Signature Healthcare at Home

“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 record reviews and interview, the agency failed to complete the comprehensive assessment that included nursing and therapy evaluations within five calendar days of the start of care date for 7 of 13 patients (Patient #110, Patient #301, Patient #303, Patient #305, Patient #307, Patient #308, and Patient #309). Failure to address the patient’s therapy needs timely puts patients a risk of injury and harm. . Findings included: 1. Document review of agency’s policy titled, “Initial and Comprehensive Assessment,” (Policy No. 4-018.1, Last Revised May 2024) showed the comprehensive assessment must be completed within five calendar days of the patient’s start of care. 2. Record review of the patient’s comprehensive assessment for Patient #110, Patient #301, #303, Patient #305, Patient #307, Patient #308, and Patient #309 showed: a. Patient #110’s referral was completed on 04/10/25 with orders 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 04/11/25. The PT evaluation was completed on 04/15/25, but the OT evaluation was completed on 04/18/25. There is no documentation to show why the OT evaluation was not completed within the 5 calendar days of the start of care. b. Patient #301’s referral was completed on 03/23/26 with orders for PT and SN services. In addition, OT was ordered as an add-on evaluation on 03/29/26. The PT initial assessment was completed on the SOC date of 03/24/26, but the SN assessment was not completed until 04/03/26, and the OT evaluation was not completed until 04/26/26. There is no documentation to show why the SN and OT evaluations were not completed within 5 calendar days of the start of care or as ordered by the primary care provider. c. Patient #303’s referral was completed on 05/18/26 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 05/19/26. The PT evaluation was completed on 05/22/26, but the OT evaluation was completed on 05/28/26. There is no documentation to show why the OT evaluation was not completed within the 5 calendar days of the start of care. d. Patient #305’s referral was completed on 03/13/26 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 03/18/26. The PT evaluation was completed on 03/26/26, but the OT evaluation was completed on 03/25/26. There is no documentation to show why the PT and OT evaluations were not completed within the 5 calendar days of the start of care. e. Patient #307’s referral was completed on 04/27/26 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 05/07/26. The PT evaluation was completed on 05/18/26, but the OT evaluation was completed on 05/29/26. There is no documentation to show why the PT and OT evaluations were not completed within the 5 calendar days of the start of care. f. Patient #308’s referral was completed on 05/13/26 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 05/14/26. The PT evaluation was completed on 05/15/26, but the OT evaluation was completed on 06/05/26. There is no documentation to show why the OT evaluation was not completed within the 5 calendar days of the start of care. g. Patient #309’s referral was completed on 06/01/26 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 06/05/26. The PT evaluation was completed on 06/08/26, but the OT evaluation had not occurred as of the survey exit date. There is no documentation to show why the OT evaluation was not initiated within the 5 calendar days of the start of care. 3. On 06/23/26 at 1:00 PM, Surveyor #1 and Surveyor #3 interviewed the agency’s executive Director (Staff #109) and the agency’s Clinical Operations Manager (Staff #110) regarding the delayed nursing and therapy evaluations. Staff #109 and Staff #110 acknowledged the findings and stated that the agency makes every attempt to complete nursing and therapy evaluations timely but stated they were not able to provide documentation as to why the therapy services were delayed. .”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: . Based on record review and interview, the agency failed to document Home Health Aide (HHA) Supervisory visits no less frequently than every 14 days for 5 of 8 patients receiving HHA services (Patient #102, Patient #110, Patient #111, Patient #303, and Patient #307). Failure to supervise the HHA at least every 14 days places the patients at risk of receiving services that are not reviewed for continued effectiveness and are not reflective of the patient’s changing needs. . . Findings included: 1. Document review of the agency’s policy and procedure titled, “Home Health Aide Supervisory Visits,” (Policy No. 1-030.1, Last Revised May 2024) indicated there will be a HHA supervisory visit assessment no less frequently than every 14 days if the patient is receiving HHA services. 2. Record review of HHA supervisory visits for Patient #102, Patient #110, Patient #111, Patient #303, and Patient #307 showed: a. Patient #102’s Start of Care (SOC) was on 05/04/26. HHA services were ordered with frequency of 1 visit weekly for 3 weeks starting 05/10/26. There was no documentation of HHA supervisory visits for the weeks of 06/07/26 through 06/20/26. b. Patient #110’s SOC was on 04/11/25. HHA services were ordered with frequency of 1 visit weekly for 2 weeks starting 04/20/25 then 1 visit weekly for 3 weeks starting 05/18/25. There was no documentation of HHA supervisory visits for the weeks of 04/27/25 through 06/09/25. c. Patient #111’s SOC was on 12/24/25. HHA services were ordered with frequency of 1 visit weekly for 4 weeks starting 12/28/25 then 1 visit weekly for 3 weeks starting 01/25/26. There was no documentation of HHA supervisory visits for the weeks of 01/04/26 through 01/24/26. d. Patient #303’s SOC was on 05/19/26. HHA services were ordered with frequency of 1 visit weekly for 4 weeks starting 05/19/26 then 1 visit weekly for 2 weeks starting 06/11/26. There was no documentation of HHA supervisory visits for the weeks of 05/24/26 through 06/20/26. e. Patient #307’s SOC was on 05/07/26. HHA services were ordered with frequency of 1 visit weekly for 4 weeks starting 05/10/26 then 1 visit weekly for 2 weeks starting 06/07/26. There was no documentation of HHA supervisory visits for the weeks of 05/21/26 through 06/16/26. 3. On 06/23/26 at 1:00 PM, Surveyor #1 and Surveyor #3 interviewed the agency’s executive Director (Staff #109) and the agency’s Clinical Operations Manager (Staff #110) regarding the lack of HHA supervisory visits. Staff #109 and Staff #110 acknowledged the findings and stated that they were unable to provide documentation that HHA supervisory visits were conducted on the patients receiving HHA services.”