Every finding on record at Complete Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, 01/22/26. 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 Emergency Preparedness requirements, on 01/22/26. Standard level deficiencies cited. Abbreviations: POC = Plan of Care PM = Afternoon

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 a review of clinical records, an interview during a home visit, and staff interviews, in 2 of 7 (Pts. #2 and 6) clinical records reviewed, the Agency failed to ensure the POC was accurate and/or complete. 2. Pt. # 6 was admitted to Home Health services on 03/21/25 with diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 01/20/26. The clinical record included a POC signed by the physician for certification period 07/19/25 to 09/16/25. The POC lacked blood sugar parameters for patient blood sugar readings. 3. Findings of Plans of Care not complete and accurate were confirmed during interviews with the Clinical Director and Administrator on 01/21/26 at 12:32 PM and 2:00PM. Findings include: 1. Pt. #2 was admitted to Home Health services on 08/12/25 with a diagnosis of, but not, limited to, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/Unspecified Chronic Kidney Disease. The clinical record was reviewed on 01/20/26. The clinical record contained the POC for the certification period of 10/11/25 to 12/09/25, and the POC effective 12/10/25 that required the Pt. to receive “Osmolyte 1.5 325 ml (milliliters) every 8 hours” for nutritional support. The weekly SN visit notes from 11/18/25 to 12/03/25, and 12/19/25 to 01/14/26 included documentation the Pt. received “Kate Farms 150 ml every 6 hours…” for nutritional support. A home visit was conducted on 01/21/26 at 2:00 PM with Employee #5. During the home visit, an interview was conducted with the caregiver that stated, the Pt. have been receiving “Kate Farms for a little over a year.” The plans of care effective 10/11/25 and 12/10/25 were inaccurate.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, in 1 of 4 (Pt. #2) clinical records reviewed where the Pt. received Home Health Aide services, the Agency failed to ensure the RN conducted Home Health Aide supervision every 14 days. Findings include: 1. Pt. #2 was admitted to Home Health services on 08/12/25 with a diagnosis of, but not, limited to, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/Unspecified Chronic Kidney Disease. The clinical record was reviewed on 01/20/26. The clinical record contained weekly Home Health Aide visit notes from 11/19/25 to 12/17/25. As of 01/20/26, the record lacked documentation the RN supervised the Home Health Aide between 11/19/25 to 12/17/25. 2. During an interview with the Administrator and Clinical Director on 01/21/26 at 12:32 PM, the Clinical Director confirmed the RN failed to supervise the Home Health Aide every 14 days.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: SOC - Start of Care Pt./ Pts. - Patient/Patients PTA - Physical Therapy Assistant RPT - Registered Physical Therapist AM - Morning PM - Afternoon, Evening

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the RPT supervised the PTA as required. This was found in 2 of 3 (Pts. #5 and 7) clinical records reviewed, wherein PTA services were provided. 2. Pt. #5. SOC 9-8-22. Primary Diagnosis: Fracture of Left Pubis. The clinical record was reviewed on 10/17/22 at 2:50 PM. The record included documentation the PTA provided service on 9/12/22, 9/14/22, 9/19/22, 9/21/22, 9/26/22, 10/3/22, 10/5/22, 10/11/22, and 10/13/22. The record lacked documentation the RPT conducted supervision of the PTA from 9/12/22 to 10/13/22. 3. Pt. #7. SOC 3/12/22. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 10/18/22 at 1:15 PM. The record included documentation the PTA provided service on 4/28/22, 5/3/22, 5/11/22, 5/13/22, 5/24/22, 5/26/22, 5/31/22, and 6/7/22. The record lacked documentation the RPT conducted supervision of the PTA from 4/28/22 to 6/7/22. 4. The Agency policy titled: “Physical Therapy Services” was reviewed on 10/18/22 at 1:15 PM. The policy required: “…The Registered Physical Therapist (RPT) will… Supervise the Physical Therapy Assistant (PTA) according to the following specifications…On-site supervision shall take place at least every 4-6 visits and with any significant changes in the patient’s condition related to therapy services…” 5. During interviews with the Administrator and the Clinical Director at 11:50 AM and at 3:00 PM, the above findings were confirmed. Findings include: 1. Pt. #4. SOC 3/31/22. Primary Diagnosis: Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 10/18/22 at 9:00 AM. The record contained the RPT evaluation/assessment dated 7/26/22, then the PTA provided service on 8/2/22 and 8/16/22. On 8/16/22, the RPT conducted a reassessment/re-evaluation, and the PTA provided service weekly from 8/23/22 to 9/13/22. The most recent RPT reassessment/re-evaluation was conducted on 9/23/22, and the PTA provided service weekly on 9/27/22 and 10/4/22. As of 10/18/22, the record lacked documentation the RPT supervised the PTA from 7/26/22 to 10/4/22.