Every finding on record at Good Shepherd Acquisition LLC

An onsite recertification survey was conducted 03/03/2026-03/04/2026. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 03/03/2026- 03/04/2026. Deficiencies to the Medicare Conditions of Participation were identified.

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 policy and procedure, clinical record review, observation, and patient interview the agency failed to review all current medications for 1 of 1 home visits conducted (#3). Findings included: Review of policy “Medication Reconciliation”, revised 02/2021 was received from the agency director on 03/04/2026 at 0915. The policy stated,” …the medication list/profile will be updated with each new or changed medication…” Patient #3 was admitted on 05/28/2025 with diagnoses of chronic venous hyptertension with ulcer and inflammation of left lower extremity, and type 2 diabetes mellitus. The plan of care for 01/23/2026 to 03/23/2026 included the following orders: skilled nursing 1 time a week for 1 week, 3 times a week for 8 weeks. A home visit was conducted on 03/04/2026 at 0815 with the registered nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Aspirin (blood thinner) 81 milligrams take 1 tablet daily by mouth was not included on the home medication list or profile. Interview with the patient on 03/04/2026 at 0837 “I’ve been taking aspirin for a long, long time”.

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 policy review, client record review, and staff interview the agency failed to provide home health aide supervision for 2 of 2 home health aide records reviewed (#1 and #2). Findings included: Review of policy “Home Health Aide Supervision”, revised 02/2024 was received from the agency director on 03/04/2026 at 0915. The policy stated,” …all home health aide supervisory visits will be made at least every 14 days…” 1.Patient #1 had a SOC (start of care) of 12/05/2025 and included diagnoses of subdural hemorrhage (brain bleed) and muscle weakness. Home health aide orders were for 1 time a week for 4 weeks. Review of the medical record on 03/03/2026 revealed a supervisory visit was not completed the week of 12/22/2025. The aide supervisory visit was completed on 12/30/2025. No other supervisory visits were noted in the record. Interview with the agency director on 03/03/2026 at 0915 confirmed the aide supervisory visits were outside of the 14 days for both records reviewed. 2. Patient #2 had a SOC (start of care) of 01/15/2026 and included diagnoses of fracture of the right shoulder, phantom limb syndrome with pain and type 2 diabetes mellitus. Home health aide orders were for 2 times a week for 1 week and 1 time a week for 3 weeks. Review of the medical record on 03/03/2026 revealed no aide supervisory visits were completed. Interview with the agency director on 03/03/2026 at 0915 confirmed the aide supervisory visits were outside of the 14 days for both records reviewed.