Every finding on record at Dayspring Healthcare Services, Inc

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey, on 1/30/25. Standard level deficiencies cited.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The “Hazard Vulnerability Assessment Tool” (risk assessment) of the Emergency Preparedness Plan was last updated with the date of “2024” and was reviewed on 01/27/25. The Assessment contained the following possible events; “Ice Snow, Flooding, Earthquake, Hurricane, Hazardous Material Accident, Fire, Tornado, Volcano, Civil Disturbance, Mass Casualty Event, Terrorist Attacks, Severe Winter Weather, Pandemic/Infectious Disease, Electrical Failure, Communication Failure, Information Failure, Water Failure, Transportation Interruption, and Environment/Altered Air Quality Pollution”. As of 01/27/25, the Emergency Preparedness Plan lacked the policies and procedures for the Agency's Hazard Vulnerability Risk Assessment. 2. During an interview with the Agency Supervisor on 01/27/25 at 2:45 PM, the Agency Supervisor confirmed the Agency failed to establish policies and procedures based on the risk assessment.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency lacked policies and procedures concerning the availability of Pt. information. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. On 1/27/25, a record review was performed of the Agency's Emergency Preparedness Plan. The plan lacked documentation of a procedure for which Pt. medical documents are kept confidential and sent in a secure manner in the event of an emergency. 2. During an interview on 1/29/25 at 1:30 PM with the Agency Supervisor, she confirmed the Agency failed to establish a method of maintaining Pt. information in a secure manner.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 12/31/23 was reviewed on 01/27/25. The Plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness in 2022, 2023, 2024, and 2025 (as of 01/27/25). 2. During an interview with the Agency Supervisor on 01/27/25 at 2:45 PM, the Agency Supervisor confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 1/30/25. Standard level deficiencies cited. Abbreviations: POC = Plan of Care PsOC = Plans of Care MG/DL = Milligrams per deciliter SOC = Start of Care Pt./Pts. = Patient/Patients W/w/WK = week Q = every PRN = as needed # = number lbs = pounds RN = Registered Nurse SN = Skilled Nurse AM = morning PM = afternoon CG = caregiver MD = Medical Doctor -- = to > = greater than PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 8 of 25 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 1/1/24 to 12/31/24, was reviewed on 1/27/25 at 2:30 PM. The report included error # -3330 for 8 of 25 late submissions, 32% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Agency Supervisor on 1/29/25 at 2:50 PM, it was confirmed that the error occurred.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 1/27/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 1/28/25: Pt. #1. SOC 10/31/24. Pt. #2. SOC 3/4/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Administrator. 3. The following clinical records were reviewed from 1/28/25 to 1/29/25: Pt. #1. SOC 10/31/24. Pt. #2. SOC 3/4/24. Pt. #3. SOC 3/6/24. Pt. #4. SOC 11/20/24. Pt. #5. SOC 5/13/24. Pt. #6. SOC 5/15/23. Pt. #7. SOC 6/18/24. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During interviews with the Agency Supervisor on 1/29/25 at 2:00 PM, the Agency Supervisor confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator's name and contact information.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 1/27/25. The folder lacked the documentation of the Agency's transfer and discharge policies. 2. The following home visits were conducted on 1/28/25: Pt. #1. SOC 10/31/24. Pt. #2. SOC 3/4/24. During the home visits, the Pt. admission folders were observed, and lacked documentation the Agency had provided Pts. information regarding the Agency's transfer and discharge policies. 2. The following clinical records were reviewed from 1/28/25 to 1/29/25: Pt. #1. SOC 10/31/24. Pt. #2. SOC 3/4/24. Pt. #3. SOC 3/6/24. Pt. #4. SOC 11/20/24. Pt. #5. SOC 5/13/24. Pt. #6. SOC 5/15/23. Pt. #7. SOC 6/18/24. The records lacked documentation the Agency provided Pts. information, regarding the Agency's transfer and discharge policies. 4. During interviews with the Agency Supervisor on 1/29/25 at 2:00 PM, the Agency Supervisor confirmed the Agency failed to provide the Pt./patient’s representative with information pertaining to the Agency's transfer and discharge policies.

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 clinical records, Agency policy, and staff interviews, it was determined in 4 of 7 (Pts. #3, 4, 2, and 6) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. # 6 was admitted to home health services, on 5/15/24 with a diagnosis of Hyperlipidemia. The clinical record was reviewed on 1/28/25. The record contained a Physician face-to-face document dated 5/1/23 which was faxed to the Agency on 5/3/23. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral. 5. During interviews with the Agency Supervisor on 1/29/25 between 11:50 AM to 2:45 PM, the above findings were confirmed. 3. Pt. #2 was admitted to home health services, on 3/4/24 with a the diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The clinical record was reviewed on 1/29/25. The clinical record included the SOC assessment completed by the SN on 3/4/24. The Physician face-to-face document which was faxed to the Agency on 3/1/24. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral. Findings include: 1. Pt. #3 was admitted for home health services on 3/6/24 with the diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 1/28/25. The clinical record included the SOC assessment form completed by the SN on 3/6/24. As of 1/28/25, the record lacked a referral or Physician order to initiate service on 3/6/24. 2. Pt. #4 was admitted for home health services on 11/20/24 with the diagnosis of Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only. The clinical record was reviewed on 1/29/25. The clinical record included a referral for SN and PT services that was faxed to the Agency on 11/14/24. The SOC assessment was conducted on 11/20/24 which was 6 days after receiving the referral. The record lacked documentation of an inpatient facility stay, physician ordered SOC date.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, it was determined for 4 of 7 Pts. (Pts. # 1, 2, 3 and 4) the Agency failed to ensure that the comprehensive assessments included a complete review of body systems. 3. Pt. #3 was admitted for home health services on 3/6/24 with the diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 1/28/25. The clinical record included the SOC assessment conducted on 3/6/24, and the recertification assessment conducted on 12/30/24, both assessments competed by the SN lacked documentation the SN assessed the patient’s respiratory, cardiac, musculoskeletal, genitourinary, gastrointestinal, and integumentary/skin status; also lacked instructions provided to the Pt. and the patient’s response. 4. Pt. #4 was admitted for home health services on 11/20/24 with the diagnosis of Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only. The clinical record was reviewed on 1/29/24. The clinical record included the SOC assessment conducted on 11/20/24, and the discharge assessment conducted on 1/11/25, both assessments competed by the SN lacked documentation the SN assessed the patient’s endocrine/hematology, respiratory, cardiac, musculoskeletal, genitourinary, neurological, gastrointestinal, and integumentary/skin status; also lacked instructions provided to the Pt. and the patient’s response. 5. During interviews with the Agency Supervisor on 1/29/25 at 11:50 AM, 1:30 PM, and 2:00 PM, the Agency Supervisor confirmed the Agency failed to ensure the comprehensive assessments included a review of body systems. 2. Pt. #2 was admitted for home health services on 3/4/24 with the diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The clinical record was reviewed on 1/29/25. The clinical record included the recertification assessment conducted on 12/24/24 which was competed by the SN and lacked documentation the SN assessed the Pt.’s endocrine/hematology, respiratory, cardiac, musculoskeletal, genitourinary, neurological, gastrointestinal, and integumentary/skin status; instructions provided to the Pt. and the Pt.’s response. Findings include: 1. Pt. #1 was admitted to home health services on 10/31/24 with the diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 1/28/25. The comprehensive assessment dated 12/29/24 lacked documentation of the psychosocial and cognitive status and assessments of the genitourinary, endocrine, cardiac, respiratory, gastrointestinal, musculoskeletal, and integumentary systems.

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 a review of clinical records, observation and interviews during a home visit, and staff interviews, it was determined in 4 of 7 (Pts. #2, 3,1, and 7) clinical records reviewed, the PsOC lacked Pt. specific interventions. 3. Pt. #1 was admitted to home health services on 10/31/24 with the diagnosis of Hypertensive Heart Disease. The clinical record was reviewed on 1/28/25. The POC for the certification period of 10/31/24 to 12/29/24 required, “SN Visit: 2W1, 1w8.” The clinical record lacked documentation of a SN visit for the week of 12/22/24 to 12/28/24. The clinical record also lacked a Physician order indicating a change in the SN visit frequency. 4. Pt. #7 was admitted to home health services on 6/18/24 with the diagnosis of Displaced Intertrochanter. The clinical record was reviewed on 1/28/25. The POC for the certification period of 6/18/24 to 8/16/24 required, “SN Frequency: 1x weekly for 6 weeks.” The clinical record lacked documentation of a SN visit for the week of 7/7/24 to 7/13/24. The clinical record also lacked a Physician order indicating a change in the SN visit frequency. 5. During interviews with the Agency Supervisor on 1/28/25 between 11:50 AM to 2:45 PM, the above findings were confirmed. 2. Pt. #3 was admitted for home health services on 3/6/24 with the diagnosis of Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 1/28/25. The clinical record included the POC for the certification period of 11/1/24 to 12/30/24 that required; “SN to assess/evaluate weights Q-WK or PRN and report to MD on weight increase of 2-3 lbs/day or 5 lbs/week…” During the week of 12/29/24 to 12/30/24, the SN conducted a recertification visit on 12/30/24, this assessment lacked the patient’s weight. During an interview with the Agency Supervisor on 1/29/24, the Agency Supervisor stated that a Pt. with the diagnosis of Heart Failure, the SN is required to weigh this Pt. Q-WK. The POC for the certification period of 11/1/24 to 12/30/24 required the SN to provide service “1 week 9”. The record lacked documentation the SN provided service during the week of 12/22/24 to 12/28/24. The POC for the certification period of 11/1/24 to 12/30/24 included an update, the Physician Order dated 11/14/24 required the PT to provide service. The PT evaluation dated 11/20/24 included the “Visit Frequency 1 WK 7”. The record lacked documentation that the PT provided service during week 7 (12/29/24 to 12/30/24). Findings include: 1. Pt. #2 was admitted to home health services on 3/4/24 with the diagnoses of Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The clinical record was reviewed on 1/29/25. The clinical record included the POC for the certification period beginning 12/29/24 and the SN notes during that certification period. Per POC the “SN to assist and instruct PT/CG to check blood sugar daily and keep a log for references. SN instruct PT/CG to report to SN/MD on fasting blood sugar 250 MG/DL or non- fasting blood sugar 300 MG/DL”. The SN visit notes dated 1/11/25, 1/14/25, and 1/21/25 had no documentation of a fasting or non-fasting blood sugar, nor did it have documentation of reporting this to the MD. The POC effective 12/24/24 required the Pt. to have "chem strips, glucometer machine, alcohol pads" On 1/28/25, during Pt. #2's home visit with the Agency Supervisor, it was observed that the Pt. does not have chem strips, a glucometer, and alcohol wipes. This was confirmed with the Pt. and Agency Supervisor during the home visit. The POC for the certification period beginning 12/29/24 required, “SN VISIT: 1 WK 9.” The clinical record lacked documentation of a SN visit for the week of 12/29/24 to 1/4/25. The record also lacked a Physician order indicating a change in the SN visit frequency.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: N = No Y = Yes x = times # = number WK = week = greater than SN = Skilled Nurse POC = Plan of care SOC = Start of care BP = blood pressure MD = Medical Doctor PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./Pts. = Patient/Patients PCG = primary caregiver ST = Speech Therapy/Therapist MMHG = millimeters of mercury PT = Physical Therapy/Therapist MG/DL = milligrams per deciliter PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist OTA = Occupational Therapy Assistant COVID-19 = Coronavirus disease 2019 CDC = Centers for Disease Control and Prevention

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. 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 informed consents were obtained for services, and the Pt. was informed of visit frequencies, prior to the SOC. This was found in 2 of 7 (Pts. #6 and 2) clinical records reviewed. 2. Pt. #2. SOC 8/2/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/8/21 at 4:00 PM. The record contained a document titled “Authorization and Agreements for Home Health Services,” which was signed by the Patient’s caregiver on 8/2/21. This form lacked the frequency of the visits of the SN and PT. 3. The Agency policy titled “Informed Consent/Refusal of Treatment” was reviewed on 11/9/21 at 2:00 PM. The policy required: “Purpose: To obtain written consent for care during the admission process and to communicate the organization’s process for informing patients and families/caregivers regarding services, as well as involving patients in the care planning process.” 4. During an interview with the Administrator and the Director of Nursing on 11/9/21 at 3:10 pm, the Director of Nursing confirmed the above findings. Findings Include: 1. Pt. #6. SOC 12/24/20. Primary Diagnosis: Hypertensive Heart and Chronic Kidney disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. The clinical record was reviewed on 11/9/21 at 1:30 PM. The record contained documentation SN, PT and OT services were provided during the episode of care from 12/24/20 to 4/13/21. Pt. #6 was transferred to an inpatient facility and discharged from the Agency on 4/22/21. As of 11/9/21, the Agency lacked documentation informed consent for services provided was obtained by the Pt./patient’s representative, prior to the SOC.

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: A. Based on review of the Agency’s admission folder, clinical record review, observations made during home visits, and staff interview, it was determined the Agency failed to provide Pts. with a copy of the Agency’s transfer/discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency’s admission folder, given to Pts. upon the SOC, was reviewed on 11/8/21 at 9:45 AM. This folder lacked a copy of the Agency’s transfer/discharge policies. 2. The following clinical records were reviewed beginning 11/8/21 at 3:00 PM to 11/9/21 at 2:30 PM: Pt. #1. SOC 3-24-21. Pt. #2. SOC 8-2-21. Pt. #3. SOC 12-29-20. Pt. #4. SOC 11-2-21. Pt. #5. SOC 10-7-21. Pt. #6. SOC 12-24-20. Pt. #7. SOC 8-21-21. The above records lacked documentation the Pts. were provided with a copy of the Agency’s transfer/discharge policies. 3. During home visits conducted with Pts. #1, 2, and 3 from 11/9/21 at 11:00 AM to 11/9/21 at 1:00 PM, the patients' admission folders were observed. These folders lacked a copy of the Agency's transfer/discharge policies. 4. During interviews with the Administrator and Agency Supervisor on 11/9/21 from 3:10 PM to 4:50 PM, both 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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 2 of 7 (Pts. #5 and 6) clinical records reviewed. Findings include: 1. Pt. #5. SOC 10/7/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 11/9/21 at 1:10 PM. The record contained the “Physician Face To Face Encounter” form signed by the Physician on 9/25/21, requiring the Agency to provide SN service. The record lacked the date the Agency received this form. The SOC visit was conducted on 10/7/21. The record lacked documentation the Pt. was discharged from an inpatient facility or had a Physician ordered SOC date. As of 11/9/21, it cannot be determined whether the SOC was conducted within 48 hours upon receipt of the “Physician Face To Face Encounter” form. 2. Pt. #6. SOC 12/24/20. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. The clinical record was reviewed on 11/9/21 at 1:30 PM. The record included the “Physician Face To Face Encounter” form signed by the Physician on 12/28/20 and faxed to the Agency on 12/29/20. The SOC comprehensive assessment form was dated 12/24/20. The record lacked documentation the Pt. was discharged from an inpatient facility or had a Physician ordered SOC date. The referral was received 5 days after the Agency initiated service. 3. During an interview with the Administrator and Agency Supervisor on 11/9/21 at 4:30 PM, the Agency Supervisor confirmed the clinical records of Pts. #5 and 6 lacked documentation, indicating services were initiated within 48 hours upon receipt of the referral.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure immunization screening for the administration of the Influenza and Pneumococcal vaccinations was assessed at the SOC. This was found in 2 of 7 (Pts. #2 and 7) clinical records reviewed. Findings include: 1. Pt. #2. SOC 8/2/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/8/21 at 4:00 PM. The record contained a document titled “Influenza/Pneumococcal Vaccination Form,” signed by the Pt. on 8/2/21, but otherwise left blank. The record lacked documentation of the patient’s Influenza and Pneumococcal vaccine status. 2. Pt. #7. SOC 8/21/21. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 11/9/21 at 9:30 AM. The record lacked documentation of the patient’s Influenza and Pneumococcal vaccine status. 3. During an interview with the Agency Supervisor on 11/9/21 at 3:10 PM, the Agency Supervisor stated the RN should determine the patient’s Influenza and Pneumococcal vaccination status at the SOC. This should include whether or not the Pt. received these vaccinations, refuses them, or wishes to receive them. If the Pt. wishes to receive them, the Pt. is referred to their Physician or clinic. This information should then be documented on the Agency’s “Influenza/Pneumococcal Vaccination” form and placed in the patient’s clinical record.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on clinical record review, the Agency’s COVID-19 screening form, and staff interview, it was determined the Agency failed to ensure Pts. were screened for symptoms of COVID-19, prior to providing service. This was found in 5 of 7 (Pts. #1, 2, 7, 5 and 6) records reviewed. __. Pt. #3. SOC 12/29/20. Primary Diagnosis: Hypertensive Heart Disease and Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/9/21 at 2:40 PM. The record contained the weekly SN visit notes from 9/14/21 to 10/12/21 and 10/26/21, indicating service was provided. The record lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. __. Pt. #5. SOC 10/7/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 11/9/21 at 1:10 PM. The record contained the weekly SN visit notes from 10/14/21 to 11/4/21, indicating service was provided. The record lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. __. Pt. #6. SOC 12/24/20. Primary Diagnosis: Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease. The clinical record was reviewed on 11/9/21 at 1:30 PM. The record contained the weekly SN visit notes from 2/23/21 to 3/23/21 and 4/13/21, indicating service was provided. The record lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing Pt. care or service. __. The Agency’s “COVID-19 Rapid Screening Form” was reviewed on 11/8/21 at 3:00 PM. The form required the staff to ask the Pt. and document in the clinical record: “CDC Guidelines Is Patient/PCG reporting symptoms of SOC, High Fever, Cough, Sore Throat, Chills, Repeated shaking with chills, Muscle pain, Headache, New loss of taste or smell, Fatigue, Congestion or runny nose, Nausea or vomiting, Diarrhea at time of Visit or last 48 hours? N, Y” __. During the entrance interview with the Administrator and Agency Supervisor on 11/8/21 at 9:27 AM, the Agency Supervisor stated staff are required: “For every visit, before they enter, call the Pt. and ask the COVID screening questions, it’s documented in …(clinical record)”. Findings include: 1. Pt. #1. SOC 3/24/21. Primary Diagnosis: Gastric Ulcer, Unspecified. The clinical record was reviewed on 11/8/21 at 3:00 PM. The record contained documentation the SN provided service on 9/24/21, 10/1/21, 10/8/21, 10/15/21, 10/22/21, 10/29/21, and 11/5/21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to these visits. 2. Pt. #2. SOC 8/2/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/8/21 at 4:00 PM. The record contained documentation the SN provided service on 9/14/21, 9/21/21, 10/1/21, 10/5/21, 10/12/21, 10/19/21, 10/26/21, and 11/2/21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to these visits. 3. Pt. #7. SOC 8/21/21. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 11/9/21 at 9:30 AM. The record contained documentation the SN provided service on 8/25/21, 9/2/21, 9/9/21, 9/16/21, 9/24/21, 9/30/21, 10/7/21, and 10/14/21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the OTA provided service on 9/1/21, 9/3/21, 9/7/21, 9/9/21, 9/14/21, and 9/16/21. The record lacked documentation the OTA screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also contained documentation the ST provided service on 8/27/21, 9/2/21, 9/11/21, and 10/7/21. The record lacked documentation the ST screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the PTA provided service on 9/18/21. The record lacked documentation the PTA screened the Pt. for signs and symptoms of COVID-19 prior to this visit.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed ensure the POC was followed. This was found in 2 of 7 (Pts. #2 and 7) clinical records reviewed. Findings include: 1. Pt. #2. SOC 8/2/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/8/21 at 4:00 PM. The record contained the POC effective 10/1/21 requiring: “…Report to SN/MD non-fasting blood sugar 300 MG/DL…” The record included documentation the patient’s non-fasting blood sugar level on 10/12/21 was 319. The record lacked documentation the Physician was notified of this blood sugar level. 2. Pt. #7. SOC 8/21/21. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 11/9/21 at 9:30 AM. The record contained the POC for the certfication period effective 8/21/21 to 10/19/21 which required: “…Monitor vital signs every visit and notify MD for any deviation from the parameters: BP below 90/60 MM HG and above 160/90 MM HG…” The record also included a PTA “communication record” dated 9/8/21, which contained “Unable to see patient due to high blood pressure reading 147/111.” The record lacked documentation the Physician was notified of this blood pressure reading.” The record also contained the “Physical Therapy Care Plan,” dated 8/25/21 which included: “Visit Frequency: 1WK1, 2WK3, 1WK2.” The record lacked documentation of any PT visits for the week of 9/5/21 to 9/11/21, as well as 9/19/21 to 9/25/21. The record also lacked documentation the Physician was notified of these missed visits. The record also included the “Speech Therapy Care Plan,” dated 8/27/21 which included: “Visit Frequency: 1WK2, 2WK3, 1WK1.” The record lacked documentation of a second weekly visit for the weeks of: 9/5/21 to 9/11/21; 9/12/21 to 9/18/21; and 9/19/21 to 9/25/21. The record lacked documentation of any ST visits for the week of 9/26/21 to 10/2/21. The record also lacked documentation the Physician was notified of these missed visits. The record also contained the “Occupational Therapy Care Plan,” dated 8/25/21 which contained: “Visit Frequency: 1WK1, 2WK3, 1WK4.” The record lacked documentation of any OT visits for the week of 9/19/21 to 9/25/21. The record also lacked documentation the Physician was notified of these missed visits. 3. During an interview with the Administrator and Agency Supervisor on 11/9/21 at 3:10 PM, the Agency Supervisor confirmed the above findings, and stated the Physician should be notified of vital signs or blood sugar levels outside of the parameters set in the POC, and should also be made aware of any missed visits.