Every finding on record at Essential Preventive Health Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/22/26. 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 01/22/26. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon OASIS = Outcome and Assessment Information Set % - Percent Pt./Pts. = Patient/Patients SN = Skilled Nurse RN = Registered Nurse PT = Physical Therapy OT = Occupational Therapy ST = Speech Therapy HHA = Home Health Aide POC = Plan of Care wk = week

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, for 385 of 588 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed. Findings include: 1. The Error Summary report for 10/01/24 to 12/19/25, was reviewed on 01/20/26 at 2:30 PM. The report included 385 of 588 late submissions, 65.48% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 11:30 AM, it was confirmed that the error occurred.

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: Based on clinical record review and staff interviews, for 2 of 7 (Pts. #4 and 1) clinical records reviewed, the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for home health care services. 2. Pt. #1 was admitted for home health services on 01/07/26 with a diagnosis of Type 2 Diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 01/22/26. The record contained a Physician order dated 12/29/25 for “SN, PT, HHA…” The initial assessment was conducted by the RN on 01/07/26. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 3. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 12:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date. During the same interview, the above findings were confirmed. Findings Include: 1. Pt. #4 was admitted for home health services on 10/21/25 with the diagnosis of Dysphagia, oropharyngeal phase. The clinical record was reviewed on 01/21/26. The referral for home health services signed by Physician on 10/07/25 and received by Agency on 10/09/25 documents: “ Attached is a referral for home health services for Pt. #4, who will be returning home on 10/16. She will need PT/OT/ST/RN.” The record lacked documentation the Agency initiated service within the required time frame.

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, for 2 of 7 (Pts. #3, and #6) the Agency failed to ensure the POC was followed. Findings include: 1. Pt. #3 was admitted for home health services on 08/15/25 with the diagnoses of but not limited to Pressure Ulcer of sacral region stage 2 and Type 2 Diabetes mellitus without complications. The clinical record was reviewed on 01/21/26. The POC effective 12/13/25 required, “SN: Assessment…of patient with…Type 2 diabetes mellitus without complications… Notify physician of Fasting Blood Sugar greater than 200 or less than 60…Random blood sugar greater than 250 or less than 60...“ The SN visit notes lacked documentation that the patient’s blood glucose was assessed and recorded on the clinical record by the SN. 2. Pt. #6 was admitted for home health services on 4/29/25 with the diagnosis of anxiety disorder. The clinical record was reviewed on 01/21/26 and included a POC for the certification period of 04/09/25 to 06/27/25. The POC required, “Orders and Treatments… SN: 1wk 9...” The record lacked documentation of an SN visit for the week of 05/25/25 to 05/31/25. 3. During an interview conducted with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 11:30 AM, the above findings

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on onsite observations and interviews during home visits, clinical record reviews and staff interviews, for 2 of 2 Pts. (Pt.#1 and 2) reviewed receiving Home Health Aide services, the Agency failed ensure that the written Pt. care instructions were based on RN assessment of the Pts. 2. Pt. #2 was admitted to home health services on 09/09/25 with the diagnosis of Phantom limb syndrome with pain. The clinical record was reviewed on 01/21/26. A home visit was conducted with HHA (Home Health Aide) on 01/21/26. During the home visit, the Pt. stated “the HHA comes twice a week to give me a shower”. The Aide Care plan reviewed prior to the visit documents under personal care: Complete bath and not a shower as stated by the pt. 3. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 10:15 AM and 11:40 AM, the Nursing Supervisor stated that the baths provided should be only either a complete bath or partial bath, or shower based on the assessment of the RN and that if during the home visit something changes, then the Aide Care Plan should be updated. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for skilled home health on 01/07/26 with a primary diagnosis of Type 2 Diabetes mellitus with diabetic polyneuropathy. A home visit was conducted with the PT on 01/22/26. During the home visit, the Pt. was asked regarding the type of bath the HHA provides and states, “gives me a shower, and I sit on the bench…” The clinical record was reviewed on 01/22/26 and included an Aide Care Plan that required the HHA to provide the Pt with both a “Complete bath" and a "Partial bath” during the same visit. The record lacked an individualized Aide Care Plan that was based on the assessment of the RN.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times w = week dk = dark # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients mg/dL = milligrams per deciliter PT = Physical Therapy/Therapist HHCCN = Home Health Change of Care Notice

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interviews, it was determined the Agency failed to ensure Pts./Pt. representatives are advised of the extent of their financial liability for care, and/or services before care is initiated. This was found in 5 of 7 (Pts. #1, 2, 3, 4 and 6) clinical records reviewed. Findings include: 1. The clinical records of the Pts. listed below were reviewed from 10/31/22 from 1:30 PM to 11/1/22 at 9:10 AM. Pt. #1. SOC: 10/14/22. Pt. #2. SOC: 10/4/22. Pt. #3. SOC: 5/26/22. Pt. #4. SOC: 6/2/22. Pt. #6. SOC: 4/15/21. The records contained a form that gave consent for the Pt. to receive service. The form included a section titled: "Responsibility for Payment", this section/record lacked documentation indicating the patient's/Pt. representative's financial responsibility. 2. During an interview with the Assistant Administrator and the Assistant Director of Nursing on 11/2/22 at 10:35 PM and 1:30 PM, both confirmed the Agency failed to ensure Pts./Pt. representatives were advised of their financial liability for care and/or services.

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: A. Based on a review of clinical records and staff interviews, it was determined the Agency failed to ensure staff provide care and/or service as specified in the POC. This was found in 3 of 7 (Pts. #2, 4 and 5) clinical records reviewed. 3. Pt. #5. SOC 10/6/22. Primary Diagnosis: Unspecified Psychosis Not Due To A Substance Or Known Physical Condition. The clinical record was reviewed on 11/2/22 at 10:30 AM. The record included a POC effective 10/6/22 requiring, "Orders and Treatment: PT: To eval and treat…” The record lacked documentation of a PT evaluation, and/or documentation that PT visits were provided. 4. During an interview with the Assistant Administrator and Assistant Director of Nursing on 11/2/22 at 10:35 AM and 1:30 PM, it was stated that the visits should be provided as required in the POC. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #2. SOC 10/4/22. Primary Diagnosis: Parkingson's Disease. The clinical record was reviewed on 10/31/22 at 2:40 PM. The record contained the POC effective 10/4/22, requiring the SN to provide service "1w9". As of 10/31/22, the record lacked a SN visit during the weeks of 10/9/22 to 10/15/22 and 10/16/22 to 10/22/22. 2. Pt. #4. SOC 6/2/22. Primary Diagnosis: Unspecified Open Wound of Right Great Toe without Damage to Nail. The clinical record was reviewed on 10/31/22 at 1:30 PM. The record contained the POC for the certification period of 8/1/22 to 9/29/22 requiring the Home Health Aide to provide service "1w9". As of 10/31/22, the record lacked a Home Health Aide visit during the week of 9/11/22 to 9/17/22. The POC effective 9/30/22 required the Home Health Aide to provide service "1w9". As of 10/31/22, the record lacked a Home Health Aide visit during the weeks of 10/2/22 to 10/8/22, 10/9/22 to 10/15/22 and 10/16/22 to 10/22/22.

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: A. Based on clinical record review, observation and interview during home visit, review of Agency policy and staff interviews, it was determined the Agency failed to ensure that changes in the patient's condition and/or concerns are communicated to the members of the healthcare team, caregivers and with the physician to ensure Pt. needs were identified and addressed. This was found in 2 of 3 (Pts. #2 and 3) Pts. wherein home visits were conducted. 2. Pt. #3. SOC 5/26/22. Diagnoses: Moderate Recurrent Major Depressive Disorder and Dysuria. The clinical record was reviewed on 10/31/22 at 4:20 PM. The record contained the "Physician Order" dated 6/13/22 that required: "Urine Analysis and Culture Sensitivity test...". The laboratory that conducted the Urine Analysis (Urinalysis) test faxed the results to the Agency on 6/15/22. The results included: "few bacteria, large blood, hazy appearance, dk. yellow color, 30 mg/dL protein". A home visit was conducted on 11/1/22 at 11:00 AM with the Assistant Director of Nursing. During the home visit, an interview was conducted with the Pt. and caregiver. The caregiver stated that several months ago the Pt. had difficulty urinating and that a "lab person came to the house to get urine for a urine test... We had to wait several weeks before getting the results...had to call the doctor to get the results, the doctor ordered an antibiotic." As of 10/31/22, the record lacked documentation the SN coordinated care with the Physician and/or the Pt./patient's representative regarding the Urinalysis test results. 3. The Agency policy titled; "Coordination of Services" was reviewed on 11/2/22 at 2:45 PM. The policy required: "...2. The following are essential components of professional coordination and supervision of services... c. Maintaining efficient communication with patient, family, physician, and all care providers to ensure prompt transmission of significant information which may require immediate action or decision-making... g. Documenting...lab work, physician contact, etc..." 4. During an interview with the Assistant Administrator and the Assistant Director of Nursing on 11/2/22 at 10:35 PM and 1:30 PM, both confirmed the Agency failed to ensure that changes in the Pts. condition and/or concerns were communicated to the members of the healthcare team, caregivers, patient's representative, and with the physician to ensure Pt. needs were identified and addressed. Findings include: 1. Pt. #2. SOC 10/4/22. Primary Diagnosis: Parkinson’s Disease. The clinical record was reviewed on 10/31/22 at 2:40 PM. A home visit was conducted with Employee #6 on 11/1/22 at 1:00 PM. During the home visit, Employee #6 observed that Pt. #2 had a nickel-sized purplish discoloration on the left hand. During the same visit, Employee #6 asked Pt. #2, the patient’s Power of Attorney and facility nurse "Where did the bruise on the left hand come from?" to which they all answered that they did not know where it came from or how it came about. During an interview conducted with the Assistant Director of Nursing and the Assistant Administrator on 11/2/22 at 1:30 PM, it was stated as of the time of the interview, Employee #6 had not communicated the observation of a discoloration on Pt. #2’s hand to the healthcare team and the Physician; and the record lacked documentation of the change in the patient's condition.

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 review of clinical records 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 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. 2. Pt. #7. SOC 9/2/21. Primary Diagnosis: Schizoaffective Disorder. The closed clinical record was reviewed on 11/1/22 at 10:30 AM. An SN Discharge comprehensive assessment dated 12/29/21 indicated that Pt.#7 was discharged from the Agency. The clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the Physician. 3. During an interview with the Assistant Administrator and Assistant Director of Nursing on 11/2/22 at 10:35 AM and 1:30 PM, it was stated the Discharge Summary should be sent to the Physician. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #6. SOC 4/15/21. Primary Diagnosis: Other Hypotension. The closed clinical record was reviewed on 11/1/22 at 9:10 AM. The record contained the SOC comprehensive assessment dated 4/15/21, indicating the SN initiated service. The SN continued to provide service until the Pt. was discharged from the Agency on 4/6/22. As of 11/1/22, the record lacked documentation that a copy of the Agency's "Discharge Summary" was forwarded to the Physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records and staff interviews, it was determined the Agency failed to ensure that documentation entered into the clinical record was complete. This was found in 4 of 7 (Pts. # 3, 4, 6 and 1) clinical records reviewed. 4. Pt. #1. SOC 10/14/22. Primary Diagnosis: Unspecified Open Wound of Scalp. The clinical record was reviewed on 10/31/22 at 2:30 PM. The record contained the forms “Notice of Medicare Non-Coverage” and “Home Health Change of Care Notice (HHCCN).” The forms were signed and dated by the Pt. but were not filled out. 5. During an interview conducted with the Assistant Administrator and Assistant Director of Nursing on 11/2/22 at 10:35 AM and 1:30 PM, it was stated that the forms should be accurate and complete. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #3. SOC 5/26/22. Diagnoses: Moderate Recurrent Major Depressive Disorder and Dysuria. The clinical record was reviewed on 10/31/22 at 4:20 PM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) signed by the Pt. The form required the SN to document the items/services to change, effective date of the change and the reason for giving the Pt. the form to review and sign. The form was left blank, it lacked the date the Pt. signed the form, and the required information indicated above as required by the CMS form. 2. Pt. #4. SOC 6/2/22. Primary Diagnosis: Unspecified Open Wound of Right Great Toe without Damage to Nail. The clinical record was reviewed on 10/31/22 at 1:30 PM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) signed by the Pt. The form was left blank, it lacked documentation of the items/services to change, effective date of the change, the reason for giving the Pt. the form, and the date the Pt. signed the form. 3. Pt. #6. SOC 4/15/21. Primary Diagnosis: Other Hypotension. The closed clinical record was reviewed on 11/1/22 at 9:10 AM. The record contained the form titled, "Home Health Change of Care Notice (HHCCN) signed by the patient's representative and dated 4/17/21. The form was left blank, it lacked documentation of the items/services to change, effective date of the change and the reason for giving the patient's representative the form.