Every finding on record at Breakthrough Healthcare Limited Liability Company

A complaint investigation 2737649 was completed on 03/02/2026 at the home health provider. The provider had 48 current patients. The complaint is substantiated. One or more of the allegations reported are verified and deficiencies were cited that are related to the allegations being investigated. One condition-level deficiency was identified during this survey. A condition-level deficiency is identified at §484.75 Condition of Participation: Skilled Professional Services. A home health provider that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G0782.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure skilled professional services were provided in an acceptable manner and as ordered by the physician (G0710). The systemic effect of this deficient practice has the potential to affect all the patients served by the provider.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure skilled professional services were provided in an acceptable manner and as ordered by the physician in two of three sampled patients (Records/Patients #1 and #3) and four additional patients (Records/Patients #4, #5, #6 and #7). This deficient practice has the potential to affect all patients on service with the home health provider. Review of the provider’s undated policy titled, “Physician Orders/Plan of Care,” showed in part that the policy is to ensure care is under the direction of a physician, and the physician should receive reports with any need to alter the plan of care. Review of the provider’s undated policy titled, “Patient Conduct, Responsibility, and Rights,” showed in part that the patient had a right to be admitted only if the agency had the ability to provide safe and effective care at the intensity needed. Example #1: RECORD/PATIENT #1: Review of the admission records showed that the patient had been on service previously with the provider. The patient was admitted to home health services for the most recent episode on 01/21/2026 with a primary diagnosis of unhealed stage 2 sacral wound (Stage II Pressure Injury - A partial thickness loss of the skin). Upon admission, the nurse was ordered to visit the patient weekly. Review of a plan of care summary showed, on 01/19/2026, the nurse (SN) was to perform wound care daily to the right lower buttock wound (wound #3). Review of an interim order dated 01/22/2026, showed the SN visit frequency was changed to daily for ulcer care to the left buttock. Review of all available nurse visit notes showed no SN visits on 01/23/2026, 01/24/2026, 01/25/2026, 01/26/2026, 01/27/2026, and 01/28/2026. There was a missed visit note entered on 01/26/2026 for inclement weather. During a nurse visit dated 01/29/2026, the nurse documented that wound #3 (right lower buttock) had serosanguineous drainage (a thin, red discharge composed of serum and blood) and “no odor” was documented. Review of all nurse visit notes showed no SN visits on 01/30/2026, 01/31/2026, 02/01/2026, 02/02/2026, 02/03/2026, and 02/04/2026. During the next nursing visit completed 02/05/2026, the nurse assessed wound #3 with “moderate odor”. Review of the nurse visit note showed the nurse coordinated with the physician regarding wound drainage, with no documentation that the physician was made aware of the new onset of wound odor. Review of a communication noted dated 02/10/2026 showed that “(the patient) was admitted to (a hospital). Admitted on 02/05/2026”. RECORD/PATIENT #3: Review of the admission assessment, completed on 10/03/2025 by registered nurse (RN)-A, showed the patient was admitted to service on 10/03/2025 with a primary diagnosis of polycythemia (an abnormal increase in red blood cells). Review of the discharge summary from 01/18/2026 showed that the patient was discharged with goals met. Review of the plan of care showed the patient was to receive nurse visits weekly. All coordination notes and notification to the physician regarding missed visits were requested from the administrator on 02/10/2026 at 1:40 PM. Review of the nurse visit notes showed the patient received no weekly nurse visits the week of 01/11/2026. All available coordination/notification notes and interim orders showed no communication that the plan of care was not followed the week of 01/11/2026. During interviews on 02/10/2026 at 12:50 PM and 1:30 PM, and on 02/11/2026 at 10:22 AM and 11:42 AM, the administrator stated that Patient #3 was completely “forgot about” and had a missed visit. The nurse, (RN-A), assigned to that patient was disciplined and educated about following the plan or care and visit schedule. Example #2: During an interview with Physical Therapist (PT-A) on 02/11/2026 at 12:10 PM, he/she stated that: - He/she had worked for the provider on a PRN (as needed) basis for two years; - When asked if he/she was available to visit patients, “I am leaving on vacation for two weeks starting Sunday (02/15/2026), I have no patients assigned”; and - When asked if there were delays in the initiation of therapy after it was ordered, he/she stated that he/she worked full-time for another provider and was not available every day, “sometimes visits have to be delayed and rescheduled because of my availability”. During an interview on 02/11/2026 at 10:48 AM, RN-A stated that: - He/she worked full-time for the provider for a year as an RN case manager; - When asked if he/she received any patient complaints about missing or delayed therapy visits, he/she stated, “multiple patients have complained about a delay in getting therapy started, (Patient #4, #5, #6 and #7) all complained about delays in therapy and home health visits”; and - He/she was aware that the director of nurses recently resigned, unaware that the therapy clinical manager was no longer employed, and that the administrator took over the role of clinical manager. During interviews on 02/10/2026 at 12:50PM and 1:30 PM, and on 02/11/2026 at 10:22 AM and 11:42 AM, the administrator stated that: - The provider had problems with missed visits starting December 19, 2025, when they contracted with a new quality assurance (QA) company. He/she assumed the QA company would track missed visits and notify him/her and they did not; - Patient #3 was completely “forgot about” and had missed visits. The nurse (RN-A) assigned to that patient was disciplined and educated about following the plan or care and visit schedule; - The (previous) director of nurses discovered the issue with missed visits on 01/06/2026. The problem with missed visits were addressed with a new system of reporting at that time. A system was started with a new case management form that was turned into the previous director of nursing on Wednesdays, the case management forms are unavailable. This system along with new missed visit practices were educated on during a weekly Wednesday meeting that occurred on 01/14/2025 with additional training on 02/04/2025; and - The missed visit issue has not been written into a performance improvement plan (PIP) or tracked in the provider’s quality assessment and performance improvement plan (QAPI) since it just occurred. Review of the provider's complaint log showed four entries in February of 2026. The concerns were as follows: - “Therapy schedule, lack of communication” (Complaint from Patient #4); - “Missed visit and poor communication” (Complaint from Patient #5); - Unhappy with therapy and wound care “going with another provider” (Complaint from Patient #6); and - Complaint about wound care supplies (Complaint from Patient #7). On 02/11/2025 at 1:15 PM, the administrator provided a missed visit report on nursing and therapy from 01/01/2025 through 02/11/2025. Review of the missed visit report, during that period, showed 118 missed visits. The administrator stated that the reason for the missed visits was not generated on the report and could be from patient refusal, etc.

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This STANDARD is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Skilled Professional Services, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 03/02/2028.