Every finding on record at Midwest Home Health, Inc.

An unannounced investigation of two complaints was completed at Angels Care Home Health on 9/18/25. The allegations related to the complaint were substantiated. The agency census was 356 (75 at the Columbus branch,138 at the Lincoln branch, and 143 at the Omaha parent location). Deficiencies were cited related to the complaint investigation at G520, G572, and G596.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure a comprehensive assessment was completed within 5 days of the patient's start of care by all disciplines ordered for 6 of 9 patient records reviewed (Patient 1, 2, 3, 4, 7, and 9). The agency census was 356 (75 at the Columbus branch,138 at the Lincoln branch, and 143 at the Omaha parent location). Findings are: A. Review of the agency policy and procedure titled Patient Assessment/Reassessment, CC.026, revised 4/23 revealed: 1. Typically, the comprehensive assessment is conducted on the same visit as the initial assessment. 2. A patient requiring referrals to additional disciplines will have an assessment initiated by the referred discipline within 96 hours. 3. Relevant assessment findings are communicated to the provider to aid in the development of the plan of care (POC). 4. Discipline specific comprehensive assessments contain information specific to the scope of practice of the specific discipline. B. Review of Patient 1's clinical record revealed: 1. The patients start of care (SOC) was 12/16/24. 2. The Home Health Certification and Plan of Care for the certification period of 12/16/24 through 2/13/24 included orders for Physical Therapy (PT) 1 time a week for 1 week to evaluate and establish a PT POC. The form indicated that a verbal SOC order was received on 12/16/24. 3. A PT Initial Evaluation visit form was completed on 12/23/24 (7 days after the patient's SOC). C. Review of Patient 2's clinical record revealed: 1. The patients SOC was 7/9/25. 2. A Client Coordination Note, Therapy Referral Form, dated 7/9/25, for a referral for PT. This note contained a follow-up comment for therapy to restart the week of 7/13/25 (leaving 2 days to complete the comprehensive assessment within the regulatory time frame). 3. The Home Health Certification and Plan of Care for the certification period of 7/9/25 through 9/6/25 included orders for PT 1 time per week for 1 week to evaluate and establish a PT POC effective 7/13/25 (leaving 2 days to complete the comprehensive assessment within the regulatory time frame). 4. A PT Initial Evaluation visit form was completed on 7/15/25 (6 days after the patient's SOC). D. Review of Patient 3's clinical record revealed: 1. The patients SOC was 7/15/25. 2. A Client Coordination Note, Therapy Referral Form, dated 7/15/25, for a referral for PT and Occupational Therapy (OT). This note contained the comment wants started as soon as possible. The note indicated the referral was sent to therapy on 7/16/25. 3. The Home Health Certification and Plan of Care for the certification period of 7/15/25 through 9/12/25 included orders for PT 1 time per week for 1 week to evaluate and establish a PT POC and Occupational Therapy (OT) 1 time per week evaluate and establish an OT POC, both effective 7/20/25 (leaving only 7/20/25 to complete the comprehensive assessment within the regulatory time frame). 4. A PT Initial Evaluation visit form was completed on 7/21/25 (6 days after the patient's SOC). 5. An OT Initial Evaluation visit form was completed on 7/15/25 (6 days after the patient's SOC). E. Review of Patient 4's clinical record revealed: 1. A referral to home health dated 8/4/25 for skilled nursing (SN), PT, and OT. 2. A Client Coordination Note Report, Intake, dated 8/5/25 revealed the ordered disciplines included OT. The note revealed the patient would be discharged to home on 8/7/25. 3. A Physicians Order dated 8/7/25 for PT and OT to evaluate and treat. 4. The patient's SOC was 8/7/25. 5. The Home Health Certification and Plan of Care for the certification period of 8/7/25 through 10/5/25 included orders for OT 1 time per week for 1 week to evaluate and establish an OT POC effective 8/10/25 (leaving 3 days to complete the comprehensive assessment within the regulatory time frame). 6. An OT Initial Evaluation visit form was completed on 8/15/25 (8 days after the patient's SOC). F. Review of Patient 7's clinical record revealed: 1. A Physician Order, dated 3/5/25, included orders for admit to home health care within 48 hours of patients discharge from the hospital for SN, PT, and OT to evaluate and treat. 2. A hospital Discharge document to the home health agency revealed the patient discharged from the hospital to home on 3/6/25. 3. The patient's SOC was 3/8/25. The admission consent forms, signed by the patient on 3/8/25, indicate that the patient was informed they would receive PT and OT 1-3 times per week after an evaluation. 4. The Home Health Certification and Plan of Care for the certification period of 3/8/25 through 5/6/25 included orders for PT and OT to evaluate and treat. 5. There was no documentation in the clinical record that an OT or PT evaluation was conducted for this patient. 6. The patient was discharged from home health on 3/18/25. G. Review of Patient 9's clinical record revealed: 1. The patient's SOC was 8/3/25. 2. The Home Health Certification and Plan of Care for the certification period of 8/3/25 through 10/1/25 included orders for PT 1 time per week for 1 week to evaluate and establish a PT POC. 3. A PT Initial Evaluation visit form was completed on 8/14/25 (11 days after the patient's SOC). H. During an interview on 9/18/25 at 10:00 AM, The Branch Manager/designated survey contact confirmed the agency did not ensure a comprehensive assessment was completed by all disciplines ordered on the plan of care within 5 days of the SOC for Patient 1, 2, 3, 4, 7, and 9.

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 record review, policy and procedure review, and staff interview, the agency failed to provide all services as ordered on the plan of care for 3 of 9 patient records reviewed (Patient 1, 7, and 8). The census was 356 (75 at the Columbus branch, 138 at the Lincoln branch, and 143 at the Omaha parent location). Findings are: A. Review of the agency policy and procedure titled Plan of Care, CC.032, revised 2/22 revealed clinical services are implemented in accordance with a plan of care (POC) established by a provider's written orders. B. Review of Patient 1's clinical record revealed: 1. The patients start of care (SOC) was 12/16/24. 2. The Home Health Certification and Plan of Care for the certification period of 12/16/24 through 2/13/24 included orders for Physical Therapy (PT) 1 time a week for 1 week to evaluate and establish a PT POC. The form indicated that a verbal SOC order was received on 12/16/24. 3. A PT Initial Evaluation Visit form (which also establishes the PT POC) was completed on 12/23/24, the evaluation form includes orders for PT 1 time a week for 1 week, then 2 times per week for 3 weeks, effective 12/22/24. The form indicates a verbal order was received for the PT POC. 4. Missed Visit notes dated 1/2/25, 1/3/25, 1/8/25, and 1/10/25 indicate the reason for these missed visits was the clinician was awaiting verbal orders, and the therapist was "unable to see the patient, waiting on physician signature." C. Review of Patient 7's clinical record revealed: 1. A Physician Order, dated 3/5/25, included orders for admit to home health care within 48 hours of patients discharge from the hospital for Skilled Nurse (SN), PT, and OT to evaluate and treat. 2. A hospital Discharge document to the home health agency revealed the patient discharged from the hospital to home on 3/6/25. 3. The patient's SOC was 3/8/25. The admission consent forms, signed by the patient on 3/8/25, indicate that the patient was informed they would receive PT and OT 1-3 times per week after an evaluation. 4. The Home Health Certification and Plan of Care for the certification period of 3/8/25 through 5/6/25 included orders for PT and OT to evaluate and treat. 5. There was no documentation in the clinical record that an OT or PT evaluation was conducted for this patient. 5. Patient discharged 3/18/25. D. Review of Patient 8's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 7/26/25 through 9/23/25 included orders for PT and OT 1 time per week for 1 week to evaluate and establish a POC. 2. A PT Initial Evaluation Visit form was completed on 7/29/25, the evaluation form includes orders for PT 1 time a week for 2 weeks, then 2 times per week for 3 weeks. 3. An OT Initial Evaluation Visit form (which also establishes the OT POC) was completed on 7/29/25, the evaluation form includes orders for OT 1 time a week for 2 weeks, then 2 times per week for 3 weeks. 4. Documentation revealed 1 PT visit was conducted and no OT visits were conducted after evaluation visits were completed. 5. A Client Coordination Note Report, Discharge Summary, dated 8/19/25, revealed the patient requested discharge due to the agency's inability to staff therapy. E. During an interview on 9/18/25 at 11:20 AM, the Business Manager/designated survey contact confirmed the agency failed to provide all services as ordered on the plan of care for patient's 1, 7, and 8.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure coordination with the patient, patient caregiver, and/or physician when changes to the plan of care were indicated for 2 of 9 (Patient 6 and 7) patient records reviewed. The agency census was 356 (75 at the Columbus branch,138 at the Lincoln branch and 143 at the Omaha parent location). Findings are: A. Review of the agency policy and procedure titled Plan of Care, CC.032, revised 2/22 revealed changes to the plan of care were to be communicated to the patient and/or the patient's caregiver, and the provider prior to the initiation of the change whenever possible. B. Review of the agency policy and procedure titled Documentation Practices, CC.013, revised 2/22 revealed: 1. Documentation of clinical activities was to be completed on the day it was provided. 2. Documentation facilitates communication, promotes care, informs care providers, on an ongoing basis, about the patient's health status and care or services provided. ` C. Review of Patient 6's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 12/15/24 through 2/15/25 included orders for Skilled Nurse (SN) 3 times per week for 1 week, then 2 times per week for 1 week, and then 1 time per week for 7 week for wound care and teaching patient wound care/management. 2. A SN note, dated 1/27/25, revealed the patient had a wound to the left shin area. The wound was noted to have purulent (a thick pus-like fluid) drainage and bright red skin surrounding the wound bed. The SN indicated that the physician was notified. The patient was instructed on signs and symptoms of wound infection and to contact agency, physician, or seek urgent care if symptoms worsen. 3. A Client Coordination Note Report, dated 1/27/25, revealed the SN contacted the physician's office to inform of changed wound status and was awaiting new orders. 4. A Physicians Order Form dated 2/2/25. The note revealed the SN found a new antibiotic in the patient's home for the treatment of the leg infection. The start date of the antibiotic was 1/31/25. 5. There was no documented communication in the clinical record to indicate the SN followed up with the physician from 1/27/25 to 2/2/25, to receive a new order for the signs and symptoms of wound infection. 6. There was no documentation of follow-up communication with the patient or the patient's caregiver from 1/27/25 to 2/2/25 to check wound status or to inform the patient of pending orders. D. Review of Patient 7's clinical record revealed: 1. The patient's start of care (SOC) was 3/8/25. 2. An L & C Consent Form Angels Home Health Care, the form included information to the patient that SN, Physical Therapy (PT), and Occupational Therapy (OT) services would be provided 1-3 times per week after evaluation. The form was signed by the patient and the agency SN on 3/8/25. 3. The Home Health Certification and Plan of Care for the certification period of 3/8/25 through 5/6/25 included orders for SN 1 week for 1 week, then 2 times a week for 1 week, then 1 time per week for 7 weeks; PT1 time per week for 1 week to evaluate; OT 1 time per week for 1 week to evaluate. 4. A Client Coordination Note Report, Therapy Referral Form, dated 3/8/25 to inform therapy of the patient PT and OT evaluation needs. The form included a follow-up comment dated 3/11/25 that the agency did not have therapy coverage for the patient's location. The follow-up comment also revealed the Columbus branch office would also not be able to provide therapy coverage. 5. A Physicians Order dated 3/18/25 for a request for outpatient referral and discharge from home health care due to the agency's inability to provide therapy in the patient's location. 6. A Client Coordination Note Report dated 3/18/25. The note documented an outpatient therapy scheduled appointment time. The note also revealed the patient voiced confusion about SN versus outpatient therapy requirements. 7. There was no documented communication between the patient and the agency regarding the agency's inability to provide PT and OT services from 3/8/25 admission through 3/18/25 discharge from home health care. E. During an interview on 9/18/25 at 11:20 AM, The Business Manager/designated survey contact, confirmed the agency failed to communicate with Patient 6 and their physician to ensure wound care orders were received timely, and the agency failed to communicate the agency's inability to provide PT and OT services to Patient 7 and/or their caregiver.

Midwest Home Health Inc dba Angels Care HomeHealth is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication profile (a real-time document used by the agency that lists the patient’s medications, including new and updated orders received between certification periods), included all medication orders as received by the agency, for 2 of 17 patient records reviewed (Patients 2 and 15). The census was 377. A. Review of the agency’s policy and procedure titled, Medication Profile / Drug Regimen Review, Policy Number CC.020, Revision Date February 2022, revealed: 1. Medication reviews will occur when any new medications are added during the episode of care, but no less than every 60 days. 2. During medication review, if the clinician identifies medications that are changed or new and is not on the medication profile, the clinician will report discrepancy to the patient’s physician to obtain resolution and will document this into the medical record. 3. The medication profile must be current and is updated as changes occur with the patient’s medication. 4. The medication profile in the clinical record is consistent with the physician orders and the patient’s plan of care. B. Review of the agency’s policy and procedure titled, Physician Orders, Policy Number CC.031, Revision Date December 2019, revealed, new or changed medications are to include dose, route, frequency, medication name, and duration if applicable. C. Review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification periods of 12/30/23 through 2/27/24 and 2/28/24 through 4/27/24, included orders for Warfarin (a medication to prevent blood clots), 5 mg (milligrams) tabs, take 10 mg on Thursday and 15 mg all other days. Okay to skip dose of Warfarin on 10/23/23. 2. A verbal order received on 3/13/24, included an order to hold Warfarin on 3/13/24, then take 10 mg on Thursday, 15 mg on Friday, 10 mg on Saturday, and 15 mg on Sunday. The medication profile was not updated. 3. A verbal order received on 3/19/24, included an order for Warfarin 15 mg daily except on Thursday, Warfarin 10 mg on Thursday. The medication profile was not updated. 4. A verbal order received on 3/27/24, included an order for Warfarin 5 mg on Monday, 15 mg on Tuesday, 10 mg on Wednesday, then starting on Thursday, alternate 15 mg and 10 mg every other day. The medication profile was not updated. 5. A verbal order received on 4/1/24, included an order for Warfarin 15 mg on all days except on Thursday, Warfarin 10 mg on Thursday. The medication profile was not updated. 6. A verbal order received on 4/8/24, included an order to hold the Warfarin on 4/8/24, take 10 mg on Tuesday, 15 mg on Wednesday, 10 mg on Thursday, 15 mg on Friday, 10 mg on Saturday, 15mg on Sunday. The medication profile was not updated. D. Review of Patient 15’s clinical record revealed: 1, The POC 6/22/23 through 8/20/23, included orders for Skilled Nursing to instruct the patient on new and changed medications. 2. A Skilled Nurse Visit on 6/29/23 at 12:15 PM, the Registered Nurse documented that the patient had PRN (as needed) Hydrocodone (a medication used to treat severe chronic pain). 3. The medication profile printed on 4/16/24, did not include Hydrocodone. E. During an interview on 4/23/24 at 11:30 AM, the Administrator confirmed agency staff failed to follow the agency’s policy and procedure for keeping the medication profile updated when medication orders were new or changed for Patients 2 and 15.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, observation of the provision of care, and staff interviews, 1 of 7 staff (Staff E), observed during the provision of care for 1 or 7 patients (Patient 2), failed to follow the agency’s policy and procedure for disposal of sharps and contaminated test strips. The total sample size was 17. The census was 377. A. Review of the agency’s policy and procedure titled Infection Control, Policy Number CC.015, Revision Date August 2022 revealed: 1. Employees were to be educated on the agency’s policy and procedure for handling medical waste which includes any material or item contaminated with dried, semi-liquid or liquid blood or other potentially infectious material. 2. Contaminated/used sharps, including needles, lancets, and contaminated slides, were to be disposed of in a closable, puncture resistant, leakproof container during handling, storage, and transport. 3. The Home Health Agency supplies sharps containers to staff to dispose of sharps and contaminated slides, used during the provision of care for the patient. 4. Medical waste, in sharps containers, transported from the patient’s home is to be disposed of at the Home Health Agency in a secured area, in a waste disposal container, to be collected by a licensed waste disposal contractor. B. Review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification 2/28/24 through 4/27/24, included orders for Skilled Nursing to check an INR (a blood test that indicates how well blood is able to clot) via finger stick, the week of 3/3/24. 2. A Verbal order on 4/8/24 at 4:05 PM, included orders to recheck INR on the following Monday. (Date 4/15/24). C. The observation of provision of care, for Patient 2 on 4/15/24 at 2:00 PM, revealed Staff E failed to: 1. Place contaminated lancets, used to perform a fingerstick to obtain a blood sample for an INR, into a sharps container. 2. Place contaminated Coagucheck strips (a test strip where a blood sample is dropped on the strip), used for an INR test, into a sharps container. D. During an interview on 4/15/24 at 3:30 PM, Staff E confirmed, [gender] did not have a sharps container to dispose of contaminated lancets and contaminated Coagucheck strips. E. During an interview on 4/23/24 at 11:30 AM, the Administrator confirmed Staff E failed to follow the agency’s policy and procedure for disposal of sharps and contaminated test strips used during the provision of cares for Patient 2.