Every finding on record at Lumar's Health Care Corp.

During the recertification survey conducted on 2/2/2026 to 2/4/2026 at Lumar's Health Care Corp, a Home Health Agency, Emergency Preparedness was reviewed. Lumar's Health Care Corp is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on 2/2/2026 to 2/4/2026 at Lumar's Health Care Corp. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Requirements for Home Health Agencies.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to document and authenticate a verbal order for 1 of 8 Sample Patients, Sample Patient (SP) #4. The findings include: During record review on 2/4/2026 at 3:46 PM, the surveyor reviewed a 12/31/2025 Case Conference report that documented SP #4's physician ordered a 1 week hold on current wound care orders. The surveyor could not find the physician's order within SP #4's record upon further review. During an interview with the Administrator, Alternate Administrator, and Director of Nursing on 2/4/2026 at 3:39 PM, the Director of Nursing said it was a verbal order. The Administrator said that it was documented in the Case Conference report. The Alternate Administrator said that he understands and it will be fixed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to complete discharge and transfer summaries for 2 of 8 Sample Patients, Sample Patient (SP) #7 and SP #8. The findings include: During record review on 2/4/2026, the surveyor failed to find discharge and transfer summaries for SP #7 and SP #8 who had both been transferred to either another facility or agency. During an interview with the Administrator, Alternate Administrator, Director of Nursing, and Quality Assurance on 2/4/2026 at 4:48 PM, the Alternate Administrator said they now know for the future. The summaries were not available at the time of the surveyor's review.

During the recertification survey conducted on 09/05/2023 to 09/07/2023 at Lumar’s Health Care Corp., a Home Health Agency, Emergency Preparedness was reviewed. Lumar’s Health Care Corp. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate that an initial training in emergency preparedness policies and procedures was provided to all new and existing staff consistent with their expected roles and provide emergency preparedness training at least every 2 years thereafter for 1 out of 10 sample active staff. (Staff F) Findings include: On 09/05/23 and 09/06/23 the Director of Nursing was informed to provide the documentation for the most recent staff training for review. On 09/06/23 and 09/07/23 personnel files were reviewed for 10 samples of active staff. Review of the personnel file for Staff F revealed no documentation of receiving initial training upon hire. Interview was conducted with the Director the Director of Nursing, Office Manager and Alternate Administrator on 09/07/2023 between 3:55 PM and 4:17 PM acknowledged the provider is not able to demonstrate Staff F received initial emergency plan training as required.

A recertification survey was conducted on 09/05/2023 to 09/07/2023 at Lumar’s Health Care Corp. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 2 out of 7 Sampled Patients (SP). SP#2 and SP#5 Findings include: Clinical records review was conducted from 09/05/23 to 09/07/23 of SP#2 and SP#5. Active clinical record review of SP#2 revealed a start of care date 11/30/2022 with the Client Service Agreement signed and dated 11/30/2022. Active clinical record review of SP#5 revealed a start of care date 08/19/2023 with the Client Service Agreement signed and dated 08/19/2023. Further review of SP#1 and SP#3 records both contained a consent form that under “Relationship of Authorized Representative” was left blank. The Director of Nursing on 09/06/2023 reviewed the consent forms and stated the ALF (assisted living facility) Administrator(s) signed the consents. Telephone interview was conducted with the ALF Administrator for SP#2 on 09/06/2023 at 1:00 PM. The ALF Administrator confirmed that he signed the consent for service for SP#2. The ALF Administrator acknowledged that he is not the patients’ legal representative. Interview conducted with Director of Nursing (DON) on 09/06/2023 at 3:10 PM. The DON confirmed the signature on the service agreements form is the ALF Administrator's signature and not the patient's legal representative for SP#2 and SP#5. Telephone interview was conducted with the Registered Nurse providing care to SP#5 on 09/06/2023 at 3:12 PM. The Registered Nurse confirmed that the ALF Administrator signed the consent for service for SP#5.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate it had the patient(s) and the patient’s legal representative participate in, be informed about, and consent or refuse care in advance of and during treatment of the care to be furnished, the completion of all assessments, the care to be furnished based on the comprehensive assessment, and the disciplines that will furnish the care and the frequency of visits for 2 out of 7 Sampled Patients (SP). SP#2 and SP#5 Findings include: Clinical records review was conducted from 09/05/23 to 09/07/23 of SP#2 and SP#5. Active clinical record review of SP#2 revealed a start of care date 11/30/2022 with the Client Service Agreement signed and dated 11/30/2022. Active clinical record review of SP#5 revealed a start of care date 08/19/2023 with the Client Service Agreement signed and dated 08/19/2023. Further review of SP#1 and SP#3 records both contained a consent form that under “Relationship of Authorized Representative” was left blank. The Director of Nursing on 09/06/2023 reviewed the consent forms and stated the ALF (assisted living facility) Administrator(s) signed the consents. Telephone interview was conducted with the ALF Administrator for SP#2 on 09/06/2023 at 1:00 PM. The ALF Administrator confirmed that he signed the consent for service for SP#2. The ALF Administrator acknowledged that he is not the patients’ legal representative. Interview conducted with Director of Nursing (DON) on 09/06/2023 at 3:10 PM. The DON confirmed the signature on the service agreements form is the ALF Administrator's signature and not the patient's legal representative for SP#2 and SP#5. Telephone interview was conducted with the Registered Nurse providing care to SP#5 on 09/06/2023 at 3:12 PM. The Registered Nurse confirmed that the ALF Administrator signed the consent for service for SP#5.

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 record review and interview, the home health agency failed to demonstrate that 1 out of 10 active staff received annual in-service on infection control. (Staff F) Findings include: Record review revealed the provider provided infection control education in-service on 01/30/2023 and 01/31/2023 to its employees. Further record review revealed no documentation to show that active Staff F participated in the infection control education in-service. Interview was conducted with the Director the Director of Nursing, Office Manager and Alternate Administrator on 09/07/2023 between 3:55 PM and 4:17 PM acknowledged that the Staff F is providing physical therapy service to patients of the home health agency and has not received infection control education in-service from the provider.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency staff failed to provide nursing service within the scope of practice for 1 out of 3 Sampled Patients (SP) with home visits done. (SP#1) Findings include: Clinical record review conducted 09/05/23 to 09/06/23 of SP#1 contained a Plan of Care with certification period of 08/04/23 to 10/02/23 that reads "To monitor vital signs - notify physician of any abnormal change or other clinical findings (will call MD (medical doctor) if BP (blood pressure) at/below 90/60 mmHg or at/above 140/90 mmHg, if Temperature is below 96.0 F or above 99.5 F, if Respiration is below 14 BPM (beat per minute) or above 24 BPM, if Pulse Rate is below 60 BPM or above 100 BPM." During home visit made to SP#1 on 09/07/23 at 12:06 PM, the surveyor observe Staff D (Licensed Practical Nurse) obtain blood pressure reading only. Interview was conducted with the Director the Director of Nursing, Office Manager and Alternate Administrator on 09/07/2023 between 3:55 PM and 4:17 PM acknowledged that the Staff D failed to obtain Temperature, Pulse and Respiration during assessment of vital signs.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed discharge summary for 2 out of 7 Sampled Patients (SP). SP#6 and SP#7 Findings include: Closed record reviews of the SP#6 and SP#7 were conducted on 09/05/23 to 09/07/23. The clinical record for SP#6 contained a discharge summary from the agency with a discharge date 06/23/23; and SP#7 contained a discharge summary from the agency with a discharge date 07/30/23. The discharge summaries for SP#6 and SP#7 omitted information such as listing the reason for admission to home health; omits the type of services provided and frequency of services; omits any Lab data (as applicable); and omits a complete summary of care/outcomes in meeting the goals in the Plan of Care. Interview was conducted with the Director the Director of Nursing, Office Manager and Alternate Administrator on 09/07/2023 between 3:55 PM and 4:17 PM, acknowledged that the summaries for SP#6 and SP#7 were incomplete, missing the required notations as previously mentioned.