Every finding on record at Egan Healthcare Corp.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 interview and record reviews, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. Findings: Review of the agency's OASIS Agency Final Validation Report with a submission date of 10/21/2025 revealed 95 records were processed with 2 records receiving error message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 12/09/2025 revealed 96 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 12/16/2025 revealed 86 records were processed with 2 record receiving error message the record was submitted late due to a submission date of more than 30 days after date on the record. In an interview on 01/30/2026 at 1:24pm, S2Director of Nursing confirmed the above records were submitted late. S2Director of Nursing indicated all OASIS Assessments should be submitted within 30 days of completion and were not submitted as required.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interviews, and record reviews, the agency failed to ensure an accurate review of all medications that were prescribed for 1 (Patient #6) of 7 sampled patients observed for medication reconciliation during home visits. Findings: Review of Patient #6’s medication profile, presented by S2Director of Nursing (DON) as the most current copy of Patient #6’s medication, revealed Patient #6 was documented as receiving, in part, Gabapentin (medication used to help control seizures) 600 milligrams (mg), one half tablet by mouth three times a day with a start date of 12/18/2025; Gabapentin 300mg Capsule, take 1 capsule by mouth daily with a start date of 12/11/2025; Lidocaine (medication used to treat pain) Plus 5% topical patch, place one patch onto skin once daily with a start date of 12/11/2025; Lidocaine 4% topical cream, apply a thin layer to skin as needed for pain with a start date of 11/06/2025; and Nystatin (medication used to treat fungal or yeast infections) 100,000 unit/gram topical cream, apply to affected areas three time a day with a start date of 08/02/2024. Observation during a home visit on 1/28/2026 at 1:35PM, revealed, in part, the following medications were in Patient #6’s home: Gabapentin 300milligram capsule, take one capsule by mouth daily with a fill date of 12/11/2025; Lidocaine 5% topical patch, apply one patch for twelve hours then remove for twelve hours, with a fill date of 12/29/2025; Lidocaine Plus 5% topical cream, apply a thin layer to skin as needed for pain, with fill date of 01/13/2026; and Nystatin 100,000 Unit/Gram Powder, apply to affected area, with a fill date of 9/23/2025 In an interview on 1/28/2026 at 1:37PM, Patient #6 stated she was only taking Gabapentin 300milligrams once a day and further indicated that the dosage had been decreased “a while back”. In an interview on 1/28/2026 at 1:38PM, S3Licensed Practical Nurse confirmed Patient #6’s current medication list did not accurately reflect Patient #6’s physician medication orders, and should have. In an interview on 01/29/2026 at 12:27PM, S1Director of Nursing indicated the skilled nurse should have identified the above mentioned medication changes and updated them on Patient #6’s medication profile.

Complaint Survey #LA000108976.

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 record reviews and interviews, the agency failed to ensure a patient received skilled nursing services per the plan of care for 1 (Patient #1) of 3 (Patient #1, Patient #2, and Patient #3) sampled patients reviewed for nursing services provided. Findings: Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 06/04/2024 through 08/02/2024 revealed, in part, Patient #1 had diagnoses of Fetal Alcohol Syndrome (a group of conditions caused by the mother consuming alcohol during pregnancy), lack of expected normal physiological development in childhood (condition which caused developmental delays), Congenital Tracheomalacia (condition in which the walls of patient’s windpipe collapse); and, Attention to Gastrostomy (an artificial tube to administer feedings directly into the stomach). Further review revealed Patient #1 was to receive up to 60 hours per week of private duty skilled nursing services for a 9 week period. Review revealed Patient #1’s skilled nurse was to assess all body systems every visit, obtain vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature) every shift and as needed, and administer tube feedings. Review of Patient #1’s record revealed no documented evidence and the agency was unable to present any documented evidence a skilled nurse had provided care to Patient #1 from 08/01/2024 through 08/19/2024. In an interview on 08/19/2024 at 11:56am, S3EHH/ED confirmed Patient #1’s caregiver wanted skilled nursing services Monday through Friday from 7:00 a.m. to 3:00 p.m. S3EHH/ED indicated that due to staffing issues, Patient #1 did not receive skilled nursing services per Patient #1’s Plan of Care from 08/01/2024 through 08/19/2024.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the patient’s Support Coordinator (SC) was notified: 1. When the agency was unable to provide skilled nursing services per the plan of care (Patient #1); and 2. When the agency was unable to contact Patient #1’s caregiver to provide services to Patient #1. This deficient practice was identified for 1 (Patient #1) of 3 (Patient #1, Patient #2, and Patient #3) sampled patients reviewed for coordination of care. Findings: Review of Patient #1’s Home Health Certification and Plan of Care for the certification period of 06/04/2024 through 08/02/2024 revealed, in part, Patient #1 was to receive skilled nursing services via Extended Home Health (EHH) up to 60 hours per week for one 9 week episode. Review of Patient #1’s Case Coordination Note dated 05/31/2024 revealed, in part, the agency had notified Patient #1’s caregiver there may be times when the agency was unable to provide all of Patient #1’s ordered/authorized visits/hours due to an ongoing critical nursing shortage and staffing crisis. Further review revealed no documented evidence and the agency presented no documented evidence the agency had notified Patient #1’s support coordinator of the agency’s staffing shortage and inability to provide staff for all of Patient #1’s authorized/ordered visits. Review of Patient #1’s Case Communication Note dated 07/11/2024 - 07/12/2024 revealed, in part, S5Case Coordinator made several attempts to contact Patient #1’s caregiver with messages left, but did not receive a return telephone call. Review of Patient #1’s Case Communication Note dated 08/08/2024 revealed S3Extended Home Health (EHH)/Executive Director (ED) had called and informed Patient #1’s caregiver and notified Patient #1’s caregiver the agency would continue to attempt to have prn (as needed) nurses provide services. In an interview 08/19/2024 at 10:12 a.m., Patient #1’s Support Coordinator indicated she was not notified about the staffing shortage and inability of the agency to provide staffing for Patient #1 until July 2024, when Patient #1’s caregiver had contacted her regarding not having nursing services. In an interview on 08/19/2024 at 2:48 p.m., S3EHH/ED indicated the agency did not notify Patient #1’s Support Coordinator of the upcoming staffing issues nor did they notify Patient #1’s Support Coordinator when the agency was unable to contact Patient #1’s caregiver about not being able to provide nursing services.

Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency maintained responsibility for the Extended Home Health (EHH) patients who were assigned to the home health agency. Findings: Review of S2Executive Director for Home Health’s Job Description revealed, in part, the Executive Director was to supervise and ensure high quality patient care services throughout the episode of care. In an interview on 08/14/2024 at 9:22 a.m., S2ED of Home Health indicated she was not aware of the agency providing EHH services. S2ED of Home Health then asked if the surveyor was asking for the pediatric patient’s census, and indicated the information on the pediatric patients would have to be obtained from S3Extended Home Health (EHH)/ED which was out of a sister agency. S2ED of Home Health indicated she did not have access to the EHH/pediatric patient census or medical records. In an interview on 08/19/2024 at 2:45 p.m., S1Administrator indicated the day to day operations and responsibility for the EHH/pediatric services was led by S3EHH/ED, and the agency was not handling the staff or coordination of care for EHH/pediatric patients. S1Administrator further indicated S3EHH/ED was responsible for the supervision and coordination of care of the EHH/pediatric program, and all of the agency’s EHH/pediatric patients were managed centrally by S3EHH/ED out of a sister agency’s office, which had a different provider number. In an interview on 08/19/2024 at 2:48 p.m., S3EHH/ED indicated there was no staff at the agency level responsible for the supervision of care and services of the EHH/pediatric patients. S3EHH/ED further indicated she was responsible for all day to day operations of EHH/pediatric patients for multiple agencies and the EHH program was not supervised or managed at the individual agencies.

The entity is in compliance with the federal emergency preparednss requirements.

Recertification Survey

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure an accurate medication reconciliation of patients medications for 2 of 7 sampled patients (Patient #1 and Patient #5) observed for medication reconciliation during home visit observations. Findings: In an interview on 01/20/2023 at 9:59 a.m., S1AdministratorDON (Director of Nursing) stated the nurses should complete medication reconciliation at every visit by verifying the medication and directions from the medication labels and compare to what is documented on the record. Patient #1 Review of Patient #1’s Medicine List, presented to the surveyor as the most current list, revealed Carvedilol (heart medication) 25mg (milligrams) one tablet by mouth twice a day. Observation on 01/31/2023at 4:15 p.m. revealed Patient #1’s bottle for Carvedilol 25mg two tablets by mouth twice a day. Review of Patient #1’s Hospital Medication Discharge List dated 07/19/2022 revealed Carvedilol 25mg two tablets by mouth twice a day. In an interview on 02/02/2023 at 2:01 p.m., S1Administrator/DON stated the nurses providing care to Patient #1 did not catch the change in the dosage of the Carvedilol and should have corrected the medicine list. Patient #5 Review of Patient #5’s Medicine List, presented to the surveyor as the most current list, revealed the following medications were not listed: Lexapro (medication used to treat anxiety) and Tagrisso (chemotherapy drug). Observation on 01/31/2023 at 2:05 p.m. revealed Patient #5 had the following medication in the home, in part, Lexapro 20mg one tablet by mouth daily with filled date of 12/30/2022, and Tagrisso 80mg one tablet by mouth daily with filled date of 01/20/2023. In an interview on 02/02/2023 at 2:09 p.m., S1AdministratorDON stated the nurse did not document the medications listed above for Patient #5.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure agency-wide surveillance for the identification and prevention of all infections for 5 of 5 sampled patients (Patient #1, Patient #5, Patient #6, Patient #11, and Patient #13) reviewed during the infection control review. Findings: Patient #1 Review of Patient #1’s Physician Order, dated 11/18/2022, revealed Patient #1 received Nitrofurantoin (an antibiotic used to treat infections) 100mg (milligrams) one capsule twice a day for 14 days for a scrotal infection. Review of Patient #1’s Client Medication Report revealed, in part, the following medications: 03/23/2022 Cefdinir (antibiotic used to treat infections) 300mg one capsule twice a day, and; 05/22/2022 Cephalexin (antibiotic used to treat infections) 500mg one tablet every 8 hours for urinary tract infection (bladder infection), and; 08/24/2022 Cephalexin 500mg one capsule four times a day for scrotal edema, and; 09/23/2022 Doxycycline Hyclate (antibiotic used to treat infections) 100mg one tablet twice a day for urinary tract infection, and; 11/17/2022 Nitrofurantoin 100mg one capsule twice a day for scrotal infection. Patient #5 Review of Patient #5’s Physician Order, dated 01/12/2023, revealed Patient #5 received Ciprofloxacin (antibiotic used to treat infections) 500mg one tablet twice a day for urinary tract infection. Review of Patient #5’s Physician Order, dated 01/23/2023, revealed Patient #5 received Cephalexin 500mg one capsule three times a day for e-coli (bacteria) in the urine. Patient #6 Review of Patient #6’s Physician Order, dated 01/11/2023, revealed Patient #6 received Amoxicillin (antibiotic used to treat infections) 500mg one capsule twice a day. Review of Patient #6’s Physician Order, dated 01/18/2023, revealed Ceftin (antibiotic used to treat infections) 250mg one tablet twice a day. Patient #11 Review of Patient #11’s Home Health Certification and Plan of Care, for the certification period of 07/16/2022 to 09/13/2022, revealed Patient #11 was admitted with an order for Cefdinir 300mg one capsule every 12 hours for 5 days. Patient #13 Review of Patient #13’s Resumption of Care Orders, dated 04/19/2022, revealed an order for Zosyn (antibiotic used to treat infections) 4.5 grams/100ml (milliliter) in dextrose Intravenous (in the vein) administer 13.5 grams daily for cellulitis/osteomyelitis (skin infection/bone infection). Review of Patient #13’s Physician Order, dated 08/01/2022, revealed an order for Bactrim (antibiotic used to treat infections) 200/400mg/5ml administer 10ml twice a day for wound infection. Review of the agency’s QI (Quality Improvement) Event Report, dated 01/01/2022 through 12/31/2022, revealed no documented evidence of Patient #1, Patient #11, or Patient #13’s infections having been documented on the infection report for tracking and trending of infections. In an interview on 02/02/2023 at 12:26 p.m., S2PCM (Patient Care Manager) stated the process for infection control for the agency was when a patient develops an infection after 72 hours post admission the nurse would complete a QI report or infection control report for review to track and trend infections. S2PCM stated the nurse would not complete any reports for tracking and trending if infection develops within 72 hours or admission. S2PCM further stated if a patient developed an infection related to the patient’s admit diagnosis at any point during any certification period the agency would not track and trend those infections either. In an interview on 02/02/2023 at 1:06 p.m., S1Administrator/DON (Director of Nursing) stated the agency only tracked and trended the following infections for identification of patterns of infections: intravenous infections, catheter infections, and wound infections. S1Administrator/DON further stated not all infections would be included in the agency’s surveillance of infections. S1Administrator/DON confirmed none of the above infections had infection reports/QI reports completed for agency surveillance to be completed.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure weekly wound care measurements were completed to monitor for wound status for 1 of 7 sampled patients (Patient #5) with wounds. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed, in part, assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes, in part: dimensions, depth, and location of and depth of any sinus tracts or undermining areas. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of the agency’s Wound Assessment, Documentation, and Photography Policy and Procedure revealed, in part, the clinician will assess wounds at least every other week for patients receiving wound care by the agency at a frequency less than daily, not infected, or receiving negative pressure therapy. Further review revealed documentation in the wound assessment tool would contain, in part: length, width, depth, and any undermining and tunneling. Review of Patient #5’s Home Health Certification and Plan of Care, for certification period of 12/27/2022 to 02/24/2023, revealed Patient #5 to receive skilled nursing services twice a week and 2 as needed skilled nurse visits for wound complications. Further review revealed Patient #5 had a stage two wound (open area on the skin caused by pressure) to his right buttock. Review of Patient #5’s Wound Record Report for certification period of 12/27/2022 to 02/24/2023 revealed no wound care measurements were recorded on the following weeks: Week of 01/01/2023 through 01/07/2023; Week of 01/08/2023 through 01/14/2023; Week of 01/15/2023 through 01/21/2023; and Week of 01/22/2023 through 01/28/2023. In an interview on 02/02/2023 at 2:09 a.m., S1Administrator/DON (Director of Nursing) stated the agency had no documentation of the wounds having been measured weekly and/or a reason as to why the wounds were not measured weekly.