Every finding on record at Distinct Home Health Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 9/11/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 9/11/25. Standard level deficiencies cited. Abbreviations: - = to x = times wk = week # = number % = percent AM = morning > = greater than SN = Skilled Nurse POC = Plan of care SOC = Start of care mg/MG = milligrams BP = Blood Pressure MD = Medical Doctor PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients MSW = Medical Social Worker PCP = Primary Care Physician ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist OT = Occupational 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 review of the Error Summary report and staff interview, it was determined in 161 of 469 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 8/1/24 to 8/29/25, was reviewed on 9/8/25. The report included error # -3330 for 161 of 469 (34.33 %) OASIS reports that were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the above findings.

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 Pt. admission booklet, observation during home visits, clinical record review, and staff interview, 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 policy. Findings include: 1. The Pt. admission booklet was reviewed on 9/8/25. The booklet lacked documentation pertaining to the Agency’s transfer policy. 2. During the home visits conducted on 9/9/25, the Pt. admission booklets were observed and lacked documentation pertaining to the Agency’s transfer policy for: Pt. #1. SOC 6/11/25. Pt. #2. SOC 5/30/25. Pt. #3. SOC 8/20/25. 3. The following clinical records were reviewed on 9/9/25 and lacked documentation pertaining to the Agency’s transfer policy: Pt. #1. SOC 6/11/25. Pt. #2. SOC 5/30/25. Pt. #3. SOC 8/20/25. Pt. #4. SOC 8/7/25. Pt. #5. SOC 8/1/25. Pt. #6. SOC 11/13/24. Pt. #7. SOC 2/24/24. 4. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the Agency failed to provide Pts. information regarding the Agency's transfer policy.

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: Based on review of the Pt. admission booklet, observation during home visits, clinical record reviews, and staff interview, in 4 of 7 (Pts. #1, 2, 3, and 7) clinical records reviewed, the Agency failed to ensure the Pts. were informed of the services to be provided in writing, and/or the frequency of visits provided by each discipline. Findings include: 1. The Pt. admission booklet was reviewed on 9/8/25. The booklet contained an Admission Consent form that required Agency staff to document the service(s) to be provided and the visit frequency of each service. 2. Home visits were conducted on 9/9/25. During the home visits, the following Pt. admission booklets were observed: Pt. #1. SOC 6/11/25. Lacked the SN and PT visit frequencies. Pt. #2. SOC 5/30/25. Lacked the SN and PT visit frequencies. Pt. #3. SOC 8/20/25. Lacked the SN, PT, OT, and Home Health Aide visit frequencies. 3. The clinical records were reviewed on 9/9/25. The records included an Admission Consent form completed by the RN. The form required the RN to document the service(s) to be provided and proposed visit frequency of each service. Pt. #1. SOC 6/11/25. Lacked the SN and PT visit frequencies. Pt. #2. SOC 5/30/25. Lacked the SN and PT visit frequencies. Pt. #3. SOC 8/20/25. Lacked the SN, PT, OT, and Home Health Aide visit frequencies. Pt. #7. SOC 2/24/24. Lacked documentation of the services to be provided (SN and PT), and the visit frequencies. 4. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the Agency failed to ensure the Pts. were informed of the services to be provided in writing, and the proposed frequency of visits provided by each discipline.

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, and staff interviews, in 5 of 7 (Pts. #2, 3, 4, 5, and 6) clinical records reviewed, the Agency failed to ensure staff provide service, as required on the POC and ordered by the Physician. 2. Pt. #3 was admitted to home health services on 8/20/25 with the diagnosis of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/20/25, that required the SN to assess the patient’s blood pressure 1 time a week for 9 weeks and notify the MD if the diastole BP is greater than 90. The SN failed to notify the MD on 8/23/25 of the BP diastole 95 and on 9/1/25 of the BP diastole of 92. 3. Pt. #4 was admitted to home health services on 8/7/25 with the diagnosis of Unspecified Dementia, Unspecified Severity with Anxiety. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/7/25, that required the PT to visit the patient, 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 6 weeks. The PT failed to visit the Pt. 2 times a week, during the week of 8/10/25 (week #2). The PT failed to visit the Pt. 1 time a week, during the week of 8/31/25 (week #5). 4. Pt. #5 was admitted to home health services on 8/1/25 with the diagnosis of “Hyp Hrt and Chr Kdny Dis w/o Hrt Fail w Stage 5 Chr Kdny /ESRD”. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/1/25, that required the SN to assess the patient’s blood pressure 1 time a week for 9 weeks and notify the MD if the diastole BP is less than 60. The SN failed to notify the MD on 8/13/25 of the BP diastole 56. 5. Pt. #6 was admitted to home health services on 11/13/24 with the diagnosis of Pressure Ulcer of Sacral Region Stage 4. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 11/13/24, that required the SN to visit the Pt., 1 time a week for 9 weeks. The SN failed to visit the Pt. during the week of 12/22/24 (week #7). 6. The above findings were confirmed, during the interviews with the Director of Nursing and Backup Director of Nursing, on 9/9/25 between 2:00 PM and 3:45 PM. Findings include: 1. Pt. #2 was admitted to home health services on 5/30/25 with the diagnosis of, but not limited to, Parkinson’s Disease without Dyskinesia, without mention of fluctuations. The clinical record was reviewed on 9/9/25. The clinical record included the POC effective 7/29/25 that required, “Notify Physician of vital sign parameters out of range… Pain level: greater than 9 (>) 6/10…” The SN visit note dated 8/13/25 lacked documentation the SN assessed Pt. #2 for pain.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and staff interviews, in 5 of 7 (Pts. #1, 2, 7, 3, and 4) clinical records reviewed, the Agency failed to ensure the POC was accurate and/or complete. 4. Pt. #3 was admitted to home health services on 8/20/25 with the diagnosis of Hemiplegia following Cerebral Infraction Affecting Right Dominant Side. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/20/25, that was revised on 8/22/25 with a physician order to start Home Health Aide services. The POC order lacked the duration of Aide visits to be made. 5. Pt. #4 was admitted to home health services on 8/7/25 with the diagnosis of Unspecified Dementia, Unspecified Severity with Anxiety. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/7/25, that required the PT to evaluate the Pt. The PT documented on 8/7/25 that the Pt. was a diabetic. The POC did not included the diagnosis of Diabetes Mellitus. 6. The above findings were confirmed, during interviews with the Director of Nursing and Backup Director of Nursing, on 9/9/25 between 2:00 PM and 3:45 PM. 1. Pt. #1 was admitted to home health services on 6/11/25 with the diagnosis of, but not limited to, Unspecified Chronic Obstructive Pulmonary disease. The clinical record was reviewed on 9/9/25. The clinical record included the POC for the certification period of 6/11/25 to 8/9/25, and the POC effective 8/10/25. Both PsOC included, “Patient with need for Advance Care Planning / Advance directives… referral to Medical Social Worker (MSW) or facilitate session with PCP (Primary Care Physician) for covered services for Advance Care Planning.” As of 9/9/25, the record lacked documentation the SN referred the Pt. to the MSW or facilitated a session with PCP for Advance Care Planning. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, the Director of Nursing stated, Pt. #1 did not require a MSW or PCP for Advance Care Planning, the PsOC for Pt. #1 were inaccurate. 2. Pt. #2 was admitted to home health services on 5/30/25 with the diagnosis of, but not limited to, Parkinson’s Disease without Dyskinesia, without mention of fluctuations. The clinical record was reviewed on 9/9/25. The clinical record included the POC for the certification period of 5/30/25 to 7/28/25, and the POC effective 7/29/25. Both PsOC included, “Patient with need for Advance Care Planning / Advance directives… referral to Medical Social Worker or facilitate session with PCP for covered services for Advance Care Planning.” As of 9/9/25, the record lacked documentation the SN referred the Pt. to the MSW or facilitated a session with PCP for Advance Care Planning. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, the Backup Director of Nursing stated Pt. #2 did not require a MSW or PCP for Advance Care Planning, the PsOC for Pt. #2 were inaccurate. 3. Pt. #7 was admitted to home health services on 2/24/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperosmolarity. The closed clinical record was reviewed on 9/9/25. The closed clinical record included the Resumption of Care assessment completed by the RN on 9/10/24 that contained, “The patient cannot be weighed because of extreme pain, immobility…” The “Resumption of Care Following Hospital Stay” POC completed by the RN on 9/10/24 required, “SN to instruct patient to notify physician of increasing weight gain…” Resumption of Care POC was inaccurate to require patient’s weight to be assessed. The “Resumption of Care Following Hospital Stay” POC completed by the RN on 9/10/24 included, “Patient with need for Advance Care Planning / Advance directives… referral to Medical Social Worker or facilitate session with PCP for covered services for Advance Care Planning.” During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/24 at 2:40 PM, the Backup Director of Nursing stated Pt. #7 did not require a MSW or PCP for Advance Care Planning, the POC for Pt. #7 was inaccurate.

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 staff interview, Agency policy review, and clinical record review, in 3 of 7 (Pts. #1, 2, and 7) clinical records reviewed, the Agency failed to assess the patient’s need for the Pneumonia and/or Influenza vaccines. Findings include: 1. During the entrance interview with the Backup Director of Nursing on 9/8/25 at 1:08 PM, the Backup Director of Nursing stated Agency staff assess the patient’s need for the Pneumonia vaccine during the SOC visit, this information is documented in the SOC assessment form. Pts. are assessed for the need of the Influenza (flu) vaccine during the flu season (September through March), if the SOC visit occurs during the flu season, this information is documented in the SOC assessment form. 2. The Agency’s policy titled; “Vaccinations” was reviewed on 9/10/25 at 11:58 AM. The policy included, “Influenza …Pneumonia … 5. The following shall be considered for documentation: a. Individual client/patient record entries identifying the assessment for the need of vaccination: date of offer or referral; client/patient response; administration, contraindication or refusal; and any follow-up activities…” 3. Pt. #1 was admitted to home health services on 6/11/25 with the diagnosis of, but not limited to, Unspecified Chronic Obstructive Pulmonary disease. The clinical record was reviewed on 9/9/25. The clinical record included the SOC assessment form completed by the RN and dated 6/11/25. The form lacked documentation the RN assessed the Pt. for the Pneumococcal Pneumonia vaccine. 4. Pt. #2 was admitted to home health services on 5/30/25 with the diagnosis of, but not limited to, Parkinson’s Disease without Dyskinesia, without mention of fluctuations. The clinical record was reviewed on 9/9/25. The clinical record included the SOC assessment form completed by the RN and dated 5/30/25. The form lacked documentation the RN assessed the Pt. for the Pneumococcal Pneumonia vaccine. 5. Pt. #7 was admitted to home health services on 2/24/24 with the diagnosis of, but not limited to, Type 2 Diabetes Mellitus with Hyperosmolarity. The closed clinical record was reviewed on 9/9/25. The closed clinical record included the SOC assessment form completed by the RN and dated 2/24/24. The form lacked documentation the RN assessed a need for the Pneumonia and Influenza vaccines. 6. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the RN failed to assess the patient’s need, refusal, or contraindication for the Pneumonia and/or Influenza vaccines during the SOC visit.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on a review of clinical records, home visit interview, and staff interview, in 2 of 7 (Pts. #3 and 6) clinical records reviewed, the Agency failed to coordinate Pt. care. Findings include: 1. Pt. #3 was admitted to home health services on 8/20/25 with the diagnosis of Hemiplegia following Cerebral Infraction Affecting Right Dominant Side. The clinical record was reviewed on 9/9/25. The clinical record included a POC dated 8/20/25, that required the evaluation of PT, OT and MSW. A home visit interview was conducted on 9/9/25 with Pt. #3, who confirmed that as of 9/9/25 the evaluations were not yet conducted. 2. Pt. #6 was admitted to home health services on 11/13/24 with the diagnosis of Pressure Ulcer of Sacral Region Stage 4. The closed clinical record was reviewed on 9/9/25. The closed clinical record included a POC dated 11/13/24, that required a MSW evaluation. The MSW evaluation was not conducted while the patient was receiving home health services. 3.The above findings were confirmed, during an interview with the Director of Nursing and Backup Director of Nursing, on 9/9/25 at 2:00 PM.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Pt. admission booklet, observation during home visits, clinical record reviews, and staff interview, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the Pts. with information regarding the Director of Nursing/Clinical Manager. Findings include: 1. The Pt. admission booklet was reviewed on 9/8/25. The booklet lacked the name and contact information of the Director of Nursing. 2. During the home visits conducted on 9/9/25, the Pt. admission booklets were observed and lacked the name and contact information of the Director of Nursing for: Pt. #1. SOC 6/11/25. Pt. #2. SOC 5/30/25. Pt. #3. SOC 8/20/25. 3. The clinical records were reviewed on 9/9/25. The records lacked documentation that the Agency provided Pts. the name and contact information of the Director of Nursing for: Pt. #1. SOC 6/11/25. Pt. #2. SOC 5/30/25. Pt. #3. SOC 8/20/25. Pt. #4. SOC 8/7/25. Pt. #5. SOC 8/1/25. Pt. #6. SOC 11/13/24. Pt. #7. SOC 2/24/24. 4. During an interview with the Director of Nursing and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the Agency failed to provide the Pts. with information regarding the Director of Nursing/Clinical Manager.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, in 1 of 1 (Pt. #3) clinical records reviewed wherein Home Health Aide services were provided, the RN failed to conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #3 was admitted to home health services on 8/20/25 with the diagnosis of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side. The clinical record was reviewed on 9/9/25. The clinical record included weekly Home Health Aide visit notes from 8/23/25 to 9/9/25 to indicate care was provided. As of 9/9/25, the record lacked documentation that the RN supervised the Home Health Aide from 8/23/25 to 9/9/25. 2. The above findings were confirmed, during an interview with the Director of Nursing and Backup Director of Nursing, on 9/9/25 at 2:00 PM.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation and interviews during home visits, clinical record reviews, Agency policy review, and staff interview, it was determined in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to ensure the medications listed in the clinical record were complete and/or accurate. Findings include: 1. Pt. #1 was admitted to home health services on 6/11/25 with the diagnosis of, but not limited to, Unspecified Chronic Obstructive Pulmonary disease. A home visit was conducted with Employee #1 on 9/9/25. During the home visit, the medications were observed, and an interview was conducted with the Pt. The prescription bottle labeled “Gabapentin 600 MG Tablets Take 1 Tablet by mouth three times daily” was observed, the Pt. stated this medication was changed from 3 times daily to 2 times daily in June 2025. The Pt. stated “Pantoprazole” was discontinued in 2024. The clinical record was reviewed on 9/9/25. The clinical record included the Medication Profile completed by the RN and dated 9/5/25. The Medication Profile included documentation that Gabapentin 600 MG Tablets was taken three times daily, and that the Pt. takes “Pantoprazole 40 mg 1 tablet once a day before breakfast By mouth”. The Medication Profile lacked the correct dosage of Gabapentin and included Pantoprazole which was discontinued. 2. Pt. #2 was admitted to home health services on 5/30/25 with the diagnosis of, but not limited to, Parkinson’s Disease without Dyskinesia, without mention of fluctuations. A home visit was conducted with Employee #2 on 9/9/25. During the home visit, the medications were observed, and an interview was conducted with the Pt. The prescription bottle labeled “Cyclobenzaprine 10 MG Tablets Take 1 Tablet by mouth three times daily as needed for muscle spasm” was observed, the Pt. stated this medication was not new and has taken for a while; the prescription bottle labeled “Naproxen 500 MG Tablets Take 1 Tablet by mouth twice daily with meals” dated 8/21/25 was observed; the prescription bottle labeled Docusate Sod (Sodium) 100 MG capsules Take one capsule by mouth as needed for constipation” dated 4/21/25 was observed. The clinical record was reviewed on 9/9/25. The clinical record included the Medication Profile completed by the RN and dated 8/22/25. The Medication Profile lacked the Cyclobenzaprine, Naproxen, and Docusate Sod. 3. The Agency’s policy titled, “Medication Profile” was reviewed on 9/10/25 at 10:10 AM. The policy required, “… The profile will be reviewed and updated as needed to reflect current medications the client is taking…” 4. During an interview with the Director of Nursing, and Backup Director of Nursing on 9/9/25 at 2:40 PM, both confirmed the medications listed in the clinical record were incomplete and/or inaccurate.