Every finding on record at Good Shepherd Hospice and Home Care of Eastern Utah Inc.

Based on a recertification survey conducted from September 15, 2025, through September 23, 2025, it was determined that the home health agency was not in compliance with the Conditions of Participation for Emergency Preparedness, as outlined in 42 Code of Federal Regulations 484.22 and 484.102, and a deficiency was cited. Due to the federal government shutdown and resulting delays in survey processing, we have updated the survey exit date to December 5, 2025, to reflect the date the CMS 2567 was sent to the provider. This update, in accordance with CMS guidance, is to ensure sufficient time to submit a plan of correction and achieve compliance based on this revised date.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) could not provide evidence that the required in-service training of at least 12 hours during each 12-month period for 1 of 2 sampled home health aides had occurred. (Employee identifier: 3.) Findings include: Surveyors reviewed the medical records of patients 1, 2, 3, 4, 5, 6, and 7 on September 18, 2025. IEPs could not be found in any of the 7 patients' medical records. On September 16, 2025, at 4:06 PM, the licensor conducted a telephone interview with the assistant director of nursing (ADON). The ADON was asked to provide copies of IEPs for all patients reviewed. The ADON responded, “It is a verbal plan, it is done while going over the OASIS with patients at the admission visit, then the patient is referred to the admission packet for more information."

Based on a recertification survey conducted from September 15, 2025, through September 23, 2025, it was determined that the agency was not in compliance with the Conditions of Participation for Home Health Services, as outlined in 42 Code of Federal Regulations Part 484. Deficiencies were cited in the areas of 484.70 Infection prevention, 484.75 Skilled Professional, and 484.80 Home Health Aide Services. Due to the federal government shutdown and resulting delays in survey processing, we have updated the survey exit date to December 5, 2025, to reflect the date the CMS 2567 was sent to the provider. This update, in accordance with CMS guidance, is to ensure sufficient time to submit a plan of correction and achieve compliance based on this revised date.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure infection control education was provided for 6 of 7 sampled employee files. (Employee identifiers: 1, 2, 3, 5, 6, and 7.) Findings Include: Surveyors reviewed seven employee files for infection control training and prevention. There was no documented evidence that employees 1, 2, 3, 5, 6, and 7 had received infection control education in the past 3 years. On September 18, 2025, at 1:49 PM, the surveyor interviewed the administrator. The administrator stated, “I know infection control training is taught by the registered nurse (RN), but we cannot find documentation.”

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure participation in HHA-sponsored in-service training for 5 of 5 skilled professionals whose personnel records were reviewed. (Employee identifiers: 1, 2, 5, 6, and 7.) Findings include: Surveyors reviewed the agency's skilled professional personnel records for employees 1, 2, 5, 6, and 7 on September 17, 2025. No documentation regarding HHA-sponsored in-service trainings could be located in any of the skilled professional personnel records. On September 18, 2025, at 1:49 PM, the surveyor interviewed the agency Administrator. The Administrator stated that in-service training for the agency's aides was completed annually; however, in-service training had not been provided to skilled professionals.

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 interview and record review, it was determined that the home health agency (HHA) could not provide evidence that the required in-service training of at least 12 hours during each 12-month period for 1 of 2 sampled home health aides had occurred. (Employee identifier: 3.) Findings Include: Surveyors reviewed the agency's home health aide personnel records on September 17, 2024. There was no documented evidence that employee 3 had received any in-service training hours for the last 12 months. On September 18, 2025, at 1:49 PM, the surveyor interviewed the administrator. The administrator stated, “in-services for the agency's aides were completed annually.” The Administrator further stated he could not provide sign-in sheets because the registered nurse provides the teaching individually. No documented evidence could be provided to indicate that employee 3 had received any of the required in-service training.

Based on a recertification survey completed 3/7/2022 through 3/10/2022, it was determined that Good Shepherd Home Care was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22. No deficiencies were cited.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview, and record review, it was determined the home health agency (HHA) failed to provide care planning, coordination of services, and quality of care as required. Additionally, for 3 of 10 patients the HHA failed to provide enough documented evidence they met the needs of the patients. (Patient identifier: 4, 8, and 9) Findings include: 1. The HHA failed to ensure that all physician orders were recorded in the plan of care (Refer to tag G576) 2. Medical record reviews were completed on 3/10/22. 3 of 10 patients’ had referrals for occupational therapist (OT). There was no documented evidence that OT went out to see any of the three patients with OT referrals. The administrator documented in an email correspondence on 3/9/22 around 10:30 AM, they did not offer OT services and did not have OT on staff or contracted. When asked what if a patient required OT, he responded, “We inform the referring provider that we do not offer OT. The provider then decides that if they want us to proceed.” The administrator was then asked if they documented any communication with the provider or the patient that they do not offer OT services. He replied, “Being transparent, it could be more consistent, some do and some do not.” No documented evidence was provided that patients or providers were notified the HHA did not offer OT services, or that the patients OT needs were met. (Note: the HHA showed they offered OT services on their website)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure all patient care orders, including verbal orders, were recorded in the plan of care (POC). Specifically, 1 of 10 sampled patients did not have all orders included on their POC. (Patient identifier: 8) Additionally, 4 of 4 sampled patients with wounds did not have wound care orders on their POC. (Patient identifiers: 4, 8, 9, and 10) On 3/10/22 at 12:20 pm, an interview was conducted with the administrator. He stated their electronic medical record (EMR) software had not caught wound care orders transferring over to the patients' POC but he will make sure that happens one way or another so that it is now captured on their POC. Findings include: 1. During a recertification survey conducted on 3/7/22 through 3/10/22, four patients with wounds were selected for record review. 4 out of the 4 sampled patients did not have specific wound care orders on their POC. On 3/9/22 at 12:36 PM, an interview was conducted with the agency’s intake coordinator and administrator. The agency’s intake coordinator stated wound care orders are typically on the nursing notes for each visit. The POC only contains the frequency for visits and to discharge when healed. (Note: this tag was written out on the HHA's last survey conducted on 4/24/2019) On 3/10/22 at 12:20 PM, an interview was conducted with the administrator. He was asked what the facility’s expectations were for wound care assessments. He stated wounds should be assessed every week and should include measurements of the wound as to determine whether or not the wound is healing. He stated he had not been auditing to see if it was being done. When he was asked about their wound care policy he stated they have a wound care policy, but “it needs some work.” A review of the HHA wound care policy was completed on 3/10/22. The policy did not include accepted standards of practice for wound care. The agency did not provide evidence wound care was performed according to policy and accepted standards of practice, and per an individualized written plan of care. 2. Patient 8 was admitted on 12/06/21, with a diagnosis of stage 2 pressure ulcer on the right and left buttocks. Patient 8’s medical record review was completed on 3/10/22 and revealed the following: Patient 8’s POC from the certification period 12/06/21 through 02/03/22, had orders for skilled nursing (SN) to go out once a week for 9 weeks and 3 visits as needed. There was also an order for physical therapy (PT) to evaluate and treat. There was no updated order frequency for PT on the POC. On 1/24/22, an order was put in for “SN visits to 3 x week for wound care. Try to coordinate with HHA (home health aides) as jack requires x 2 assist to get up and family is not always available to assist.” The updated order was not included on the POC. On 3/9/22 at 12:36 PM, an interview was conducted with the agency’s intake coordinator and administrator. The intake coordinator stated she was not aware patient's POC needed to be updated with new orders. She stated they updated the POC every 60 days. Their system does not allow them to update the POC as new orders come in during the certification period.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and document review, it was determined the home health agency (HHA) failed to maintain a home health-wide, data-driven quality assessment and performance improvement (QAPI) program. Specifically, the HHA failed to develop, implement, evaluate, and maintain an effective, ongoing, QAPI program which reflected the complexity of its organization and services. Findings include: 1. The HHA failed to provide evidence they had developed, implemented, evaluated, and maintained an effective, ongoing, HHA-wide, data-driven QAPI program which reflected the complexity of its organization and services. Therefore none of the standards and accompanying tags under this condition (tag: G640) were met. (Tags: G642, G644, G646, G648, G650, G652, G654, G656, G658, and G660). 2. On 3/7/22, the following was requested from the HHA administrator: adverse event/grievance/complaint logs, QAPI plan, performance improvement projects (PIPs) , QAPI and governing body (GB) meeting minutes (MM), and infection control program and surveillance data for monitoring infections for patients & employees. The agency administrator could not provide the survey team with a QAPI program/plan, PIPs, or QAPI MM. Furthermore, the agency could not provide evidence that they were measuring or analyzing quality indicators. Lastly, no evidence could be provided to indicate the agency’s infection control program was a part of QAPI. GB MM for the month of February was reviewed. The GB MM was minimal and did not provide any evidence of a QAPI program which reflected the complexity of its organization and services. Additionally, the HHA could not provide evidence of GB oversight to ensure the HHA had an ongoing QAPI program. 3. In an interview with the HHA administrator on 3/10/22 at 9:02 AM, the administrator stated he did not have an official QA program. He stated they do not have any QAPI meeting minutes, projects or any tracking to provide. He was aware hospice needed a QAPI program, but was not aware home health needed a QAPI program as well.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to provide necessary oversight and supervision of the HHA. Specifically, the HHA failed to have a functioning governing body that ensured appropriate care planning, coordination of services, and quality care to meet the needs of the patients. The HHA failed to have a fully implemented and maintained quality assurance performance improvement (QAPI) program. Findings include: 1. The HHA failed to provide care planning, coordination of services, and quality of care as required. (Refer to tag G570) 2. The HHA governing body (GB) did not ensure that all physician orders were recorded on the plan of care (Refer to tag G576) 3. The HHA failed to fully develop, implement, evaluate, and maintain an effective, ongoing, QAPI program which reflected the complexity of its organization and services. (Refer to tag G640) 4. The HHA GB did not ensure the HHA had a functioning QAPI program. Additionally, the GB could not provide sufficient evidence they were involved in all the ongoing operations of the HHA. (Refer to tag G942)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not have a governing body (GB) that had assumed responsibility for the overall operation of the agency. Specifically, the GB did not ensure that services were provided to patients in accordance with Medicare requirements. Findings include: 1. The HHA's GB did not ensure compliance with the following: a. The GB did not fully implement and maintain a home health-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, the HHA did not fully develop, implement, evaluate, and maintain an effective, ongoing, QAPI program which reflected the complexity of its organization and services. In an interview with the HHA administrator on 3/10/2022 at 9:02 AM, the administrator stated he did not have an official QA program. He stated they do not have any QAPI meeting minutes, projects or any tracking to provide. He was aware hospice needed a QAPI program, but was not aware home health needed a QAPI program as well. b. The GB did not ensure all physician orders were recorded in the plan of care. On 3/9/2022 at 12:36 PM, an interview was conducted with the agency’s intake coordinator and administrator. The agency’s intake coordinator stated wound care orders are typically on the nursing notes for each visit. The POC only contains the frequency for visits and to discharge when healed. On 3/10/22 at 12:20 pm, an interview was conducted with the administrator. He stated their electronic medical record (EMR) software had not caught wound care orders transferring over to the patients' POC but he will make sure that happens one way or another so that it is now captured on their POC. c. The GB did not ensure coordination of care delivery to meet the needs of the patients. Specifically, the GB did not ensure that occupational therapy (OT) was provided to the patients that had orders for it. The administrator documented in an email correspondence on 3/9/22 around 10:30 AM, they did not offer OT services and did not have OT on staff or contracted. When asked what if a patient required OT he responded, “We inform the referring provider that we do not offer OT. The provider then decides that if they want us to proceed.” The administrator was then asked if they documented any communication with the provider or the patient that they do not offer OT services. He replied, “Being transparent, it could be more consistent, some do and some do not.” No documented evidence was provided of the provider or the patients being notified the HHA did not offer OT services.