Every finding on record at Aim Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/20/25. 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 06/20/25. Standard level deficiencies cited. Abbreviations: Pt. = Patient

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 the clinical record review and staff interview, it was determined that in 1 of 2 closed (Pt. #7) clinical records reviewed, the Agency failed to ensure a completed discharge summary was sent to the physician. Findings include: 1. Pt. #7 was admitted to the Home Health Services on 03/25/24 with the diagnosis of Pressure Ulcer of Sacral Region Stage 2. The clinical record was reviewed on 06/17/25. The clinical record lacked a completed discharge summary. The discharged summary lacked the documentation that the discharge summary was sent to the physician. 2.The above findings were confirmed, during the interview with the Acting Administrator / Director of Nursing, on 06/17/25 at 10:10 AM.

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that includes the names and contact information of all staff members, entities providing services under arrangement, and Pt. Physicians. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 3/16//22 at 9:30 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information of all staff members, entities providing service under arrangement, and Pt. Physicians. 2. During an interview with the Administrator, Director of Nursing, and RN Case Manager on 3/16/22 at 12:05 PM, the Administrator confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse AM = Morning PM = Afternoon, Evening E = Employee X = times cm = centimeters L = long W = wide COVID-19 = Coronavirus 2019 ABN = Advance Beneficiary Notice of Non-Coverage HHCCN = Home Health Change of Care Notice

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation during home visits and staff interview, it was determined the Agency failed to ensure Pts are informed of the extent of their financial liability before care is initiated. This was found in 7 of 7 (Pts. # 1, 2, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed between 3/14/22 at 3:00 PM to 3/16/22 at 9:10 AM. Pt. #1. SOC: 1/28/22. Pt. #2. SOC: 3/9/22. Pt. #3. SOC: 1/18/22. Pt. #4 SOC: 12/31/20. Pt. #5 SOC: 11/30/21. Pt. #6 SOC: 1/20/22. Pt. #7 SOC: 12/31/21. The clinical records lacked documentation that the Pts. and/or caregiver were informed of the extent of the patient's financial liability. 2. Home visits were conducted on 3/14/22 at 11:45 AM and 3/15/22 1:30 PM and 2:30 PM with the following Pts: Pt. #1. SOC: 1/28/22. Pt. #2. SOC: 3/9/22. Pt. #3. SOC: 1/18/22. During the home visits the "Patient Information" booklets were observed, and lacked documentation the Pt. and/or caregiver were informed of the extent of the patient's financial liability. 3. During interviews with the Administrator, Director of Nursing and the RN Case Manager on 3/16/22 at 12:05 PM, and 3/16/22 at 2:20 PM with the Director of Nursing and the RN Case Manager, the Director of Nursing confirmed the above findings.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on Agency employee COVID-19 vaccination record review, Agency policy, and staff interview, it was determined the Agency failed to ensure its employee COVID vaccination policy included criteria for the evaluation and acceptance of employee requests for exemption from the COVID-19 vaccination. This was found in 1 of 13 (Employee #3) employees reviewed for compliance with COVID-19 vaccinations, and has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. E #3’s COVID-19 vaccination status was reviewed on 3/15/22 at 10:30 AM. E #3 wrote a 5-page summary dated 9/19/21, which indicated E #3 declined to receive the COVID-19 vaccination due to religious reasons and individual rights. There was no documentation E #3’s declination was evaluated or accepted by the Agency. 2. The Agency policy titled “Employees Who Want to Exempt from Vaccination” was reviewed on 3/15/22 at 11:00 AM. The policy required: "…Employees may request exemption from mandatory vaccination if the vaccination is medically contraindicated for them on religious basis or for medical necessity…" The policy lacks further criteria for evaluating/accepting such employee requests. 3. During an interview with the Administrator, Director of Nursing, and the RN Case Manager on 3/16/22 at 12:05 PM, it was confirmed the Agency's policy lacked criteria for evaluation and acceptance of employee COVID-19 vaccination exemption requests.

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: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure forms were complete. This was found in 6 of 7 (Pts. #2, 3, 4, 1, 6, and 7) clinical record reviewed. Findings include: 1. Pt. #2. SOC 3/9/22. Primary Diagnosis: Acute Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/15/22 at 10:40 AM. The record contained the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) completed by the RN, signed by the Pt. and dated 3/9/22. The form required the RN to document the service not covered, reason for noncoverage and estimated cost of the service. Sections in the ABN form were left blank, lacking documentation of the service not covered, reason for noncoverage and estimated cost of the service. 2. Pt. #3. SOC 1/18/22. Primary Diagnosis: Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side. The clinical record was reviewed on 3/16/22 at 9:10 AM. The record contained the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) completed by the RN, signed by the patient's Power of Attorney and dated 1/18/22. Sections in the ABN form were left blank, lacking documentation of the service not covered, reason for noncoverage and estimated cost of the service. 3. Pt. #4. SOC 12/31/20. Primary Diagnosis: Unspecified Vitamin B12 Deficiency Anemia. The clinical record was reviewed on 3/15/22 at 11:00 AM. The record contained the form titled, "Advance Beneficiary Notice of Noncoverage (ABN) completed by the RN, signed by the Pt. and dated 12/31/20. Sections in the ABN form were left blank, lacking documentation of the service not covered, reason for noncoverage and estimated cost of the service. 4. Pt. #1. SOC 1/28/22. Primary Diagnosis: Pressure Ulcer of Left Hip, Stage 4. The clinical record was reviewed on 3/14/22 at 11:45 AM. The record contained the SOC initial comprehensive assessment, dated 1/28/22. This assessment included documentation Pt. #1 had a stage 4 pressure ulcer of the left great trochanter, measuring 3.5 cm L x 3.5 cm W x 1.2 cm in depth. SN visit notes dated 1/31/22, 2/3/22, 2/7/22, 2/14/22, 2/17/22, 2/21/22, 2/28/22, 3/3/22 and 3/7/22 lacked measurements of this left hip ulcer. The SOC initial comprehensive assessment dated 1/28/22 also contained documentation Pt. #1 had a stage 3 pressure ulcer of the left ankle, measuring 1.0 cm L x 1.4 cm W x 0.2 cm in depth. SN visit notes dated 1/31/22, 2/3/22, and 2/7/22 lacked measurements of this left ankle ulcer. The SOC initial comprehensive assessment dated 1/28/22 also included documentation Pt. #1 had a stage 2 right sacral ulcer, measuring 1.0 cm L x 1.0 cm W x 0.1 cm in depth. SN visit notes dated 1/31/22, 2/3/22, and 2/7/22 lacked measurements of this right sacral ulcer. SN visit note dated 2/7/22 contained documentation Pt. #1 developed a new, stage 2 pressure ulcer of the left buttock, measuring 2 cm L x 2 cm W x 0.1 cm in depth. SN visit notes dated 2/17/22, 2/21/22, 2/28/22, 3/3/22, and 3/7/22 lacked measurements of this left buttock ulcer. SN visit note dated 2/14/22 included documentation Pt. #1 developed a new, stage 2 pressure ulcer of the right great trochanter, previously since the SOC as a stage 1 closed, epithelialized area. This ulcer measured 2 cm L x 2 cm W x 0.1 cm in depth. SN visit notes dated 2/28/22, 3/3/22, and 3/7/22 lacked measurements of this right great trochanter ulcer. 5. Pt. #6. SOC 1/20/22. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease. The clinical record was reviewed on 3/15/22 at 11:15 AM. The record contained a form titled “Home Health Change of Care Notice (HHCCN).” This form was signed by the Pt., and dated 1/20/22. The form included the following sections: date, what items/services will change, the reason for the change, the doctor’s order to change the patient’s home care, and the home care Agency’s decision to stop giving the pt. the care listed. All of these sections were left blank. The record also contained the form titled “Beneficiary Elected Transfer,” which was signed by Pt. #6, and dated 1/20/22. The form lacked the name of the agency Pt. #6 was transferring from. The record also included the form titled “Advance Beneficiary Notice of Non-Coverage (ABN). This form was signed by Pt. #6, and dated 1/20/22. The form contained the following sections: services that may not be covered by Medicare, the reason Medicare may not pay, and the estimated cost. All off these sections were left blank. 6. Pt. #7. SOC 12/31/21. Primary Diagnosis: Traumatic Subdural Hemorrhage without Loss of Consciousness. The clinical record was reviewed on 3/15/22 at 12:20 PM. The record contained the form titled “Advance Beneficiary Notice of Non-Coverage (ABN). This form was signed by Pt. #7, and dated 12/31/21. The form contained the following sections: services that may not be covered by Medicare, the reason Medicare may not pay, and the estimated cost. All off these sections were left blank. 7. The Agency policy titled “Home Health Advance Beneficiary Notice” was reviewed on 3/16/22 at 11:00 AM. The policy required: “…The Home Health Advance Beneficiary Notice will be provided to patients if: at the start of care the Agency determines the Patient is not eligible for Medicare reimbursed services…Describe the charges for the services and patient liability on the form…” 8. The Agency policy titled “Clinical Records/Medical Record Retention” was reviewed on 3/16/22 at 11:30 AM. The policy required: “…Clinical records are legal documents containing comprehensive, accurate, and organized information concerning the Patient’s health and emotional status, treatments, and services rendered by the Registered Professional Nurses and other health care team members…” 9. The Agency policy titled “Pressure Ulcer Dressing Change” was reviewed on 3/16/22 at 10:00 AM. The policy required: “…Measure wound perimeter with disposable device…Document in the clinical record: Location, size of ulcer…” 10. During interviews with the Administrator, Director of Nursing, and RN Case Manager on 3/16/22 at 12:05 PM and 2:20 PM, the above findings were confirmed. The Director of Nursing stated wounds should be measured and those measurements documented at least every other week—weekly if the condition of the wound is deteriorating. All forms the Pt. signs should be completely filled out.