Every finding on record at Home Health Enterprise, LLC

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted in your facility from 05/18/2026 through 05/20/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484.102 - Emergency Preparedness Program. The unannounced, on-site Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. There were no regulatory deficiencies identified in the agency's Emergency Preparedness Program.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted in your facility from 05/18/2026 through 05/20/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484 - Home Health Services. The unannounced, on-site Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The active census on the first day of the survey was 51. There were seven patient records reviewed. There were three home visits conducted. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 observation, interview, and policy review, the facility failed to ensure written instructions were in the homes for 2 of 3 patients (Patient (P)2 and P3) who were selected for a joint visit with a clinician. The agency folder in each patient's home lacked current, written instructions of specific care and services to be provided. This deficient practice had the potential to prevent appropriate care and needed services from being provided as ordered by the physician for all patients on the agency's service. Findings include: On 05/19/2026 at 9:45 AM during a home visit with Home Health Aide (HHA1), a review of P3’s home folder was completed. The folder lacked a current Plan of Care (diagnoses, physician orders, specific written instructions of care and services to be provided, disciplines involved and visit frequencies). The Plan of Care (POC) was/is also known as the Centers for Medicare and Medicaid (CMS) 485. On 05/19/2026 at 10:00 AM during an interview, HHA1 could not explain why there was no current POC in P3's folder.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to show measurable indicators of documented events in the Quality Assurance Performance Improvement (QAPI) program for five months. The failure to monitor measurable indicators of events created missed opportunities for performance improvement and had the potential to affect all 51 current patients. Findings include: On 05/18/2026 at 10:20 AM during an interview, the Quality Assurance Manager (QAM) revealed the agency's "Back Office" was located in the Philippines. QAM verified the "Back Office" was responsible for communication with the patients to schedule clinician visits. The QAM provided a record of "QAPI Minutes of Meeting, dated January 2026 until May 2026. The record revealed the Back Office Manager (BOM) failed to document measurable indicators of tracked data which included the "Monitoring Back Office performance with focus on communication improvement". Between 01/02/2026 and 05/15/2026, the "Monitoring Back Office performance with focus on communication improvement" was documented as an issue in 13 of 14 "Minutes of Meeting" without measurable indicators to identify potential problems and to identify opportunities for improving care. The same QAPI "Minutes of Meeting" revealed the QAM failed to document measurable indicators of tracked data which included the "reminders to clinicians for pending documentation". Between 01/02/2026 and 05/15/2026 the "clinicians' timely submission of service notes" was documented as an issue in 11 of 14 "Minutes of Meetings" without measurable indicators to identify potential problems and to identify opportunities for improving care. On 05/20/2026 at 11:50 AM during an interview, Director of Clinical Operations verified the QAPI failed to show measurable indicators for communication improvement and missing documentation. The agency failed to provide a surveyor-requested policy for the agency's QAPI and measurable indicators improvement plan.

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 policy review, the agency failed to ensure personnel records accurately reflected infection control education and training for 5 of 5 sampled clinicians: Restorative Nursing Assistant (RNA1), Registered Nurse (RN), Home Health Aide (HHA1), Certified Nursing Assistant (CNA1), and Social Worker (SW). This deficient practice had the potential to affect all 51 patients currently receiving services from the agency. Findings include: On 05/20/2026 at 9:05 AM, the survey team requested access to the personnel training records for RNA1, RN, HHA1, CNA1, and SW to review and verify infection control training. On 05/20/2026 at 9:30 AM, the Director of Clinical Operations (DCO) confirmed the agency was unable to provide documentation that RNA1, RN, HHA1, CNA1, and SW participated in infection control training. The DCO stated training was completed without a staff signature to document attendance. The agency’s policy and procedure, "Attendance at Orientation and Training," with no documented reviewed date, revealed, "At or near the time of hire, all employees are required to be presented with the Agency's general orientation program and Employee Handbook and are required to attend all Agency orientation and training programs. Employee may also be required to attend further training programs, meetings, conferences, or other similar matters, and sign documents proving attendance at them. The refusal or failure of an employee to attend such programs or meetings or to sign documentation proving attendance, are grounds for disciplinary action up to and including termination."

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 record review, interview, and policy review, the agency failed to ensure 1) annual continuing education was tracked for 8 of 10 (Home Health Aides (HHA)1, HHA2, HHA3, HHA4, HHA5, HHA6, HHA7, HHA8) and 2) monthly in-service training for continuing education was completed by 1 of 2 (Restorative Nursing Assistants (RNA)1). This deficient practice of allowing staff to work without proper education had the potential to affect all patients receiving care from the above-identified HHAs and RNA. Findings include: Based on record review, interview, and policy review, the agency failed to ensure 1) annual continuing education was tracked for 8 of 10 (Home Health Aides (HHA)1, HHA2, HHA3, HHA4, HHA5, HHA6, HHA7, HHA8) and 2) monthly in-service training for continuing education was completed by 1 of 2 (Restorative Nursing Assistants (RNA)1). This deficient practice had the potential to affect all patients on service by allowing staff to work without proper education. Findings include: The agency provided an undated in-service list of annual education for aides, along with a list of staff and their date of hire (DOH). The two documents revealed the following information: - HHA1: There was no continuing education recorded since DOH on 02/18/2026. - HHA2: There was no continuing education recorded since DOH on 09/15/2025. - HHA3: There was one in-service recorded for the year (DOH 06/30/2025). - HHA4: There was no continuing education recorded for the year (DOH 08/06/2019). - HHA5: There was no continuing education recorded for the year (DOH 05/14/2019). - HHA6: There was no continuing education recorded since DOH on 10/31/2025. - HHA7: There was no continuing education recorded since DOH on 02/20/2026. - HHA8: There was no continuing education recorded since DOH on 02/20/2026. - RNA1: There was no continuing education recorded since DOH on 01/01/2026. On 05/18/2026 at 11:15 AM, the Administrative Assistant (AA) indicated the tracking was January through December. The AA explained, “Staff got their own training from the computer course . . . the facility had not been tracking the training.” On 05/19/2026 at 9:45 AM during an interview, HHA1 acknowledged receiving a schedule about available monthly in-services and continuing education. On 05/19/2026 at 11:45 AM during an interview, RNA1 denied being aware of any available monthly in-services and continuing education offerings. On 05/20/2026 at 9:33 AM, the Director of Nursing (DON) indicated there was no formalized program for tracking the staff education. The agency’s undated “In-Service Education” policy documented the following: “Purpose: To provide staff members with information, to improve Agency’s performance, and to ensure the competency of the Agency’s staff. Policy: The Agency provides in-services education programs for its staff. Procedure: 1. DON plans annual in-service calendar. . . 4. Home Health Aides must attend twelve (12) hours of in-service during each twelve (12) month period. The 12-month period shall begin on the Date of Hire. . . 5. Maintain an in-service notebook which contains: A) Inservice content materials. B) Minutes/Attendance sheets. C) Employee Inservice/ Continuing Education Record. . .”

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) from 06/20/22 to 06/21/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 06/20/22 to 06/21/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiency listed below.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for all patients receiving care from the HHA. Findings include: During an interview on 06/20/22 at 9:00 AM the Director of Nursing (DON) stated the agency uses a web-based electronic medical record (EMR) program called "Wellsky," that the agency does not provide electronic devices to access the EMR, and that staff access the program using their personal computers. Surveyor received a log-in and password to access the patient records in the web-based EMR. During review of patient information, the surveyor identified that the patient assessments, plan of care, visit notes, and personal information including address, date of birth, social security number, and insurance information could be saved to the computer desktop which allowed access when not logged into the web based EMR. During an interview on 06/21/22 at 8:45 AM, the DON provided the agency policy related to confidentiality of patient information and access to the EMR stating, "We have done training with all the staff on HIPAA, keeping the password confidential, and maintaining the security of patient information." The DON confirmed that it would be possible for staff to save the passwords used to access "Wellsky" and that patient information could be downloaded to the staff persons personal computer desktop. The DON also confirmed that the agency is not able to monitor, manage, or maintain the electronic devices owned by individual staff. The HHA does not have a policy that specifically addresses the use of personal computers for accessing the web-based EMR beyond the use of a log-in and password and training on confidentiality of patient information.