Every finding on record at Debtag Home Health Services Inc

Purpose of the visit: Recertification survey and complaint Intake #541537 and 542297 survey. Entrance conference date 08/05/2025 The census was 56. 16 Licensed and Certified, 0 Licensed Home Health, and 40 Personal Assistance Services clients. Purpose of the visit: Recertification survey. The agency was in substantial compliance with the emergency preparedness conditions of participation.

Purpose of the visit: Recertification survey and complaint Intake #541537 and 542297 survey. Entrance conference date 08/05/2025. The census was 56. 16 Licensed and Certified, 0 Licensed Home Health, and 40 Personal Assistance Services clients. The census was 11. Abbreviations: HHA – Home Health Agency IQIES - Quality Improvement Evaluation System CMS – Centers for Medicare and Medicaid Services OASIS – Outcome and Assessment Information Set DON – Director of Nurses / Supervising Nurse POC- Plan of Care PEG – Percutaneous endoscopic gastrostomy tube

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 record review and interview the HHA failed to encode and electronically transmit 4 (19.05% of assessments submitted over the previous 12 months) of 21 completed OASIS assessments to the CMS system within 30 days of completing the assessment of the beneficiary (patient). This failure meant the agency and CMS were unable to evaluate timely outcomes of care provided by the agency and potentially subjected patients to poor health outcomes and a lack of quality care. Findings: Review of the agencies HHA error summary report (produced by CMS for all certified agencies nationwide after agencies submit patient assessment data) for 07/05/2024 to 07/05/2025 revealed 4 of the 21 assessments processed were submitted late (CMS defines this as more than 30 days after the date of the assessment.) During an interview with the Administrator / DON and the Alternate Administrator / Alternate DON on 08/07/2025 at 1:45 PM the surveyor reviewed the late assessment submission data error report findings. The surveyor asked the Administrator / DON to describe the policy and procedures for OASIS assessment collection and submission. The Administrator / DON stated: “I complete the OASIS assessments.” The surveyor asked who was responsible for transmitting the completed OASIS assessments. The Administrator / DON stated: “I am doing that.” The surveyor asked when the transmissions occurred. The Administrator / DON stated: “I was told to do this at thirty days.” The surveyor asked why 19 percent of the assessments were transmitted to CMS after 30 days. The Administrator / DON stated this was “probably poor time management and not understanding it.” The surveyor asked how the late transmissions affected patient care. The Administrator / DON stated he “didn’t know” and “didn’t understand” the time requirements. The surveyor asked the Alternate Administrator / Alternate DON if they had additional information or comment to explain the findings. The Alternate Administrator / Alternate DON nodded their head no and made no comment. The surveyor asked if the agency reviewed OASIS transmission as part of QAPI. The Administrator / DON stated they used a consultant for QAPI and that they “sometimes” reviewed the reports. Agency policy titled “Timelines IM.10… reviewed 120508” read in part: “Policy - Agency will ensure timely provision of care and services to meet the client’s needs in compliance with all federal and state laws and regulations… Encoding and submission of OASIS data to the state at least monthly and prior to billing… The Agency’s quality /performance improvement activities may monitor effectiveness of the medial records parameters and will reevaluate the parameters is negative trends are identified.

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 observation, record review, and interview the agency failed to ensure the individualized plan of care for 4 patients (1,2,3, and 4) of 7 failed to include the statement of risks for emergency room and hospitalization, all pertinent diagnoses, medications, and orders for treatment, as follows: Patients 1 and 3 had a plan of care that failed to include a risk assessment that included the potential for emergency room and hospitalization from bleeding for clients who were on anticoagulant (blood thinning) medications. Patient 4 had a plan of care that failed to include all pertinent diagnoses (kidney failure, and all medications (insulins - hormones that regulate blood sugar and allows cells in the body to function). Patient 2 had a plan of care that failed to include orders for care of the clients peg tube (tube surgically inserted into the abdomen to the stomach for feeding) and colostomy care (a surgical procedure to make and opening called a stoma in the abdominal wall to connect a section of the large intestine to the stoma for removal of fecal matter.) These failures potentially subjected patients to poor health outcomes and a lack of quality care. Review of Patient 1’s POC dated 05/17/2025 to 07/15/2025 found diagnoses of Hypertension (high blood pressure), Atrial Fibrillation (rapid and irregular heart beating), Hyperlipidemia (high blood fat level), Pain, Muscle Weakness, Tremor (involuntary shaking), Unsteadiness on Feet, and Urinary Incontinence (issues controlling urination). The POC included orders for nursing care once a week for nine weeks. Medications listed included Eliquis 5 milligram tablet twice a day (a medication given to prevent blood clots and strokes that has common side effects of bleeding, nausea and anemia, and may have severe side effects including severe bleeding, dizziness, or confusion). The plan of care failed to include a risk assessment that included the potential for emergency room and hospitalization from bleeding for the client who was on anticoagulant (blood thinning) medications. The plan of care contained only a general statement that the patient would be instructed on risk factors. There were no specific risks for this patient identified as potential risks for emergency room visits and hospitalizations. Review of Patient 3’s POC dated 06/26/2025 to 08/24/2025 found diagnoses of Congestive Obstructive Pulmonary Disease with Acute Exacerbation (a worsening of chronic lung disease causing shortness of breath), Hypertension (high blood pressure), Activated Protein C Resistance (the body’s natural ability to regulate blood clotting is impaired, making the blood more likely to clot), Edema (swelling), Shortness of breath (trouble breathing), Tachycardia (rapid heart rate), Viral Hepatitis C (infection of the liver), and Pulmonary Embolism (blood clots in the lungs). The POC included orders for nursing care once a week for nine weeks. Medications listed included Xarelto 20 milligrams tablet by mouth every day (a blood thinning medication given to treat prevent conditions involving blood clots that has common side effects of bleeding, nausea and anemia, and may have severe side effects including severe bleeding, dizziness, or confusion). The plan of care failed to include a risk assessment that included the potential for emergency room and hospitalization from bleeding for the client who was on anticoagulant (blood thinning) medications. The plan of care contained only a general statement that the patient would be instructed on risk factors. There were no specific risks for this patient identified as potential risks for emergency room visits and hospitalizations. Review of Patient 4’s POC dated 05/15/2025 to 07/13/2025 found diagnoses of Chronic Pain Syndrome, Type 2 Diabetes with Polyneuropathy (blood sugar regulation condition with nerve damage to multiple nerves throughout the body from prolonged high blood sugar levels), Long Term (current) Use of Insulin (external injected medication to allow the body to use blood sugar for fuel in the cells that helps control high blood sugar levels), Hypertension (high blood pressure), Hyperlipidemia (high blood fat level), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood and loss of interest in activities causing significant impairment in daily life, Anxiety Disorder (intense. Excessive and persistent worry and fear about everyday situations), Hypothyroidism (condition where the thyroid gland doesn’t produce enough thyroid hormone), Chronic Fatigue (long lasting extreme tiredness), Unsteadiness on Feet (lack of ability to balance while walking or standing), and Repeated Falls (experiencing two or more falls in a year). The POC included orders for nursing care once a week for nine weeks. Patient 4’s plan of care failed to include the pertinent diagnoses kidney failure (the kidneys no longer work to clean the blood from wastes and excess fluid), and all medications (insulins - hormones that regulate blood sugar and allows cells in the body to function). During a visit to Patient 4’s home on 08/06/2025 at 11:56 AM the patient stated they were going to be starting peritoneal dialysis (a method of removing waste products and excess fluid from the blood when the kidneys are failing) within the next week or two because her kidneys were failing. The patient provided her medications for the surveyor to review. The surveyor observed Novolog Insulin (rapid acting) and Basaglar Insulin (long-acting insulin) pens kept in the patients refrigerator with current prescriptions as follows: Novolog Flex pen (a fast acting insulin) – inject 18 units under the skin three times daily with meals and Insulin glargine (Basaglar Kwik Pen u-100 Insulin) (a long acting insulin) – inject 40 units under the skin at bedtime. The patient stated she had been on these medications for more than a year. The surveyor asked how long the patient had been having kidney failure issues. The patient stated they had been getting worse for months. The surveyor asked if the nurses assisted the patient with medications. The patient stated the nurse checked them and reordered from pharmacy as needed. Review of Patient 2’s POC dated 06/07/2025 to 08/05/2025 found diagnoses of Cerebral Palsy (damage to the brain before or during birth that affects muscle movement and coordination), Long Term Use of Insulin (external injected medication to allow the body to use blood sugar for fuel in the cells that helps control high blood sugar levels), Gastrostomy status (presence of a surgically created opening in the stomach used for feeding and some medications), Bed Confinement Status (requires assistance to get out of bed, sit in a chair, and is unable to walk), Urinary Incontinence (inability to control urine flow), Other complications of gastrostomy (undefined issues with gastrostomy the most common is infection), and Open Wound Left Hip (a break in the skin that may involve deeper tissues). The POC included orders for nursing care once a week for nine weeks. The POC included “The patient was recently seen in the emergency department on May 20th for PEG (percutaneous endoscopic gastrostomy) tube placement (feeding tube inserted through the abdominal wall directly into the stomach). At this time, the PEG site shows mild redness but no drainage or signed of active infection…. Colostomy remains intact with no signs of leakage or infection… Skilled nursing services are essential to monitor and manage the PEG site, reinforce caregiver training, provide wound care, and prevent further clinical decline… Patient/Caregiver to be instructed on risk factors for increased risk of exacerbations requiring ER visits and/or hospitalizations and strategies for decreasing those risks… SN to instruct Caregiver on wound care orders to include: location, technique, frequency, supplies, end date and proper disposal of soiled dressings. SN to perform wound care as follows: location, technique, frequency, supplies, end date and proper disposal of soiled dressings…” Review of the POC and all orders found no specific orders on Patient 2's plan of care to include wound care orders for care of the patients peg tube site and no specific colostomy care orders. Review of the nursing visit notes for Patient’s 1, 2 and 3 and 4 revealed a lack of completed weekly skilled visit notes. The visit calendars had LVN A assigned for weekly in June and July 2025. The Administrator / DON was assigned and completed comprehensive assessments of the patients in the May to August 2025 review period for these patients. During an interview on 08/06/2025 at 3:08 PM with LVN A the surveyor asked if the nurse was providing care for patient’s 1,2,3, and 4. The nurse stated she had been seeing the patients weekly. The surveyor asked if patients 1 and 3 were at risk of bleeding due to taking anticoagulants. LVN A stated they were. The surveyor asked about insulin orders for Patient 4. LVN A state she would have to check on that and get back to me. The surveyor asked how long the nurse had to complete the visit notes. LVN A stated “48 hours to complete the notes.” The surveyor asked if that was done in the agency’s electronic medical record or did she have other paper documents. LVN A stated everything is in the electronic medical record, and the nurse stated they had no paper documents. The surveyor asked why the notes for the patients were not in the electronic medical record for the weekly visits in June and July 2025. LVN A stated: “I was a little bit behind, and I just need to go back in and finish the notes.” The surveyor asked how many visits the nurse usually completed per week. LVN A stated: “It depends, every week up to 10 to 15 visits a week.” The surveyor asked how the nurse interacted with the DON. LVN A stated they had a weekly report on the telephone “and debriefed like a mini case conf.” LVN A stated they reviewed each client she was visiting. The surveyor asked about the missing visit notes in the client records. LVN A stated the patients were seen weekly by her, that she discussed the patient visits and status with the Administrator / DON every week , and she had documented the visits in the electronic medical record. The surveyor asked about the missing visit notes. LVN A stated “I can double check. That is weird. I know I have done them.” The surveyor asked about the care for Patient 2’s PEG tube site and colostomy. LVN A said she was at her other job and would have to call the surveyor back. LVN A confirmed that she would call the surveyor back at am 11am on 08/07/2025 to complete the interview. No call was received at the agreed time and date. The surveyor attempted to contact LVN A on 08/07/2025 and there was no answer. The surveyor asked the Administrator / DON to have LVN A call the surveyor. No call was received by the end of the survey. The surveyor was unable to ask the additional questions planned about the POCs, missing information on the POCs, and how the LVN knew what to do for the patients. During an interview with the Administrator / DON on 08/07/2025 at 2:38 PM the surveyor reviewed the findings regarding Patients 1,2,3, and 4. The surveyor asked if the risk factors emergency room visits and hospitalization for Patient’s 1 and 3 should have included the risk of bleeding. The Administrator / DON stated yes, he didn’t know he should have included those on the POC. The surveyor asked about the PEG tube site care and colostomy site care for Patient 2. The Administrator / DON stated they changed the dressing including cleaning the site with normal saline and applying a clean gauze bandage to the PEG site and provided the colostomy site care as needed during the visits. The surveyor asked about the policy for wound care orders on the plan of care. The Administrator / DON stated they should be on the POC. The surveyor asked who was responsible for completing and reviewing the patient’s plans of care. The Administrator / DON stated he was responsible. The surveyor asked about the lack of Patient #3’s kidney disease diagnosis and insulin medications on the POC. The Administrator / DON stated they should be on the POC and it was his mistake. The surveyor asked about the outcome for the patients of the incomplete plans of care. The Administrator / DON stated it might cause issues in the care for the nurse who did the weekly visits after he completed the assessments. He further stated the] nurse would not know how to care for the patient to meet their specific needs. He stated he sees some of the agency’s patients weekly and the nurse was newly hired in May of 2025. The surveyor asked why the plan of care policy did not include anything to address specific risks for hospitalizations and emergency room visits and was not updated since 04/04/2011. The Administrator / DON stated they did not know and that was the manual they were given from the previous owners. Agency policy titled: “Plan of Care vised date:040411” read in part “Purpose – To develop an individualized Plan of Care to ensure client specific needs are met appropriately according to state and federal regulations…Policy- Agency will utilize data/information gathered during client assessments in the care planning which involves the identification of client goas, actions or interventions that will resolve or alleviate the client’s problems and / or needs… The Plan of Care, which includes the following elements … Client’s primary and secondary diagnoses/problems, … safety measure to protect against injury …list of current medications … physician orders to include the discipling to render the services / treatments… the specific procedures / treatments to be performed…” The surveyor noted in the review that the specific requirement for a statement of the specific risks for hospitalization and emergency room visits were not included in the Plan of Care policy and that the policy had not been updated since 04/04/2011 to include these specific requirements.