Every finding on record at Compass Home Health and Rehab LLC

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on August 5 through August 8, 2025, Compass Home Health and Rehab, 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, onsite Medicare recertification survey conducted August 5 through August 8, 2025, Compass Home Health and Rehab, LLC was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The Medicare recertification survey was conducted onsite at the Kingston parent office on August 5, 6 and 8, 2025 and at the Berwick branch office on August 7, 2025.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on review of agency policy/procedure and clinical records and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure the discharge planning was conducted in accordance with agency policy/procedure for two (2) of two (2) patients discharged from the agency or skilled nursing (SN) services without goals having been met. (Patient #7 and #11) Findings include: On August 8, 2025 at approximately 12:22 PM, review of agency policy 2-024, titled "Discharge Planning Process" revealed the following: Policy...Patients will not be discharged without appropriate preparation. The patient's continuing care needs will be assessed on an ongoing basis...Information will be provided to assist the patient in planning his/her discharge... Patient #7 (Branch Office-Discharge): Between August 6, 2025 at approximately 1:16 PM and August 8, 2025 at approximately 10:40 PM, review of the clinical record revealed the start of care date was 05/21/2025, that skilled nursing (SN) services were to be provided one (1) time a week, that SN was to provide wound care to the left fourth toe and right shin and that SN goals had been developed as documented on the "Plan of Care" order form for the initial certification period of 05/21/2025 through 07/19/2025. Visit note documentation revealed three (3) SN visits had been performed by the registered nurse (RN-Employee #5) between 05/21 and 05/29/2025. Review of the SN visit note dated 05/27/2025 revealed the patient had developed a reddened area on the buttock and that the patient was applying barrier cream to the area. Visit note documentation dated 05/29/2025 revealed the RN (Employee #5) documented a new pressure area was present on the right buttock. Review of the off-site SN comprehensive discharge visit note dated 06/02/2025 revealed the (RN (Employee #5) documented the patient was being discharged due to non-compliance and having missed a visit with the attending physician. There was no documentation in the clinical record which provided evidence the patient had met the SN goals included on the "Plan of Care" order form for the above referenced certification period. There was no documentation in the clinical record which revealed RN had provided discharge planning prior to the patient's discharge on 06/02/2025. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12 PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the start of care date was 02/21/2022, the primary diagnosis is Type-2 diabetes mellitus (diabetes), SN services were to be provided one (1) time a week for eight (8) weeks and that SN goals had been established as documented on the "Plan of Care" order form for the recertification period of 06/05/2025 through 08/03/2025. Review of visit note documentation revealed four (4) SN visits were performed by the registered nurse (RN-Employee #2) between 06/04/2025 and 06/24/2025. Review of Home Health Chage of Care Notice (HHCCN) form documentation revealed the patient was being discharged from SN services. Review of the interim verbal order dated 07/03/2025 revealed the patient was being discharged from SN services without goals having been met. There was no documentation in the clinical record which revealed the RN had provided discharge planning between 06/04/2025 and 06/24/2025. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the agency had provided discharge planning in accordance with agency policy/procedure for the above identified patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policy/procedure and clinical records and Pennsylvania state licensure regulations, and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure the name of the collaborating or supervising physician was included on the plan of care (treatment) for five (5) of five (5) patients for whom orders for home health services were provided by a nurse practitioner or physician assistant. (Patients #5, #10, #11, #12 and #13) Findings include: On August 8, 2025 at approximately 12:10 PM, review of agency policy 2-018, titled "Care Planning Process" revealed the following under "Procedure": 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: R. Other appropriate items...and additional items the organization or physician (or other licensed practitioner) may choose to include. On August 8, 2025 at approximately 1:40 PM, review of the Pennsylvania Health Care Facilities Act-Licensure, COVID-19 Regulatory Flexibility Authority and Repeal Act 30 of 2022 revealed the following under Section 806 (d) Licensure: (2) Home health care services may be ordered by nurse practitioners and physician assistants as provided under sections 1814(a) and 1835(a) of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 et seq.), if the nurse practitioner's or physician assistant's collaborating or supervising physician is identified in the patient's written plan of treatment. Patient #5 (Branch Office): On August 6, 2025 at approximately 12:31 PM review of the clinical record revealed the start of care date was 06/04/2025 and that verbal orders for home health services were provided by a certified registered nurse practitioner (CRNP) as documented on the "Plan of Care-Preview" order form for the recertification period of 08/03/2025 through 10/01/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 08/03/2025 through 10/01/2025 included the name of the CRNP's collaborating physician. Patient #10 (Branch Office--Discharge): Between August 7, 2025 at approximately 1:35 PM and August 8, 2025 at approximately 10:47 AM, review of the clinical record revealed the start of care date was 01/28/2025 and that verbal orders for home health services were provided by a CRNP as documented on the "Plan of Care" order form for the initial certification period of 01/28/2025 through 03/28/2025. The "Plan of Care" for the initial certification period was countersigned by the CRNP on 02/28/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 01/28/2025 through 03/28/2025 included the name of the CRNP's collaborating physician. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12 PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the start of care date was 02/21/2022 and that verbal orders for home health services were provided by a CRNP as documented on the "Plan of Care" order form for the recertification period of 06/05/2025 through 08/03/2025. The "Plan of Care" for the initial certification period was countersigned by the CRNP on 06/19/2025. There was no documentation in the clinical record which provided evidence the plan of care for the recertification period of 06/05/2025 through 08/03/2025 included the name of the CRNP's collaborating physician. Patient #12 (Branch Office): Between August 7, 2025 at approximately 2:37 PM and August 8, 2025 at approximately 11:04 AM, review of the clinical record revealed the start of care date was 07/18/2025 and that verbal orders for home health services were provided by a PA-C as documented on the "Plan of Care" order form for the initial certification period of 07/18/2025 through 09/152025. The "Plan of Care" for the initial certification period was countersigned by the PA-C on 08/07/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 07/18/2025 through 09/15/2025 included the name of the PA-C's supervising physician. Patient #13 (Branch Office): Between August 7, 2025 at approximately 2:54 PM and August 8, 2025 at approximately 11:11 AM, review of the clinical record revealed the start of care date was 07/18/2025 and that verbal orders for home health services were provided by a PA-C as documented on the "Plan of Care" order form for the initial certification period of 07/18/2025 through 09/152025. The "Plan of Care" for the initial certification period was countersigned by the PA-C on 08/07/2025. There was no documentation in the clinical record which provided evidence the plan of care for the initial certification period of 07/18/2025 through 09/15/2025 included the name of the PA-C's supervising physician. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the name of the CRNP's or PA-C's collaborating/supervising physician had been included on the plan of care for the patients for whom home health services were ordered by a CRNP or PA-C.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of agency policy/procedure and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN-Employee 8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure verbal orders included on the plan of care were countersigned by the primary care provider (PCP) within 30 days of the verbal order date for three (3) of six (6) patients for whom home health services were provided for a minimum of 30 days during the current certification period. (Patients #8, #9 and #10) Findings include: On August 8, 2025 at approximately 12:35 PM, review of agency policy 2-020, titled "Verification of Physician Orders" revealed the following under "Procedure": 11. Signed orders will be placed in the clinical record within 30 days of initiation of the order... Patient #8 (Branch Office--Discharge): On August 7, 2025 at approximately 10:26 AM, review of the clinical record revealed the start of care date was 06/25/2025 and that verbal orders for skilled nursing (SN) and physical and occupational therapy (PT and OT) services were obtained by the ADM/RN on 06/24/2025 as documented on the "Plan of Care-Preview" order form for the initial certification period of 06/25/2025 through 08/23/2025. There was no documentation in the clinical record which provided evidence the verbal orders included on the "Plan of Care-Preview" for the initial certification period of 06/25/2025 through 08/23/2025 had been countersigned by the attending physician. Patient #9 (Branch Office): On August 7, 2025 at approximately 10:46 AM, review of the clinical record revealed the start of care date was 08/21/2024 and that verbal orders for SN services were obtained by the ADM/RN on 06/13/2025 as documented on the "Plan of Care-Preview" order form for the recertification period of 06/17/2025 through 08/15/2025. There was no documentation in the clinical record which provided evidence that the verbal orders included on the "Plan of Care-Preview" for the recertification period of 06/17/2025 through 08/15/2025 had been countersigned by the attending physician. Patient #10 (Branch Office--Discharge): Between August 7, 2025 at approximately 1:35 PM and August 8, 2025 at approximately 10:47 AM, review of the clinical record revealed the start of care date was 01/28/2025 and that verbal orders for SN and PT services were obtained by the ADM/RN on 01/28/2025 as documented on the "Plan of Care" order form for the initial certification period of 01/28/2025 through 03/28/2025. The initial "Plan of Care" was countersigned by the certified registered nurse practitioner (CRNP) on 02/28/2025 which was more than 30 days after the verbal order date of 01/28/2025. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed there was no documentation in the clinical record which provided evidence the PCP had countersigned the verbal orders included on the "Plan of Care-Preview" or "Plan of Care" form within 30 days of the verbal order date for the above identified patients.

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 review of agency policy/procedure, Centers for Disease Control and Prevention (CDC) recommendations and the Pennsylvania Department of Health (PA DOH) tuberculosis screening recommendations and/or requirements, clinical records and personnel files, and based on interview with the administrator/registered nurse (ADM/RN-Employee #8) and the president/clinical manager/occupational therapist (PRES/CM/OT-Employee #9), the agency failed to ensure TB screening was completed in accordance with agency policy/procedure, CDC and PA DOH recommendations or requirements for two (2) of two (2) agency staff whose date of hire was after October 5, 2022. (Employees #2 and #7) Findings include: On August 8, 2025 at approximately 9:30 AM, review of policy 9-002, titled "Tuberculosis Exposure Control Plan", revealed the following under "Procedure": 9. All personnel will be tested for TB...in accordance with federal, state...regulations. On August 8, 2025 at approximately 9:37 AM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html The TB screening process for health care personnel includes: -A baseline individual TB risk-assessment; -TB symptom evaluation; and -A TB test (TB blood test or a TB skin test (2-Step)). On August 8, 2025 at approximately 9:45 AM review the PA DOH webpage ( https://www.pa.gov/agencies/health/diseases-conditions/infectious-disease/tuberculosis/tb-testing-health-care-workers.html ) revealed the following: Tuberculosis Testing Health Care Workers...On May 17, 2019 the Centers for Disease Control and Prevention (CDC) issued updated recommendations for TB testing of health care personnel. Key points include: The updated recommendations call for health care personnel to be screened for TB upon hire with an individual risk assessment(opens in a new tab), a symptom evaluation, and a TB test (either the interferon gamma-release assay, or IGRA, blood test or the tuberculin skin test-). On August 8, 2025 at approximately 9:55 AM, review of the PA DOH TB manual ( https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/diseases-and-conditions/tb/CMHD%20TB%20Manual%202023.pdf ) revealed the following: LAWS PERTAINING TO TB CONTROL...Pennsylvania laws on TB can be found in the Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, 35 P.S. Sec. 521.1 . Under the provisions of the Pennsylvania Administrative Code of 1929 and the Disease Prevention and Control Law of 1955, DOH has the authority to "protect the health of the people of this Commonwealth, and to determine and employ the most efficient and practical means for the prevention and suppression of disease." Patient #6 (Branch Office): Between August 6, 2025 at approximately 12:44 PM and August 8, 2025 at approximately 12:03 PM, review of the clinical record revealed the physical therapy assistant (PTA) provided PTA services on 08/04/2025. Patient #11 (Branch Office): Between August 7, 2025 at approximately 2:12PM and August 8, 2025 at approximately 10:55 AM, review of the clinical record revealed the RN (Employee #2) provided skilled nursing services between June 4 and June 24, 2025. Between August 6,, 2025 at approximately 2:01 PM and August 9, 2025 at approximately 8:09 AM, review of personnel file documentation revealed the following: Employee #2: The date of hire of the RN was 06/12/2024. There was no documentation in the personnel file which provided evidence a TB individual risk assessment nor a TB symptom screen had been completed prior to the assignment to provide SN services. Employee #7: The date of hire of the PTA was 06/05/2023. There was no documentation in the personnel file which provided evidence a TB symptom screen had been completed prior to the assignment to provide PTA services. During interview conducted on August 8, 2025 at approximately 12:45 PM, the ADMIN/RN and PRES/CM/OT confirmed initial TB screening was not conducted in accordance with agency policy/procedure, CDC and/or PA DOH recommendations/requirements for the above referenced employees.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on August 9 through August 12, 2022, Compass Home Health and Rehab, 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, onsite Medicare recertification survey conducted August 9 through August 12, 2022, Compass Home Health and Rehab, LLC was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The Medicare recertification survey was conducted at the Kingston parent office on August 9, 10 and 12, 2022 and at the Berwick branch office on August 11, 2022.

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 review of agency policies/procedures and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure physician orders for certification and recertification were reviewed/countersigned by the attending physician within 30 days of the start of care date for three (3) of three (3) active patients for whom home health services were provided for a minimum of 30 days during the current certification period. (Patients #3, #4 and #5) Findings include: On August 12, 2022 at approximately 4:14 PM, review of agency policy 2-018, titled "Care Planning Process" revealed the following: Policy...The plan of care will be signed by a doctor of medicine, osteopathy, or podiatric medicine or an allowed practitioner... On August 12, 2022 at approximately 5:39 PM, review of agency policy 2-020 titled "Verification of Physician Orders" revealed the following under "Procedure": 10. Signed orders will be placed in the clinical record within 30 days of initiation of the order... Patient #3 (Parent Office): Between August 10, 2022 at approximately 8:01 AM and August 11, 2022 at approximately 10:44 AM, review of the clinical record revealed the start of care date was 07/14/2022 as documented on the plan of care for the initial certification period of 07/14/2022 through 09/11/2022. Review of "Visit Details" report documentation revealed skilled nursing (SN), physical (PT) and occupational therapy (OT) services were provided between 07/14/2022 and 08/10/2022. There was no documentation in the clinical record which provided evidence that the "Plan of Care-Preview" for the initial certification period of 07/14/2022 through 09/11/2022 had been reviewed and countersigned by the attending physician. Patient #4 (Parent Office): Between August 10, 2022 at approximately 8:06 AM and August 11, 2022 at approximately 11:09 AM, review of the clinical record revealed the start of care date was 07/02/2022 as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022. Review of "Visit Details" report documentation revealed SN and PT services were provided between 07/02/2022 and 08/10/2022. There was no documentation in the clinical record which provided evidence that the "Plan of Care-Preview" for the initial certification period of 07/02/2022 through 08/30/2022 had been reviewed and countersigned by the attending physician. Patient #5 (Parent Office): Between August 10, 2022 at approximately 8:12 AM and August 12, 2022 at approximately 8;54 AM, review of the clinical record revealed the start of care date was 07/02/2022 as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022. Review of "Visit Details" report documentation revealed SN, PT and OT services were provided between 07/02/2022 and 08/10/2022. There was no documentation in the clinical record which provided evidence that the "Plan of Care-Preview" for the initial certification period of 07/02/2022 through 08/30/2022 had been reviewed and countersigned by the attending physician. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence that the attending physician had reviewed and countersigned the "Plan of Care-Preview" form within 30 days of the start of care or recertification date for the above identified patients.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on review of agency job descriptions, Medicare Beneficiary Manual requirements and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure a RN or qualified practitioner responsible for furnishing or supervising care generated/obtained verbal orders to initiate home health services for two (2) of two (2) active patients for whom physician orders for skilled nursing (SN) and/or physical therapy (PT) services were included on the initial "Plan of Care-Preview" form. (Patients #4 and #7) Findings include: On August 12, 2022 at approximately 4:10 PM, review of the RN job description revealed the following: Job Description Summary...The RN plans, organizes and directs home care services... On August 12, 2022 at approximately 4:11 PM, review of the OT job description revealed the following: Job Description Summary...The OT is responsible for the implementation of standards of care for occupational therapy... On August 12, 2022 at approximately 5:34 PM, review of Chapter 7-Home Health Services of Medicare Benefit Policy Manual revealed the following: 30.2.6 - Use of Oral (Verbal) Orders....Effective: 03-01-20 ...Implementation: 01- 11-21) When services are furnished based on a physician or allowed practitioner’s oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies. The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. Patient #4 (Parent Office): Between August 10, 2022 at approximately 8:06 AM and August 11, 2022 at approximately 11:09 AM, review of the clinical record revealed an occupational therapist (OT-employee #10) generated/obtained a physician order to initiate home health service on 07/02/2022 and that home health services were to include skilled nursing (SN) and physical therapy (PT) services. Review of the "Plan of Care-Preview" for the initial certification period of 07/02/2022 through 08/30/2022 revealed SN and PT services were to be provided as ordered by the attending physician. There was no documentation in the clinical record which provided evidence that a RN or PT obtained the physician order to initiate home health services. Patient #7 (Berwick Branch): Between August 10, 2022 at approximately 3:58 PM and August 11, 2022 at approximately 2:01 PM, review of the clinical record revealed an OT (Employee #10) generated/obtained a physician order to initiate home health service on 07/28/2022 and that home health services were to include skilled nursing (SN) and physical therapy (PT) services. Review of the "Plan of Care-Preview" for the initial certification period of 07/28/2022 through 09/25/2022 revealed SN and PT services were to be provided as ordered by the attending physician. There was no documentation in the clinical record which provided evidence that a RN or PT obtained the physician order to initiate home health services. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence a RN or PT obtained the physician order to initiate home health services for the above identified patients.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure the updated visit schedule/frequency was provided in writing to three (3) of three (3) patients whose admission folder was available for review during the onsite home visit. (Patients #3, #4 and #5) Findings include: On August 12, 2022 at approximately 4:13 PM, review of agency policy 1-001, titled "Rights/Responsibilities" revealed the following: Policy...Each patient will be an active informed participant in his/her plan of care... On August 12, 2022 at approximately 4:14 PM, review of agency policy 2-018, titled "Care Planning Process" revealed the following: Procedure...17. The organization shall provide the patient and caregiver with a copy of written instructions outlining...A. Visit schedule, including frequency of visits by personnel and personnel acting on behalf of the organization. Patient #3 (Parent Office): Between August 10, 2022 at approximately 8:01 AM and August 11, 2022 at approximately 10:44 AM, review of the clinical record revealed skilled nursing (SN) services were to be provided one (1) time a week for four (4) weeks as documented on the plan of care for the initial certification period of 07/14/2022 through 09/11/2022. Review of physician order form documentation dated 08/02/2022 revealed the SN visit frequency was extended by four (4) weeks (1 time a week for 4 weeks) beginning 08/07/2022. During home visit conducted on 08/10/2022 at approximately 9:00 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home there was no evidence that the RN (Employee #1) provided the updated SN visit schedule/frequency to the patient in writing. Patient #4 (Parent Office): Between August 10, 2022 at approximately 8:06 AM and August 11, 2022 at approximately 11:09 AM, review of the clinical record revealed physical therapy (PT) services were to be provided one (1) time a week for one (1) week, followed by two (2) times a week for one (1) week then one (1) time a week for one (1) week as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022. Review of physician order form documentation dated 07/20/2022 revealed the PT visit frequency was extended by one (1) week (1 time a week for 1 week) beginning 07/24/2022. During home visit conducted on 08/10/2022 at approximately 10:25 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home but there was no evidence the updated PT visit schedule/frequency had been provided to the patient in writing. Patient #5 (Parent Office): Between August 10, 2022 at approximately 8:12 AM and August 12, 2022 at approximately 8;54 AM, review of the clinical record revealed the following services were to be provided as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022: PT: One (1) time a week for one (1) week followed by two (2) times a week for eight (8) weeks; and OT: One (1) time a week for one (1) week. Review of physician order form documentation revealed the following updated visit schedule/frequency orders were received: PT--07/27/2022 order beginning on 07/02/2022: One (1) time a week for one (1) week, two (2) times a week for four (4) weeks, three (3) times a week for two (2) weeks, two (2) times a week for two (2) weeks followed by one (1) time a week for one (1) week; OT--07/27/2022 order beginning 07/07/2022: One (1) time a week for five (5) weeks; and Home Health Aide (HHA)-07/06/2022 order beginning 07/06/2022: One (1) time a week for one (1) week, two (2) times a week for seven (7) weeks followed by one (1) time a week for one (1) week. During home visit conducted on 08/10/2022 at approximately 11;05 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home but there was no evidence the updated PT and OT visit schedule/frequency had been provided to the patient in writing. Review of the hand-written HHA plan of care revealed the HHA visit frequency was documented as being two (2) times a week for eight (8) weeks. There was no documentation the updated HHA visit frequency had been provided to the patient in writing. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence that the updated SN, PT, OT and HHA visit schedules/frequencies had been provided to the above identified patients in writing.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure updated treatment orders were provided in writing to three (3) of three (3) patients whose admission folder was available for review during the onsite home visit. (Patients #3, #4 and #5) Findings include: On August 12, 2022 at approximately 4:13 PM, review of agency policy 1-001, titled "Rights/Responsibilities" revealed the following: Policy...Each patient will be an active informed participant in his/her plan of care... On August 12, 2022 at approximately 4:14 PM, review of agency policy 2-018, titled "Care Planning Process" revealed the following: Procedure...17. The organization shall provide the patient and caregiver with a copy of written instructions outlining...D. Any treatments to be administered by the organization's personnel... Patient #3 (Parent Office): Between August 10, 2022 at approximately 8:01 AM and August 11, 2022 at approximately 10:44 AM, review of the clinical record revealed skilled nursing (SN) was to provide the following wound care to the right shin wound/laceration (wound #1) as documented on the plan of care for the initial certification period of 07/14/2022 through 09/11/2022: Cleanse with normal saline solution (NSS), pat dry, cover with Optifoam (wound dressing), Change every five (5) to seven days and as needed. Review of physician order form documentation dated 08/02/2022 revealed the following wound care orders for wounds #1 and #2 (new-right lower leg skin tear) were obtained: Cleanse with NSS, pat dry, apply Polymen (wound pad/dressing), secure with gauze/tape. Change two (2) times a week and as needed. During home visit conducted on 08/10/2022 at approximately 9:00 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home there was no evidence that the RN (Employee #1) provided the updated wound care orders to the patient in writing. Patient #4 (Parent Office): Between August 10, 2022 at approximately 8:06 AM and August 11, 2022 at approximately 11:09 AM, review of the clinical record revealed SN was to provide the following wound care to the right upper foot wound (wound #1) as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022: Cleanse with NSS or soap/water, pat dry, apply Unna Boot (compression wrap), cover with Coban (bandage/wrap). Apply weekly and as needed. Review of physician order form documentation dated 07/20/2022 revealed the following wound care orders for wounds #1 was obtained: Cleanse with NSS or soap/water, pat dry, apply ThreeFlex compression boot (compression wrap), cover with Coban (bandage/wrap). Apply weekly and as needed. During home visit conducted on 08/10/2022 at approximately 10:25 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home there was no evidence the updated wound care orders were provided to the patient in writing. Patient #5 (Parent Office): Between August 10, 2022 at approximately 8:12 AM and August 12, 2022 at approximately 8;54 AM, review of the clinical record revealed a 16 French (Fr) Foley (urinary) catheter with a 10 cc balloon was included under the equipment orders as documented on the plan of care for the initial certification period of 07/02/2022 through 08/30/2022 but there was no documentation which provided evidence that SN was responsible for changing the Foley catheter. Review of physician order form documentation dated 08/01/2022 revealed a physician order was obtained for SN to change the 16 Fr, 10 cc Foley catheter monthly and as needed. During home visit conducted on 08/10/2022 at approximately 11;05 AM, review of the patient admission folder revealed a copy of the initial plan of care was present in the home but there was no evidence the updated Foley catheter orders were provided to the patient in writing. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence that the updated above referenced treatment orders were provided in writing to the above identified patients.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on review of agency policies/procedures and documentation, and Pennsylvania (PA) Department of Health (DOH) Event Reporting System (ERS) website reports, and based on interview with the administrator/registered nurse (ADMIN/RN), president/clinical manager/occupational therapist (PRES/CM/OT) and clinical supervisor/RN (CS/RN), the agency failed to submit a report of six (6) of six (6) reportable incidents to the PA DOH ERS website prior to August 9, 2022. Findings include: On August 12, 2022 at approximately 4:10 PM, review of agency policy 4-017, titled "Incident Reporting", revealed the following under "Procedure": 6. Incident requiring reporting to the state and/or Federal regulatory agencies...C. As applicable, the Performance Improvement Coordinator or designee will complete and submit the necessary forms within the required time frame to the appropriate organization... On August 10, 2022 at approximately 3:23 PM, review of the COVID-19 tracking log revealed the following: Patient #10 (Berwick Branch): The patient notified the agency on 06/08/2021 that the patient tested positive for COVID-19. Employee #1: The registered nurse (RN) tested positive for COVID-19 on 01/05/2021. Employee #13: The physical therapist (PT)/Director of Rehabilitation tested positive for COVID-19 on 11/09/2021. Employee #14: The physical therapist (PT) tested for positive for COVID-19 on 12/22/2021. On August 12, 2022 at approximately 10:32 AM, review of incident report documentation revealed the agency was notified of bedbug infestation at a personal care facility on 03/25/2022 and 05/10/2022. On August 9, 2022 at approximately 8:45 AM, review of the PA DOH ERS website revealed Health Department Reportable Diseases, subcategories COVID-19 and bedbugs, are PA DOH reportable events. There was no documentation which provided evidence that the agency had submitted a report positive COVID-19 results, nor the bedbug infestations, prior to August 9, 2022. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and the CS/RN confirmed the above listed incidents/events had not been reported to the PA DOH ERS website prior to 08/09/2022.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of job descriptions, observation and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN), the agency failed to ensure wound measurements were obtained or intravenous site assessment was completed for two (2) of seven (7) active patients for whom wound or intravenous care was provided by skilled nursing (SN). (Patients #3 and #13) Findings include: On August 12, 2022 at approximately 4:10 PM, review of agency Registered Nurse (RN) job description revealed the following: Essential Job Functions/Responsibilities...Patient Care... 2. Regularly re-evaluates patient nursing needs. Patient #3 (Parent Office): Between August 10, 2022 at approximately 8:01 AM and August 11, 2022 at approximately 10:44 AM, review of the clinical record revealed skilled nursing (SN) services are to be provided one (1) time a week, that SN is to assess wounds weekly and that SN was to provide wound care to the right shin wound/laceration (wound #1) as documented on the plan of care for the initial certification period of 07/14/2022 through 09/11/2022. Review of physician order form documentation dated 08/02/2022 revealed the following wound care orders for wounds #1 and #2 (new-right lower leg skin tear) were obtained: Cleanse with NSS, pat dry, apply Polymen (wound pad/dressing), secure with gauze/tape. Change two (2) times a week and as needed. During home visit conducted on 08/10/2022 at approximately 9:00 AM, an open wound of the right lower leg/shin was noted and wound care was provided by the SN. Review of the "Visit Details" SN note dated 07/27/2022 revealed the RN (Employee #21) documented that an open wound was present but there was no documentation which provided evidence that the RN measured the right shin wound during the weekly SN visit performed on 07/27/2022. Patient #13 (Parent Office): On August 12, 2022 at approximately 1:32 PM, review of the clinical record revealed skilled nursing (SN) services are to be provided one (1) time a week, that SN is to observe the central line insertion site for complications and that SN was to perform central line dressing change weekly as documented on the plan of care for the recertification period of 07/01/2022 through 08/29/2022. Review of "Visit Details" SN note documentation revealed the RN (Employee #4) changed the right chest central line dressing on 07/05, 07/11, 07/18, 08/01 and 08/08/2022 but the aforementioned “Visit Details” SN notes failed to include an assessment of the central line insertion site appearance. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence that wound measurements were obtained, nor that central line insertion site assessment was completed, for the above identified patients on the aforementioned dates.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, professional nursing guidance, clinical records and personnel files, and based on interview with a registered nurse (RN-employee #6), the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the administrator failed to ensure personnel files included documentation of completion of PICC (peripherally inserted central catheter) skills demonstration for one (1) of two (2) registered nurses (RN) who provided PICC line care to patients receiving skilled nursing (SN) services from the Berwick Branch office. (Employee #6) Findings include: On August 10, 2022 at approximately 1:40 PM, review of the "Initial Competency Assessment Skills Checklist-Registered Nurse" revealed the following subject matter was included under the "Competency for the Registered Nurse" column: 3. Central Venous Devices a. Drawing blood from b. Site care c. Flushing d. Cap change... f. Other... On August 12, 2022 at approximately 7:45 AM, review of the “RegisteredNurseRN.Com” () internet article titled “PICC Line Care | PICC Line Dressing Change Clinical Nursing Skills” revealed the following: Changing PICC line dressing takes patience and skill in order to do correctly. Patient #2 (Berwick Branch): Between August 9, 2022 at approximately 12:54 PM and August 11, 2022 at approximately 10:12 PM, review of the clinical record revealed SN was to perform PICC line flushes, change the PICC line dressing and perform cap changes weekly as documented on the "Plan of Care" for the initial certification period of 05/25/2022 through 07/23/2022. Review of "Physician Order Form" documentation revealed a physician order was obtained to discontinue the PICC line after completion of the antibiotic on 06/04/2022. Review of SN "Visit Detail" documentation revealed the RN (Employee #6) performed the following: 05/25/2022: PICC line assessment including measurement of PICC length and arm circumference, and PICC line flush. 05/31/2022: PICC line flush, PICC line and arm circumference measurement. 06/05/2022: PICC line removal, measurement of the PICC line post removal and assessment of arm circumference. During interview conducted on 08/11/2022 at approximately 1:20 PM, the RN (Employee #6) reported that prior to home health employment, the RN did not have previous training/experience with PICC line care/maintenance. The RN reported that the home health PICC line training program included video courses. Between 08/10/2022 at approximately 1:40 PM and 08/12/2022 at approximately 2:35 PM, review of personnel files revealed the following: Employee #6: The date of hire of the RN was 01/04/2022. Review of the "Initial Competency Assessment Skills Assessment-Registered Nurse" revealed the following under "3. Central Venous Access Devices": a. Drawing blood from: Verbal demonstration on 02/26/2022. b. Site care, c. Flushing and d. Cap Change: A date of 01/10/2022 was entered but the method to determine competency was not documented. There was no documentation on the "Initial Competency Assessment Skills Assessment-Registered Nurse" which provided evidence that the RN demonstrated competency for PICC line removal. During interview conducted on August 12, 2022 at approximately 5:05 PM, the CS/CM reported that the RN (Employee #6) did complete a PICC line skills demonstration to determine competency but the CS/RN confirmed that there was no documentation on the RN's "Initial Competency Assessment Skills Assessment-Registered Nurse" which provided evidence that a demonstration to determine competency to perform PICC line flushes, site care, cap changes and removal had been completed. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and the CS/RN confirmed there was no documentation in the personnel file for the RN (Employee #6) which provided evidence that the RN completed a PICC line skills demonstration to determine competency to perform PICC line flushes, site care, cap changes and removal.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, job descriptions and clinical records, and based on interview with the administrator/registered nurse (ADMIN/RN), the president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN), the agency failed to ensure the start of care or recertification comprehensive assessments were approved by the assessing clinician following completion of OASIS data review for six (6) of twelve (12) active patients who were admitted or recertified for care. (Patients #3, #7, #9, #12, #13 and #14) Findings include: On August 12, 2022 at approximately 4:09 PM, review of agency policy 5-005, titled "Contents of the Clinical Records" revealed the following: Procedure...The following information will be available in the clinical record... M. Record and findings of initial an ongoing assessments... CC. Documentation of the assessment data collected... On August 12, 2022 at approximately 4:10 PM, review of agency Registered Nurse (RN) job description revealed the following: Communication...1. Prepares clinical notes... Patient #3 (Parent Office): Between August 10, 2022 at approximately 8:01 AM and August 11, 2022 at approximately 10:44 AM, review of the clinical record revealed an RN (employee #1) performed the start of care (SOC) comprehensive assessment and created the SOC "Visit Details" SN note on 07/14/2022. Review of the "Visit Signon/Off History" included on the SOC "Visit Details" SN note revealed a physical therapist (PT-employee #12) entered an electronic signature verifying that the visit was complete on 08/01/2022. There was no documentation that the RN (employee #1) had approved the final version of the SOC "Visit Details" SN note after the PT (employee #12) entered an electronic signature verifying the visit was complete. Patient #7 (Berwick Branch): Between August 10, 2022 at approximately 3:58 PM and August 11, 2022 at approximately 2:01 PM, review of the clinical record revealed an RN (employee #1) performed the SOC comprehensive assessment and created the SOC "Visit Details" SN note 07/28/2022. Review of the "Visit Signon/Off History" included on the SOC "Visit Details" SN note revealed a PT (employee #9) entered an electronic signature verifying that the visit was complete on 08/01/2022. There was no documentation that the RN (employee #1) had approved the final version of the SOC "Visit Details" SN note after the PT (employee #12) entered an electronic signature verifying the visit was complete. Patient #9 (Berwick Branch): Between August 10, 2022 at approximately 4:27 PM and August 11, 2022 at approximately 3:05 PM, review of the clinical record revealed an RN (employee #1) performed the recertification (Recert) comprehensive assessment and created Recert "Visit Details" SN note 07/27/2022. Review of the "Visit Signon/Off History" included on the Recert "Visit Details" SN note revealed a PT (employee #9) entered an electronic signature verifying that the visit was complete on 08/01/2022. There was no documentation that the RN (employee #1) had approved the final version of the Recert "Visit Details" SN note after the PT (employee #12) entered an electronic signature verifying the visit was complete. Patient #12 (Parent Office): On August 12, 2022 at approximately 1:20 PM, review of the clinical record revealed an PT (employee #20) performed the Recert comprehensive assessment and created Recert "Visit Details" PT note 07/27/2022. Review of the "Visit Signon/Off History" included on the Recert "Visit Details" PT note revealed the PRES/CM/OT (Employee #18) entered an electronic signature verifying that the visit was complete on 07/28/2022. There was no documentation that the PT (Employee #20) had approved the final version of the Recert "Visit Details" PT note after the PRES/CM/OT (employee #18) entered an electronic signature verifying the visit was complete. Patient #13 (Parent Office): On August 12, 2022 at approximately 1:32 PM, review of the clinical record revealed an RN (employee #4) performed the Recert comprehensive assessment and created Recert "Visit Details" SN note 06/27/2022. Review of the "Visit Signon/Off History" included on the Recert "Visit Details" SN note revealed the PT (Employee #12) entered an electronic signature verifying that the visit was complete on 06/29/2022. There was no documentation that the RN (Employee #4) had approved the final version of the Recert "Visit Details" SN note after the PT (Employee #12) entered an electronic signature verifying the visit was complete. Patient #14 (Parent Office): On August 12, 2022 at approximately 2:34 PM, review of the clinical record revealed an RN (employee #21) performed the Recert comprehensive assessment and created Recert "Visit Details" SN note 07/27/2022. Review of the "Visit Signon/Off History" included on the Recert "Visit Details" SN note revealed the PT (Employee #12) entered an electronic signature verifying that the visit was complete on 08/10/2022. There was no documentation that the RN (Employee #21) had approved the final version of the Recert "Visit Details" SN note after the PT (Employee #12) entered an electronic signature verifying the visit was complete. During interview conducted on August 12, 2022 at approximately 5:05 PM, the ADMIN/RN, PRES/CM/OT and CS/RN confirmed there was no agency documentation which provided evidence that the start of care or recertification comprehensive assessments were approved by the assessing clinician following completion of OASIS data review for the above identified patients.