Every finding on record at K S Home Healthcare Inc

An Emergency Preparedness recertification survey was initiated on 02/26/2026. Census: Licensed and Certified: 0 Licensed Home Health: 10 Personal Assistance Services: 21 The agency was in compliance with the Medicare Conditions of Participation for Emergency Preparedness and no deficiencies were cited.

A Recertification survey was initiated on 02/26/2026. Census: Licensed and Certified: 0 Licensed Home Health: 10 Personal Assistance Services: 21 Acroynym: OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services IQIES- Quality Improvement and Evaluation System DON- Director of Nurses LHH- Licensed Home Health

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 record review and interview, the agency failed to transmit completed OASIS assessments (a tool used by CMS to collect certain patient information to measure patient service needs and measure care quality) to the CMS, within 30 days of completing the OASIS assessment of the beneficiaries (patients) for 5 (Patients #1, 2, 3, 4 and 5) of 5 active patient records reviewed. From 01/01/2025 through 01/01/2026, 1 OASIS assessment was transmitted greater than 30 days from the assessment date. This failure prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. FINDINGS INCLUDE: Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the IQIES (A CMS data based system for patient analysis and care trends) revealed 1 assessment contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 (the date the assessment is finished) on this new record.” Patient #1: Review of the record showed an OASIS assessment was completed on 10/01/2025 for the certification period 10/01/2025-11/29/2025. The OASIS assessment had not been submitted to IQIES. Patient #2: Review of the record showed an OASIS assessment was completed on 10/27/2025 for the certification period 10/27/2025-12/25/2025. The OASIS assessment had not been submitted to IQIES. Patient #3: Review of the record showed an OASIS assessment was completed on 02/03/2025 for the certification period 02/03/2025 to 04/30/2025. The OASIS assessment had not been submitted to IQIES. Patient #4: Review of the record showed an OASIS assessment was completed on 10/23/2025 for the certification period 10/23/2025-12/21/2025. The OASIS assessment had not been submitted to IQIES. Patient #5: Review of the record showed an OASIS assessment was completed on 11/17/2025 for the certification period 11/17/2025-01/15/2026. The OASIS assessment had not been submitted to IQIES. On 03/03/2026 at approximately 3:00 PM, at 2:30 PM, the surveyor reviewed the findings with the Administrator, DON and Consultant H. The surveyor asked who was responsible in the agency to submit the OASIS assessments to the IQIES portal for CMS. Consultant H stated she was the one who submitted OASIS assessments. The surveyor asked why the OASIS assessments for Patients #1-5 were not submitted. Consultant H stated, “I didn’t think they (OASIS assessments) had to be submitted because all the patients were from (Healthcare Provider, Identifier G) and are under the LHH category. I just didn’t know about the new rule.” The Administrator stated he was not aware they (OASIS assessments) needed to be submitted for the patients from Healthcare Provider, G either. Agency Policy, dated 02/01/2026, quoted in part, “Initial Patient/Client Comprehensive Assessment, … Policy: … II. A. The collection and submission of OASIS data includes all patients/clients, regardless of payer source, who begin receiving home healthcare services on or after July 1, 2025. …”

Purpose of visit: Recertification/Relicensure Survey Entrance: 02/16/2023 at 10:45 AM with the Administrator/Director of Nursing. Agency Census: Licensed and Certified Home Health Services-4 Licensed Home Health Services-13 Personal Assistance Services-0 Exit Conference was conducted on 02/22/2023 with the Administrator/Director of Nursing and the Office Manager at 4:54 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations Plan of Care (POC) Quality Assessment Performance Improvement Plan (QAPI). As needed-(PRN) Milligram-(MG) Milliliter-(ML)

Purpose of visit: Recertification/Relicensure Survey Entrance: 02/16/2023 at 10:45 AM with the Administrator/Director of Nursing. Agency Census: Licensed and Certified Home Health Services-4 Licensed Home Health Services-13 Personal Assistance Services-0 Exit Conference was conducted on 02/22/2023 with the Administrator/Director of Nursing and the Office Manager at 4:54 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations Plan of Care (POC) Quality Assessment Performance Improvement Plan (QAPI). As needed-(PRN) Milligram-(MG) Milliliter-(ML)

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: THIS IS A CONTINUED DEFICIENCY CITED AT G158 ON SURVEY DATED 03/24/2017 AND CITED AT G572 ON SURVEY DATED 03/09/2020. Based on record review and interviews, the agency failed to ensure that each patient received the services that were written in their individualized plans of care for four of four (Patients 1,2, 3 and 4) records reviewed. The patients’ weights were not assessed by skilled nursing services as ordered for four of four (Patients 1, 2, 3 and 4) records reviewed and nursing visits were not made as ordered for two of four patients (Patients 1 and 3). This failure placed the patients at risk of not receiving interventions as needed and could potentially cause complications and a decline in health status. Findings include: Patient Record #1: The medical record contained a plan of care (POC) for the certification period 12/08/2022 to 02/05/2023 digitally signed by Physician A, on 12/21/2022. The POC included a principal diagnosis of Peripheral vascular disease unspecified and other diagnosis Dependence on supplemental oxygen, and Dependence on real dialysis. The plan of care included orders for the skilled nurse to visit the patient once a week for nine weeks effective 12/08/2022. The medical record did not contain a skilled nursing visit for the week of 12/08/2022 and only contained eight of nine skilled nurse visits. The POC contained orders for the skilled nurse to assess the patient's weight every week. The medical record contained skilled nursing visits conducted by RN A; however, the note dated 02/02/2023 did not contain a weight performed by the skilled nurse. During an interview on 02/22/2023 at approximately 2:19 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, “I spoke with the nurse, and she couldn’t explain why the weight wasn’t done. The nurse wrote the nurse frequency wrong for the nurse visits. It was overlooked by me and QA (Quality Assurance).” Patient Record #2: The medical record contained a plan of care (POC) for the certification period 11/10/2022 to 01/08/2023 digitally signed by Physician A, on 11/29/2022. The POC included a principal diagnosis of Hypertensive heart disease without heart failure and other diagnosis Type 2 diabetes mellitus with diabetic polyneuropathy. The POC contained orders for the skilled nurse to assess the patient's weight every week. The medical record contained skilled nursing visits conducted by LVN A on 11/10/2022, 11/17/22, 11/23/22, 12/01/22, 12/08/22, 12/15/22, 12/22/22 and 12/29/22 did not contain weights performed by the skilled nurse. The medical record contained skilled nursing visit conducted by RN A on 01/04/23 did not contain a weight performed by the skilled nurse. During an interview on 02/22/2023 at approximately 2:32 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, “I can’t say what happened. I don't know the weights were not done. It was a mistake." Patient Record #3: The medical record contained a plan of care (POC) for the certification period 11/24/2022 to 01/22/2023 digitally signed by Physician A, on 12/22/2022. The POC included a principal diagnosis of Hypertensive heart disease with heart failure and other diagnosis Chronic pain syndrome, Presence of cardiac pacemaker. The plan of care included orders for the skilled nurse to visit the patient once a week for nine weeks effective 11/24/2022. The medical record did not contain a skilled nursing visit for the week of 11/24/2022 and only contained eight skilled nurse visits. The POC contained orders for the skilled nurse to assess the patient's weight every visit. The medical record contained skilled nursing visits conducted by LVN A on 11/30/2022, 12/07/22, 12/14/22, 12/21/22, 12/28/22, 01/04/22, and 01/11/22 did not contain weights performed by the skilled nurse. The medical record contained skilled nursing visit conducted by RN A on 01/18/23 did not contain a weight performed by the skilled nurse. During an interview on 02/22/2023 at approximately 2:40 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, “I can’t say what happened. I don't know the weights were not done. The nurse documented the wrong nurse frequency for the nurse visits. It was a mistake." Patient Record #4: The medical record contained a plan of care (POC) for the certification period 11/29/2022 to 01/27/2023 digitally signed by Physician A, on 12/18/2022. The POC included a principal diagnosis of Hypertensive heart disease with heart failure and other diagnosis Rheumatoid arthritis, unspecified. The POC contained orders for the skilled nurse to assess the patient's weight every visit. The medical record contained skilled nursing visits conducted by LVN B on 12/09/22, 12/14/22, 12/21/22, 12/29/22, 01/05/23, 01/12/23 and 01/18/23 did not contain weights performed by the skilled nurse. The medical record contained skilled nursing visit conducted by RN A on 01/23/23 did not contain a weight performed by the skilled nurse. During an interview on 02/22/2023 at approximately 2:40 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, “I can’t say what happened. I don't know the weights were not done.” Agency Policy with a revision date of 01/01/22 read in part, "... Plan of Care PC.8 ...V…. Each patient/client must receive the home health services that are written in an individualized plan of care that identifies patient/client specific measurable outcomes and goals…"

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 develop a POC that covered all pertinent elements in 2 of 4 (Patient #3 and #4) records reviewed. The patients’ POCs failed to include pain parameters to notify the they physician of out-of-range levels of pain. . These failures placed Patient #3 and #4 at risk for inadequate pain control, exacerbation of orthopedic complications and falls. This failure also placed all the named patients at risk of subsequent emergency room visits and/or hospital re-admissions. FINDINGS INCLUDE: Patient Record #3: The medical record contained a plan of care (POC) for the certification period 11/24/2022 to 01/22/2023 digitally signed by Physician A, on 12/22/2022. The POC included a principal diagnosis of Hypertensive heart disease with heart failure and other diagnosis Lumbago with sciatica unspecified site, Chronic pain syndrome, Other abnormalities of gait and mobility, and History of falling. The POC included the following: "... SN to minimize/eliminate risk for hospitalizations due to prior hospitalizations... Patient identified to be at high risk for falls ... Patient/caregiver will be free of pain within 6 weeks...." Review of the entire POC failed to reveal evidence of orders for the SN to teach on pain management, or pain parameters to notify the physician of an unacceptable level of pain. Patient Record #4: The medical record contained a plan of care (POC) for the certification period 11/29/2022 to 01/27/2023 digitally signed by Physician A, on 12/18/2022. The POC included a principal diagnosis of Hypertensive heart disease with heart failure and other diagnosis Rheumatoid arthritis, unspecified. The POC included the following: "...Hydrocodone-Acetaminophen 10 Milligram (MG)-325 MG/15 Millimeter (ML) ORAL SOLUTION 1 every 6 hours as needed (PRN) By mouth IBUPROFEN 600 MG ORAL TABLET 1 every 6 hours By mouth… SN to minimize/eliminate risk for hospitalizations due to prior hospitalizations... Patient/caregiver will be free of pain within 6 weeks…Patient with pain that interferes with activity causing decreased mobility ..." Review of the entire POC failed to reveal evidence of orders for the SN to teach on pain management, or pain parameters to notify the physician of an unacceptable level of pain. In an interview with the Administrator/Director of Nurses on 02/22/2023 at approximately 2:45 p.m., the surveyor reviewed the findings and asked questions regarding the POC's for Patient's 3 and 4. The surveyor asked why the POCs failed to include orders for the SN to teach on pain management, or pain parameters to notify the physician of an unacceptable level of pain. Administrator/Director of Nurses stated, "I don't know why it's not included." Agency Policy with a revision date of 01/01/22 read in part, "... Plan of Care PC.8 ...III…A. The individualized plan of care must include the following…13. Patient/client and caregiver education and training to facilitate timely discharge; 14. Patient/client specific interventions and education; 15. Measurable outcomes and goals identified…"

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: THIS IS A CONTINUED DEFICIENCY CITED AT G658 ON SURVEY DATED 03/09/2020. Based on interview and record review, the agency failed to document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects for 3 of 3 (2020, 2021 and 2022) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the home health's program for which performance could be improved. Findings included: Review of the documentation regarding the agency's QAPI Program included no documentation to indicate the hospice had developed, implemented and described the reasons for conducting the projects, or evaluated the measurable progress achieved for the years of 2020 2021 and 2022. During an interview on 02/21/2023 at 12:24 p.m., with the Administrator/Director of Nurses, the surveyor discussed the above findings. The Administrator/Director of Nurses said, "We didn’t do any performance improvement projects. I can’t say why I didn’t do any. It was overlooked." Agency policy titled: "PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" revised 011318 read in part: " ...PROCEDURE III. The QAPI Plan will be developed based on: ... D. Performance Improvement projects 1. The number and scope of distinct projects conducted annually will reflect the scope, complexity, and past performance of the Agency's services and operations. 2. The agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects...."