Every finding on record at Mj Home Care, Inc.

An Emergency Preparedness survey was conducted along with a recertification survey beginning 5/4/2026. The facility was found to be in compliance with the regulations reviewed related to Emergency Preparedness.

A recertification survey was conducted along with a complaint investigation for complaint #2808527 beginning 5/4/2026. The facility was informed of the survey findings on 5/7/2026 and allowed time for questions.

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 policy review, medical record review, observation and interview, the facility failed to follow the Plan of Care (POC) for visit frequencies and wound care orders for 3 of 9 (Patient #2, #4 and #6) sampled active patients. The findings included: 1. Review of the facility’s “Plan of Care (POC)” policy (3/1/2026) revealed, “…The POC includes…Types, frequency, and duration of services required…Medications and treatments…The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner…Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner…Alterations to the POC are made only with the physician/authorized practitioner’s approval…” Review of the facility’s “Coordination of Care, From Admit Through Discharge” policy (12/1/2025) revealed, “…Coordination of care with physician/authorized practitioner…When a missed visit occurs altering the Plan of Care…” 2. Medical record review for Patient #2 revealed a POC date of 4/9/2026 through 6/7/2026 with diagnoses which included fractured right patella (kneecap) and Type 2 Diabetes. Review of Skilled Nurse (SN) visit frequency beginning 4/9/2026 revealed SN 1 time weekly for 7 weeks. There was no documentation of a SN visit week of 4/12/2026. There was no documentation the physician was notified of the deviation from the POC. 3. Medical record review for Patient #4 revealed a POC date of 4/7/2026 through 6/5/2026 with diagnoses which included venous insufficiency and non-pressure chronic ulcer of the lower leg. A 4/21/2026 physician’s order revealed an update to the POC for wound care. The order documented, “Cleanse wounds to bilateral lower extremities with wound cleanser. Apply Santyl [used to remove dead tissue from chronic skin ulcers and help promote healing] to wound beds. Cover with Vaseline gauze…” Observations in the home of Patient #4 on 5/5/2026 at 9:10 AM revealed RN #1 providing wound care. RN #1 cleaned the left leg wound then cleaned the right leg wound with wound cleanser. RN #1 then proceeded to cover each wound with Vaseline gauze. RN #1 failed to apply Santyl to the wounds, prior to covering with Vaseline gauze, as per the POC. 4 Medical record review for Patient #6 revealed a POC date of 3/25/2026 through 5/23/2026 with diagnoses which included unspecified Dementia and Hypertensive Chronic Kidney disease. Review of SN visit frequency beginning 3/25/2026 revealed SN 1 time weekly for 9 weeks. There was no documentation of a SN visit week of 4/5/2026. There was no documentation the physician was notified of the deviation from the POC. In an interview on 5/6/2026 at 11:30 AM, the facility’s Executive Director (ED) verified missed visits should be reported to the physician and documented in the medical record. The ED verified there was no observation of RN #1 applying Santyl to Patient #4’s wounds as ordered.

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 Centers for Disease Control (CDC) guidelines, policy review, observation and interview, the facility failed to ensure staff implemented measures to prevent the spread of potentially infectious bacteria during home visits for 1 of 5 (RN #1) staff observed. The findings included: 1. Review of CDC’s “Clinical Safety: Hand Hygiene for Healthcare Workers” guidelines revealed, “…know when to clean your hands…After touching a patient or patient’s surroundings…After contact with blood, body fluids, or contaminated surfaces… Immediately after glove removal…” 2. Review of the facility’s “Infection Control Plan” policy (10/1/2025) revealed, “…Hand Hygiene Compliance: Prevent transmission of infection through proper adherence of hand hygiene procedure by staff per Center for Disease Control (CDC) guidelines…” 3. Observations in the home of Patient #4 on 5/5/2026 at 9:10 AM revealed RN #1 providing wound care. RN #1 cleaned the wound of the left leg then immediately cleaned the wound of the right leg. RN #1 failed to change gloves and perform hand hygiene before moving from one wound to another. After RN #1 completed cleaning both leg wounds, RN #1 removed gloves and donned a new pair of gloves. RN #1 failed to perform hand hygiene after removing gloves. RN #1 picked a package of Coban (a cohesive, self-adhering elastic bandage wrap) up off the floor, then removed gloves and donned a new pair of gloves. RN #1 failed to perform hand hygiene after removing gloves. In an interview on 5/6/2026 at 11:30 AM, the facility’s Executive Director (ED) verified staff should follow CDC guidelines. The ED verified staff should perform hand hygiene after glove removal. The ED verified RN #1 should have changed gloves and performed hand hygiene between cleaning of the two leg wounds.

An unannounced onsite visit was conducted on 3/17/2025 to investigate Complaint #112255. An entrance conference was held with the Patient Care Manager at 11:35 AM. An exit conference was held via telephone on 3/21/2025 at 1:35 PM, and the investigation results were given. Adequate time was provided for questions. The allegation of Administration/ Personnel was substantiated, and the agency was cited.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure patients' rights to receive all services outlined in the plan of care for 4 of 5 (Patient #1, #2, #3, and #4) sampled patients reviewed. The findings included: 1. Review of the agency’s policy “Staffing and Back up Services,” dated 11/2/2020, revealed, “…COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE,” dated 5/1/1999, revealed, “…The agency provides care and services within an integrated continuum of care system. This is accomplished by…Coordinating patient care…to ensure that services are continuous and coordinated from admission through discharge…When a missed visit occurs altering the Plan of Care…All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director…Missed visits and changes to scheduled visits…Reason for missed visit…changes to patient schedule…” 2. Review of medical records revealed that Patient #1 was admitted with a Start of Care (SOC) date of 10/4/2019 with diagnoses that included Unspecified Dementia, Osteoarthritis, Asthma, and Hypertension. Review of the Physician Orders dated 8/28/2024, revealed continue care for 30 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/3/2024-12/1/2024, revealed the Home Health Aide (HHA) was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/2/2024-1/30/2025, revealed the Home Health Aide was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living (ADL) and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Schedule Records from 10/3/2024-1/18/2025, revealed the following HHA service visits: The week of 10/6/2024-10/12/2024 – total of 24 hours (6 hours missing) The week of 10/13/2024-10/19/2024 – total of 27 hours 23 minutes (2 hours 37 minutes missing) The week of 10/20/24-10/26/024 – no visits (30 hours missing) The week of 10/27/2024-11/2/2024 – no visits (30 hours missing) The week of 11/3/2024-11/9/2024 – no visits (30 hours missing) The week of 11/10/2024-11/16/2024 – total of 9 hours 19 minutes (20 hours 41 minutes missing) The week of 11/17/2024-11/23/2024 – total of 21 hours 43 minutes (8 hours 17 minutes missing) The week of 11/24/2024-11/30/2024 – no visits (30 hours missing) The week of 12/8/2024-12/14/2024 – total of 29 hours 35 minutes (25 minutes missing) The week of 12/15/2024-12/21/2024 – total of 21 hours 22 minutes (7 hours 38 minutes missing) The week of 12/22/2024-12/28/2024 – total of 28 hours 56 minutes (1 hour 4 minutes missing) The week of 12/29/2024-1/4/2025 – total of 10 hours 31 minutes (19 hours 29 minutes missing) The week of 1/5/2025-1/11/2025 – total of 12 hours (18 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours 30 minutes (1 hours 30 minutes missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/2/2024-1/30/2025…HHA Hourly…10:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation of what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/3/2024-1/30/2025. 3. Review of the closed medical records revealed that Patient #2 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Other Sequelae of other Cerebrovascular Disease, Muscle Weakness, Unspecified Dementia, Osteoporosis, and Hearing Loss. Review of the Physician Orders dated 10/1/2024, revealed HHA/CNA services for ADL assistance, personal care, and medication reminders for 35 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024- 2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 14 hours (21 hours missing) The week of 10/13/2024-10/19/2024 – no visits (35 hours missing) The week of 10/27/2024-11/2/2024 – no visits (35 hours missing) The week of 11/10/2024-11/16/2024 – total of 21 hours (14 hours missing) The week of 11/17/2024-11/23/2024 – total of 6 hours 35 minutes (28 hours 25 minutes missing) The week of 11/24/2024-12/7/2024 – no visits (35 hours missing) The week of 12/8/2024-12/14/2024 – total of 22 hours 7 minutes (12 hours 53 minutes missing) The agency provided no Missed Visit Notes for HHA services not provided from 10/7/2024 - 2/3/2025. 4. Review of the medical records revealed that Patient #3 was admitted with a Start of Care (SOC) date of 10/14/2024 with diagnoses that included Abnormal Gait, Morbid Obesity, Type 2 Diabetes, and Hypertension. Review of the Home Health Certification and Plan of Care from 10/14/2024-12/12/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/13/2024-2/10/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/14/2024-2/10/2025, revealed the following HHA service visits: The week of 10/14/2024-10/19/2024 – total of 11 hours 44 minutes (23 hours 16 minutes missing) The week of 10/20/2024-10/26/2024 – total of 24 hours 39 minutes (10 hours 21 minutes missing) The week of 10/27/2024-11/2/2024 – total of 33 hours 11 minutes (1 hour 49 minutes missing) The week of 11/3/2024-11/9/2024 – total of 28 hours 24 minutes (6 hours 36 minutes missing) The week of 11/17-2024-11/23/2024 – no visits (35 hours missing) The week of 11/24/2024-11/30/2024 – total of 28 hours (7 hours missing) The week of 12/1/2024-12/7/2024 – total of 23 hours 29 minutes (11 hours 31 minutes missing) The week of 12/15/2024-12/21/2024 – total of 7 hours (28 hours missing) The week of 12/22/2024-12/28/2024 – total of 27 hours 29 minutes (7 hours 31 minutes missing) The week of 1/5/2025-1/11/2025 – total of 28 hours (7 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours (7 hours missing) The week of 1/26/2025-2/1/2025 – total of 21 hours (14 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/13/2024-2/10/2025…HHA Hourly…9:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/14/2024-2/10/2025. 5. Review of the medical records revealed that Patient #4 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Hemiplegia, Chronic Obstructive Pulmonary Disease, Dissected Aortic Arch, Hypertensive Heart Disease with Heart Failure. Review of the Physician Orders dated 9/3/2024, revealed CNA/HHA services for ADL assistance, personal care, and medication reminders for 35 hours weekly for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024-2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 27 hours 24 minutes (7 hours 36 minutes missing) The week of 10/13/2024-10/19/2024 – total of 30 hours (5 hours missing) The week of 12/15/2024-12/21/2024 – total of 23 hours (12 hours missing) The week of 12/22/2024-12/28/2024 – total of 30 hours (5 hours missing) The week of 12/29/2024-1/4/2025 – total of 29 hours 11 minutes (5 hours 49 minutes missing) The week of 1/5/2025-1/11/2025 – total of 27 hours 6 minutes (7 hours 54 minutes missing) The week of 1/12/2025-1/18/2025 – total of 30 hours (5 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/6/2024-2/3/2025…HHA Hourly…6:00-12:00 [6:00 AM- 12:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care assistant]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/7/2024-2/3/2025. 6. During an interview on 3/17/2025 at 2:33 PM, the Case Manager stated that during the recertification, nursing identified a backup caregiver (family) that can assist with patient care when staff were not available, and the backup caregiver was documented on the plan of care (POC). She said that when the scheduled staff member called in or was unavailable, they would notify the family if they had another worker on standby. She said if there was someone on standby, they can do a schedule change. She said the family can accept or decline the alternate staff member. She said that if the patient of family member declined alternate staff, then they must activate their back up plan, and they document a missed visit. During an interview on 3/18/2025 at 12:57 PM, the Clinical Manager verified the above missed visits for Patient #1, #2, #3, and #4 and confirmed that the agency has issues with maintaining adequate staff to provide HHA services. During an interview on 3/21/2025 at 12:16 PM, Family Member #1 confirmed that she had an issue with her mother (Patient #1) not receiving services. Family Member #1 stated that her mother could feed herself and dress herself and stated, “I don’t have anybody.” Family Member #1 said some of the aides just would not show up, and the aides would not even let her know that they were not going to show up. She said she had to placed cameras in the home to watch her mother because she had to work, and she never knew if the aide was going to show up.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to assure the revision and implementation of the coordinated plan of care by ensuring communication with physicians or allowed practitioners about missed visits for 4 of 5 (Patient #1, #2, #3, and #4) sampled patients reviewed. The findings included: 1. Review of the agency’s policy “Staffing and Back up Services,” dated 11/2/2020, revealed, “…COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE,” dated 5/1/1999, revealed, “…The agency provides care and services within an integrated continuum of care system. This is accomplished by… Coordinating patient care…to ensure that services are continuous and coordinated from admission through discharge…At admission, through care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician…When a missed visit occurs altering the Plan of Care…All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director…Missed visits and changes to scheduled visits…Reason for missed visit…changes to patient schedule…” 2. Review of medical records revealed that Patient #1 was admitted with a Start of Care (SOC) date of 10/4/2019 with diagnoses that included Unspecified Dementia, Osteoarthritis, Asthma, and Hypertension. Review of the Physician Orders dated 8/28/2024, revealed continue care for 30 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/3/2024-12/1/2024, revealed the Home Health Aide (HHA) was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/2/2024-1/30/2025, revealed the Home Health Aide was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living (ADL) and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Schedule Records from 10/3/2024-1/18/2025, revealed the following HHA service visits: The week of 10/6/2024-10/12/2024 – total of 24 hours (6 hours missing) The week of 10/13/2024-10/19/2024 – total of 27 hours 23 minutes (2 hours 37 minutes missing) The week of 10/20/24-10/26/024 – no visits (30 hours missing) The week of 10/27/2024-11/2/2024 – no visits (30 hours missing) The week of 11/3/2024-11/9/2024 – no visits (30 hours missing) The week of 11/10/2024-11/16/2024 – total of 9 hours 19 minutes (20 hours 41 minutes missing) The week of 11/17/2024-11/23/2024 – total of 21 hours 43 minutes (8 hours 17 minutes missing) The week of 11/24/2024-11/30/2024 – no visits (30 hours missing) The week of 12/8/2024-12/14/2024 – total of 29 hours 35 minutes (25 minutes missing) The week of 12/15/2024-12/21/2024 – total of 21 hours 22 minutes (7 hours 38 minutes missing) The week of 12/22/2024-12/28/2024 – total of 28 hours 56 minutes (1 hour 4 minutes missing) The week of 12/29/2024-1/4/2025 – total of 10 hours 31 minutes (19 hours 29 minutes missing) The week of 1/5/2025-1/11/2025 – total of 12 hours (18 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours 30 minutes (1 hours 30 minutes missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/2/2024-1/30/2025…HHA Hourly…10:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation of what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/3/2024-1/30/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/3/2024-1/30/2025. 3. Review of the closed medical records revealed that Patient #2 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Other Sequelae of other Cerebrovascular Disease, Muscle Weakness, Unspecified Dementia, Osteoporosis, and Hearing Loss. Review of the Physician Orders dated 10/1/2024, revealed HHA/CNA services for ADL assistance, personal care, and medication reminders for 35 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024- 2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 14 hours (21 hours missing) The week of 10/13/2024-10/19/2024 – no visits (35 hours missing) The week of 10/27/2024-11/2/2024 – no visits (35 hours missing) The week of 11/10/2024-11/16/2024 – total of 21 hours (14 hours missing) The week of 11/17/2024-11/23/2024 – total of 6 hours 35 minutes (28 hours 25 minutes missing) The week of 11/24/2024-12/7/2024 – no visits (35 hours missing) The week of 12/8/2024-12/14/2024 – total of 22 hours 7 minutes (12 hours 53 minutes missing) The agency provided no Missed Visit Notes for HHA services not provided from 10/7/2024 - 2/3/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/7/2024 - 2/3/2025. 4. Review of the medical records revealed that Patient #3 was admitted with a Start of Care (SOC) date of 10/14/2024 with diagnoses that included Abnormal Gait, Morbid Obesity, Type 2 Diabetes, and Hypertension. Review of the Home Health Certification and Plan of Care from 10/14/2024-12/12/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/13/2024-2/10/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/14/2024-2/10/2025, revealed the following HHA service visits: The week of 10/14/2024-10/19/2024 – total of 11 hours 44 minutes (23 hours 16 minutes missing) The week of 10/20/2024-10/26/2024 – total of 24 hours 39 minutes (10 hours 21 minutes missing) The week of 10/27/2024-11/2/2024 – total of 33 hours 11 minutes (1 hour 49 minutes missing) The week of 11/3/2024-11/9/2024 – total of 28 hours 24 minutes (6 hours 36 minutes missing) The week of 11/17-2024-11/23/2024 – no visits (35 hours missing) The week of 11/24/2024-11/30/2024 – total of 28 hours (7 hours missing) The week of 12/1/2024-12/7/2024 – total of 23 hours 29 minutes (11 hours 31 minutes missing) The week of 12/15/2024-12/21/2024 – total of 7 hours (28 hours missing) The week of 12/22/2024-12/28/2024 – total of 27 hours 29 minutes (7 hours 31 minutes missing) The week of 1/5/2025-1/11/2025 – total of 28 hours (7 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours (7 hours missing) The week of 1/26/2025-2/1/2025 – total of 21 hours (14 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/13/2024-2/10/2025…HHA Hourly…9:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/14/2024-2/10/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/14/2024-2/10/2025. 5. Review of the medical records revealed that Patient #4 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Hemiplegia, Chronic Obstructive Pulmonary Disease, Dissected Aortic Arch, Hypertensive Heart Disease with Heart Failure. Review of the Physician Orders dated 9/3/2024, revealed CNA/HHA services for ADL assistance, personal care, and medication reminders for 35 hours weekly for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024-2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 27 hours 24 minutes (7 hours 36 minutes missing) The week of 10/13/2024-10/19/2024 – total of 30 hours (5 hours missing) The week of 12/15/2024-12/21/2024 – total of 23 hours (12 hours missing) The week of 12/22/2024-12/28/2024 – total of 30 hours (5 hours missing) The week of 12/29/2024-1/4/2025 – total of 29 hours 11 minutes (5 hours 49 minutes missing) The week of 1/5/2025-1/11/2025 – total of 27 hours 6 minutes (7 hours 54 minutes missing) The week of 1/12/2025-1/18/2025 – total of 30 hours (5 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/6/2024-2/3/2025…HHA Hourly…6:00-12:00 [6:00 AM- 12:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care assistant]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/7/2024-2/3/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/7/2024-2/3/2025. 6. During an interview on 3/17/2025 at 2:33 PM, the Case Manager stated that during the recertification, nursing identified a backup caregiver (family) that can assist with patient care when staff were not available, and the backup caregiver was documented on the plan of care (POC). She said that when the scheduled staff member called in or was unavailable, they would notify the family if they had another worker on standby. She said if there was someone on standby, they can do a schedule change. She said the family can accept or decline the alternate staff member. She said that if the patient of family member declined alternate staff, then they must activate their back up plan, and they document a missed visit. During an interview on 3/18/2025 at 12:57 PM, the Clinical Manager verified the above missed visits for Patient #1, #2, #3, and #4 and confirmed that the agency has issues with maintaining adequate staff to provide HHA services. During an interview on 3/21/2025 at 12:16 PM, Family Member #1 confirmed that she had an issue with her mother (Patient #1) not receiving services. Family Member #1 stated that her mother could feed herself and dress herself and stated, “I don’t have anybody.” Family Member #1 said some of the aides just would not show up, and the aides would not even let her know that they were not going to show up. She said she had to placed cameras in the home to watch her mother because she had to work, and she never knew if the aide was going to show up.

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 policy review, medical record review, and interview, Administration failed to be actively involved in all day-to-day operations of the agency to ensure adequate staff to provide services for patient care and to ensure patients' rights to receive all service visits designated on the patient's plan of care (POC) for 4 of 5 (#1, #2, #3, and #4) sampled patients reviewed. The findings included: 1. Review of the agency’s policy “Staffing and Back up Services,” dated 11/2/2020, revealed, “…COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE,” dated 5/1/1999, revealed, “…The agency provides care and services within an integrated continuum of care system. This is accomplished by… Coordinating patient care…to ensure that services are continuous and coordinated from admission through discharge…At admission, through care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician…When a missed visit occurs altering the Plan of Care…All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director…Missed visits and changes to scheduled visits…Reason for missed visit…changes to patient schedule…” Review of the agency’s policy “Staffing and Back up Services,” dated 11/2/2020, revealed “…It is the expectation of the governing body that all personnel provide patient/ clients served with quality professional services…In turn, the governing body accepts the responsibility to provide…staffing to maintain and pursue personnel practices that make provisions for illness, vacation, and adequate pay. It is policy of the agency to ensure that services are provided when the employee or contractor is not able to deliver the services. Back up personnel will be available to dispatch to endure no interruption in services…The Governing Body, along with management, is responsible for establishing the staffing standards considered appropriate…In the event that staff abruptly resign[s] or for some reason staff are unable to perform work duties, management will triage patients and contact outside sources of nurses, such as other branches, cooperative agencies, or staffing agencies to make visits to those patients who need care. In the event this still does not meet the needs of patients, patients will be referred to other home care agencies, where the patient can receive appropriate care. This will be done in a manner to prevent disruption of patient care services…The Executive Director or designee will ensure that services can be provided 7 days per week and backup personnel are always available…” 2. Review of medical records revealed that Patient #1 was admitted with a Start of Care (SOC) date of 10/4/2019 with diagnoses that included Unspecified Dementia, Osteoarthritis, Asthma, and Hypertension. Review of the Physician Orders dated 8/28/2024, revealed continue care for 30 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/3/2024-12/1/2024, revealed the Home Health Aide (HHA) was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/2/2024-1/30/2025, revealed the Home Health Aide was scheduled for 30 hours weekly to provide services including medication reminders, assistance with activities of daily living (ADL) and personal care including bathing, oral care, nail care, and skin care, assist with transfers, toileting, preparing meals, assist with feeding, linen changes. There was no documented physician’s signature. Review of the Schedule Records from 10/3/2024-1/18/2025, revealed the following HHA service visits: The week of 10/6/2024-10/12/2024 – total of 24 hours (6 hours missing) The week of 10/13/2024-10/19/2024 – total of 27 hours 23 minutes (2 hours 37 minutes missing) The week of 10/20/24-10/26/024 – no visits (30 hours missing) The week of 10/27/2024-11/2/2024 – no visits (30 hours missing) The week of 11/3/2024-11/9/2024 – no visits (30 hours missing) The week of 11/10/2024-11/16/2024 – total of 9 hours 19 minutes (20 hours 41 minutes missing) The week of 11/17/2024-11/23/2024 – total of 21 hours 43 minutes (8 hours 17 minutes missing) The week of 11/24/2024-11/30/2024 – no visits (30 hours missing) The week of 12/8/2024-12/14/2024 – total of 29 hours 35 minutes (25 minutes missing) The week of 12/15/2024-12/21/2024 – total of 21 hours 22 minutes (7 hours 38 minutes missing) The week of 12/22/2024-12/28/2024 – total of 28 hours 56 minutes (1 hour 4 minutes missing) The week of 12/29/2024-1/4/2025 – total of 10 hours 31 minutes (19 hours 29 minutes missing) The week of 1/5/2025-1/11/2025 – total of 12 hours (18 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours 30 minutes (1 hours 30 minutes missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/2/2024-1/30/2025…HHA Hourly…10:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation of what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/3/2024-1/30/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/3/2024-1/30/2025. 3. Review of the closed medical records revealed that Patient #2 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Other Sequelae of other Cerebrovascular Disease, Muscle Weakness, Unspecified Dementia, Osteoporosis, and Hearing Loss. Review of the Physician Orders dated 10/1/2024, revealed HHA/CNA services for ADL assistance, personal care, and medication reminders for 35 hours a week for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly to provide medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024- 2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 14 hours (21 hours missing) The week of 10/13/2024-10/19/2024 – no visits (35 hours missing) The week of 10/27/2024-11/2/2024 – no visits (35 hours missing) The week of 11/10/2024-11/16/2024 – total of 21 hours (14 hours missing) The week of 11/17/2024-11/23/2024 – total of 6 hours 35 minutes (28 hours 25 minutes missing) The week of 11/24/2024-12/7/2024 – no visits (35 hours missing) The week of 12/8/2024-12/14/2024 – total of 22 hours 7 minutes (12 hours 53 minutes missing) The agency provided no Missed Visit Notes for HHA services not provided from 10/7/2024 - 2/3/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/7/2024 - 2/3/2025. 4. Review of the medical records revealed that Patient #3 was admitted with a Start of Care (SOC) date of 10/14/2024 with diagnoses that included Abnormal Gait, Morbid Obesity, Type 2 Diabetes, and Hypertension. Review of the Home Health Certification and Plan of Care from 10/14/2024-12/12/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/13/2024-2/10/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/14/2024-2/10/2025, revealed the following HHA service visits: The week of 10/14/2024-10/19/2024 – total of 11 hours 44 minutes (23 hours 16 minutes missing) The week of 10/20/2024-10/26/2024 – total of 24 hours 39 minutes (10 hours 21 minutes missing) The week of 10/27/2024-11/2/2024 – total of 33 hours 11 minutes (1 hour 49 minutes missing) The week of 11/3/2024-11/9/2024 – total of 28 hours 24 minutes (6 hours 36 minutes missing) The week of 11/17-2024-11/23/2024 – no visits (35 hours missing) The week of 11/24/2024-11/30/2024 – total of 28 hours (7 hours missing) The week of 12/1/2024-12/7/2024 – total of 23 hours 29 minutes (11 hours 31 minutes missing) The week of 12/15/2024-12/21/2024 – total of 7 hours (28 hours missing) The week of 12/22/2024-12/28/2024 – total of 27 hours 29 minutes (7 hours 31 minutes missing) The week of 1/5/2025-1/11/2025 – total of 28 hours (7 hours missing) The week of 1/12/2025-1/18/2025 – total of 28 hours (7 hours missing) The week of 1/26/2025-2/1/2025 – total of 21 hours (14 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/13/2024-2/10/2025…HHA Hourly…9:00-16:00 [10:00 AM- 4:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care technician]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/14/2024-2/10/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/14/2024-2/10/2025. 5. Review of the medical records revealed that Patient #4 was admitted with a Start of Care (SOC) date of 10/7/2024 with diagnoses that included Hemiplegia, Chronic Obstructive Pulmonary Disease, Dissected Aortic Arch, Hypertensive Heart Disease with Heart Failure. Review of the Physician Orders dated 9/3/2024, revealed CNA/HHA services for ADL assistance, personal care, and medication reminders for 35 hours weekly for 52 weeks. Review of the Home Health Certification and Plan of Care from 10/7/2024-12/5/2024, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Home Health Certification and Plan of Care from 12/6/2024-2/3/2025, revealed the HHA was scheduled for 35 hours weekly for medication reminders and personal care. There was no documented physician’s signature. Review of the Schedule Records from 10/7/2024-2/3/2025, revealed the following HHA service visits: The week of 10/7/2024-10/12/2024 – total of 27 hours 24 minutes (7 hours 36 minutes missing) The week of 10/13/2024-10/19/2024 – total of 30 hours (5 hours missing) The week of 12/15/2024-12/21/2024 – total of 23 hours (12 hours missing) The week of 12/22/2024-12/28/2024 – total of 30 hours (5 hours missing) The week of 12/29/2024-1/4/2025 – total of 29 hours 11 minutes (5 hours 49 minutes missing) The week of 1/5/2025-1/11/2025 – total of 27 hours 6 minutes (7 hours 54 minutes missing) The week of 1/12/2025-1/18/2025 – total of 30 hours (5 hours missing) Review of the Missed Visit Note dated 1/10/2025, revealed “...Certification Period 12/6/2024-2/3/2025…HHA Hourly…6:00-12:00 [6:00 AM- 12:00 PM]…HHA/CNA [certified nursing assistant]/ PCA [patient care assistant]…Cancelled By Agency- No Available Staff…Back up plan was initiated [there was no documentation what the back up plan was]…Follow-Up Action(s): Notified Caregiver [selection box unmarked] Notified Physician [selection box unmarked]…Unable to Reschedule Due To [selection box checked]…Due to inclement weather caregiver will not work on date services visit will be missed backup plan was...Backup plan was initiated...Printed name, Discipline [no documented name or discipline] 01/10/2025…Signature, Date…” The agency provided no other Missed Visit Notes for HHA services not provided from 10/7/2024-2/3/2025. The agency provided no documentation that the physician was notified of any missed visits or HHA services not provided from 10/7/2024-2/3/2025. 6. During an interview on 3/17/2025 at 2:33 PM, the Case Manager stated that during the recertification, nursing identified a backup caregiver (family) that can assist with patient care when staff were not available, and the backup caregiver was documented on the plan of care (POC). She said that when the scheduled staff member called in or was unavailable, they would notify the family if they had another worker on standby. She said if there was someone on standby, they can do a schedule change. She said the family can accept or decline the alternate staff member. She said that if the patient of family member declined alternate staff, then they must activate their back up plan, and they document a missed visit. During an interview on 3/18/2025 at 12:57 PM, the Clinical Manager verified the above missed visits for Patient #1, #2, #3, and #4 and confirmed that the agency has issues with maintaining adequate staff to provide HHA services. During an interview on 3/21/2025 at 12:16 PM, Family Member #1 confirmed that she had an issue with her mother (Patient #1) not receiving services. Family Member #1 stated that her mother could feed herself and dress herself and stated, “I don’t have anybody.” Family Member #1 said some of the aides just would not show up, and the aides would not even let her know that they were not going to show up. She said she had to placed cameras in the home to watch her mother because she had to work, and she never knew if the aide was going to show up. During an interview on 3/21/2025 at 1:40 PM, the Executive Director stated that she was not aware of the agency's private duty staffing issues.

An Emergency Preparedness recertification and re-licensure survey was conducted on 5/15/2023-5/17/2023. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification survey was conducted on 5/15/2023-5/17/2023. An entrance conference was held on 5/15/2023 at 8:15 AM, with the Administrator. An exit conference was held on 5/17/2023 at 3:30 PM, with the agencies administration.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to update the medication profile for 3 of 4 (Patient #1, #2, and #4) patients reviewed. The findings included: 1. Review of the agencies "Monitoring Medications," last revised 5/1/2019, revealed "...PURPOSE: To provide a process to ensure continuous monitoring of medications in the patient's home...POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode...The physician is contacted immediately if any discrepancies between agency information and patient medications are found..." 2. Review of the medical record revealed Patient #1 was admitted on 8/8/2022 with diagnoses of Hemiplegia Following Cerebral Infarction, Pressure Ulcer of Sacral Region, Unstageable, Pressure Ulcer of Right Buttock, Stage 3, Chronic Obstructive Pulmonary Disease, and Acquired Absence of Right Leg Above Knee. Review of the Physician Order dated 1/27/2023, revealed "...Labetalol [Anti-hypertensive] 200 mg [milligram]...oral...2 times daily..." Review of the Visit Note dated 5/16/2023, revealed "...SN [Skilled Nurse] called [Named Physician #1] to obtain order as well as verify if pt [patient] is still taking Labetalol due to CG [caregiver] stated it was stopped. SN spoke with [Named Physician's Nurse] who states pt is still on this medication..." During an interview with Patient #1s sister on 5/16/2023 at 1:25 PM, she stated "...It [Labetalol] was discontinued in the doctor's office because it caused my brother's blood pressure to be too low. He hasn't taken this medication in 1-2 months..." 3. Review of the medical record revealed Patient #2 was admitted to the agency on 12/9/2022 with diagnoses of Diabetes Mellitus with Foot Ulcer, End Stage Renal Disease, Hypertensive Heart and Chronic Kidney Disease, and Dependence on Dialysis. Review of the Physician Order dated 6/1/2022, revealed "...Amlodipine [Anti-Hypertensive] 10 mg ...oral...daily..." Review of the Physician Order dated 6/11/2022, revealed "...Aspirin Low Dose 81 mg ...oral...daily..." Review of the Physician Order dated 6/11/2022, revealed "...Atorvastatin [Treats High Cholesterol] ...40 mg ...oral...bedtime..." Review of the Physician Order dated 12/9/2022, revealed "...Calcium Acetate 667 mg ...oral...three times daily..." Review of the Physician Order dated 5/24/2022, revealed "...Midodrine [Anti-Hypotensive] 10 mg ...oral...three times daily..." Review of the Physician Order dated 12/9/2022, revealed "...Vitamin D2 1,250 mcg [microgram] (50,000 units) ...oral...weekly..." Review of the Visit Note Report dated 5/12/2023, revealed "...Alert...Oriented to Person...Place...Time..." During an interview with a woman that refused to give name, stated she was Patient #2's caregiver on 5/17/2023 at 10:57 AM, she stated "...he has not taken his medications, except for his Sevelamer, because his new insurance company doesn't pay for them. I have spoken with his MD's office a couple of weeks ago..." Patient #2 confirmed his caregiver's statement. 4. Medical record review revealed Patient #4 was admitted to the agency on 4/12/2023 with diagnoses of Neurocognitive Disorder with Lewy Bodies, Dementia, Diabetes Mellitus, Hypertension, and Venous Insufficiency. Observations of Patient #4's medications on 5/17/2023 at 12:50 PM, revealed Patient was prescribed on 5/8/2023 Quetiapine 25 mg oral at night and Hydralazine 25 mg oral twice a day. Patient #4 was also prescribed on 9/15/2022 Dorzolamide-Timolol Opthalmic Solution, 1 drop both eyes twice daily and Lantaprost 0.005% Opthalmic Solution, 1 drop both eyes at night. Review of the Physician Orders revealed the agency did not have orders in Patient #4's medical record for these medications. During an interview with the Administrator on 5/17/2023 at 1:20 AM, she confirmed the medical record was inaccurate.