Every finding on record at Healthstar Medical Services Inc

Purpose of the visit: Recertification and licensure survey. Entrance conference date was12/02/2025. The census was 4: 0 Licensed and Certified, 0 Licensed Home Health, and 4 Personal Assistance Services patients. Abbreviations: DON- Director of Nurses / Supervising Nurse

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every 2 years, and that was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach that included strategies for addressing emergency events identified by the risk assessment for 1of 1 emergency preparedness plan. This failure meant the agency’s efforts to keep patients and staff safe during emergencies could not be determined. Clients and staff were subjected to unsafe care and services. During the entrance conference 12/02/2025 at 11:30 AM the surveyor requested all Emergency preparedness documents for the survey review period November 2022 to November 2025 in writing and verbally to the Administrator and DON. The surveyor requested all Emergency preparedness documents again on 12/03/2025. No Emergency preparedness documents plan risk assessments were provided by the end of the survey. During an interview on 12/03/2025 with the Administrator at 1 PM. The surveyor asked about the missing Emergency preparedness program documentation of risk assessments to provide to the surveyor. The Administrator stated: The DON is the Disaster Coordinator, and the surveyor would need to speak with him for that information. During an interview with the DON / Disaster Coordinator on 12/03/2025 at 1:02 PM the surveyor asked about the agency’s risk assessment, the records for the required risk assessment update at least every 2 years for the last three years. The DON / Disaster Coordinator stated: “I didn’t do it.” The surveyor asked about the plan requirements and agency policy and procedures for emergency preparedness risk assessments. The DON / Disaster Coordinator stated the policy, and plan required risk assessment, review, and updates annually. The surveyor asked about the effect on the agency patients. The Disaster Coordinator / DON stated they had a backup agency to take care of the patients if the agency cannot, and funds were available to care for the patients. The surveyor asked why the agency had not documented the risk assessment. The Disaster Coordinator stated he was just returning to work from a serious illness. “That’s not an excuse, and I was gone for 6 months.” The surveyor asked what the biggest risks to the agency patients and the agency were. The Disaster Coordinator / DON stated: “That would be finding attendants. This is becoming a big issue. I can’t find one to go from one place to another because of the pay, and I can’t find anyone to go. It is too low, the pay.” The surveyor asked what the agency’s policy on the risk assessment was. The Disaster Coordinator / DON stated: “Ensure the safety of the patients and have the resources to care for the patients”. The surveyor asked if the policy required the risk assessment to be documented. The Disaster Coordinator / DON stated: “Yes, I haven’t done that since I came back to work.” The surveyor asked how this could affect the patients. The Disaster Coordinator / DON stated: “It is difficult for someone to jump in and implement (the plan). We still need to have it documented. l don’t have an excuse, it needs to be here.” Agency policy and procedures: “Emergency Preparedness and Response Plan Reviewed:”100112” read in part: “Purpose - To ensure Agency develops, maintains, and implements a written Emergency Preparedness and Response Plan, based on the Agency’s risk assessment. To establish a plan of action for providing continuous patient care and continuous business operations, I the event of a disaster. To ensure compliance with “Emergency Preparedness Planning and Implementations”, Licensing Standards for Home and Community Support Services Agencies… Policy-… The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in Agency’s service area…”

Purpose of the visit: Recertification and licensure survey. Entrance conference date was12/02/2025. The census was 4: 0 Licensed and Certified, 0 Licensed Home Health, and 4 Personal Assistance Services patients. The agency was in compliance with the Conditions of Participation for Home Health agencies.

Purpose: Recertification Survey Entrance Date: 11/28/2022 Census Licensed and Certified- 0 patients The agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification Survey Entrance Date: 11/28/2022 Census Licensed and Certified- 0 patients

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to comply with 42 Code of Federal Regulations, 405.1200 through 405.1204, in 4 (#2, #5, #6,#7) of 4 discharge patient records reviewed where the patients were discharged with goals met. The agency did not provide proper written notice in advance of terminating on-going care. The failure resulted in the patients were unable to exercise their right to dispute discharge from the home health agency. "§ 405.1200 - Notifying beneficiaries of provider service terminations. (a) Applicability and scope. (1) For purposes of §§ 405.1200 through 405.1204, the term, provider, is defined as a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice. (2) For purposes of §§ 405.1200 through 405.1204, a termination of Medicare-covered service is a discharge of a beneficiary from a residential provider of services, or a complete cessation of coverage at the end of a course of treatment prescribed in a discrete increment, regardless of whether the beneficiary agrees that the services should end. A termination does not include a reduction in services. A termination also does not include the termination of one type of service by the provider if the beneficiary continues to receive other Medicare-covered services from the provider. (b) Advance written notice of service terminations. Before any termination of services, the provider of the service must deliver valid written notice to the beneficiary of the provider's decision to terminate services. The provider must use a standardized notice, as specified by CMS, in accordance with the following procedures: (1) Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the beneficiary's services are expected to be fewer than 2 days in duration, the provider must notify the beneficiary at the time of admission to the provider. If, in a non-residential setting, the span of time between services exceeds 2 days, the notice must be given no later than the next to last time services are furnished. (2) Content of the notice. The standardized termination notice must include the following information: (i) The date that coverage of services ends; (ii) The date that the beneficiary's financial liability for continued services begins; (iii) A description of the beneficiary's right to an expedited determination under § 405.1202, including information about how to request an expedited determination and about a beneficiary's right to submit evidence showing that services must continue; (iv) A beneficiary's right to receive the detailed information specified under § 405.1202(f); and (v) Any other information required by CMS. (3) When delivery of the notice is valid. Delivery of the termination notice is valid if - (i) The beneficiary (or the beneficiary's authorized representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents; and (ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section. Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 6/26/2022 to 8/24/2022. The Plan of Care indicated that Patient #2 started on the agency's services on 2/26/2022. The record contained a consent for services that indicated Patient #2 was a Medicare patient. Patient #2's record contained a Discharge Summary that indicated that Patient #2 was discharged from the agency's services on 8/24/2022. Patient #2's record did not contain evidence that Patient #2 had been given the standardized notice, specified by CMS (Form CMS 10123) that included the following information: Date the coverage of services end; Date that the beneficiary's financial liability for continued services begins; Description of the patient's right to an expedited determination including information on how to request an expedited determination and how to submit evidence that services must continue; The right to receive the detailed information specified of the responsibilities of the provider. Patient #5: Record review of Patient #5's clinical record revealed a Plan of Care dated 5/27/202 to 7/25/2020. The Plan of Care indicated that Patient #5 had started on the agency's services on 4/3/2019. The record contained a consent for services that indicated Patient #5 was a Medicare patient. Patient #5's record contained a Discharge summary that indicated that Patient #5 was discharged from the agency's services on 7/25/2020. Patient #5's record did not contain evidence that Patient #5 had been given the standardized notice, specified by CMS (Form CMS 10123) that included the following information: Date the coverage of services end; Date that the beneficiary's financial liability for continued services begins; Description of the patient's right to an expedited determination including information on how to request an expedited determination and how to submit evidence that services must continue; The right to receive the detailed information specified of the responsibilities of the provider. Patient #6; Record review of Patient #6's clinical record revealed a Plan of Care dated 5/12/2020 to 7/10/2020. The Plan of Care indicated that Patient #6 started on the agency's services on 11/14/2019. The record contained a consent for services that indicated Patient #6 was a Medicare patient. Patient #6's record contained a discharge summary that indicated that Patient #6 was discharged from the agency's services on 7/10/2019. Patient #6's record did not contain evidence that Patient #6 had been given the standardized notice, specified by CMS (Form CMS 10123) that included the following information: Date the coverage of services end; Date that the beneficiary's financial liability for continued services begins; Description of the patient's right to an expedited determination including information on how to request an expedited determination and how to submit evidence that services must continue; The right to receive the detailed information specified of the responsibilities of the provider. Patient #7: Record review of Patient #7's clinical record revealed a Plan of Care dated 7/2/2022 to 8/30/2022. The Plan of Care indicated that Patient #7 started on the agency's services on 3/4/2022. Patient #7's record contained a Discharge Summary that indicated that Patient #7 was discharged on 8/30/2022. Patient #7's record did not contain evidence that Patient #7 had been given the standardized notice, specified by CMS (Form CMS 10123) that included the following information: Date the coverage of services end; Date that the beneficiary's financial liability for continued services begins; Description of the patient's right to an expedited determination including information on how to request an expedited determination and how to submit evidence that services must continue; The right to receive the detailed information specified of the responsibilities of the provider. During an interview on on 12/1/2022 at approximately 11:15 a.m. with the Supervising Nurse, the surveyor discussed the Medicare Discharge Notice and that the patients had not received the 2-day Medicare notice that was on a Medicare specified form. The Supervising Nurse stated, "Not the 5 day notice?" The surveyor discussed with the Supervising Nurse that Medicare required a specific form that included information so that patients could appeal discharge from an agency. The Supervising Nurse stated, "I agree" that a Medicare specific discharge notice had not been given to the patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to individualize the Plans of Care to include patient-specific interventions for heart failure monitoring with reporting parameters for 3 (#2, #3, and #4) of 3 discharged patients with a diagnosis of heart failure. The failure placed the patients at risk of exacerbations of heart failure, emergency room visits, and hospitalizations. Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 6/26/2022 to 8/24/2022. The Plan of Care indicated that Patient #2 started on the agency's services on 2/26/2022. The Plan of Care listed Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart failure as a diagnosis. The Plan of Care listed Furosemide (diuretic - used to treat excess fluid retention (edema) and swelling caused by congestive heart failure) as a medication. Review of Patient #2's Plan of Care between 6/26/2022 through 8/24/2022 indicated Heart Failure interventions with reporting parameters were not included in the Plan of Care. Patient #3: Record review of Patient #3's clinical record revealed a Plan of Care dated 1/8/2020 to 3/7/2020. The Plan of Care indicated that Patient #3 started on the agency's services on 7/12/2019. The Plan of Care listed Unspecified Systolic (Congestive) Heart Failure as a diagnosis. The Plan of Care listed Furosemide as a medication. Review of Patient #3's Plan of Care between 1/8/2020 and 3/7/2020 indicated Heart Failure interventions with reporting parameters were not included in the Plan of Care. Patient #4: Record review of Patient #3's clinical record revealed a Plan of Care dated 8/18/2021 to 10/16/2021. The Plan of Care indicated that Patient #4 started on the agency's services on 4/20/2021. The Plan of Care listed Acute Diastolic (Congestive) Heart Failure as a diagnosis. The Plan of Care listed Furosemide and Carvedilol (used to treat Heart Failure) as medications. Review of Patient #4's Plan of Care between 8/18/2021 to 10/16/2021 indicated Heart Failure interventions with reporting parameters were not included in the Plan of Care. During an interview on 12/1/2022 at approximately 11:15 a.m. with the Supervising Nurse, the surveyor discussed the finding that the Plans of Care did not include heart failure interventions with reporting parameters. The Supervising Nurse reviewed the Plans of Care for Patients 2, 3, and 4. The Supervising Nurse stated, "There is no weight, should be on Plan of Care. That is a great omission." The surveyor asked what was the agency's policy regarding heart failure, for patients with a diagnosis of heart failure. The Supervising Nurse stated, "We would weigh at visit and report a weight gain of five pounds in a week. We teach the patient to weigh. We measure the legs (for patients that were not able to be weighed)." The agency had a policy titled "Plan of Care" and was labeled PC.8. The policy read in part:..."Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems...Policy I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient's/client's problems and/or needs...Procedure...III. Each patient/client 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/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. the individualized plan of care must also specify the patient/client and caregiver education and training. A. The individualized plan of care must include the following: All pertinent diagnoses; The patient's/client's mental, psychosocial, and cognitive status; The types of services, supplies, and equipment required; The frequency and duration of visits to be made; Prognosis; Rehabilitation potential; Functional limitations; Activities permitted; Nutritional requirements; All medications and treatments; Safety measures to protect against injury; A description of the patient's/client's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Patient/client and caregiver education and training to facilitate timely discharge; Patient/client-specific interventions and education; Measurable outcomes and goals identified by the HHA and the patient/client; Information related to any advanced directives; and Any additional items the HHA or physician or allowed practitioner may choose to include." "Furosemide...Indications and Dosages...Edema (swelling) and Hypertension (high blood pressure)...Adverse Reactions...CV (cardiovascular): orthostatic hypotension (low blood pressure)...Metabolic: volume depletion...Nursing considerations: Monitor weight... Comerford, Karen C., ed, Nursing Drug Handbook.35th Edition. Philadelphia: Wolters Kluwer, 2015.Print. Pages 664 - 667. "Heart Failure. Heart Failure, also called congestive heart failure (CHF), is a clinical syndrome that results from the heart's inability to pump the amount of oxygenated blood necessary to meet the metabolic requirements of the body...Signs and Symptoms...edema (swelling) of ankles, unexplained weight gain...liver congestion...distended neck veins,,,abnormal fluid in body cavities...Cardiovascular findings...Cardiomegaly (enlargement of the heart)...Ventricular gallop...Rapid Heart rate...Development of pulsus alternans (alteration in strength of beat)...Management Treatment is directed at eliminating excessive accumulation of body water, increasing the force and efficiency of myocardial contraction and reducing the workload of the heart...Diuretics...eliminate excess body water and decrease ventricular pressures...Patient Education...Teach the signs and symptoms of recurrence. Watch for: gain in weight - report weight gain of more than 2-3 pounds in a few days...." Stead, Lisa. ed. The Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott-Raven Publishers. Pages 382 - 385.