Every finding on record at At Home Therapy Solutions, PLLC

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 document review and interview, the agency failed to ensure their Emergency Preparedness Plan was reviewed and updated every 2 years. The findings included: Review of the agency's Emergency Preparedness Plan revealed the plan was last reviewed on 10/21/2022. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the Emergency Preparedness Plan was not updated as required.

A recertification survey was conducted on 4/14/2025 - 4/16/2025. An entrance conference was held on 4/14/2025 at 9:30 AM, with the Administrator. An exit conference was held on 4/16/2025 at 11:00 AM with agency administration.

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 policy review, medical record review, observation, and interview, the agency failed to ensure an accurate Patient Medication Record for 3 of 5 (Patient #7, #8, and #9) sampled patients with home visits. The findings included: 1. Review of the agency's "Addendum to Medication Policy due to update with...EMR [Electronic Medical Record] of [Named] Home Health Agency Medication Reconciliation Policy" effective 9/2/2024 revealed, "...The purpose of this updated policy is to ensure the accurate and consistent reconciliation of medications for patients receiving home health services...Definitions...Medication Reconciliation: The process of comparing a patient's current medication regimen (prescriptions, over-the counter drugs, herbal supplements...) with what is actually being prescribed or administered, to identify and resolve discrepancies...Medication reconciliation will be revisited and updated at each home visit by the healthcare provider...Any changes to medications during the patient's care...must be communicated to the interdisciplinary team and accurately documented int he patient's EMR..." 2. Medical record review for Patient #7 revealed a Start of Care date of 3/5/2025 with diagnoses which included Fibromyalgia, Osteoarthritis, Hypertensive Heart Disease with Heart Failure, and Polyneuropathy. Observations in Patient #7's home on 4/14/2025 at 11:15 AM, revealed the Patient was taking the following medications which were not included on the Patient Medication Record: Gabapentin (used to treat neuropathy and/or nerve pain) 600 milligrams (mg) three times a day Amlodipine (used to treat high blood pressure) 5 mg once a day Duloxetine HCL (used to treat depression) 60 mg once a day Austedo (used to treat side effects of involuntary movements caused from other medications) 12 mg 2 tablets twice daily During an interview on 4/14/2025 at 11:20 AM, Patient #7 confirmed she was taking the above medications in addition to the other medications listed on the Patient Medication Record. 3. Medical record review for Patient #8 revealed a Start of Care date of 2/11/2025 with diagnoses which included Surgical Aftercare following surgery on the digestive system, Malignant Neoplasm of Rectosigmoid Junction, Multiple Myeloma, and Nutritional Anemia. Observations in Patient #8's home on 4/14/2025 at 10:40 AM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Quetiapine Fumarate (used to treat psychosis, depression, and insomnia) 25 mg at bedtime Additionally, the Patient Medication Record indicated Patient #8 was taking Amitriptyline HCL (used to treat depression) 25 mg daily; however, the medication was not found in the Patient's home. During an interview on 4/14/2025 at 10:40 AM, Patient #8 stated her physician discontinued the Amitriptyline and started the Quetiapine Fumarate about 3 months ago. 4. Medical record review for Patient #9 revealed a Start of Care date of 3/12/2025 with diagnoses which included Dementia, Depression, Heart Failure, Diabetes Mellitus, and Stage 3 Chronic Kidney Disease. Observations in Patient #9's home on 4/14/2025 at 12:10 PM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Loratadine (treats allergic symptoms) 10 mg orally as needed, Over the Counter (OTC) Centrum 50+ Years (multivitamin) every day, and OTC Magnesium Glycinate (supplement)1 orally every day. 5. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the medications the patients took in the home should match the Patient Medication Record and should be reviewed and updated each home visit. Based on policy review, medical record review, observation, and interview, the agency failedto ensure an accurate Patient Medication Record for of 3 of 5 (Patient #7, #8, and #9) sampled patients with home visits. The findings included: 1. Review of the agency's "Addendum to Medication Policy due to update with...EMR [Electronic Medical Record] of [Named] Home Health Agency Medication Reconciliation Policy" effective 9/2/2024 revealed, "...The purpose of this updated policy is to ensure the accurate and consistent reconciliation of medications for patients receiving home health services...Definitions...Medication Reconciliation: The process of comparing a patient's current medication regimen (prescriptions, over-the counter drugs, herbal supplements...) with what is actually being prescribed or administered, to identify and resolve discrepancies...Medication reconciliation will be revisited and updated at each home visit by the healthcare provider...Any changes to medications during the patient's care...must be communicated to the interdisciplinary team and accurately documented int he patient's EMR..." 2. Medical record review for Patient #7 revealed a Start of Care date of 3/5/2025 with diagnoses which included Fibromyalgia, Osteoarthritis, Hypertensive Heart Disease with Heart Failure, and Polyneuropathy. Observations in Patient #7's home on 4/14/2025 at 11:15 AM, revealed the Patient was taking the following medications which were not included on the Patient Medication Record: Gabapentin, used to treat neuropathy and/or nerve pain, 600 mg three times a day Amlodipine, used to treat high blood pressure, 5 mg once a day Duloxetine HCL, used to treat depression, 60 mg once a day Austedo, used to treat side effects of involuntary movements caused from other medications, 12 mg 2 tablets twice daily During an interview on 4/14/2025 at 11:20 AM, Patient #7 confirmed she was taking the above medications in addition to the other medications listed on the Patient Medication Record. 3. Medical record review for Patient #8 revealed a Start of Care date of 2/11/2025 with diagnoses which included Surgical Aftercare following surgery on the digestive system, Malignant Neoplasm of Rectosigmoid Junction, Multiple Myeloma, and Nutritional Anemia. Observations in Patient #8's home on 4/14/2025 at 10:40 AM revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Quetiapine Fumarate, used to treat psychosis, depression, and insomnia, 25 mg at bedtime Additionally, the Patient Medication Record indicated Patient #8 was taking Amitriptyline HCL 25 mg daily; however, the medication was not found in the Patient's home. During an interview on 4/14/2025 at 10:40 AM, Patient #8 stated her physician discontinued the Amitriptyline and started the Quetiapine Fumarate about 3 months ago. 4. Medical record review for Patient #9 revealed a Start of Care date of 3/12/2025 with diagnoses which included Dementia, Depression, Heart Failure, Diabetes Mellitus, and Stage 3 Chronic Kidney Disease. Observations in Patient #9's home on 4/14/2025 at 12:10 PM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: 3/5/2025 Loratadine (treats allergic symptoms) 10 mg orally as needed, Over the Counter (OTC) Centrum 50+ (supplement) years every day, and OTC Magnesium Glycinate (supplement)1 orally every day. 5. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the medications the patient is taking in the home should match the Patient Medication Record and should be reviewed and updated each home visit.

The Emergency Preparedness survey was conducted during the recertification survey. The facility staff were informed of the findings during an exit meeting on 9/21/2022.

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), §485.625(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 document review and interview, the facility failed to update the Emergency Preparedness Plan at least every 2 years. The findings included: 1.Review of the "EMERGENCY PREPAREDNESS PLAN" revealed a date of 10/12/16. 2.In an interview on 9/21/2022, in the conference room, at 10:45 AM, the Administrator verified the facility was unable to provide a current Emergency Preparedness Plan.

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), §485.625(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 interview, the facility failed to include a documented risk assessment, utilizing an all-hazards approach. The findings included: In an interview on 9/21/2022 at 10:42 AM, the Administrator verified the agency did not have a current facility-based and community-based risk assessment, utilizing an all-hazards approach.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on document review and interview, the facility failed to ensure the communication plan was reviewed and updated at least every 2 years. The findings included: 1. Review of the :EMERGENCY PREPAREDNESS PLAN" revealed a date of 10/12/16. 2. In an interview on 9/21/2022 at 10:45 AM, the Administrator verified the agency could not provide an updated communication plan.

A recertification survey was conducted on 9/19/2022 through 9/21/2022. An entrance conference was held with the Director of Professional Services (DOPS) on 9/19/2022 at 9:20 AM. An exit conference was held with the DOPS and Administrator on 9/22/2022. The facility representatives were informed of the survey findings and were given an opportunity to ask questions.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the facility failed to document the date patients signed consent for home health services and were informed of their rights for 5 of 12 (Patient #1, 3, 8, 10 and 11) sampled active patinets The findings included: 1. Medical record review for Patient #1 revealed an admission date of 8/19/2022 with a primary diagnosis of nutritional anemia. Review of the admission consent form for Patient #1,which included the patient rights and responsibilities, was not dated. 2. Medical review for Patient #3 revealed an admission date of 9/9/2022 with a primary diagnosis of Lymphedema. Review of the admission consent form, which included the patient rights and responsibilities, was not dated. 3. Medical record review for Patient #8 revealed an admission date of 9/1/2022 with a primary diagnosis of neck fracture. Review of the admission consent form for Patient #8, which included the patient rights and responsibilities, was not dated. 4. Medical record review for Patient #10 revealed an admission date of 8/2/2022 with a primary diagnosis of osteoarthritis. Review of the admission consent form for Patient #10, which included the patient rights and responsibilities, was not dated. 5. Medical record review for Patient #11 revealed an admission date of 7/28/2022 with a primary diagnosis of Oseoarthritis of the hip. Review of the admisssion consent form for Patient #11, which included the patient rights and responsibilites, was not dated. 6. The survyeor requested a copy of the consent forms for Patient #1 and #3 on 9/19/2022 at 2:30 PM. The copies provided had the date completed and had been altered from the patient consent form in the electronic medical record. The surveyor requested a copy of the consent form for Patient #8 on 9/21/2022 at 10:30 AM. The copy provided had the date completed and had been altered from the patient consent form in the electronic medical record. 7. The survey team requested a policy regarding the admission process and how new patients were informed of their rights on 9/21/2022 at 8:35 AM and 10:45 AM, the policy was not provided.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the facility failed to ensure all patient care orders were reflected in the plan of care for 3 of 7 (Patient #2, 4, and 5) sampled patients with home visits. The findings included: 1. Review of the facility's policy,"MEDICATION LIST AND MONITORING" undated revealed, "...Agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient..." 2. Medical record review for Patient #2 revealed a Start of Care (SOC) date of 8/24/2022 with a Certification Period of 8/24/2022 through 10/22/2022 with diagnoses which included Covid-19 and Chronic Obstructive Pulmonary Disease. Observations in the home on 9/20/2022 at 2:28 PM, revealed Certified Occupational Therapy Assistant (COTA) #1 reconciled Patient #2's medications. Patient #2 had 1 additional medication which was not on the medication profile provided by the agency: Vitamin D3 OTC. In an interview on the home on 9/20/2022 at 2:30 PM, Patient #2 and another family member verified Patient #2 was taking Vitamin D3. 3. Medical record review for Patient #4 revealed a SOC date of 8/8/2022 with a Certification Period of 8/8/2022 through 10/6/2022 with diagnoses which included Covid-19 and Hypertension. Observations in the home on 9/20/2022 at 9:20 AM, revealed Physical Therapy Assistant (PTA) #1 reconciled Patient #4's medications. Patient #4 had 2 additional medications which were not on the medication profile provided by the agency: Solifenacin (used to treat overactive bladder) 5 milligrams (mgs) 1/2 tablet every night and Flonase (used to treat allergies) daily. 4. Medical record review for Patient #5 revealed a SOC date of 6/16/2022 with a Certification Period of 8/15/2022 through 10/13/2022 with diagnoses which included Cellulitis of the left lower limb. Observations in the home on 9/20/2022 beginning at 12:20 PM, revealed Registered Nurse (RN) #1 reconciled Patient #5's medications. RN #1 revealed the Isosorbide Dinitrate (used for heart failure) was entered onto the medication profile, "in error on the nurses part." Myrbetriq (used to treat overactive bladder) 50 mg everyday as needed was listed on the medication profile. According to the label on the bottle and Patient #5, this medication was prescribed by the physician to be taken evey day. 3 medications on the medication profile provided by the facility, had been discontinued prior to the home visit: Mupirocin ointment for wound care, Diclofenac cream for pain, and Meloxicam an anti-inflammatory. 3 current medications for Patient #5 were not included on the profile: Insulin Lispo (for insulin pump), Biotin (for hair, skin, and nails), and a multi-vitamin. 5. In an interview in the conference room on 9/21/2022 at 10:25 AM, the Director of Professional Services verified medication profiles should be accurate and reconciled at each visit.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on policy review, document review and interview, the facility failed to ensure 1 of 1 home health aide (home health aide #1) had the required 12 annual hours of inservice training. The findings included: 1. Review of the policy "Agency Inservices Education" revealed, "...All Home Health Aides are required to have at least twelve (12) hours of inservices based on the individual's employment anniversary..." 2. Review of the inservice training hours for HHA #1 revealed she had 3 hours of inservices in 2021. 3. In an interview on 9/21/2022 at 10:40 AM, the Administrator verified the CNA did not have the required inservice hours.