Every finding on record at Accelerated Home Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/26/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 06/26/26. Standard level deficiencies cited. Abbreviations: Pt./Pts. = patient/patients E = Employee # = number % = percent AM = morning PM = afternoon SN = Skilled Nurse PT = Physical Therapist HHA = Home Health Aide RN = Registered Nurse SOC = Start of Care POC = Plan of Care mg = milligram mmHg = millimeters of Mercury OASIS = Outcome and Assessment Information Set

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 the review of the Error Summary report and staff interview, for 74 of 391 assessments submitted in the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed, which resulted in a warning. Findings include: 1. The Error Summary report for 06/01/26 TO 06/16/26 was reviewed on 06/22/26 at 9:30 AM. The report stated that 74 (18.93%) of 391 OASIS reports were submitted late, or more than 30 days after the assessment was completed. 2. During an interview with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/24/26 at 11:30 AM, it was confirmed the error occurred.

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 clinical record reviews and staff interview, in 5 of 7 (Pts. # 2, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts./ Pts. representative were informed in advance the disciplines to provide care/service and frequency of visits provided by each discipline. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/24/26. The admission folder included a "Consent and Agreement for Home Care Services” which lacked documentation of what services / disciplines are to be provided and their frequencies. 2. The following clinical records were reviewed from 06/22/26 to 06/24/26 and lacked documentation of the services/disciplines and proposed visit frequencies: Pt. #2 SOC 01/12/26 Pt. #4 SOC 05/21/26 Pt. #5 SOC 03/11/26 Pt. #6 SOC 05/14/25 Pt. #7 SOC 11/28/25 2. During interviews with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/24/26 between 11:30 AM to 3:00 PM and on 06/26/26 at 9:30 AM, the Administrative staff confirmed that the Pts. were given the same Pt. admission documents at the Start of Care. During the same interview, the Administrative staff confirmed the above findings.

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 clinical record review and staff interviews, in 3 of 7 (Pts. #3,4, and 7) clinical records reviewed The Agency failed to ensure a RN performed the initial assessment within 48 hours of the Physician's referral for home health care services. Findings include: 1. Pt. #3 was admitted to home health services on 03/13/26 with diagnosis of Type 2 Diabetes mellitus with hyperglycemia. The clinical record was reviewed on 06/23/26. The Face-to-Face signed by the Physician and received by the Agency on 02/27/26 required Skilled Nursing and Physical Therapy services. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 06/24/26, the record lacked documentation, the Agency initiated service within the required time frame. 2. Pt. #4 was admitted to home health services on 05/21/26 with diagnosis of Other specified arthritis, left knee. The clinical record was reviewed on 06/24/26. The Face-to-Face conducted by Advanced Practice Nurse on 05/07/26, was signed by the Physician on 05/15/26 and received by the Agency on the same day/date required: Skilled Nursing, Physical Therapy and Home Health Aide services. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 06/24/26, the record lacked documentation, the Agency initiated service within the required time frame. 3. Pt. #7 was admitted to home health services on 11/28/25 with Diagnoses of but not limited to Polyosteoarthritis. The clinical record was reviewed on 06/24/26. The record included a Physician note dated 11/19/25 that required Skilled Nursing and therapy services. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 06/26/26, the record lacked documentation, the Agency initiated service within the required time frame. 4. During interviews with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/24/26 at 2:30 PM and on 06/26/26 at 9:30 AM, the Administrative staff confirmed the above findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation and interview during a home visit, clinical record review and staff interviews, for 1 of 7 (Pt. #1) clinical record reviews, the Agency failed to ensure that a complete review of the medications was conducted during the comprehensive assessment. Findings include: 1. Pt. #1 was admitted to home health services on 05/06/26 with the diagnosis of but not limited to Congestive Heart Failure, Parkinson’s Disease without dyskinesia and hypertension. During a home visit conducted with the E#2 (Physical Therapist) on 06/22/26, the patient’s medications were reviewed. The clinical record was reviewed on 06/23/26. The record included documentation that a comprehensive recertification assessment was conducted on 04/28/26 by E#2 and included a POC effective 05/01/26. The POC lacked documentation of the following medications that were found during the home visit: Carbidopa-Levodopa 25-100 mg 2 tablets 4 times a day, Entacapone 200 mg 1 tablet 4 times a day, Dorzolamide hydrochloride/Timolol Maleate 2%/0.5%, 1 drop into both eyes in the morning and 1 drop in the evening, Brimodine tartrate 0.2% left eye every morning, Systane eye gel both eyes, Systane eye gel both eyes, Vitamin C 500 mg once a day, Multivitamins 1 tablet, Setraline 100 mg 2 tablets daily, Metroprolol succinate XL 25 mg, Gabapentin 100 mg 1 capsule daily. During an interview with Pt. #1’s family, it was stated that there have been no changes in medications. A “Medication Profile” which the Administrator confirmed was Pt. #1’s current medication list, was reviewed on 06/23/26 did not include the medications listed above resulting in an incomplete review to check for potential drug interactions, adverse effects, significant drug interactions and duplicates was incomplete. The profile includes the documentation, “Drug Regimen Review Acknowledgement: I have reviewed all the listed medications for potential adverse effects, drug reactions, including ineffective drug therapy, significant side effects and significant drug interactions, duplicate drug therapy and non-compliance with drug therapy” lacked the signature of the clinician and the date of review. 2. On 06/24/26 at 11:30 AM, during an interview with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator, the above finding was confirmed.

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 clinical records reviews and staff interviews, for 2 of 7 clinical records reviewed (Pts. #1 and 5), the Agency failed to ensure physician orders were followed. Findings include: 1. Pt. #1 was admitted to home health on 01/01/26 with the diagnosis of Congestive Heart Failure. The clinical record was reviewed on 06/23/26 and included the document titled, “Encounter, dated 12/03/25” which included the documentation: “Dysphagia remains a concern with frequent choking episodes…recommend following up SLP evaluation.” The record included a physician order 12/16/25: “Request for Home Health Comments: PT/SLP…” The record lacked documentation that SLP (Speech Language Pathology) services were provided or documentation of refusal of SLP services. 2. Pt. #5 was admitted to home health services on 03/11/26 with the Diagnoses of but not limited to Unilateral Primary Osteoarthritis, Essential (primary) Hypertension and Type 2 Diabetes Mellitus. The clinical record was reviewed on 06/23/26. The record included a PsOC effective 03/11/26 to 05/09/26 and 05/10/26 to 07/08/26, that required to “Notify Physician of vital sign parameters out of range:…Diastolic Blood Pressure: greater than (>) 90 mmHg less than ()200 mg/dL less than ()250 mg/dL less than (<) 70 mg/dL....SN to assess diabetic status….” The clinical record included SN visits dated 05/13/26, 05/20/26 and 05/27/26 with Diastolic Blood pressure readings of 58 mmHg and lacked a Physician notification for Diastolic Blood pressure falling outside parameters, as ordered. The clinical record included SN visits 1 time a week from 05/06/26 to 06/10/26 and lacked an assessment of diabetic status / blood sugar assessments, as ordered. 3. During interviews with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/24/26 at 11:30 AM and on 06/26/26 at 9:30 AM, the Administrative staff confirmed the above findings.

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 a review of clinical records and staff interviews, in 1 of 2 (Pt. # 2) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the Registered Nurse conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. # 2 was admitted to home health services on 01/12/26 with the diagnosis of Heart Failure, Unspecified. The clinical record was reviewed on 06/23/26. The clinical record included documentation that the Home Health Aide (HHA) provided service, 1 time a week from 05/16/26 to 06/23/26. As of 06/24/26, the record lacked documentation of Home Health Aide supervision by the Registered Nurse. 2. During an interview with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/26/26 at 9:30 AM, the Administrative staff confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, for 2 of 2 discharged clinical records reviewed (Pts. #6 and 7) the Agency failed to ensure a copy of the discharge summary was sent to the physician. Findings include: 1. Pt. #6 was admitted to home health services on 05/14/25 with the diagnosis of Type 2 Diabetes Mellitus. The record included a discharge assessment, indicating that Pt. #6 was discharged from the Agency on 07/10/25. As of the clinical record review on 06/24/26, the record lacked documentation that a copy of Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home health services on 11/28/25 with diagnoses of but not limited to Polyosteoarthritis. The clinical record was reviewed on 06/24/26. The record included a Discharge assessment dated 05/20/26, indicating that Pt. was discharged from the Agency. The record included a discharge summary dated 06/22/26. As of 06/26/26, the record lacked documentation that the discharge summary was sent to the Physician. 3. During interviews with the Administrator, Assistant Administrator, Owner, Director of Nursing and Intake Coordinator on 06/24/26 at 11:30 AM and on 06/26/26 at 9:30 AM, the Administrative staff confirmed the above findings.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 7/13/2023. The Agency was not in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to review and update its Emergency Preparedness Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan binder was reviewed on 7/12/23 at 11:30 AM. This plan was titled "Emergency Preparedness Plan." The Plan was last reviewed in 1/2/2020. 2. During an interview with the Alternate Administrator, Director of Nursing (DON) and Office Manager/Intake on 7/12/23 at 3:15 PM, they confirmed the above findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the plan was established based on an updated risk assessment utilizing an all-hazards approach. This has the potential to affect all Pts. served. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 712/20/23 at 11:30 AM. The plan lacked a hazard vulnerability assessment and an updated community specific risk assessment utilizing an all-hazard approach. 2. During an interview with the Alternate Administrator, Director of Nursing and Office Manager/Intake on 7/12/23 at 3:15 PM the above findings were confirmed.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to have a communication plan that included an accurate list of required names and contact information. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 7/12/23. The plan lacked a communication plan that meets the following requirements: Current list of names and contact information for staff members and entities providing service under contract, and Patient’s Physicians providing care. 2. During an interview with the Alternate Administrator and Director of Nursing and Office Manager/Intake on 7/12/23 at 3:15 PM, the Alternate Administrator confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete and accurate.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 7/13/23. Standard level deficiencies cited. Abbreviations: # = number AM = morning POC = Plan of care SOC = Start of care mcg = microgram mg = milligram PM = afternoon/evening Pt./Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

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 review of clinical records and staff interviews, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 3 of 7 (Pts. #1, 5 and 7) clinical records reviewed. Findings include: 1. Pt. #1 was admitted to Home Health Services on 4/8/23 with the principal diagnosis of Encephalopathy, unspecified. The clinical record was reviewed on 7/11/23 and included a SOC comprehensive assessment dated 4/11/23. The record included a “Face to Face note” signed by Physician dated 4/4/23 with order for skilled nursing care and physical therapy. The Agency failed to start service within 48 hours of the Face-to-Face received by the Agency on 4/5/22. 2. Pt. #5 was admitted to Home Health Services on 6/19/23 with the principal diagnosis of Primary Generalized Osteoarthritis. The clinical record was reviewed on 7/11/23 and included a SOC comprehensive assessment dated 6/19/23. The record included a “Face to Face note” signed by Physician dated 6/12/23 with order for skilled nursing care and physical therapy. The Agency failed to start service within 48 hours of the Face-to-Face received by the Agency. 3. Pt. #7 was admitted to Home Health Services on 12/26/22 with the principal diagnosis of Wedge Compression Fracture Second Lumbar Vertebrae. The clinical record was reviewed on 7/11/23 and included a SOC comprehensive assessment dated 12/26/22. The record included a “Face to Face encounter” signed by Physician dated 12/16/22 with order for skilled nursing care, physical therapy, and occupational therapy. The Agency failed to start service within 48 hours of the Face-to-Face received by the Agency on 12/15/22. 4. During an interview with the Alternate Administrator, Director of Nursing (DON) and Office Manager/Intake on 7/12/23 at 3:15 PM, the Alternate Administrator confirmed that the patients should have been admitted within 48 hours of the referral.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on review of clinical records, policy review, and staff interview, it was determined the Agency failed to complete the comprehensive assessment/OASIS for a recertification period. This was found in 1 of 5 (Pt. #3) clinical records reviewed, wherein recertification was conducted. Findings include: 1. Pt. #3 was admitted to Home Health on 3/1/23 with a Principal Diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. The clinical record was reviewed on 7/11/23 and included an SOC comprehensive assessment dated 3/1/23, and a Physician order to recertify Pt. #3 on 6/24/23. As of 7/11/23, the record lacked a completed comprehensive assessment/OASIS for the period of 6/29/23 to 8/27/23. 2. The Agency Policy titled, “Comprehensive Patient Assessment” was reviewed on 7/12/23 and required, “A thorough, well-organized, comprehensive, and accurate assessment consistent with the patient’s immediate needs will be completed for all patients in a timely manner…all Medicare and Medicaid patients…will have comprehensive assessments that include the OASIS data set specific to mandated time points…The depth and frequency of ongoing assessments will depend on patient needs, goals and care treatment and services provided, but will be done at least once every sixty (60) day period…8. The comprehensive assessment must be updated and revised (including the administration of the OASIS) …10. …All patients will have the comprehensive assessments completed within five (5) days of the initial visit…” 3. An interview was conducted with the Alternate Administrator, Director of Nursing and Office Manager/Intake on 7/11/23 at 2:15 PM. The Alternate Administrator stated that a comprehensive assessment/OASIS must be completed within 5 days. During the same interview, the above finding was confirmed.

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 clinical record review, policy review and staff interview, the Agency failed to ensure that an individualized written plan of care was developed and/or revised for 2 of 7 (Pts. #2 and #3) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to Home Health Services on 6/15/23 with a Principal Diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 7/11/23. As of 7/11/23, the clinical record lacked an individualized plan of care after the initial assessment, for the period of 6/15/23 to 8/13/23. 2. Pt. #3 was admitted to Home Health Services on 3/1/23 with a Principal Diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. The clinical record was reviewed on 7/11/23 and indicated that Pt. #3 was recertified on 6/24/23. As of 7/11/23 the clinical record lacked a revised plan of care, after the recertification assessment, for the period of 6/29/23 to 8/27/23. 3. The Agency Policy titled, “Care Plans” was reviewed on 7/12/23 and required, “Each patient will have a care plan that addresses their identified needs and the agency’s plan to respond to those needs…1.Following the initial assessment, a Care Plan shall be developed with the patient and the caregiver…The Care Plan shall be reviewed, evaluated, and revised (minimally every sixty [60] days and as needed) …The Care Plan must be filed in the client’s chart within ten (10) days of the initial visit…” 4. On 7/12/23 at 1:15 PM, an interview was conducted with the Alternate Administrator, Director of Nursing and Office Manager/Intake and it was stated that Pts. should have Care Plans at the start of care and, also during recertification. During the same interview the above-mentioned finding was confirmed.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records, policy review, and staff interview, it was determined the Agency failed to ensure that services were provided as ordered by the Physician. This was found in 2 of 2 (Pt. #2 and #4) clinical records reviewed wherein Occupational Services were ordered. Findings include: 1. Pt. #2 was admitted to Home Health Services on 6/15/23 with a Principal Diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 7/11/23. The record contained a Physician order for Occupational Therapy Services dated 6/15/23. As of 7/12/23, the record lacked documentation that Occupational Therapy was provided. There was no documentation on the clinical record that Pt./caregiver refused Occupational Therapy services. 2. Pt. #4 was admitted to Home Health Services on 4/16/23 with Principal Diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 7/11/23. The record contained a Physician order for Occupational Therapy Service dated 3/20/23. The record lacked documentation that Occupational Therapy was provided at the SOC and for the period of 4/16/23 to 6/17/23. There was no documentation on the clinical record that Pt./caregiver refused Occupational Therapy services. 3. The Agency Policy titled, “Therapy Services” was reviewed on 7/13/23 and required, “Therapy Services are an integral part of the interdisciplinary scope of services offered by (Agency)…Therapist shall provide services as determined by assessments and as per physician orders…” 4. The Agency Policy titled, “Physician Orders” was reviewed on 7/13/23 and required, “All medications, treatments and services provided to patients must be ordered by a physician…Orders must be implemented within 24 hours…” 5. During an interview was conducted with the Alternate Administrator, Director of Nursing and Office Manager/Intake on 7/12/23 at 1:45 PM, it was stated that Physician orders should be followed. During the same interview, the above finding was confirmed.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations and interviews during home visit, review of clinical records, policy review and staff interview, it was determined the Agency failed to ensure the information contained in the clinical records were accurate. This was found in 2 of 7 (Pts. #2 and #3) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to Home Health Services on 6/15/23 with Principal Diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. A home visit was conducted on 7/11/23 at 3:00 PM with the Physical Therapist. During the home visit, Pt#2's medications were reviewed. The following medication were found at Pt #2’s home: Budesonide inhaler, Ondansetron 4 mg, Mucinex 300 mg, which were also listed on the medication list in the patient’s home. The Pt. and caregiver were interviewed and confirmed Pt. was taking the above-mentioned medications. The clinical record was reviewed on 7/11/23 and included a form “Medication Profile” for the episode/period of 6/15/23 to 8/13/23. The record also included a “Post-Acute Skilled Nursing Home Follow-up Visit Note” which included the above-mentioned medications however, these medications were not listed on the form “Medication Profile.” 2. Pt. #3 was admitted to Home Health Services on 3/1/23 with Principal Diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. A home visit was conducted on 7/11/23 with the Registered Nurse. During the home visit, Pt. #3’s medications were reviewed. The following medications were found at Pt. #3’s home: Hydrochlorothiazide 25 mg (bottle with original date ordered 8/14/19), Saw Palmetto 160 mg, CoQ10, Niacin 500 mg, Magnesium Sulfate 250 mg, Docusate Sodium 100 mg, Vitamin D3 125 mcg, Vitamin E 400 International Units. During an interview with the Pt at the home visit, Pt. #3 confirmed taking the medications listed above. The clinical record was reviewed on 7/11/23 and included a form “Medication Profile” for the episode/period of 6/29/23 to 8/27/23. The “Medication Profile” did not list any of the medications listed above. The profile also listed the medication Amlodipine 5 mg tablet, but the medication was not found at Pt. #3’s home. 3. The Agency Policy titled “Medication Profile” was reviewed on 7/13/23 and required, “The Registered Nurse or Therapist will complete a medication profile for each patient at the time of admission. The medication profile shall include all prescription and nonprescription including regularly scheduled medications and those taken intermittently or as needed. The profile shall be reviewed and updated as needed to reflect current medications the patient is taking…The Nurse/Therapist shall record on the Medication Profile all prescribed and over the counter (OTC) medications the patient is currently taking.” 4. An interview was conducted with the Alternate Administrator, Director of Nursing and Office Manager/Intake on 7/12/23 at 2:00 PM. During the interview, the Director of Nursing stated that a medication reconciliation should be conducted, and the medication profile should be updated. During the same interview the above finding was confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 8/18/22 with the Principal Diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 7/11/23 and included a Physician's order dated 6/16/23 to discharge Pt. from the Agency. The clinical record lacked documentation the Agency sent a copy of the discharge summary to the Physician. 2. Pt. #7 was admitted to Home Health Services on 12/26/22 with the principal diagnosis of Wedge Compression Fracture Second Lumbar Vertebrae. The clinical record was reviewed on 7/11/23 and included a Physician’s order dated 3/10/23, indicating Pt. #7 was discharged from the Agency. The clinical record lacked documentation the Agency sent a copy of the Transfer/discharge summary to the Physician. 3. During an interview with the Alternate Administrator, the Director of Nursing, and the Office Manager/Intake on 7/12/23 from 2:00 PM to 3:00 PM, the above findings were confirmed