Signature Healthcare at Home

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on document review, record reviews, and interview, the agency failed to follow the plan of care as ordered by the physician, resulting in changes to the patient’s plan of care in 7 of 17 patients (Patient #105, Patient #106, Patient #107, Patient #108, Patient #109, Patient #110, and Patient #115). Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s wellbeing. Findings included: 1. Document review of the agency’s policy titled, “Missed Visits” (Policy No. 4-069.1, Date Revised: May 2024) showed that missed visits will be communicated to the clinical supervisor and the patient’s approved medical provider. A missed visit will be rescheduled for the same week and will be documented in the patient’s clinical record. 2. Record review of the patients records for 7 of 17 patients (Patient #105, Patient #106, Patient #107, Patient #108, Patient #109, Patient #110, and Patient #115) showed: a. Patient #105 was admitted on 10/20/25. Occupational Therapy (OT) services were ordered with frequency of 1 visit weekly starting 10/20/25 and continuing for 4 additional weeks. During the Medicare week of 11/02/25 the patient received no OT visits. There was no documentation in the patient’s records as to why the OT visit was not made, and no physician notification of the missed OT visits. b. Patient #106 was admitted on 08/26/25. Physical Therapy (PT) services were ordered with frequency of 1 visit weekly for 8 weeks starting 09/02/25. During the Medicare weeks of 09/21/25, 09/28/25, 10/05/25, and 10/12/25 the patient received no PT visits. OT services were ordered with frequency of 1 visit weekly starting 09/04/25. During the Medicare weeks of 09/02/25 and 10/19/25 the patient received no OT visits. There was no documentation in the patient’s records as to why the PT and OT visits were not made, and no physician notification of the missed PT and OT visits. c. Patient #107 was admitted on 11/06/25. PT services were ordered with frequency of 1 visit weekly for 9 weeks starting 11/06/25. During the Medicare week of 11/23/25 the patient received no PT visits. OT services were ordered with frequency of 1 visit weekly for 5 weeks starting 11/09/25. During the Medicare weeks of 11/16/25 and 11/30/25 the patient received no OT visits. There was no documentation in the patient’s records as to why the PT and OT visits were not made, and no physician notification of the missed PT and OT visits. d. Patient #108 was admitted on 02/19/25. PT services were ordered with frequency of 1 visit weekly for 6 weeks starting 10/19/25. During the Medicare weeks of 11/16/25 and 11/23/25 the patient received no PT visits. Skilled Nursing (SN) services were ordered with frequency of 1 visit weekly for 9 weeks starting 10/19/25. During the Medicare week of 11/23/25 the patient received no SN visits. There was no documentation in the patient’s record as to why the PT and SN visits were not made, and no physician notification of the missed PT and SN visits. e. Patient #109 was admitted on 04/08/25. SN services were ordered with frequency of 2 visits weekly for 2 weeks starting on 04/08/25 and continuing with 1 weekly visit for 3 additional weeks. Then, 1 visit every 2 weeks for 2 weeks, then 1 visit every week for 2 weeks, and then 2 visits every 3 weeks for 3 weeks starting 04/13/25. During the Medicare weeks of 04/13/25, 04/20/25, and 05/11/25 the patient received no SN visits. There was no documentation in the patient’s record as to why the SN visit was not made, and no physician notification of the missed SN visits. f. Patient #110 was admitted on 02/04/25. SN services were ordered with frequency of 2 visits weekly for 4 weeks and then 1 visit weekly for an additional 3 weeks. During the Medicare weeks of 02/09/25 and 02/23/25 the patient received only 1 of 2 SN visits. Home Health Aide (HHA) services were ordered with frequency of 1 visit weekly for 5 weeks starting 02/09/25. During the Medicare weeks of 02/09/25 and 03/16/25 the patient received no HHA visits. There was no documentation in the patient’s record as to why the SN and HHA visits was not made, and no physician notification of the missed SN and HHA visits. g. Patient #115 was admitted on 10/21/24. PT services were ordered with frequency of 2 visits weekly for 3 weeks and then 1 visit weekly for an additional 5 weeks. During the Medicare week of 11/03/24 the patient received only 1 of 2 PT visits. There was no documentation in the patient’s record as to why the PT visit was not made, and no physician notification of the missed PT visits. 3. On 12/10/25 at 3:00 PM, Surveyor #1 interviewed the agency’s Director of Clinical Services (Staff #111) about the lack of documentation and physician notification of the missed visits. Staff #111 acknowledged the findings and stated that they were unable to provide documentation as to why the missed visits occurred and why the patients’ physicians were not notified of the missed visits.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: . Based on observation, record review, and interview, the agency failed to ensure home health staff followed their policies and procedures (P&P) for infection prevention and control related to exposure to contamination from the patient’s environment for 1 of 7 staff members (Staff #206) observed during a home visit. Failure of the agency to ensure staff followed their policies for preventing cross-contamination of personal items in the patient’s environment puts the staff member and other patients at risk of harm from infection. Findings included: 1. On 12/09/25 at 10:00 AM, Surveyor #2 visited the Adult Family Home where Patient #202 lives. The surveyor observed a Licensed Practical Nurse (LPN) (Staff #206) as they provided care to the patient. The observation showed: a. When Staff #206 started their visit, they placed their phone on the patient’s side table without a barrier. During the visit, Staff #206 repeatedly picked up their phone and returned it to the patient’s side table without first placing a barrier under the phone to prevent cross-contamination. c. Staff #206 placed medical equipment used on the patient to obtain vital signs, on their wheeled bag, without first placing a barrier under the equipment to prevent cross-contamination. d. Staff #206 reached into their bag without first removing their gloves and performing hand hygiene. 2. Record review for Staff #206 showed they were hired on 05/12/25. Their record contained a completed skills verification document that included infection prevention and control in the patient’s home setting that was verified by supervising staff. 3. On 12/11/25 at 10:30 AM, Surveyor #2 interviewed the Director of Clinical Services (Staff #211) about the agency’s process for infection prevention and control training for new staff. Staff #211 stated that all new staff are trained in the agency’s P&P on infection prevention and control upon hire. The staff’s skills are verified by a return demonstration to ensure they can follow the P&P. .”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: . Based on document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within 48 hours of the referral for 9 of 17 patients (Patient #101, Patient #102, Patient #103, Patient #106, Patient #107, Patient #108, Patient #109, Patient #111, and Patient #112). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “Admission Criteria and Process,” (Policy No. 4-018.1, Revised Date: May 2024) showed that the initial assessment visit must be conducted within forty-eight hours of the referral. 2. Record review of the patients records for 9 of 17 patients (Patient #101, Patient #102, Patient #103, Patient #106, Patient #107, Patient #108, Patient #109, Patient #111, and Patient #112) showed: a. Patient #101’s Start of Care (SOC) date was 11/13/25. The referral was dated 11/07/25 for Physical Therapist (PT) services. The SOC for PT services did not occur until 11/13/25. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. b. Patient #102’s SOC date was 10/30/25. The referral was dated 10/21/25 for PT services. The SOC for PT services did not occur until 10/30/25. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. c. Patient #103’s SOC date was 10/08/25. The referral was dated 10/04/25 for Skilled Nursing (SN) services. The SOC for SN services did not occur until 10/08/25. There was no documentation as to why the SN Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. d. Patient #106’s SOC date was 08/26/25. The referral was dated 08/20/26 for PT services. The SOC for PT services did not occur until 08/26/25. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. e. Patient #107’s SOC date was 11/06/25. The referral was dated 11/03/25 for SN, PT services. The SOC for SN services did not occur until 11/06/25. There was no documentation as to why the SN Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. f. Patient #108’s SOC date was 02/19/25. The referral was dated 02/11/25 for SN services. The SOC for SN services did not occur until 02/19/25. There was no documentation as to why the SN Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. g. Patient #109’s SOC date was 04/08/25. The referral was dated 04/01/25 for SN services. The SOC for SN services did not occur until 04/08/25. There was no documentation as to why the SN Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. h. Patient #111’s SOC date was 10/15/25. The referral was dated 10/13/25 for PT services. The SOC for PT services did not occur until 10/15/25. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. i. Patient #112’s SOC date was 11/12/25. The referral was dated 11/06/25 for PT services. The SOC for PT services did not occur until 11/12/25. There was no documentation as to why the PT Initial assessment did not occur within 48 hours of the referral, and no documentation that the physician was notified of the delayed admission. 3. On 12/10/25 at 3:00 PM, Surveyor #1 interviewed the agency’s Director of Clinical Services (Staff #111) of the lack of documentation on the delayed admission. Staff #111 acknowledged the findings and stated they were not aware of the timely issues with the referral and the SOC admissions. .”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on document review, record reviews, and interview, the agency failed to complete the comprehensive assessment that included Occupational Therapy (OT) evaluations within five calendar days of the start of care date for 5 of 17 patients (Patient #103, Patient #108, Patient #109, Patient #116, and Patient #117). Failure to address the patient’s therapy needs timely puts patients at risk of injury and harm. Findings included: 1. Document review of agency’s policy titled, “Initial and Comprehensive Assessment,” (Policy No. 4-018.1, Date Revised May 2024) showed the comprehensive assessment must be completed within 5 calendar days of the patient’s start of care. Each patient must receive a patient-specific comprehensive assessment that identifies the patient’s nursing and rehabilitative needs. 2. Record review of the patients records for 5 of 17 patients (Patient #103, Patient #108, Patient #109, Patient #116, and Patient #117) showed: a. Patient #103’s referral was dated 10/04/25 for Skilled Nursing (SN) initial assessment, Physical Therapy (PT) evaluation, and Occupational Therapy (OT) evaluation. The SN assessment was completed on the Start of Care (SOC) date of 10/08/25. The OT evaluation was completed on 10/21/25. There is no documentation to show why the OT evaluations were not completed within the 5 days of the start of care date. b. Patient #108’s referral was dated 02/11/25 for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 02/19/25. The OT evaluation was completed on 03/17/25. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care date. c. Patient #109’s referral was dated 04/01/25 for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 04/08/25. The OT evaluation was completed on 04/30/25. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care date. d. Patient #116’s referral was dated 05/08/25 for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 05/13/25. The OT evaluation was completed on 06/12/25. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care date. e. Patient #117’s referral was dated 11/19/24 for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 11/21/24. The OT evaluation was completed on 12/17/24. There is no documentation to show why the OT evaluation was not completed within the 5 days of the start of care date. 3. On 12/10/25 at 3:00 PM, Surveyor #1 interviewed the agency’s Director of Clinical Services (Staff #111) of the lack of documentation regarding the delayed OT evaluations. Staff #111 acknowledged the findings and stated that the agency makes every attempt to complete therapy evaluations timely but stated they were not able to provide documentation as to why the therapy services were delayed. .”