Every finding on record at Best Care Home Health, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 03/25/26. 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 the Emergency Preparedness requirements, on 03/25/26. Standard level deficiencies cited. Abbreviations: POC = Plan of Care SN = Skilled Nurse PT = Physical Therapist OT = Occupational Therapist Pt. / Pts. = Patient / Patients PM = Afternoon

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 home visit observation, clinical record reviews and staff interviews, for 3 of 7 (Pts. 1, 3 and 4) clinical records reviewed, the Agency failed to ensure services/treatments were provided according to the POC. 3. Pt. #4 was admitted for home health services on 02/19/26 with the diagnoses of but not limited to Primary osteoarthritis and Type 2 Diabetes Mellitus. The clinical record was reviewed on 03/23/26 and included a POC effective 02/19/26 and required staff to notify the Physician if the parameters of the "Fasting Blood Sugar greater than (>) 200 or less than () 300 or less than ( 4. During an interview conducted with the Executive Director and Director of Nursing on 03/24/26 at 1:30 PM to 3:00 PM, the above findings were confirmed. Findings include: 1. Pt. # 1 was admitted to home health services on 03/11/26 with the diagnoses of but not limited to Urinary Tract Infection and Long Term use of Oral Hypoglycemic Drugs. The clinical record was reviewed on 03/23/26. The clinical record included a POC effective 03/11/26 to 05/09/26, included orders: “Notify physician of:…Fasting blood sugar greater than (>) 200 or less than () 300 or less than () 400 or less than () 400 or less than (<) 70….” The clinical records included SN notes dated 02/26/26, 03/03/26, 03/05/26, 03/09/26 and 03/12/26, and lacked blood sugar assessments as ordered.

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 1 of 2 (Pt. #6) closed records reviewed, the Agency failed to ensure the Discharge summary was sent to the Physician within the required time frame. Findings include: 1. Pt. #6 was admitted for home health services on 12/28/23 with a diagnosis of Unspecified Dementia, unspecified severity, with other behavioral disturbance. The clinical record was reviewed on 03/24/26. The record included a discharge assessment, indicating that the Pt. was discharged on 02/26/26. The record lacked documentation that a copy of the discharge summary was sent to the Physician within 5 days of discharge. 2. During an interview with the Executive Director and Director of Nursing on 03/24/26 at 3:00 PM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: Pt. =Patient Pts. =Patients SOC = Start of care

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on the clinical record review, policy review and Staff interview, it was determined the Agency failed to ensure the clinical record was complete with all required items. This was found in 3 of 7 clinical records (Pts. #4, 5 and 6) reviewed. 3. Pt. # 6 SOC 01/02/21 Diagnosis: Encounter for Orthopedic Aftercare. The discharged clinical record was reviewed on 12/20/22 at 11:30 AM and 5:00 PM. The discharged clinical record lacked documentation of Pt. #6’s consent to care/services. During interview with the Administrator and Director of Nursing on 12/21/22 at 3:00 PM, the Director of Nursing stated that consent should have been uploaded in the clinical record. 4. The Agency’s policy titled: “ Medical Record Content” was reviewed on 12/22/22 at 9:45 AM and included “….4. Each medical record will contain the following:… Evidence of consent for care on admission and during the course of care….Coordination of care activities….” 5. During interviews with Administrator and Director of Nursing on 12/22/22 between 9:30 AM and 10:30 AM the above findings were confirmed. Findings include: 1. Pt. #4 SOC 12/09/22 Diagnoses: COVID- 19 and Acute Respiratory Disease. The clinical record was reviewed on 12/21/22 at 9:00 AM. The Physical therapy visit notes dated 12/15 and 12/19/22 were incomplete. The Physical therapy visit notes dated 12/15 and 12/19/22, lacked documentation of the assessment for the pain rating scale. 2. Pt. #5 SOC 10/25/22 Diagnoses: COVID- 19, Acute Respiratory Disease and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 12/21/22 at 9:30 AM. The Physical Therapist assessed the Patient on 10/25/22 and the Registered Nurse assessed the Patient on 10/26/22. During the interview with the Administrator on 12/21/22 at 1:00 PM, it was stated that this was a Therapy only case. The record lacked the documentation of the updated order.