Every finding on record at Elite Home Health Care Inc

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted February 24, 2025 through February 26, 2025, and offsite on February 28, 2025, Elite Home Health Care, Inc., was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an onsite Medicare recertification survey conducted February 24, 2025 through February 26, 2025, offsite on February 28, 2025, Elite Home Health Care, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy, clinical records (CR), and an interview with the agency Alternate Administrator, the agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for seven (7) of seven (7) clinical records reviewed, (CR#1, 2, 3, 4, 5, 6, and 7). Findings include: A review of Agency policy titled “Administration of Medications and Therapies” conducted on February 25, 2025, at approximately 2:00 PM states, “2. Medication Review/Patient Education and Documentation: A. All prescription medication, over-the-counter medications and/or container labels are to be reviewed at each visit. The medication review includes a review of all medications the patient is currently using in order to identify any potential adverse effects and drug interactions. This includes ineffective drug therapy, significant side effects, drug interactions, including food interactions, duplicate drug therapy and non-compliance drug therapy…” A review of CRs was conducted on February 24, 2025, at approximately 2:15 PM and completed on February 26, 2025, at approximately 10:30 AM revealed the following: CR #1, Start of Care: 2/19/18: Certification period reviewed 1/1/25 through 3/1/25, contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #2, Start of Care: 9/30/24: Certification period reviewed 1/28/25 through 3/28/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #3, Start of Care: 2/11/25: Certification period reviewed 2/11/25 through 4/11/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #4, Start of Care: 8/24/24: Certification period reviewed 12/22/24 through 2/19/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #5, Start of Care: 2/15/24: Certification period reviewed 2/9/25 through 4/9/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #6, Start of Care: 7/15/22; Discharge Date: 2/24/25: Certification period reviewed 12/31/24-2/28/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. CR #7, Start of Care: 4/25/24: Certification period reviewed 12/21/24 through 2/18/25; contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. An interview with the Alternate Administrator conducted on February 26, 2025, at approximately 11:30 AM confirmed the above findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a review of agency policy, review of clinical records (CR), and an interview with the agency Alternate Administrator, the agency failed to provide documentation that all patient care was provided as ordered in the plan of care for four (4) of seven (7) CRs reviewed, (CR #3, 4, 6, and #7). Findings include: A review of agency policy titled “Missed Visits/Deviation from Prescribed Frequency of Services” conducted on February 25, 2025, at approximately 2:05 PM states, “Purpose: In order to comply with federal and state laws and regulations, the attending physician is informed of any missed visits that deviate from the patient’s plan of care as signed by the attending physician. Procedure: 1. When any clinician misses a scheduled patient visit, a Missed Visit Report form will be completed by the clinician and faxed to the physician. 2. A copy of the fax confirmation sheet and completed missed visit report form will be filed in the patient’s clinical record…” A review of CRs was conducted on February 24, 2025, at approximately 2:15 PM and completed on February 26, 2025, at approximately 10:30 AM revealed the following: CR #3, Start of Care: 2/11/25: Certification period reviewed 2/11/25 through 4/11/25. The "Home Health Certification and Plan of Care" (POC) contained orders as follows: Home Health Aide (HHA) Monday through Friday, 8:30 AM to 4:00 PM. File contained documentation of a missed visit on 2/14/25. There was no documentation the physician was notified of the missed visit. CR #4, Start of Care: 8/24/24: Certification period reviewed 12/22/24 through 2/19/25. The POC contained orders as follow: "SN [Skilled Nursing] Saturday 3:00 PM to 7:00 AM, Sunday 2:00 PM to 10:00 PM, and every other Friday 11:00 PM to 7:00 AM for sixty (60) days. Provide backup coverage when primary agency unavailable. File contained documentation of missed visits on: 12/27/24; 12/28/24; 12/29/24; 1/11/25; 1/12/25; 2/1/25; and 2/2/25. There was no documentation the physician was notified of the missed visits. CR #6, Start of Care: 7/15/22, Discharge Date: 2/24/25: Certification period reviewed 12/31/24 through 2/28/25. The POC contained orders as follows: "SN [Skilled Nursing] twenty-four (24) hours daily for sixty (60) days shared with another agency. Elite provides services on Monday, Tuesday, Friday, Saturday, and Sunday 7:00 AM to 7:00 PM. File contained documentation of missed visits on: 12/31/24; 2/8/25; and 2/9/25. There was no documentation the physician was notified of the missed visits. CR #7, Start of Care: 4/25/24, Discharge Date: 1/13/25: Certification period reviewed 12/21/24 through 2/18/25. POC contained orders as follows: "HHA 3:00 PM to 3:00 AM, seven (7) days per week for sixty (60) days. File contained documentation of a missed visit on 12/30/24. There was no documentation the physician was notified of the missed visit. An interview with the Alternate Administrator conducted on February 26, 2025, at approximately 11:30 AM confirmed the above findings.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on a review of agency policy, observational patient home visit, and an interview with the agency Alternate Administrator, the agency failed to provide documentation of a current Plan of Care in the patient’s home for one (1) of two (2) observational patient home visited conducted, (OBS #1). Findings include: A review of agency policy titled “Patient/Family/Caregiver Education” conducted on February 28, 2025, at approximately 9:00 AM states, “Policy: It is the policy of Elite Home Health Care for all members of the home health care team to provide patients, caregivers and/or their families with specific education and information relevant to their care and services throughout the course of care up through and including the point of discharge. Procedure: E. The teaching that occurs to the patient, family and/or caregiver in home health is based on the knowledge base of each discipline and includes, but is not limited to, the following disciplines in the following content areas: Home Health Care Nurses: d. The patient/family plan of care…” Observational patient home visits were conducted on February 25, 2025, at 11:30 AM and 3:00 PM revealed the following: OBS #1, Arrived at the home of CR #1 at 11:30 AM on 2/25/25. Observed agency binder contained a Plan of Care for Certification Period 5/5/24 through 7/4/24. There was no documentation of a current Plan of Care in the home. An interview with the Alternate Administrator conducted on February 26, 2025, at approximately 11:30 AM confirmed the above findings.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on a review of agency policy, personnel records (PF), and an interview the agency Alternate Administrator, the agency failed to provide Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for two (2) of three (3) HHAs reviewed. Findings include: A review of agency policy titled “Inservice Education Programs” conducted on February 25, 2025, at approximately 2:30 PM states, “Procedure: 5. All Home Health Aides receive in-service education provided in accordance with the Home Health Inservice Education Policies with all aides attending a minimum of twelve (12) hours per year/per twelve (12) month period…” A review of PF's conducted on February 24, 2025, from approximately 11:00 AM to 2:10 PM revealed the following: PF #1, Date of Hire: 8/14/23, did not contain any documentation of twelve (12) hours of in-service education for 2024. PF #9, Date of Hire: 1/20/23, did not contain any documentation of twelve (12) hours of in-service education for 2024. An interview with the Alternate Administrator conducted on February 26, 2025, at approximately 11:30 AM confirmed the above findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with the agency Alternate Administrator, the agency failed to provide documentation the Home Health Aide (HHA) completed tasks as ordered on the Aide Care Plan for one (1) of four (4) CRs that receive HHA services, (CR # 5). Findings include: A review of agency policy titled “Charting/Observation Skills for Home Health Aides” conducted on February 28, 2025, at approximately 9:05 AM states, “Policy: The home health aide’s observations and documentation assist in keeping the patient’s plan of care up-to-date and guaranteeing that our agency continues to provide high quality home care. Procedure: Electronic Documentation of Care Provided: 1. Ensure Documentation Reflects the Plan of Care – Record all tasks completed as outlined in the Home Health Aide Plan of Care...3. Structured Documentation – Use designated fields to document completed tasks, observations, and any changes in the patient’s condition. 4. Narrative Notes – Include a brief but clear description of care provided, patient responses, and any concerns…” A review of CRs was conducted on February 24, 2025, at approximately 2:15 PM and completed on February 26, 2025, at approximately 10:30 AM revealed the following: CR #5, Start of Care: 2/15/24: Certification Period reviewed 2/9/25 through 4/9/25; contained a HHA/Homemaker Care Plan that includes the following tasks: Meal Preparation Daily and as needed (PRN); Oral Care/Hygiene Daily and PRN; Dressing Assist Daily and PRN; Feeding Assist Daily and PRN; Bathing Assist Daily and PRN; and Hair Care Daily and PRN. Random review of HHA visit documentation revealed the following: 2/10/25: Tasks listed: Meal Preparation; Oral Hygiene; Dressing; Eating or Drinking; Bathing; and Hair care. All tasks are marked as “incomplete” with no reason documented for not being completed. 2/13/25: Tasks listed: Meal Preparation; Oral Hygiene; Dressing; Eating or Drinking; Bathing; and Hair care. All tasks are marked as “incomplete” with no reason documented for not being completed. 2/18/25: Tasks listed: Meal Preparation; Oral Hygiene; Dressing; Eating or Drinking; Bathing; and Hair care. All tasks are marked as “incomplete” with no reason documented for not being completed. 2/24/25: Tasks listed: Meal Preparation; Oral Hygiene; Dressing; Eating or Drinking; Bathing; and Hair care. All tasks are marked as “incomplete” with no reason documented for not being completed. An interview with the Alternate Administrator conducted on February 26, 2025, at approximately 11:30 AM confirmed the above findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on a review of agency policy, personnel records (PF), and an interview the agency Alternate Administrator, the agency failed to be responsible for all day-to-day operations by not following its policies to provide documentation of the following: orientation documentation for four (4) of ten (10) PFs reviewed, (PF # 3, 5, 6, and 10); initial competency evaluation for two (2) of ten (10) PFs reviewed; Home Health Aide (HHA) documentation of twelve (12) in-service hours per year for two (2) of three (3) HHAs reviewed, (PF #1 and 9; (PF # 3 and 4); Hepatitis B vaccination documentation for two (2) of ten (10) PFs reviewed, (PF #1 and 9). Findings Include: A review of agency policy titled "Personnel/Contractor Records” conducted on February 25, 2025, at approximately 2:10 PM states, “Procedure: Elite Home Health Care maintains a master personnel record on each employee or contractor which contains relevant information with respect to each employee or contractor...1. Each personnel or contract file should contain, at a minimum, the following information: K. Orientation Checklist. L. Skills Checklist M. Competency Test…V. Completion of Any Training Programs…4. A. The Medical File should contain, at minimum, the following information: iii. Documentation of acceptance or declination of Hepatitis B vaccination…" A review of agency policy titled "Orientation” conducted on February 25, 2025, at approximately 2:15 PM states, “Policy: Elite Home Health Care’s orientation program assists new staff (employees/contractors) in understanding the values and cultures of the agency and providing a firm foundation on which to build their understanding of the home health program of care and services…Procedures: F. The signed orientation checklist is filed in the employee’s personnel file. 4. Providing Care or Performing Job Functions: A. Orientation is conducted with all staff prior to their assuming patient service/care responsibilities or performing job functions..." A review of agency policy titled, "Core Competency Skills/Employee Performance Criteria” conducted on February 25, 2025, at approximately 2:20 PM states, “Purpose: The purpose of this policy is to ensure that all agency personnel are able to display competence in skills specific to the agency’s needs on an annual basis…Procedure: Core Competency Skill: 2. Discipline specific Competency Skill Assessment Checklists will be reviewed with new personnel during their orientation based on their specific disciplines..." A review of agency policy titled “Inservice Education Programs” conducted on February 25, 2025, at approximately 2:30 PM states, “Procedure: 5. All Home Health Aides receive in-service education provided in accordance with the Home Health Inservice Education Policies with all aides attending a minimum of twelve (12) hours per year/per twelve (12) month period…” A review of agency policy titled “Access to Hepatitis B Vaccine” conducted on February 25, 2025, at approximately 2:25 PM states, “Policy: Elite Home Health Care provides all direct care personnel access to the Hepatitis B Vaccine in accordance with CDC and OSHA guidelines. Procedure: 2. The employee will be required to complete a Hepatitis B Vaccine Consent/Decline Form…” A review of PF's conducted on February 24, 2025, from approximately 11:00 AM to 2:10 PM revealed the following: PF #1, HHA Date of Hire: 8/14/23, did not contain any documentation of twelve (12) hours of in-service education for 2024 or a completed Hepatitis B Vaccine Consent/Decline Form. PF #3, LPN (licensed practical nurse) Date of Hire: 11/6/23, did not contain any documentation of orientation documentation or an initial competency/skills evaluation. PF #4, LPN Date of Hire: 8/3/23, did not contain any documentation of an initial competency/skills evaluation. PF #5, LPN Date of Hire: 5/15/24, did not contain any documentation of orientation documentation. PF #6, RN (registered nurse) Date of Hire: 10/3/24, did not contain any documentation of orientation documentation. PF #9, HHA Date of Hire: 1/20/23, did not contain any documentation of twelve (12) hours of in-service education for 2024 or a completed Hepatitis B Vaccine Consent/Decline Form. PF #10, RN Date of Hire: 4/12/22, did not contain any documentation of orientation documentation. An interview with the Alternate Administrator on February 26, 2025, at approximately 11:30 AM confirmed the above findings.