Every finding on record at Directmed Health Services, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/28/25. Standard level deficiencies cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on the Agency's Emergency Preparedness Program review and staff interview, the Agency failed to provide annual staff training of the Emergency Preparedness Program since 2022. Findings include: 1. The Emergency Preparedness Program was reviewed on 08/27/25. The program lacked documentation of Agency providing annual staff training on the Emergency Preparedness Program. 2. During an interview with the Director of Nursing on 0828/25 at 11:00 AM, findings of the Agency failing to provide staff training on the Emergency Preparedness Program was confirmed.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 8/29/25. Standard level deficiencies cited. Abbreviations: SOC = Start of Care RN = Registered Nurse Pt / Pts = Patient / Patients 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 review of the Error Summary report and staff interview, in 63 of 759 assessments submitted for the last 12 months, the Agency failed to submit reports timely, resulting in a warning. Findings include: 1. The Error Summary report for 7/1/24 to 7/24/25, was reviewed on 8/25/25. The report included error # -3330 for 63 of 759 (8.30 %) OASIS reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing on 8/27/25 at 12:30 PM, the Director of Nursing confirmed the above findings.

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: Based on clinical records review, Agency policy review and staff interviews in 6 of 7 (Pts. # 1,2,3,4,6 and 7) clinical records reviewed, the Agency failed to screen patients for pneumonia vaccination status on admission according to Agency policy. Findings include: 1. The following clinical records were reviewed between 8/25/25 and 8/28/25. Pt. # 1 SOC 6/9/25 Pt. # 2 SOC 6/4/25 Pt. # 3 SOC 6/23/25 Pt. # 4 SOC 6/18/25 Pt. # 6 SOC 8/23/24 Pt. # 7 SOC 4/25/25 The clinical records lacked pneumonia vaccination status assessment at SOC. 2. The Agency policy titled "Administration of Influenza Vaccine" was reviewed on 8/28/25 and required "Procedure...2...On the start of care visit, the RN instructs the client regarding the need for influenza and Pneumonia Vaccination. The RN records the information on the Influenza and Pneumonia Vaccination Status form". 3. During interviews with the Director of nursing on 8/27/25 at 12:30 PM and on 8/28/25 at 11:00 AM finding of the clinical records not having the pneumonia assessments were confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Covid-19 = Coronavirus disease 2019 OT = Occupational Therapy PT = Physical Therapy Pt / Pts = Patient / Patients SOC = Start of Care

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 clinical records review a review of Agency's policy and staff interview. It was determined that the Agency failed to ensure informed patient consents contained the frequency visits of the disciplines that will furnish care . This was found in 6 of 7 clinical records reviewed. (Pts. # 1, 2, 3, 5, 6 and 7) Findings Include: 1. The following clinical records were reviewed on 05/09/22, 05/10/22 and 05/11/22 between 10:00 AM to 3:00 PM. Pt. #1 SOC: 04/13/22 Pt. #2 SOC: 03/05/22 Pt. #3 SOC: 04/19/22 Pt. #5 SOC: 02/09/22 Pt. #6 SOC: 06/07/21 Pt. #7 SOC: 12/20/21 The clinical records contained a signed patient consent titled "Authorization for Home Health Services". The consent lacked the frequency of visits to be furnished by the disciplines. 2. The Agency policy titled "Service Agreement" was reviewed on 05/12/22 at 10:00AM. The policy required....Special Instructions...2..Before care is provided, the client shall be advised of...b...The type and frequency of visits/services proposed to be furnished.." 3. During an interview with the Administrator and Agency Supervisor on 05/11/22 at 10:53AM. and at 10:00AM on 05/12/22 with the Agency Supervisor it was confirmed that the records lacked documentation of frequency of services to be provided prior to SOC.

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 or Physician order. This was found in 3 of 7 (Pts. #2, 3 and 7) clinical records reviewed. Findings include: 1. Pt. #2. SOC 03/05/22. Diagnoses: Subsequent Encounter Burn of Third Degree of Right Foot and Unspecified Heart Failure. The clinical record was reviewed on 05/11/22 at 9:30 AM. The record contained the inpatient discharge summary completed by the Physican on 02/22/22, and the Agency's "Referral Info" form dated 2/24/22. The SOC comprehensive assessment was conducted on 03/05/22, nine (9) days after receipt of the referral. The record lacked documentation the Agency started care/service within 48 hours of receiving the referral. 2. Pt. #3. SOC 04/19/22. Diagnoses: Atherosclerosis of Native Arteries of Left Leg with Ulceration of Other Part of Foot and Acute on Chronic Systoloic (Congestive) Heart Failure. The clinical record was reviewed on 05/09/22 at 4:15 PM. The record contained the Physician order signed on 04/02/22 to start "Nursing and Physical Therapy" services. The order was faxed to the Agency on 04/13/22. The SOC comprehensive assessment was conducted on 04/19/22, six (6) days after receipt of the Physician's order. The record lacked documentation the Agency started care/service within 48 hours of receiving the referral. 3. Pt. #7. SOC 12/20/21. Diagnoses: Unspecified Chronic Atrial Fibrillation and Non-Pressure Chronic Ulcer of Left Calf with Unspecific Severity. The clinical record was reviewed on 05/09/22 at 12:30 PM. The record contained the "Referral Info" indicating an inpatient facility referred the Pt. for service on 12/16/21. The SOC comprehensive assessment was conducted on 12/20/21, four (4) days after receipt of the referral. The record lacked documentation the Agency started care/service within 48 hours of receiving the referral. 4. During an interview with the Administrator and the Agency Supervisor on 5/11/22 at 10:53 AM, the Agency Supervisor confirmed the above findings.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on a review of Agency staff vaccination binder, Agency policy and staff interview, it was determined the Agency failed to ensure documentation of 100 percent compliance of field staff COVID-19 vaccination. Or initiate additional precautions for staff not vaccinated for COVID-19. This has the potential to affect all Pts. receiving services. Findings include: 1. On 05/10/22 at 11:00 AM, the Agency's binder titled, "COVID-19 vaccination record" was reviewed. The binder contained religious exemption documentation for Employee #4 dated 11/29/2021. The binder lacked documentation of weekly testing for Employee #4 as required by Agency policy. 2. The Agency policy titled "DirectMed Health's Covid-19 vaccination policy" was reviewed on 05/11/22 at 1:30PM. The policy required... "Option 2: Submit to weekly testing....Persons subject to this policy who choose not to be vaccinated against Covid-19 will be subject to submit a negative Covid-19 test result weekly". 3. During an interview with the Agency Supervisor on 05/12/22 at 10:00AM. The Agency Supervisor confirmed the Agency has no proof of weekly Covid-19 testing for Employee #4.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. 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 Physician was sent a copy of the Discharge Summary. This was found in 1 of 2 (Pt. #7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #7. SOC 12/20/21. Diagnoses: Unspecified Chronic Atrial Fibrillation and Non-Pressure Chronic Ulcer of Left Calf with Unspecific Severity. The clinical record was reviewed on 05/09/22 at 12:30 PM. The record contained the OT Discharge Summary dated 03/22/22 and the PT Discharge Summary dated 04/01/22 indicating the reasons for the discharge, goals achieved, goals not achieved and treatment summaries. As of 05/09/22, the Agency lacked documentation that a copy of the OT and PT discharge summaries were sent to the Physician. The record also included the Agency's Discharge Summary completed by a Registered Nurse and dated 04/18/22. As of 05/09/22, the Agency lacked documentation that a copy of the Agency's Discharge Summary was sent to the Physician. 2. The Agency policy titled, "Patient Discharge/Transfer Process" was reviewed on 05/11/22 at 10:00 AM. The policy required: "...7. A copy of the discharge summary is mailed to the physician within 5 days of discharge". 3 During an interview with the Administrator and the Agency Supervisor on 05/11/22 at 10:53 AM, the Agency Supervisor confirmed that the Agency was unable to provide documentation that a copy of the OT, PT and Agency discharge summaries were sent to the Physician.