Every finding on record at Carepine Home Health, LLC

Based on the findings of an unannounced on-site Medicare recertification survey conducted July 23, 2025, through July 24, 2025, Carepine Home Health LLC was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site Medicare recertification survey conducted July 23, 2025, through July 24, 2025, Carepine Home Health LLC was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of the Medicare recertification survey findings, six (6) Standard level deficiencies were cited.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on a review of agency patient welcome packet, clinical records (CR), and an interview with the agency Director of Operations, the agency failed to provide the patient or their representative with the required discharge and transfer policies upon admission for seven (7) of seven (7) CR reviewed. (CR #1, 2, 3, 4, 5, 6, and 7) Findings include: Review of agency patient welcome packet on July 23, 2025, at approximately 10:45 A.M. revealed that there was no documentation of the agency’s discharge and transfer policies in the welcome packet. Review of CR on July 23, 2025, from approximately 11:00 A.M. to 3:00 P.M. revealed the following: CR #1, start of care June 25, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #2, start of care July 14, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #3, start of care June 7, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #4, start of care July 7, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #5, start of care June 19, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #6, start of care July 9, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. CR #7, start of care June 4, 2025, contained no documentation that the patient or their representative received the required discharge and transfer policies at start of care. An interview with the agency Director of Operations on July 24, 2025, at approximately 3:00 P.M. confirmed the above findings.

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: Based on a review of agency policy, clinical records (CR), and an interview with the agency Director of Operations, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for five (5) of seven (7) CR reviewed (CR#1, 2, 3, 4, and 5). Findings include: Review of agency policy '2-005.1', 'Admission Criteria and Process' on July 24, 2025, at approximately 8:00 A.M. states, “(3) 'Procedure' section (3): The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patients return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner). (B) The initial and comprehensive assessments must be conducted by a registered nurse, unless physical therapy or speech language pathology is the only requested service for the patient." A review of CR conducted July 23, 2025, from approximately 11:00 A.M. to 3:00 P.M. revealed the following: CR#1, start of care June 25, 2025, contained a coordination note for intake dated June 18, 2025. The patient was discharged from the hospital on June 19, 2025. A coordination note dated June 20, 2025, documented the patient requested a start of care on June 25, 2025, due to physician appointments. There was no physician order to amend the start of care date. CR #2, start of care July 14, 2025, contained a coordination note for intake pending skilled nursing facility discharge on July 11, 2025. A coordination note dated July 10, 2025, noted that the daughter was “ok with visit on Monday (July 14, 2025). There was no indication that the daughter requested the start of care date. There was no physician order for an amended start of care date. CR #3, start of care June 7, 2025, contained a coordination note for intake pending hospital discharge on June 2, 2025. A coordination note dated June 4, 2025, noted that the patient requested a start of care date of June 7, 2025. There was no physician order for an amended start of care date. CR #4, start of July 7, 2025, contained a coordination note for intake pending hospital discharge on July 2, 2025. The patient was discharged from the hospital on July 3, 2025, and requested start of care on July 7, 2025. There was no physician order for an amended start of care date. CR #5, start of care June 19, 2025, contained a physician referral for services noting “schedule within provider’s discretion”. A coordination note dated June 16, 2025, noted a conversation with the patient’s daughter. There was no reason documented for the delayed start of care and no physician order amending the start of care date. An interview with the Director of Operations on July 24, 2025, at approximately 3:00 P.M. 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 a review of agency policy, clinical records (CR), and an interview with the agency Director of Operations, the agency failed to document physician notification and/or obtain a verbal order to amend frequencies for missed visits for four (4) of seven (7) CR reviewed. (CR #1, 2, 3, and 5) Findings include: Review of agency policy #X-001.1 titled ‘Missed Visits’ states, “Procedure: 2. Clinicians should document on the patient chart: D. That MD was notified of the missed visit. 3. If missed visits become routine and regular for a particular patient, through actions not originating from the clinician, the clinician should obtain a modified physician order adjusting the visit frequency order, intervention and goals...” Review of clinical records on July 23, 2025, from approximately 11:00 A.M. to 3:00 P.M. revealed the following: CR #1, start of care June 25, 2025. Certification period reviewed, June 25, 2025, through August 23, 2025, contained orders for physical therapy (PT), one (1) visit per week for two (2) weeks, then two (2) visits per week for seven (7) weeks. A missed visit was documented on July 3, 2025, July 9, 2025, and July 11, 2025. Skilled nursing visits were ordered one (1) visit per week for one (1) week. A verbal order dated July 3, 2025, amended the skilled nursing visits effective June 29, 2025, one (1) visit per week for one (1) week, then two (2) visits per week for two (2) weeks. A missed skilled nursing visit was documented on July 11, 2025. There was no documentation that the primary physician was notified of the missed visits and no verbal order to amend the visit frequency. CR #2, start of care July 14, 2025. Certification period reviewed, July 14, 2025, through September 11, 2025, contained orders for one (1) PT visit. A missed PT visit was documented on July 17, 2025. There was no documentation that the primary physician was notified of the missed visit and no verbal order to amend the visit frequency. CR #3, start of care June 7, 2025. Certification period reviewed, June 7, 2025, through August 5, 2025, contained orders effective June 8, 2025, for PT one (1) visit per week for one (1) week, then two (2) visits per week for two (2) weeks. A missed visit was documented on June 21, 2025, and the order was amended on June 21, 2025, to PT one (1) visit every two (2) weeks for two (2) weeks. There were no subsequent PT visits documented. There was no documentation that the primary physician was notified of the missed visits and no verbal order to amend the visit frequency. There was no order to discharge the patient. CR #5, start of care June 19, 2025. Certification period reviewed, June 19, 2025, through August 17, 2025, contained orders for PT one (1) visit per week for one (1) week. A missed visit was documented on June 21, 2025, and June 28, 2025. Orders were amended effective June 29, 2025, to one (1) visit per week for one (1) week, then two (2) visits per week for two (2) weeks, then one (1) visit per week for three (3) weeks. The week of July 6 through July 12, 2025, only one (1) visit was completed. There was no documentation of a missed visit. A missed visit was documented on July 17, 2025. There was no documentation that the primary physician was notified of the missed visits and no verbal order to amend the visit frequency. An interview with agency Director of Operations on July 24, 2025, at approximately 3:00 P.M. confirmed the above findings.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on a review of agency policy, a request of quality indicator data utilized for the agency QAPI (quality assurance and performance improvement) program, and an interview with the agency Director of Operations, the agency failed to utilize data to monitor the effectiveness and safety of services and quality of care and/or identify opportunities for improvement. Findings include: Review of agency policy titled ‘Provider’s Quality Management Plan’ on July 24, 2025, at approximately 2:30 P.M. states, " ... must maintain an environment that fosters continuous improvement strategies. This is achieved through implementation of a Quality Management Program (QMP), a system to monitor and objectively evaluate health home quality, efficiency, and effectiveness. To track their performance, Carepine Home Health must collect, analyze, and report on data in a way that measures the effectiveness of care coordination and chronic disease management… member satisfaction… quality of care outcomes ..." QAPI documentation was requested for review on July 24, 2025, at approximately 2:15 P.M. No data was available due the location only providing services since May 2025. There was no documentation to demonstrate the agency has a system in place to collect, track and analyze data. An interview with the agency Director of Operations on July 24, 2025, at approximately 3:00 P. M. confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on a review of agency policy, personnel files (PF), and an interview with the agency Director of Operations, the agency failed to conduct TB testing per agency policy for three (3) of five (5) PF reviewed (PF #1, 2, and 4). Findings include: Review of agency policies on July 24, 2025, at approximately 2:30 P.M. revealed the following: Policy 1-004.1 'Selection/Hiring of Personnel' 'Hiring' states, “11. A current physical and TB test/chest x-ray must be received prior to the first day of employment." Policy 7-002.1 'Tuberculosis Exposure Control Plan' states, “3. Procedure: 12. Where required by state and/or local regulations, a two-step Mantoux PPD skin test will be given to all personnel upon hire, if no PPD skin test has been performed within 12 months of hire date, and thereafter, according to risk assessment.” A review of personnel files conducted on July 24, 2025, at approximately 2:00 P.M. revealed the following: PF#1, date of hire July 9, 2024, contained documentation of a single TST completed on June 23, 2024. There was no documentation that a second TST was completed. PF#2, date of hire August 5, 2024, contained documentation of a single TST completed on July 30, 2024. There was no documentation that a second was TST completed. PF#4, date of hire February 24, 2017, contained documentation of a single TST completed on February 22, 2019. There was no documentation that a second TST was completed. An interview with agency Director of Operations on July 24, 2025, at approximately 3:00 P.M. confirmed the above findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on the review of agency' s organizational chart and interview with the agency Director of Operations, the governing body failed to assume full legal authority and responsibility for the agency's overall management and operation, and the provision of all home health services by not having an on-site full-time administrator, alternate administrator, and clinical manager at this location. Findings include: Review of the agency’s organizational chart on July 24, 2025, at approximately 2:30 P.M., identified the designated administrator, alternate administrator, and clinical supervisor. An interview with the agency Director of Clinical Operations on July 24, 2025, at approximately 2:30 P.M. revealed that the administrator, alternate administrator and clinical manager assume the same roles for two (2) additional, separately licensed and Medicare certified agencies under the same ownership.

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted on August 8, 2022, CarePine Home Health, LLC., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on a review of agency policy, emergency preparedness (EP) documentation, and an interview with the office manager, the agency failed to follow its policy to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated at least annually. Findings Included: Review of agency policy "Emergency Management Plan" on August 8, 2022, at approximately 1:45 pm states, "Procedure: 11. CarePine Home Health will test the emergency management plan at least annually, either in response to an actual emergency or planned drill. All actual responses and drills will be critiqued to identify deficiencies and opportunities for improvement...12. Organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually thereafter...." Review of agency emergency preparedness documentation on August 8, 2022, at approximately 1:30 pm revealed no documentation of an emergency preparedness plan testing program completed annually in accordance with agency policy. Review of personnel files on August 8, 2022, at approximately 11:50 am revealed the following: PF #3, Date of Hire: 5/3/18, contained documentation of EP training completed at hire only. PF #4, Date of Hire: 5/15/17, contained documentation of EP training completed at hire only. PF #5, Date of Hire: 3/18/19, contained documentation of EP training completed at hire only. Interview with the office manager on August 8, 2022, at approximately 2:00 pm confirmed the above findings.

Based on the findings of an unannounced onsite home health agency Medicare recertification survey conducted on August 8, 2022, CarePine Home Health, LLC., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on review of agency policy, personnel files (PF), and an interview with office manger, the agency failed to provide documentation of an annual competency evaluation for four (4) of five (5) PF's reviewed, (PF #1, 3, 4, and 5); and failed to provide documentation of an annual performance evaluations for four (4) of five (5) PF's reviewed, (PF #1, 3, 4, and 5). Findings Included: A review of agency policy titled "Competency Assessment" on August 8, 2022 at approximately 1:50 pm states, "Policy: The competence of all organization personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation...Procedure: Ongoing Assessments: 1. Competency assessments will be completed at least one time per year...Annual Performance Evaluation: 1. During the annual performance evaluation, personnel's competence in performing specified activities will be evaluated..." A review of PF's conducted on August 8, 2022 from approximately 11:50 am to 12:45 pm revealed the following: PF #1, Date of Hire: 8/24/2020, did not contain any documentation of an annual competency evaluation for 2021 and did not contain any documentation of an annual performance evaluation for 2021. PF#3, Date of Hire: 5/3/18, did not contain any documentation of an annual performance evaluation for 2020. PF#4, Date of Hire: 5/15/17, did not contain any documentation of an annual performance evaluation for 2020. PF#5, Date of Hire: 3/18/19, did not any documentation of an annual performance evaluation for 2020. An interview with the office manager on August 8, 2022, at approximately 2:00 pm confirmed the above findings.