K and J Sunshine Home Health Care, Inc.

“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 within 30 days of completing the assessment of the patient for 1 out of 7 of the assessments processed for the time-period reviewed of 2/21/2024 to 2/21/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings include: In a review of the HHA Error Summary Report for the time period of 2/21/2024 to 2/21/2025, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 1 assessment and the percentage of assessments with this error was 14.29% of assessments completed by the Agency. In an interview completed with the Administrator on 2/26/25 at 1:03 PM, the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 1 out of 7 OASIS assessments were late by the agency. Surveyor A asked the Administrator why assessments were submitted late to OASIS. Administrator stated she was aware of the 30 day submission expectation. She reported that said did recall one assessment being submitted late but could not recall a reason why. The Surveyor asked how this impacted client care. The Administrator reported that that this does not impact client care, because the assessment was done on time, it was just the submission that was late . The CFO stated there had been a problem with their internet that day. Review of the Agency’s policy titled “Timelines”, undated, reads in part, “Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and sate laws and regulations”.”

“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 have a performance improvement project, either in development, on-going, or completed, within the calendar year in 3 out of the 3 years (2022, 2023, and 2024). Failure of the agency to complete a performance improvement project resulted in a missed opportunity to improve upon an area of weakness and improve agency functioning and patient care. Findings include: Per record review, the agency had an annual document labeled “Annual Performance Improvement Assessment” and dated 12/4/2024. This document was an agency report that included listed criteria and whether that criteria was met, and if not, provided a space for comments and corrective action taken. All listed criteria were marked as “met” for 2024. These items were standard every year, and did include steps planned for improvement, goals, or evaluation criteria. In an interview with the administrator and Chief Financial Officer on 2/24/25 at 12:28 PM, Surveyor B asked administrator if the agency had any ongoing Performance Improvement projects. Administrator asked what a Performance Improvement project is. Administrator said everything they had regarding performance improvement was in the QAPI binder. Surveyor B reported they could not locate documentation of a specific Performance Improvement project, either on-going, in development, or completed, for any of the last 3 years reviewed. Administrator stated that they do not have any issues to perform a project on. She stated that if they had an infection or a similar issue, then they would do a project on that to improve client care . Of note, administrator and Chief Financial Officer are the only staff employed by agency, so hold sole responsibility for meeting requirements and enforcing agency policy. Review of the undated policy titled “Quality Assessment/Performance Improvement Plan”, under a heading titled “Board of Directors”, read in part, “these leaders are responsible for the following: a basic knowledge of performance improvement” and under a heading titled “Administrator” stated, “these leaders are responsible for the following: a fundamental knowledge of the background principles, and techniques of performance improvement.” Review of the undated policy titled “Quality Assessment/Performance Improvement Plan” found no specific information addressing the requirements for Performance improvement projects.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to follow acceptable standards of practice to prevent the transmission of infections in 1 out of 1 clients (Client 1) observed during a home visit. Administrator was observed placing equipment directly on client surfaces, not cleaning items before returning them to bag, and touching equipment and bag with contaminated gloves. Failure of the agency to ensure compliance with infection control policy and equipment cleaning procedures puts the client and employees at risk for acquiring a preventable infection. Findings include: During an observation in Client 1’s home om 2/25/25 at 2:05 PM, administrator removed equipment from her larger roller bag and placed it directly on client’s table without cleaning table or using a barrier. One bag contained blood pressure cuff and one bag contained smaller items included pulse oximeter (plastic device that clamps around finger to read blood oxygen levels) and thermometer. The Administrator used the blood pressure cuff, stethoscope, and pulse oximeter on Client 1 and returned them to the bag without cleaning them. The Administrator did clean the thermometer with Clorox wipe prior to placing it back in the bag. At 2:20 PM, the administrator donned gloves to check patient’s blood sugar. The administrator performed finger stick and did not remove contaminated gloves prior to reaching back in her roller bag and removing sharps container to place lancet (sharp device used to prick finger for blood sugar) in. After removing gloves and cleaning hands with Clorox wipe, Administrator placed sharps container back in bag without cleaning. During an interview with Administrator on 2/26/25 at 10:45 AM, administrator stated they do not have a specific bag policy outside of what is included in the Exposure Control policy and the Procedure for Cleaning and Management of Equipment. During an interview with Administrator on 2/26/25 at 12:39 AM, surveyor asked what the agency’s process was for cleaning items used in the client’s home. Administrator stated she cleans items regularly. Surveyor shared observations of watching Administrator place items directly on the patient’s table, using them on the patient, and returning them to her bag without cleaning. Surveyor asked if she typically used a barrier to set down her items in the client’s home. Admin. stated client cleans table ahead of time. Administrator also stated she cleans her bag once a week. Administrator stated she cleans, stethoscope, blood pressure cuff, scale, pulse oximeter when she returns home. Surveyor asked that if she is placing contaminated items in the bag at the client’s home, cleaning them upon returning to the agency, and then putting them back in the bag, then isn’t the bag itself already contaminated? Administrator seemed confused. Admin again stated the supplies were not cleaned in front of the surveyor, but were cleaned later at her home. Administrator stated she was not familiar with policy that sated “do not place contaminated items in bag”. Surveyor showed administrator the agency document labeled “Procedure for: Cleaning and Management of Supplies and Equipment”. Documented stated “Prevent contamination by washing hands prior to entering bag and by not placing contaminated supplies back inside the bag”. Administrator had no further comments. Per record review of the agency’s policy titled “Infection Control Program”, undated, the document stated in part, “Other policies to be followed by staff to prevent and control infection include: Hand Hygiene, Cleaning and management of Supplies and Equipment…” In addition, the document read, in part, under the stethoscope column, to clean “ear tips, bell/diaphragm, and tubing between each patient use”. Under the pulse oximeter column, the document states to clean “after each use” using and “alcohol pad”. Under the thermometer column, the document states to clean “after each use” using the following method: “wipe with alcohol, rinse with tap water and pat with paper towel or rinse with soap and water to remove mucous.” Per record review of the agency’s policy titled, “Exposure Control Policy”, undated, the document stated in part, under a heading titled “Methods of Implementation of Exposure Control Plan” and a sub-heading titled “Standard Precautions”, that “All employees will be provided with appropriate equipment and instruction on required guidelines though the use of in-services and written protocols. Proper hand hygiene by health care personnel at the beginning and end of each visit, and after any procedure considered as occupational risk.” Per record review of the agency’s policy titled “Infection Control Program”, undated, the document stated in part, “Other policies to be followed by staff to prevent and control infection include: Hand Hygiene, Cleaning and management of Supplies and Equipment…” Per the interpretive guidelines for “§484.70(a) Standard: Prevention”, the agency should follow the 6 CDC core guidelines on infection prevention, including “Environmental Cleaning and Disinfection” and “Reprocessing, Storage, Transport, and Usage/Operation of Equipment or Devices Used for Patient Care”. The guidelines state, in part, “Examples of how this might be accomplished include but are not limited to: Cleaning and disinfecting or placing a clean barrier on the surface in the home where clean equipment will be placed and/or preparation of injectable medications will be performed. Additionally, items that are taken from one home to another should be cleaned and disinfected in accordance with accepted standards of practice, which include manufacturer’s instructions for use.” The guidelines also state, “Cleaning and disinfecting of medical equipment is essential. Staff should follow the manufacturer’s instructions for reprocessing (i.e., cleaning and disinfection or cleaning and sterilization) and use and current standards of practice for transport and storage of patient care equipment…Reusable medical equipment (e.g., blood glucose meters and other point-of-care meters, blood pressure cuffs, oximeter probes) are reprocessed prior to use on another patient and when soiled. The HHA must ensure that HHA staff are trained to maintain separation between clean and soiled equipment to prevent cross contamination in the patient care environment and during transport.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the HHA failed to maintain a program for surveillance, identification, prevention, control, and investigation of infectious diseases that included a method for identifying infectious disease problems in 1 out of 1 active patient. This failure placed the patient at risk of contracting and transmitting communicable diseases. Findings included: Record review of document titled “Home Health Certification and Plan of Care,” signed and dated 01/30/2025, revealed that Client 1 was ordered to received skilled nursing services with a frequency of once a week for 8 weeks with 4 visits as needed for the certification period dating from 01/29/2025 – 03/29/2025. Record review of document titled “Physician Order,” dated 02/01/2025, revealed a clinical finding of “nail fungus/athlete foot,” which a medication order for a topical antifungal cream for Client 1. Record review of document titled “Recertification,” dated 01/25/2025, revealed that the Administrator marked that skin turgor was “good,” left the section describing skin blank, and described nails as “normal.” The ordered on 02/01/2025 was not listed in the medication list of this document. Record review of document titled “Nursing Visit Note,” dated 02/01/2025, revealed that the Administrator marked “warm, dry, and WNL” under the section titled “integumentary” and checked the box title “N/A” next to the section titled “Skin Assessment.” The section titled “New Meds/Treatment,” indicated a new medication “for fungal toes.” Review of blank document titled “Patient/Employee Infection Report,” no date revealed a document that indicated use for tracking infections. In an interview with the Administrator on 2/24/25 at 11:48 AM, the Administrator reported to the Surveyor that the agency did not have an infection control log because they did not have a patient with an infection in the past 3 years. In an interview with the Administrator on 2/26/25 at 12:55 PM, Surveyor B asked why Client 1’s fungal infection had not been documented per agency policy using “Patient/Employee Infection Report”. The Administrator stated that she did not know why they had not documented it and that she would document it now. Surveyor B asked how this impacted patient care. The Administrator responded that it did not impact patient care and that they would still treat the infection. Patient was currently receiving an antifungal cream for this infection during the time of survey, as referenced in the document titled “Physician Order”. Of note, the administrator is also the supervising nurse, and responsible for clinical operations. Review of policy titled “Infection Control Program,” no date, revealed that “a. the agency would track all infections including nosocomial, home acquired and professional exposure; b. every patient/client infection would be reported as soon as any agency staff member was aware of it; c. all reported infections would be documented on the appropriate agency form for monthly review, analysis, trending, and initiation of performance improvement activities if deemed necessary; d. all signs and symptoms of patient/client infections would be reported to the physician.” Review of policy titled “Quality Assessment Performance Improvement Plan,” no date, revealed that “collecting, aggregating and trending infection forms” would be a component of monitoring for the QAPI program.”