Every finding on record at Associates Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/7/25. Standard level deficiencies cited.

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 review of the Agency's Emergency Preparedness Plan, Agency Policy, and Staff interview, the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all patients served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/5/25. The plan lacked documentation of Hazard Vulnerability Assessments for the years 2023 and 2024. 2. The policy “Emergency Preparedness Policy” dated 11/15/17 required, “1. Risk Assessment and Hazard: The Agency will perform risk assessment at least annually to identify potential natural and man-made hazards… 2. Emergency Plan: Be based on the risk assessment…” 3. During an interview with the Administrator and Director of Patient Care Services on 8/6/25 at 1:45 PM, the above finding was 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 the review of the Agency's Emergency Preparedness Plan, policy review, and staff interview, the Agency failed to have a communication plan that included the 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 8/5/25. The plan lacked a communication plan that includes the updated list of the following requirements: Names and contact information for entities providing service under arrangement, Patients' Physicians, and Volunteers. 2. The policy “Emergency Preparedness Policy” dated 11/15/17 requires, “Communication Plan: Maintain up to date emergency contact information for patients, staff, local emergency and supplies…” 3. During an interview with the Administrator and Director of Patient Care Services on 8/6/25 at 1:45 PM, the above finding was confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Program and Plan, and staff interview, the Agency failed to ensure the Agency conducted the required individual and/or community exercises every two years to ensure the effectiveness of the Emergency Preparedness Plan. This has the potential to affect all patients receiving home health services. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/5/25. The Plan lacked documentation that full-scale community or individual exercises were conducted by the Agency for the years reviewed (2023 and 2024). 2. During an interview with the Administrator and Director of Patient Care Services on 8/6/25 at 1:45 PM, it was confirmed the Agency failed to meet the testing requirements of the Agency’s Emergency Plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 8/7/25. Standard level deficiencies cited. Abbreviations: % = percent SOC = Start of Care Pt./Pts. = Patient/Patients # = number cm = centimeter SN = Skilled Nurse AM = morning PM = afternoon PT = Physical Therapy OT = Occupational Therapy HHA = Home Health Aide OASIS = Outcome Assessment and Information Set

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 review of the Agency’s Pt. admission folder, observations and interviews during home visits, clinical record reviews, and staff interviews, the Agency failed to ensure the Pt./representative was informed in writing of the frequency of visits on 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 8/4/25 at 2:30 PM. The folder included the “Admission Consent” which lacked the frequency of visits proposed to furnish care by discipline. 2. The following clinical records were reviewed on 8/5/25 to 8/6/25: Pt #1. SOC 2/28/25. Pt. received SN, PT and HHA services. Pt. #2. SOC 7/11/25. Pt. received SN, and PT services. Pt. #3. SOC 7/19/25. Pt. received SN, and PT services. Pt. #4 SOC 6/23/25. Pt. received SN, PT, OT and HHA services. Pt. #5 SOC 3/7/23. Pt. received SN, and HHA services. Pt. #6 SOC 8/15/24. Pt. received SN and PT services. Pt. #7 SOC 1/21/25. Pt. received SN and PT services. The clinical records included the “Admission Consent” form signed by the Pt./representative. The consent forms lacked documentation of the visit frequencies. 3. Home visits were conducted on the following Pts. on 8/4/25 and 8/5/25: Pt #1. SOC 2/28/25. Pt. #2. SOC 7/11/25. Pt. #3. SOC 7/19/25. During the home visits of Pts. #1, 2, and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the frequency of visits in writing. 4. During staff interviews with the Administrator and Director of Pt. Care Services on 8/6/25 at 1:30 PM, and 2:30 PM, the administrative team confirmed the above findings.

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 record reviews, policy review and staff interviews, the Agency failed to ensure that wound treatment provided for 2 of 7 (Pts. #6 and #7) was ordered by the Physician. Findings include: 1. Pt. #6 was admitted to home health services on 8/5/24 with the diagnosis of Cellulitis of Right Lower Limb. The clinical record was reviewed on 8/6/25. The Skilled Nurse Visit note dated 8/19/24 included the documentation, “ Wound 1 - Location: sacral area, Status: Open , Present on Admission , Type: Pressure Injury , Stage:2 , Size: Length: 1.4 cm, Width: 1.5 cm, Depth: 0.1 cm , Wound Bed: , Granulation: 90% , Slough: 10% , Wound Edges: Attached , Drainage: Serous , Amount: Small , Odor: Musty, Surrounding Tissue: Fragile Treatment: cleansed wound of sacral area with wound spray, patted dry applied foam dressing to area and secured..” The clinical record lacked documentation the Physician was notified that the pressure injury has worsened from Stage 1 to Stage 2, and lacked documentation Physician orders were obtained for the use of the above-mentioned wound treatment. 2. Pt. #7 was admitted to home health services on 1/21/25 with the diagnosis of Pneumonia. The clinical record was reviewed on 8/5/25. The Skilled Nurse Visit note in the clinical record dated 2/4/25 included documentation, “Wound 1 - Location: Sacrum, Status: Open , Onset Date: 2/4/25 , Type: Pressure Injury, Stage:2 , Size: Length: 0.8 cm, Width: 1.0 cm, Depth: 0.1 cm , Wound Bed: Red , Pink/Red: 80% , Slough: 20% , Wound Edges: Attached , Drainage: None , Amount: None , Odor: None , Surrounding Tissue: Intact Treatment: Cleanse with wound spray, pat dry, apply Medi honey gel to wound bed, cover with foam island border dressing…” The clinical record lacked documentation the Physician was notified of new onset of wound and, lacked documentation Physician orders were obtained for the use of the above-mentioned wound treatment. 3. During an interview with the Administrator and Director of Patient Care Services on 8/6/25 at 1:45 PM, the above findings were confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records, policy review and staff interview, in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7) the Agency failed to conduct complete assessments for Pts. for influenza and pneumonia status. Findings include: 1. The following clinical records were reviewed on 8/5/25 and 8/6/25. The records lacked documentation of dates of when the influenza and pneumonia vaccines were received by the Pts. Pt. #1 SOC: 2/28/25 Pt. #2 SOC: 7/11/25 Pt. #3 SOC: 7/19/25 Pt. #4 SOC: 6/23/25 Pt. #5 SOC: 3/7/23 Pt. #6 SOC: 8/15/24 Pt. #7 SOC: 1/21/25 2. The policy titled, “Policy on Pneumonia and Flu Shot Vaccines” was reviewed on 8/6/25 and required, “Agency Responsibility and Patient Offer: Eligible patients are offered pneumonia/flu shots unless they are medically contraindicated, or they refuse the shots… During the OASIS evaluation, the nurses ask the patients about previous records of their pneumonia and flu shot vaccines…Documentation is each patient record must indicate whether it was offered, given, or refused.” 3. During the Entrance interview with the Administrator and Director of Patient Services on 8/4/25, it was stated that staff assesses the status of the pneumonia vaccination at the SOC and enters the information in the OASIS SOC assessment. 4. During an interview with the Director of Patient Clinical Services on 8/6/25 at 1:45 PM and at 2:45 PM, the above findings were 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, for 2 of 7 (Pts. #1 and 6) clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. 2. Pt. #6 was admitted to home health services on 8/15/24 with the diagnosis of Cellulitis of Right Lower Limb. The clinical record was reviewed on 8/6/25. The record included a Discharge comprehensive assessment dated 8/22/24, indicating that Pt. #6 was discharged from the Agency. The record lacked documentation that a copy of the Pt. #6’s discharge summary was sent to the Physician. Findings include: 1. Pt. #1 was admitted for home health services on 2/28/25 with the diagnosis of Pressure Ulcer of the Left Hip, Stage 2. The clinical record was reviewed on 8/5/25. The record included the discharge summary completed by the PT dated 6/12/25. The record lacked documentation that a copy of the summary was sent to the Physician. 3. During staff interviews with the Administrator and Director of Pt. Care Services on 8/6/25 at 1:30 PM, and 2:30 PM, the administrative team confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon, Evening RN = Registered Nurse

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure initial comprehensive assessments were performed by the RN within 48 hours of the Physician’s referral to begin home health services/the Patient's return home. This was found in 2 of 7 clinical records reviewed (Pts. #5 and 6). Findings include: 1. Pt. #5. SOC 5/2/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 5/31/22 at 2:20 PM. The record included the Physian's referral for the Agency to provide home health services, which was faxed to the Agency on 4/28/22. The record also contained the initial comprehensive assessment performed by the RN on 5/2/22, 4 days after the Physician's referral. 2. Pt. #6. SOC 12/27/21. Primary Diagnosis: Unspecified Fracture of Left Femur. The clinical record was reviewed on 6/1/22 at 9:30 AM. The record included the Physician's referral for the Agency to provide home health services, which was faxed to the Agency on 12/22/21. This referral noted the Pt. would be discharged from an in-patient facility as of 12/23/21. The record also contained the initial comprehensive assessment performed by the RN on 12/27/21, 4 days after the Pt. was discharged/returned home from the in-patient facility. 3. During an interview with the Administrator and the Director of Pt. Care Services on 6/1/22 at 1:00 PM, the Administrator confirmed the initial comprehensive assessment was not performed by the RN within 48 hours of the Physician's referrral for home health services/the Patient's return home.