Every finding on record at Maximum Home Health Care, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/13/24. Standard level deficiencies cited. Abbreviations: # = number AM = morning Tempts = temperatures

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan, and staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan last updated on 06/21/24 was reviewed on 12/09/24. The Plan included the “Hazard Vulnerability Assessment Tool” (risk assessment), which contained potential hazardous events. The Assessment tool contained; “Hurricane, Lightning Strike, Extreme Tempts., High Winds” as possible events. As of 12/11/24, the Emergency Preparedness plan lacked policies and procedures pertaining to “Hurricane, Lightning Strike, Extreme Tempts., High Winds”. 2. During an interview with the Administrator on 12/12/24 at 11:20 AM, the Administrator confirmed the Agency failed to establish policies and procedures based on the risk assessment.

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 review of the Agency's Emergency Preparedness plan, staff in-service binder, personnel files, and staff interview, it was determined in 2 of 5 (Employees #3 and 5) personnel files reviewed, the Agency failed to ensure staff received training pertaining to the Agency's Emergency Preparedness plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated on 06/21/24 was reviewed on 12/09/24. The plan lacked documentation that the following staff received education on the Agency’s Emergency Preparedness: Employee #3. Date of hire 12/3/20. Employee #5. Date of hire 01/30/24. 2. The staff in-service binder was reviewed on 12/9/24. The in-service binder lacked documentation that the following staff received education on the Agency’s Emergency Preparedness: Employee #3. Date of hire 12/3/20. Employee #5. Date of hire 01/30/24. 3. On 12/09/24, a request was made for the personnel files. As of 12/11/24, the Agency failed to provide the personnel files of Employee #3 and Employee #5. 3. During an interview with the Administrator on 12/12/24 at 11:20 AM, the Administrator confirmed the above findings. .

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated on 06/21/24 was reviewed on 12/09/24. The plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness in 2021, 2022, 2023, and 2024 (as of 12/09/24). 2. During an interview with the Administrator on 12/09/24 at 11:20 AM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/13/24. Standard level deficiencies cited. Abbreviations: bpm = beats per minute mmHg = millimeters of mercury VS = vital signs BP = blood pressure PT = Physical Therapy / Physical Therapist SN = Skilled Nurse RN = Registered Nurse MSW = Medical Social Worker x = times wk = week # = number % = percent AM = morning > = greater than POC / PsOC = Plan of care / Plans of care SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

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 the review of the Agency’s Error Summary report and Staff interview, it was determined in 47 of 134 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 10/01/23 thru 12/10/24, was reviewed on 12/11/24 at 10:10 AM. The report included error # -3330 for 47 submissions. 35.07% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/11/24 at 1:00 PM.

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 review of Agency’s Pt. admission folder, observation and interview during home visits, clinical record review and staff interviews, it was determined that in 5 of 7 (Pts. #1, 2, 3, 4, 5) clinical records reviewed the Agency failed to ensure the Pt. /representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1.The Pt. admission folder was reviewed on 12/09/24. The folder included a “ Home care Patient agreement’’ form that lacked what services and proposed frequencies will be provided. 2.The following clinical records were reviewed on 12/11/24: Pt. # 1 SOC 12/06/24 Pt. received SN and PT services. Pt. #2 SOC 10/08/24 Pt. received SN and PT services. Pt. #3 SOC 11/08/24 Pt. received SN and PT services. Pt. #4 SOC 12/03/24 Pt. received SN, PT and MSW services. Pt. #5 SOC 11/02/24 Pt. received SN and PT services. The clinical records lacked documentation of the service(s) to be provided and visit frequencies. 3. During a home visit of Pt. #3 conducted on 12/11/24 at 10:30 AM, the admission folder was observed and lacked documentation indicating the Pt./ representative was notified of the discipline(s) to provide service and frequency of visits in writing. 4. During interviews with the Administrator and Director of Nursing on 12/11/24 at 2:14 PM and on 12/12/24 from 11:20 AM to 1:15 PM, the Administrator confirmed the above findings.

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: Based on a review of the clinical record and staff interviews, it was determined the Agency failed to ensure staff provide service/treatment as ordered by the Physician and indicated in the POC. This was found in 4 of 7 (Pts. #2, 3, 6, and 7) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to Home Health Services on 06/10/24 with the Diagnosis of Other Fracture of Left Lower Leg, Initial for Closed Fracture. The clinical record was reviewed on 12/11/24. The clinical record included the “PT Re-evaluation “conducted on 10/07/24 and required the PT to provide service “3wk4”. The record contained PT visit notes for 1 to 2 times a week from 11/07/24 to 11/30/24, and the OASIS-E Recertification completed by the PT , all indicated that PT services were provided. The record lacked a Physician order to continue PT services after week 4 (10/27/24 to 11/02/24). The POC for the certification period of 10/08/24 to 12/06/24 required the SN to provide service “1wk9”. The record lacked documentation the SN provided any services after 10/07/24. The record included a SN Discharge Summary completed on 10/08/24. However, the record lacked a Physician order to discontinue SN services. The POC effective 10/08/24 required; “Notify Physician of vital sign parameters out of range… Systolic Blood Pressure: greater than (>) 160 mmHg less than ( Diastolic Blood Pressure: greater than ( The “SN Discharge Summary” form completed on 10/8/24 contained; “Condition of discharge (Include VS… BP 144/96”. The record lacked documentation the SN notified the Physician of the Diastolic Blood Pressure (>) 90. The POC effective 10/08/24 required; “Notify Physician of vital sign parameters out of range: Heart Rate: greater than (>) 100 bpm less than ( The PT visit notes dated 11/13/24, 11/19/24, 11/23/24, 11/26/24, and 11/30/24 included a Heart Rate of “102”. As of 12/11/24, the record lacked documentation the PT notified the Physician of the Heart Rate (>) 100. The POC effective 10/08/24 lacked any goals for Pt. #2. 3. Pt. #6 was admitted to the Home Health Services on 03/13/24 with the diagnoses of: Unspecified Dementia, Unspecified Severity, without Behavior/Psych/ mood/anxiety. The clinical record was reviewed on 12/11/24. The clinical record contained a POC dated 03/13/24 that required SN to assess the patient 1 time a week for 5 weeks. The SN failed to visit/assess the patient week #2. The same POC required the PT to assess the patient 1 time a week for 9 weeks. The PT failed to visit/assess the patient week #6 and 7. 4. Pt. #7 was admitted to the Home Health Services on 11/06/23 with the diagnoses of: Urinary Tract Infection, Site not specified and Essential (Primary) Hypertension. The clinical record reviewed on 12/03/24, required SN to assess the patient, 1 time a week for 5 weeks. The SN failed to visit/assess the patient week #5. 5. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/12/24 between 11:30 AM and 2:00 PM. 2. Pt. #3 was admitted to Home Health Services on 11/08/24 with the Diagnosis of Bell’s Palsy. The clinical record was reviewed on 12/11/24. The clinical record included a POC effective 11/08/24 to 01/06/25, required: “Orders for Discipline and Treatment….Notify Physician of vital sign parameters out of range:….Heart rate: greater than (>)100 bpm….Diastolic Blood Pressure greater than (>) 90 mmHg...." The SN assessment dated 11/08/24 included a heart rate of 102 and Diastolic Blood Pressure of 92. There was no documentation of Physician notification as ordered in the plan of care.

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 a review of clinical records and staff interviews, it was determined that 4 of 7 (Pts. #2, 3, 6, and 7) clinical records reviewed, the Agency failed to ensure the POC contained Pt. specific interventions. Findings include: 1. Pt. #2 was admitted to Home Health Services on 06/10/24 with the Diagnosis of Other Fracture of Left Lower Leg, Initial for Closed Fracture. The clinical record was reviewed on 12/11/24. The clinical record included the POC for the certification period of 10/08/24 to 12/06/24 that required; “SN to perform wound care to Left Lateral side of lower extremity cleanse wound with sterile saline solution, apply calcium silver alginate and wet to dry gauze cover and secure with adhesive pad and wrap with gauze roll, using aseptic technique. SN may teach patient/caregiver to perform wound care”. The POC lacked a frequency for the wound care. 3. Pt. #6 was admitted to the Home Health Services on 03/13/24 with the diagnoses of: Unspecified Dementia, Unspecified Severity, without Behavior/Psych/ mood/anxiety. The clinical record was reviewed on 12/11/24. The clinical record contained a POC dated 03/13/24. The POC lacked the diagnosis for the random blood sugar orders. 4. Pt. #7 was admitted to the Home Health Services on 11/06/23 with the diagnoses of: Urinary Tract Infection, Site not specified and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 11/06/23. The POC lacked the diagnosis for the random blood sugar orders, lacked the frequency of the PT visits and lacked the frequency of the SN visits. 5. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/12/24 between 12:00 PM and 2:00 PM. 2. Pt. #3 was admitted to Home Health Services on 11/08/24 with the diagnosis of Bell’s Palsy. The clinical record was reviewed on 12/11/24. The clinical record contained a POC effective 11/08/24 to 01/06/25, orders for discipline and treatment: “Notify Physician…. Blood sugar, Fasting….Blood Sugar, Random…” The POC included a blood sugar assessment intervention that was not indicated for Pt. #3’s diagnosis. The POC lacked Pt. specific orders/ interventions and goals for Nursing.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on staff interview, and a review of clinical records, it was determined the Administrator failed to provide clinical records upon request. This has the ability to affect the daily operation of the Agency. Findings include: 1. During the entrance interview with the Administrator on 12/09/24 between 10:00 AM and 10:30 AM, a request was made to have access to clinical records for review. 2. The following clinical records were not available for review until 12/11/24: Pt. # 1 SOC 12/06/24. Pt. # 2 SOC 06/10/24. Pt. # 3 SOC 11/08/24. Pt. # 4 SOC 12/03/24. Pt. # 5 SOC 10/08/24. Pt. # 6 SOC 03/13/24. Pt. # 7 SOC 11/06/23. 3. During an interview with the Administrator on 12/11/24 at 10:24 AM, access was granted for clinical record reviews.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: BP = Blood pressure Pt/Pts = patients # = number x = times w = week SOC = Start of Care PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist MSW = Medical Social Worker HHA = Home Health Aide POC = Plan of Care AM = morning PM = afternoon/evening COVID-19 = Coronavirus 2019 SN = Skilled Nurse RN = Registered Nurse OASIS = Outcome and Assessment Information Set

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that includes the names and contact information of all staff members, entities providing services under arrangement, Pt. Physicians, and Volunteers. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 10/12/21 at 11:35 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information of staff members, entities providing service under arrangement, Pt. Physicians, and Volunteers. 2. During an interview with the Back Up Administrator and Director of Nursing on 10/13/21 at 1:50 PM, the Assistant Administrator confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: BP = Blood pressure Pt/Pts = patients # = number x = times w = week SOC = Start of Care PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist MSW = Medical Social Worker HHA = Home Health Aide POC = Plan of Care AM = morning PM = afternoon/evening COVID-19 = Coronavirus 2019 SN = Skilled Nurse RN = Registered Nurse OASIS = Outcome and Assessment Information Set

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: A. Based on clinical record review and Staff interview, it was determined the Agency failed to ensure that Pts. were informed of the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 10/21/21 at 12:00 PM to 10/15/21 at 9:00 AM: Pt #1 SOC 10/1/21 Pt. received SN and PT services. Pt #2 SOC 7/16/21 Pt. received SN, PT, OT, MSW and HHA services. Pt #3 SOC 8/30/21 Pt. received SN and PT services. Pt # 4 SOC 8/27/21 Pt. received SN and PT services. Pt # 5 SOC 9/13/21 Pt. received SN and PT services. Pt #6 SOC 7/1/21 Pt. received PT and HHA services. Pt #7 SOC 4/29/21 Pt. received SN and PT services. The records lacked documentation that at SOC, the Pt./patient’s representative participated or was notified of each discipline’s frequency of visits, prior to providing Pt. care and services. 3. During an interview with the Back up Administrator on 10/15/21 at 10:00 AM, the Back Up Administrator confirmed the above findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: A. Based on a review of closed clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was updated at discharge. This was found in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed. Findings include: 1 . Pt. #6. SOC 07/01/21. Primary Diagnosis: Primary (Essential Hypertension). The closed clinical record was reviewed on 10/12/21 at 1:00 PM. The record included documentation the Physical Therapist (PT) and Home Health Aide (HHA) provided service during certification period of 07/01/21 to 08/29/21 and that the Agency discharged the Pt. on 08/19/21. The record included an incomplete PT discharge form dated 8/19/21. The record lacked documentation the PT updated the comprehensive assessment at discharge. 2. Pt #7. SOC 4/29/21. Primary Diagnosis: Long Standing Persistent Atrial Fibrillation. The closed clinical record was reviewed on 10/12/21 at 3:00 PM. The record included documentation the Skilled Nurse (SN) and Physical Therapist (PT) provided service during certification period of 4/29/21 to 6/16/21 and that the Agency discharged the Pt. on 6/16/21. The record included an incomplete documentation of PT discharge form dated 6/16/21. The record lacked documentation the SN or PT updated the comprehensive assessment at discharge. 3. The Agency policy titled: “Discharge Criteria and Process” was reviewed on 10/15/21 at 9:30 AM. The policy required: “….An update to the comprehensive assessment, including required OASIS data elements, will be completed, as required by regulation.” 4. During an interview with Back Up Administrator and Director of Nursing on 10/13/21 at 3:30 PM and with Back Up Administrator on 10/15/21 at 10:00 AM, the Back Up Administrator and Director of Nursing confirmed the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide services as ordered by the Physician. This was found in 5 of 7 (Pts. #4, 2, 6, 7, and 3) records reviewed. Findings include: 1. Pt. #4. SOC 8/27/21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 10/12/21 at 1:45 PM. The record contained a PT Plan of Care dated 9/2/21, which included "PT Frequency and Duration: 2x5 weeks." The record lacked a second PT visit for the week of 8/29/21 to 9/4/21; 9/19/21 to 9/25/21; and 9/26/21 to 10/2/21. The record also lacked documentation Pt. #4's Physician was notified of these missed visits. The record also contained the POC effective 8/27/21 to 10/25/21, which included the Physician’s order for “HHA 2x9." The record lacked documentation the HHA provided any services to the Pt., and lacked a Physician's order to discontinue HHA services. 2. Pt. #2. SOC 7/16/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 10/13/21 at 9:30 AM. The record contained the PT Plan of Care dated 8/21/21, which included “PT Frequency and Duration: 1x1w, 2xw5 weeks.” The record lacked a second PT visit for the weeks of 8/29/21 to 9/4/21; 9/5/21 to 9/11/21; 9/12/21 to 9/18/21; and 9/26/21 to 10/2/21. There were no PT visits ordered for the week of 9/19/21 to 9/25/21. The record also lacked documentation Pt. #2’s Physician was notified of these missed visits. The record included the POC effective 7/16/21 to 9/13/21, which included the Physician’s order for “HHA 3w9.” The record lacked documentation the HHA provided a third visit for the weeks of 8/15/21 to 8/21/21; 8/22/21 to 8/28/21; 8/29/21 to 9/4/21. There were no HHA visits documented for the week of 9/5/21 to 9/11/21. The record also lacked documentation Pt. #2’s Physician was notified of these missed visits. This POC also contained the Physician’s order for MSW 1m1.” The record lacked documentation the Pt. received a MSW visit, or a Physician’s order to discontinue MSW services. This POC also included the Physician’s order for “OT 2w9.” The record lacked documentation the Pt. received OT visits, or a Physician’s order to discontinue OT services. This POC also included the Physician’s order for “SN 1w9.” The record lacked documentation the Pt. received a SN visit for the week of 8/8/21 to 8/14/21, and for the week of 8/15/21 to 8/21/21. There was no documentation the Physician was notified of these missed visits. 3. Pt #6. SOC 07/01/21 Primary Diagnosis: Primary (Essential Hypertension). The clinical record was reviewed on 10/12/21 at 1:00 PM. The signed POC for certification period of 07/01/21 to 08/29/21 addressed Physical therapy (PT) services but did not indicate a frequency. There were no other physician orders to indicate frequency for PT services. The SOC assessment dated 07/05/21 documented a Physical Therapy frequency of 2 times a week for 9 weeks. The clinical record lacked documentation of any other visits for weeks of 7/18/21 to 7/24/21, 8/1/21 to 8/7/21 and 8/8/21 to 8/14/21. The record also lacked documentation that Physician was notified of these missed visits. The same clinical record documented a Physician order for HHA visits 2 times a week for 6 weeks. The record contained a HHA visit on 7/16/21 but lacked another visit for week of 7/11/21 to 7/17/21. The record contained a missed visit form dated 8/9/21 "Physician notified: No". The record lacked a second visit attempted for that week or that Physician was notified of these missed visits. The record also documented Home Health Aide care plan that required HHA to report vital sign parameters out of range: “Systolic BP – less than () 160…. Diastolic BP less than ()90”. The HHA visit note dated 8/3 documented a BP reading of 161/106, on HHA note visit dated 8/5 BP reading of 161/98 and on 8/12 – BP reading of 173/90, with no documentation on reporting vital sign parameters. 4. Pt #7. SOC 4/29/21 Primary Diagnosis: Long Standing Persistent Atrial Fibrillation. The clinical record was reviewed on 10/12/21 at 3:00 PM. The signed POC for certification period of 4/29/21 to 6/16/21 required the SN to visit 1 time a week for 9 weeks. The record lacked documentation for SN visits for weeks of 06/6/21 to 6/12/21 and 6/13/21 to 6/19/21. There were no modification orders for SN frequency in the record. The same POC also required PT visit 2 times a week for 2 weeks and 1 time a week for 6 weeks. The record included 2 visits for weeks of 5/9/21 to 5/1/215, 5/23/21 to 5/29/21, and 5/30/21 to 6/5/21. The record lacked documentation of visits for week of 5/16/21 to 5/22/21. There were no modification orders for PT frequency in the record. 5. Pt #3. SOC: 8/30/21 Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart failure. The clinical record was reviewed on 10/13/21 at 11:00 AM. The signed POC for certification period of 8/30/21 to 10/28/21 that documented orders for Home Health Aide (HHA) frequency 2 times a week for 9 weeks. A home visit was conducted with Patient #3 on 10/13/21 at 9:15 AM and stated HHA services were not discussed at the Start of Care. The record lacked documentation that HHA services were offered or that HHA visits attempted. The POC also required that SN to visit 1 time a week for 9 weeks and there was no documentation of SN for week of 9/26/21 to 10/2/21 with no modification orders for SN frequency in the record. 6. The Agency policy titled: Agency policy titled “Entries into the Clinical Record” was reviewed on 10/12/21 at 3:15 PM. The policy required: “…A clinical record be initiated and maintained for each Patient receiving care or services, according to organization policies found in this manual, and will include, at a minimum…E. dates, times, and types of interventions, assessments and coordination of care... J. reasons for interruptions in the provision of care and services...” 7. During interview with Back up Administrator and Director of Nursing on 10/13/21 at 1:50 PM and 3:30 PM, the above findings were confirmed.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: A. Based on clinical records review, Agency policy review, Agency practice and staff interview, it was determined that the Agency failed to ensure that the Aide supervision was conducted every 14 days by skilled professionals. This was found in 2 of 2 clinical records reviewed with Aide Services provided (Pt #6 and #2). 2. Pt. #2. SOC 7/16/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 10/13/21 at 9:30 AM. The record included the POC effective 7/16/21 to 9/13/21, which included the Physician’s order for “HHA 3w9.” The record contained HHA visit notes, beginning 7/26/21. The record lacked documentation a Skilled Professional provided HHA supervision from 7/26/21 through 10/12/21. Findings include: 1. Pt #6. SOC 07/01/21. Primary Diagnosis: Primary (Essential Hypertension). The clinical record was reviewed on 10/12/21 at 1:00 PM. The signed Physician order documented HHA 2 times a week for 6 weeks for certification period of 07/01/21 to 08/29/21. The clinical record contained HHA visit notes from 7/16 to 8/19 and PT notes from 7/5 to 8/19. The record lacked documentation that a Skilled Professional provided HHA supervision from 7/16/21 through 10/21/21. 3. During entrance interview on 10/12/2021 at 10:00 AM, the Back up Administrator stated that Agency practice is that Aides are supervised every 14 days by the RN. During interview with Back Up Administrator and Director of Nursing on 10/13/21 at 1:50 PM and at X:XX PM, both confirmed the above findings.

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: A. Based on review of clinical records, Agency policy and staff interview, it was determined that the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt #6. SOC 07/01/21. Primary Diagnosis: Primary (Essential Hypertension). The closed clinical record was reviewed on 10/12/21 at 1:00 PM. The clinical record lacked documentation that the Agency sent a copy of the Discharge Summary to the Physician. Pt #6 was discharged on 08/19/21. 2. Pt #7 SOC 4/29/21 Primary Diagnosis: Long Standing Persistent Atrial Fibrillation. The closed clinical record was reviewed on 10/12/21 at 3:00 PM. The clinical record lacked documentation that the Agency sent a copy of the Discharge Summary to the Physician. Pt #6 was discharged on 06/16/21. 3. The Agency Policy titled: “Discharge Criteria and Process” was reviewed on 10/15/21 at 9:30 AM. The policy required: “Procedure:…8. A discharge summary will be completed for all discharged patients. A copy will be mailed to the primary physician.” 4. During interview with Back up Administrator and Director of Nursing on 10/13/21 at 3:30 PM and with the Back Up Administrator on 10/15/21 at 10:00 AM, the above findings were confirmed.