Four Seasons Home Health Services Inc.

“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 interview and record review, the Agency failed to ensure physician orders were appropriately authenticated in 4 of 4 sampled patient records (Patient 1, 2, 3, and 4.) Specifically, the physician signature on the Plans of Care were illegible and the agency was unable to provide documentation, such as a signature log or other authenticated records, that established the identity of the physician who signed the orders. This failure prevented the Agency from demonstrating that the Plans of Care had been authenticated by the physician responsible for the patient’s care which placed the patients at risk for potential injury, poor care planning, and poor health outcomes. Finding Included: Patient 1: Record review of Patient 1’s EMR (Electronic Medical Record) contained a POC (Plan of Care) dated, 06/19/2026-08/17/2026 that had an illegible physician signature. Review of the EMR and other agency documents did not contain a signature log, attestation, or other documentation that allowed the surveyor to verify the identity of the individual who signed the POC. Patient 2: Record review of Patient 2’s EMR (Electronic Medical Record) contained a POC (Plan of Care) dated, 06/14/2026-08/12/2026 that had an illegible physician signature. Review of the EMR and other agency documents did not contain a signature log, attestation, or other documentation that allowed the surveyor to verify the identity of the individual who signed the POC. Patient 3: Record review of Patient 3’s MR (Electronic Medical Record) contained a POC (Plan of Care) dated, 06/19/2026-08/17/2026 that had an illegible physician signature. Review of the EMR and other agency documents did not contain a signature log, attestation, or other documentation that allowed the surveyor to verify the identity of the individual who signed the POC. Patient 4: Record review of Patient 4’s MR (Electronic Medical Record) contained a POC (Plan of Care) dated, 04/20/2026-06/18/2026 that had an illegible physician signature. Review of the EMR and other agency documents did not contain a signature log, attestation, or other documentation that allowed the surveyor to verify the identity of the individual who signed the POC. During an interview with the ADM (Administrator) on 09/09/2026 at 1:30PM, the ADM was unable to identify the physician based on the signature appearing on the POC’s for Patients 1-4. The Surveyor asked the ADM who was responsible for ensuring the signatures were authenticated and the ADM reported he was. The Surveyor asked how the ADM authenticates the signatures that are illegible and the ADM reported there was a form. The Surveyor asked the ADM why the form was not used for the illegible signatures and the ADM reported that the form had never been used in the past. The Surveyor asked what the Agency policy was on authentication of physician / practitioner signatures and the ADM reported there should be an attestation or signature log. The Surveyor asked the ADM why the Agency policy was not followed and the ADM reported he did not know why. Agency policy, dated 09/17/2018, quoted in part, “TX.5 Physician Orders…Physician contact for verification or clarification will be made when there is a question, concern, issues, order is unclear, incomplete or illegible…Orders will be resubmitted until timely physician signature/date is obtained…Illegible physician signatures will have a letter of attestation or signature log…””

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on observation, interview, and record review, the Agency failed to ensure patients were provided with written information identifying the name of Agency’s Administrator for 3 of 3 patients reviewed (Patients 1, 2, and 3.) The failure to provide patients with the name of the Agency’s Administrator prevented the patients from having the required information necessary to contact the agency’s Administrator in the event of an emergency, patient concerns, or complaints. Findings Included: During the home visit observation for Patient 1 on 09/09/2026 at 10AM, concurrent review of the patient’s agency-provided information / home folder did not contain the name for the Administrator. The Surveyor asked Patient 1 if any items had been removed from the folder and Patient 1 reported nothing had been removed. During the home visit observation for Patient 2 on 09/09/2026 at 11AM, concurrent review of the patient’s agency-provided information / home folder did not contain the name of the Administrator. The Surveyor asked Patient 2 if any items had been removed from the folder and Patient 2 reported nothing had been removed. During the home visit observation for Patient 3 on 09/09/2026 at 12PM, concurrent review of the patient’s agency-provided information / home folder did not contain the name of the Administrator. The Surveyor asked Patient 3 if any items had been removed from the folder and Patient 3 reported nothing had been removed. During an interview with the ADM (Administrator) the Surveyor asked what the Agency policy was regarding providing the name and contact information for the Administrator to the patients and the ADM stated, “I am not sure.” The Surveyor asked who was responsible for ensuring that patients have the name and contact information of the Administrator and the ADM reported he was. The Surveyor asked why the contact information for the Administrator was not provided to the patients and the ADM reported he was not aware that was required. Agency policy, dated 11/29/2019, quoted in part, “R1.1.Patient Bill of Rights and Responsibilities / Rights of the Elderly…Contact information for the Agency Administrator, including the administrators name…in order to receive complaints…””

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, interview, and record review, the Agency failed to ensure patients were provided with written information identifying the name and contact information of the Agency’s Clinical Manager for 3 of 3 patients reviewed (Patients 1, 2, and 3.) The failure to provide patients with the name and contact information of the Clinical Manager prevented the patients from having the required information necessary to contact the agency’s clinical manager in the event of an emergency, patient concerns, or complaints. Findings Included: During the home visit observation for Patient 1 on 09/09/2026 at 10AM, concurrent review of the patient’s agency-provided information / home folder did not contain the name and contact information for the Clinical Manager. The Surveyor asked Patient 1 if any items had been removed from the folder and Patient 1 reported nothing had been removed. The Surveyor asked the patient the name of the Clinical Manager and the patient reported they did not know. During the home visit observation for Patient 2 on 09/09/2026 at 11AM, concurrent review of the patient’s agency-provided information / home folder did not contain the name and contact information for the Clinical Manager. The Surveyor asked Patient 2 if any items had been removed from the folder and Patient 2 reported nothing had been removed. The Surveyor asked the patient the name of the Clinical Manager and the patient reported they did not know. During the home visit observation for Patient 3 on 09/09/2026 at 12PM, concurrent review of the patient’s agency-provided information / home folder did not contain the name and contact information for the Clinical Manager. The Surveyor asked Patient 3 if any items had been removed from the folder and Patient 3 reported nothing had been removed. The Surveyor asked the patient the name of the Clinical Manager and the patient reported they did not know. During an interview with the ADM (Administrator) on 09/09/2026 at 12:45PM the Surveyor asked what the Agency policy was in regard to providing the name and contact information for the Clinical Manager and the ADM stated, “I am not sure.” The Surveyor asked who was responsible for ensuring that patients have the name and contact information of the Clinical Manager and the ADM reported he was. The Surveyor asked why the contact information for the Clinical Manager was not provided to the patients and the ADM reported he was not aware that was required. Agency policy, dated 11/29/2019, quoted in part, “R1.1.Patient Bill of Rights and Responsibilities / Rights of the Elderly…Telephone number and for the Clinical Manager for answering questions about their services…””

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on interview and record review, the Agency failed to ensure that staff providing services to patients participated in the Agency’s QAPI (Quality Assessment and Performance Improvement Program.) Specifically, the Agency failed to demonstrate participation by physical or occupational therapy, Home Health Aide, Master Social Worker, and PAS (Personal Assistance Services) staff. This failure resulted in the Agency not having an appropriately representative interdisciplinary team to participate in the development, implementation, monitoring, and evaluation of the Agency’s QAPI activities which placed patients at risk by limiting the Agency’s ability to provide safe, quality care for services provided by Agency. Findings Included: Record review of The Home Health Agency Survey Report (CMS-1572) form that was completed by the Agency Administrator on 09/02/2026 revealed that the agency provided services of Skilled Nursing, Physical and Occupational Therapy, Speech Therapy, and Social Work. Record review of QAPI meeting minutes for 2023, 2024, 2025, and 2026 revealed that only the Director of Nursing was in attendance for each meeting and failed to demonstrate participation by therapy staff and Social Work staff. Record review of the QAPI manual, Titled, “QAPI Manual, undated, revealed one list naming the Director of Nursing and Assistant Director of Nursing as being the only QAPI committee members. During an interview with the ADM on 09/02/2026 at 11AM the surveyor asked who participated in the makeup of the QAPI committee and the ADM reported the Director of Nursing / Administrator and Alternate Administrator / Assistant Director of Nursing. The Surveyor asked what the Agency’s policy was regarding QAPI committee make-up and the ADM reported, “it is just the two of us.” The Surveyor asked why all the services that the agency reported they had were not part of the QAPI committee and the ADM reported that it was difficult to get “contractors to come.” The Surveyor asked the ADM whose responsibility it was to ensure that the QAPI Committee included all staff providing services to patients and the ADM reported, “I was.” Agency policy, dated 01/13/2018, quoted in part, “QAPI 1…The QAPI committee consisting of the, at minimum, The Administrator, supervising nurse or therapist, and individuals representing the scope of services provided by the agency will meet…””