knew what happened with Pt #1’s home health aide services. Prov A stated that she was the aide for Pt #1 but once she complained about not getting paid and the issue was not resolved, she resigned from her position with the agency. Prov A stated that she believed Pt #1 needed more aide hours than the agency was willing to provide and she was on the phone when Pt#1 called her insurance company who verified she had been approved for 47 hours of aide services per week. During an interview with the DON on 7/27/2026 at approximately 1:00 PM, Surveyor asked the DON what she knew about the order to discontinue aide services to Pt #1. DON stated that she wasn’t sure, but she believed services were discontinued because the agency did not have an aide in that area after Prov A resigned from the agency but stated she would look further into the matter. The Surveyor asked if the agency couldn’t provide services that were on the patient’s plan of care what the normal process would be to address the issue. The DON stated the agency would attempt to find a replacement aide or transfer the patient to another agency that could provide all the services. Surveyor asked the DON if an attempt to find another aide or agency that could provide the services was attempted. The DON stated that they did not have another aide in the area. During a joint interview with the Alt Admin and DON on 7/27/2026 at approximately 1:30 PM, the Surveyor asked what the process was when an agency cannot provide the required services to a patient. The DON stated the process would be to try and find those services or transfer the patient. The Surveyor asked what they could have done since they were unable to find an aide in her area. The DON stated the patient should have been transferred to another agency. On 7/27/2026 at 4:30 PM a phone call was attempted to reach the MD listed on the order to discontinue aide services. The office would not provide the Surveyor with a direct number for MD and would not take a message to pass along requesting a return call. Survyeor asked to be transferred to the office manager. The Surveyor was transferred to a line that rang but no voicemail option was available. On 7/28/2026 at approximately 10:00 AM, the Surveyor asked the DON what was determined to be the reason that aide services were discontinue for Pt #1. The DON stated that she was able to confirm services were discontinued because they did not have an aide in the area any longer. Surveyor asked the DON if she spoke to MD prior to placing the order to discontinue aide services to the patient. DON stated she did not speak to MD prior to placing the order. The surveyor asked the DON to confirm that she placed an order to discontinue services to the patient prior to obtaining permission from the physician to which the DON stated she did not speak to the physician first. The Surveyor asked the DON if she spoke to Pt #1 prior to discontinuing her aide services to make the patient aware she would no longer be receiving the service and discuss transferring the patient. DON stated that she did not speak to the patient before discontinuing services or discuss transferring the patient. Review of agency policy titled “Plan of Care” dated 1/1/26, read in part, “… any revision to the plan of care due to a change in [patient] health status must be communicated to the [patient]… and all physicians or allowed practitioners issuing orders for the agency plan of care…”.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on interview and record review, the agency failed to transfer or discharge the patient when the home health agency could no longer meet the patient’s needs in 1 of 2 (Pt #1) patient medical records reviewed in that the agency discontinued aide services because they could no longer provide the service. This failure placed the patient at risk for physical and emotional harm. Findings include: Record review of Pt #1’s medical record revealed a start of care date as 1/2/2026 and a certification period 5/02/2026- 6/30/2026. The primary diagnosis for Pt #1 was listed as primary generalized osteoarthritis (joint disease where the cushioning of your bones wears away causing pain). The plan of care had a section titled “Orders for Disciplines and Treatment”. Under this section, skilled nursing care was ordered 1 time per week for 9 weeks and home health aide services were ordered 2 times per week for 8 weeks followed by 1 time per week for 1 week. The patient visit calendar for certification period 5/2/2026-6/20/2026 revealed home health aide visits were completed on 6/9/26, 6/12/26, 6/16/26, 6/19/26, and a missed aide visit was documented for 6/23/26. Review of Pt #1’s plan of care for a certification period of 7/1/2026-8/29/2026 was also reviewed. Under “Orders for Disciplines and Treatment”, skilled nursing services were again ordered 1 time per week for 9 weeks and home health aide services 1 time per week for 1 week followed by 2 times per week for 8 weeks. Review of the visit schedule for the certification period of 7/1/2026-8/29/2026 was reviewed. The patient visit calendar listed skilled nursing visits for the following dates: 7/8/26, 7/15/26, 7/20/26, 8/3/26, 8/10/26, 8/17/26, and 8/24/26. There were no home health aide visits listed on Pt #1’s visit schedule for this certification period. A document titled “Physician Order” was in Pt #1 clinical record. The document had an order that stated, “discontinue Home Health Aide services effective 7/1/2026”. The document contained the digital signature of the DON dated 7/1/2026 with an electronic signature for the MD dated 7/10/2026. A phone interview with Pt #1 on 7/24/2026 at 10:00 AM was conducted. Pt #1 stated she was receiving home health aide services from [agency name] but hasn’t received any aide services since the end of June 2026. Surveyor asked Pt #1 if she knew why she was no longer receiving the aide services and Pt #1 stated she believed it was because Prov A quit because she wasn’t getting paid for the hours that she worked. Surveyor asked Pt #1 if the agency had any communication with her regarding discontinuing aide services. Pt #1 stated that the agency didn’t tell her, they just stopped sending an aide to help her. On 7/27/2026 at approximately 1:00 PM, Surveyor asked the DON what she knew about the order to discontinue aide services to Pt #1. DON stated that she wasn’t sure, but she believed services were discontinued because the agency did not have an aide in that area after Prov A resigned from the agency but stated she would look further into the matter. The Surveyor asked if the agency couldn’t provide services that were on the patients’ plan of care, what the normal process would be to address the issue. The DON stated the agency would attempt to find a replacement aide or transfer the patient to another agency that could provide all the services. During a joint interview with the Alt Admin and DON on 7/27/2026 at approximately 1:30 PM, the Surveyor asked why the patient wasn’t made aware that her services were being discontinued. The DON stated they were sending a nurse to the patients home. Review of agency policy titled “Patient Transfer, Discharge, and Agency Dissolution” dated 01/01/26 read in part, “…transfer or discharge is necessary for the patient’s welfare because the Agency… can no longer meet the patients needs based on the patient’s acuity. The agency must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the Agency’s capabilities…”.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review the agency failed to investigate complaints made by a patient regarding treatment or care that was furnished by the agency in 1 of 2 patient (Pt #1) records reviewed. This failure placed the agency’s patients at risk of complaints not being addressed, allowing the patient care issues to continue which could result in physical harm. Record review of agency complaint logs titled “Complaint Trending Log” for years 2025 and 2026 showed 1 complaint received in April 2025 titled “patient related”. The 2026 log showed no complaints received or investigated by the agency from or about Pt #1. A phone call was placed to Pt #1 on 7/24/2026 at 10:00 AM. Pt #1 stated she expressed concern about not receiving the services she needed multiple times to different people within the agency. Surveyor asked Pt #1 who she made the complaints to and if the concerns were ever addressed by the agency. Pt #1 stated that she made complaints on different occasions to PHCC A and to OA A and asked that she be given the services she needed because she was suffering. Pt #1 stated she told PHCC A and OA A that Prov A was providing aide services to her and she needed additional hours which she was previously approved for by her insurance company. Surveyor asked Pt #1 if she could remember the dates that she spoke to PHCC A and OA A about her concerns. Pt #1 stated she could not remember the exact dates because she was in a lot of pain right now. A phone call was placed to Prov A on 7/24/2026 at 10:10 AM. Surveyor asked Prov A if she ever heard Pt #1 make a complaint about not getting enough hours. Prov A stated both PHCC A and OA A were aware of Pt #1 requesting more hours and to receive the services she was supposed to receive. On 7/24/2026 at approximately 12:00 PM, the Surveyor asked the Admin if he was aware of any complaints received by patients. Admin denied knowledge of any complaints being made to the agency. Surveyor asked Admin who would know of complaints made and what the process of receiving patient complaints is. Admin stated PHCC A or OA A would know about complaints being called in and the process is when a complaint is received it is escalated to the DON and Admin for further review. Surveyor again asked Admin if he was aware of any complaints made and he stated that he was not. Surveyor asked the Admin to provide the Surveyor with the phone number for the DON. On 7/24/2026 at 12:28PM the Surveyor conducted a phone interview with DON. Surveyor asked DON if she was aware of any complaints made by any patients. DON stated that she was not aware of any complaints. Surveyor asked the DON who would know of any complaints being called in and what their process for complaints was. DON stated that PHCC A or OA A would know of complaints being called in and that when complaints are called in, they are escalated either to the DON or Admin. On 7/24/2026 at 12:47 PM the Surveyor called PHCC A and asked if he was aware of any complaints made to the agency from patients. PHCC A stated he could not recall any complaints being called into the office. Surveyor asked who would know of complaints being called in. PHCC A stated OA A would know of complaints. Upon arrival to the agency on 7/27/2026 at 10:00 AM, Surveyor was notified that OA A had quit effectively immediately due to multiple final warnings for behavior related issues documented in her employee file. OA A was unavailable for interview. Surveyor was also notified that Admin had quit effectively immediately and was unavailable for interview. Review of agency policy titled “Resolution of Patient Conflicts, Grievances or Complaints” dated 8/1/2024 read in part, “The agency will investigate complaints made by the patient… including but not limited to: treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately… the agency will document the receipt of the complaint/ grievance and initiate and investigation within 10 calendar days. Management will be informed of the complaint…”.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide services only as ordered by a physician or allowed practitioner in 1 of 2 patient (Pt #1) records reviewed in that, the agency discontinued aide services before obtaining the order from the physician. This failure placed the patient at risk of physical harm due to services being discontinued before approved by the physician. Findings include: Record review of Pt #1’s medical record revealed a start of care date as 1/2/2026 and a certification period 5/02/2026- 6/30/2026. The primary diagnosis for Pt #1 was listed as primary generalized osteoarthritis (joint disease where the cushioning of your bones wears away causing pain). The plan of care had a section titled “Orders for Disciplines and Treatment”. Under this section, skilled nursing care was ordered 1 time per week for 9 weeks and home health aide services were ordered 2 times per week for 8 weeks followed by 1 time per week for 1 week. The patient visit calendar for certification period 5/2/2026-6/20/2026 revealed home health aide visits were completed on 6/9/26, 6/12/26, 6/16/26, 6/19/26, and a missed aide visit was documented for 6/23/26. Review of Pt #1’s plan of care for a certification period of 7/1/2026-8/29/2026 was also reviewed. Under “Orders for Disciplines and Treatment”, skilled nursing services were again ordered 1 time per week for 9 weeks and home health aide services 1 time per week for 1 week followed by 2 times per week for 8 weeks. Review of the visit schedule for the certification period of 7/1/2026-8/29/2026 was reviewed. The patients visit calendar listed skilled nursing visits for the following dates: 7/8/26, 7/15/26, 7/20/26, 8/3/26, 8/10/26, 8/17/26, and 8/24/26. There were no home health aide visits listed on Pt #1’s visit schedule for this certification period. A document titled “Physician Order” was in Pt #1 clinical record. The document had an order that stated, “discontinue Home Health Aide services effective 7/1/2026”. The document contained the digital signature of the DON dated 7/1/2026 with an electronic signature for the MD dated 7/10/2026. On 7/27/2026 at approximately 1:00 PM, Surveyor asked the DON what she knew about the order to discontinue aide services to Pt #1. DON stated that she wasn’t sure, but she believed services were discontinued because the agency did not have an aide in that area after Prov A resigned from the agency but stated she would look further into the matter. The Surveyor asked if the agency couldn’t provide services that were on the patients’ plan of care, what the normal process would be to address the issue. The DON stated the agency would attempt to find a replacement aide or transfer the patient to another agency that could provide all the services. Surveyor asked why the process wasn’t followed and the DON could not provide an answer. On 7/27/2026 at 4:30 PM a phone call was attempted to reach the MD listed on the order to discontinue aide services. The office would not provide the Surveyor with a direct number for MD and would not take a message to pass along requesting a return call. Survyeor asked to be transferred to the office manager. The Surveyor was transferred to a line that rang but no voicemail option was available. On 7/28/2026 at approximately 10:00 AM, the Surveyor asked the DON if she spoke to MD prior to placing the order to discontinue aide services to the patient. DON stated she did not speak to MD prior to placing the order. The surveyor asked the DON to confirm that she placed an order to discontinue services to the patient prior to obtaining permission from the physician to which the DON stated she did not speak to the MD first. A joint interview with Alt Admin and DON was conducted on 7/28/2026 at approximately 1:30 PM. The discontinuation of home health aide services prior to MD authorization was discussed. DON stated that a lot of times they don’t get to speak to the doctor before they need an order. Surveyor asked the DON if she had attempted to get in contact with the MD before she placed the order to discontinue services to the patient and the DON stated she did not. Review of agency policy titled “Implementing Care and Treatment” dated 1/1/2026 read in part, “When the provision of care and treatment cannot be implemented as established on the care planning documents, the patients’ physician or allowed practitioner will be notified… the physician or allowed practitioner will decide whether… additional intervention is required by the agency due to the impact on the patient…”.”