Every finding on record at Passion 05 Health Services Inc

Purpose of visit: Recertification, Relicensure Survey and Investigation of intakes 1027949 and 1033267 Entrance conference date: 2/12/2026 The census was -98 Licensed and Certified Patients – 0 Licensed Home Health Patients – 1 Personal Assistance Service Patients- 97 The Home Health Agency was compliant with emergency preparedness.

Purpose of visit: Recertification, Relicensure Survey and Investigation of intakes 1027949 and 1033267 Entrance conference date: 2/12/2026 The census was -98 Licensed and Certified Patients – 0 Licensed Home Health Patients – 1 Personal Assistance Service Patients- 97 Abbreviations: Adm- Administrator DON- Director of Nurses or Supervising Nurse OASIS – Outcome and Assessment Information Set CMS – Centers for Medicare and Medicaid Services IQIES – Internet Quality Improvement and Evaluation System PAS- Personal Assistance Service HHA- Home Health Agency SOC- Start of Care POC- Plan of Care EMR-Electronic Medical Record PT- Physical Therapy OT- Occupational Therapy #- number cm-centimeter PIP-Performance Improvement Project PHC- Primary Home Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record reviews and interviews the agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect and report patient information for quality improvement and monitoring) to the CMS system within 30 days of completing the patient’s assessment for 1 (Patient 1) of 6 patients’ records reviewed. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. Findings: Review of the HHA Error Summary by Agency report in IQIES (CMS system to manage provider and patient information and ensure quality healthcare) on 2/09/2026 revealed 1 late OASIS submission with error code 3330 (code for a late submission greater than 30 days after the patient’s assessment completion date) out of 2 assessments processed during the period of 02/09/2025-02/08/2026. Review of the HHA Activity Report in IQIES on 02/09/2026 for report period 02/09/2025 to 02/08/2026 revealed the Agency submitted the OASIS Start of Care assessment dated 8/29/2025 for Patient 1 to CMS on 10/22/2025. The report did not contain any additional OASIS assessment submissions after 10/22/2025. An entrance conference was conducted with the Adm/DON/Agency Owner on 2/12/2026 at 10:45am. When asked about the Agency’s policy on OASIS patient assessment submissions to CMS. The Adm/DON stated she completed all nursing visits, OASIS patient assessments, and submissions of the OASIS assessments to CMS. The Adm/DON stated OASIS patient assessments were submitted to CMS “within 30 days” of the patient’s assessment completion date. The Adm/DON stated the Agency discontinued the EMR services provided by Vendor B “about a year” ago because the agency had only “one patient” and Vendor B “was getting expensive.” The Adm/DON stated patient records were currently in paper form. The Adm/DON stated that the Agency manually submitted the OASIS patient assessments to CMS through the IQIES portal. The surveyor requested the confirmations of the agency’s OASIS submissions for 2025. The Adm/DON/Agency owner stated she would try and locate the confirmations on her computer. Record review of Patient 1’s paper chart revealed an OASIS Start of Care Assessment dated 08/29/2025 signed by the Adm/DON/Agency Owner. Record review of Patient 1’s paper chart revealed an OASIS recertification “Follow-Up Assessment” with a “Date Assessment Completed” of 10/24/2025 signed by the Adm/DON/Agency Owner. Patient 1’s records did not contain any evidence that the OASIS recertification “Follow-Up Assessment” was submitted to CMS. Record review of Patient 1’s paper chart revealed an OASIS recertification “Follow-Up Assessment” with a “Date Assessment Completed” of 12/24/2025 signed by the Adm/DON/Agency Owner. Patient 1’s records did not contain any evidence that the OASIS recertification “Follow-Up Assessment” was submitted to CMS. An interview was conducted with the Adm/DON/Agency Owner on 2/20/2026 at 1:18pm. The surveyor shared the findings on Patient 1. When asked why Patient 1’s OASIS SOC assessment was submitted late (greater than 30 days) to CMS, the Adm/DON stated she was responsible for the OASIS submissions, and she could not recall why Patient 1’s OASIS SOC assessment was submitted late to CMS. When asked why Patient 1’s OASIS recertification assessments dated 10/24/2025 and 12/24/2025 were not submitted to CMS. The Adm/DON/Agency Owner stated, “I submitted the first one, the start of care (OASIS assessment), but the second (OASIS recertification assessment) and the 3rd (OASIS recertification assessment) at that time it was my understanding that” patients funded through payor source A “didn’t need to be submitted.” The Adm/DON/Agency owner stated, “The change occurs March of this year (2026) when you (the agency) have to submit all (patient’s OASIS assessments) payor sources.” The surveyor reviewed the agency’s “Timelines” policy with the Adm/DON. When asked about the potential patient outcome for not submitting required OASIS patient assessment data to CMS per the agency’s policy, the Adm/DON/Agency owner refused to directly answer the question and stated, “I don’t know why I thought the change (in OASIS assessment submission requirements) was in March (2026).” It (submission of Patient 1’s recertification OASIS assessments dated 10/24/2025 and 12/25/2025) will be late but I will submit it.” The Adm/DON did not provide any electronic validation records indicating that any OASIS assessment transmissions were successful for Patient 1. Review of the agency’s policy “Timelines” with last review date of 07/01/2025 (policies located online from a HHA consulting group) read in part “The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure. A registered nurse, physical therapist, or speech therapist will complete the Initial Comprehensive Assessment no later than five calendar days after the start of care (SOC) for all patients/clients in a licensed and certified agency, regardless of payer. The collection and transmission of the Outcome and Assessment Information Set (OASIS) data excludes the following patients/clients: Patients/Clients under 18 years old; Maternity patients/clients; Homemaker or chore service only patients/clients; and receiving only personal care services (regardless of payer source). Recertifications/comprehensive reassessments will be completed no earlier than five days prior to end of the episode and no later than the last day of the episode (the 56th through the 60th day). All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set, and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 (the date the assessment is completed) date. The State Operations Manual recommends the Agency keep copies of the electronic validation records indicating transmission was successful, for 12 months or until the next set of reports are available. Transmittal includes all payer sources. Mandatory OASIS data collection and submission includes all start of care and subsequent OASIS time point assessments (resumption of care, recertification, other follow-up, transfer, discharge, and death at home). Review of the agency’s policy “Timelines” with last review date of 07/01/2025 contained the reference to CMS letter “Transition to All-Payer OASIS Data Collection and Submission” which read “Effective July 1,2025. Collect and submit OASIS data for all patients with any pay source who are not exempt from OASIS data collection and who begin receiving home health care services with an OASIS SOC M0090 (the date the assessment is completed) date on or after July 1, 2025. Include all subsequent OASIS time point assessments (resumption of care, recertification, other follow-up, transfer, discharge, and death at home). Continue Exclusions: Continue to exclude patients under the age of 18, those receiving maternity services, and those receiving only personal care, housekeeping, and/or chore services from OASIS data collection and submission requirements.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the Home Health Agency failed to ensure the patient’s individualized plan of care contained the following: The patient's mental, psychosocial, and cognitive status; The types of services, supplies, and equipment required; The frequency and duration of visits to be made; Rehabilitation potential; Functional limitations; Activities permitted; Nutritional requirements; All medications and treatments; Safety measures to protect against injury; 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; Patient and caregiver education and training to facilitate timely discharge; Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient for 1 (Patient 1) of 6 patients’ records reviewed. The failure to provide all required detailed information in an individualized plan of care can potentially lead to inadequate patient treatments, education, worsening symptoms, and preventable hospital re-admissions. Findings: Record review of Patient 1’s “Home Health Certification and Plan of Care” for period 08/29/2025 to 10/27/2025 signed by the Adm/DON/Agency Owner revealed a start of care date of 08/29/2025. The POC contained a primary diagnosis of a non-pressure chronic ulcer (a slow-healing or nonhealing sore on the skin caused by injury, infection, nerve damage or poor blood circulation) and secondary conditions of a pressure ulcer (damaged skin and tissue caused by prolong unrelieved pressure) of left heel and absence of left great toe. The POC contained an order that read “Skilled Nurse to instruct Patient/Caregiver in wound care and offload pressure to foot and elevate feet. Assess/Perform/Instruct, patient/caregiver: Wound care to left heel and big left amputated toe, twice every week. Cleanse with normal saline (solution of salt and water), pat dry with gauze, apply Iodine (substance used to kill or stop the growth of germs) to wound bed, cover with gauze, secure with” gauze bandage roll “and tape.” Record review of Patient 1’s “Home Health Certification and Plan of Care” for recertification period 10/28/2025-12/26/2025 signed by the Adm/DON/Agency Owner revealed no documentation under mental status, medical equipment/supplies, safety measures, functional limitations, activities permitted, nutritional requirements, allergies, orders for discipline and treatments, and goals/rehabilitation potential/discharge plans.” The POC did not contain wound orders/treatments, 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. The POC also did not contain patient-specific interventions, education, measurable outcomes and goals. Review of Patient 1’s OASIS recertification assessment dated 10/24/2025 signed by the Adm/DON/Agency owner contained documentation of the assessment of Patient 1. The Adm/DON check marked the box that the patient was “oriented” under mental status. The Adm/DON check marked “Falls” and “Infection Control/Standards” under safety measures. The Adm/DON check marked “Amputation, Bowel/bladder (incontinence), Endurance, Ambulation” under functional limitations. The Adm/DON check marked “Exercised prescribed” and “wheelchair” under activities permitted. The Adm/DON check marked “Bathroom safety devices, dressing aids, wheelchair (electric and manual) and transfer equipment” under equipment. The Adm/DON check marked “Multiple hospitalizations (2 or more) in the past 6 months, multiple emergency department visits (2 or more) in the last 6 months, reported or observed history of difficulty complying with any medical instructions, currently taking 5 or more medications, and other risks not listed” under risk for hospitalization. The Adm/DON documented “Wound # 1” to “Left big toe” measured 1cm length by 1cm width by 0.2cm depth with “eschar (a thick dry, leathery layer of dead tissue that forms over a wound)” to wound bed and a small amount of “serous (component of the blood that is clear, pale yellow, and watery)” drainage. The Adm/DON documented “Wound # 2” to “left heel” measured 1.5cm length by 1cm width by 0.1cm depth with fibrotic (thick scar tissue) wound bed and a small amount of serous drainage. The OASIS recertification assessment “wound care” section was blank and did not contain any wound orders for the wounds to Patient 1’s “left big toe” or “left heel.” The Adm/DON documented “assessment, wound care” under the skilled intervention and procedures section. An interview was conducted with the Adm/DON/Agency Owner on 2/20/2026 at 1:18pm. When asked about the agency’s policy on what was required in the patient’s plan of care. The Adm/DON stated the patient’s “diagnosis, comorbidities, problems, intervention and goals, positive outcomes, frequency of visits and any orders.” The surveyor shared the findings on Patient 1. When asked about the missing orders, treatments, interventions, patient education, outcomes and goals on Patient 1’s POC for recertification period 10/28/2025-12/26/2025. The Adm/DON stated, “I don’t know why I did not notice that (missing orders, treatments, interventions, patient education, outcomes and goals on Patient 1’s POC).” When asked about Patient 1’s wound orders and nurse visit frequency during the period of 10/28/2025 to 12/26/2025. The Adm/DON stated the wound order and nurse visit frequency of twice a week did not change between the period of 8/29/2025 to 1/12/2026. When asked about the potential patient outcome for missing orders, treatments, interventions, patient education, outcomes and goals on the POC. The Adm/DON stated, “I do the nursing visits, so I know the patient, but if any other nurse followed up, they would not be aware of the orders” for the patient. Review of the agency’s policy “Plan of Care” with last reviewed date of 03/17/2023 (policies located online from a HHA consulting group) read in part “The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. Procedure. The individualized Plan of Care must include the following: All pertinent diagnoses; The patient’s/client’s mental, psychosocial, and cognitive status; The types of services, supplies, and equipment required; The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care; The frequency and duration of visits to be made; Prognosis; Rehabilitation potential; Functional limitations; Activities permitted; Nutritional requirements; All medications and treatments; Safety measures to protect against injury; A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors; Patient/client and caregiver education and training to facilitate timely discharge; Patient/client-specific interventions and education; Measurable outcomes and goals identified by the Agency and the patient/client; Information related to any advance directives; and any additional items the Agency or physician or allowed practitioner may choose to include.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record reviews and interviews the agency failed to conduct a performance improvement project annually to address identified problems with care and to evaluate past performance of the home health agency’s services and operations for 3 (2023, 2024 and 2025) of the 3 years of the survey review period. This failure prevented the agency from identifying and correcting problems with the quality of patient care, which put patients at risk of poor health outcomes. Findings: Record review of the agency’s undated “QAPI Manual” provided by the Adm/DON/Agency Owner on 2/12/2026 revealed the QAPI meeting summaries for first quarter 2023 (undated), 4/15/2024, 7/17/2024, 10/16/2024, 1/16/2025, 4/15/2025, 7/17/2025, 10/16/2025 and 1/16/2026. Review of the agency’s QAPI manual provided no evidence that the agency conducted Performance Improvement Projects for 2023, 2024 and 2025. Record review of the agency’s undated “Board of Directors” list provided by the Adm/DON/Agency Owner on 2/12/2026 revealed the names of the Administrator/DON and Alternate Administrator as the only members of the governing body. An interview was conducted with the Adm/DON/Agency Owner on 2/20/2026 at 1:18pm. When asked about the agency’s policy on conducting Performance Improvement Projects, the Adm/DON/Agency Owner stated, “All I know about it (Performance Improvement Projects) is the change that required PIPs came out in 2024 and I have not had the time to sit down and get into the details of it (conducting a PIP).” The surveyor shared the findings of the missing PIPs for 2023, 2024 and 2025. When asked about the missing PIPs the Adm stated “Like I said before I had not looked into the details of it and it was not done.” The surveyor reviewed the agency’s “Performance Improvement Project (PIP) instructions dated 1/13/2018 with the Adm/DON. When asked about the potential patients’ outcomes due to the agency’s failure to conduct PIPs annually to address identified problems with care and to evaluate past performance of the HHA’s services. The Adm/DON/Agency Owner stated “It’s (the PIP is) used to report things (problems with care and services) that are not right so they (the problems) can be corrected.” The Adm/DON stated if the PIP was not conducted “The problem issues won’t be resolved” which can affect the care of the patients. The Adm/DON stated the PIP “Is also used to monitor the progress” of the agency’s corrective measures to address the identified problems with patient care. Review of the agency’s “Performance Improvement Project (PIP) Instructions” with last reviewed date of 01/13/2018 (policies located online from an HHA consulting group) read in part “Purpose: Agencies must conduct performance improvement projects (PIPs). The number and scope of these projects must reflect the scope, complexity, and past performance of the agency’s services and operations. The agency must document the PIP undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. The agency should have one PIP either in development, on-going or completed each calendar year. The agency decides, based on the QAPI program activities and data, what projects are indicated and the priority of the projects.” Review of the agency’s policy “Quality Assessment Performance Program” with last reviewed date 05/01/2024 (policies located online from a HHA consulting group) read in part “The Governing Body will ensure that the QAPI program: Focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions, and re-admissions; and Takes actions that address the Agency's performance across the spectrum of care, including the prevention and reduction of medical errors. Agency’s Governing Body is responsible for ensuring the following: That the Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient/client safety, and that all improvement actions are evaluated for effectiveness; Understanding of performance improvement principles and methods and will be responsible for providing education for staff as needed. Procedure. Performance improvement projects. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.” Review of the agency policy “Performance Improvement Process: Improvement Activities” with last review date of 05/01/2024 read in part “The Governing Body will be responsible for setting the priorities for improvement activities or projects based on Agency functions, the defined data collection, the resources required to facilitate the improvement, and the organization's mission. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually. When developing and prioritizing the improvement activities or projects, the Governing Body will consider the following: The scope, complexity, and past performance of the Agency’s services and operations; The expected impact of the improvement on performance, patient/client outcomes and safety; High-risk, high-volume, or problem-prone areas of service to include the incidence, prevalence, and severity of problems in those areas; Data obtained from OASIS generated reports; Previous problematic issues where there is clear evidence of poor patient/client outcomes; and Agency resources. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure clinical records were retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time for 3 (Patients 2, 3, and 4) of 6 patients’ records reviewed. The failure of the agency to retain the discharged patients’ electronic medical records potentially prevented the discharged patients from accessing documentation on assessments and treatment history needed for continuity of care. Findings: An entrance conference was conducted with the Adm/DON/Agency Owner on 2/12/2026 at 10:45am. When asked about the format the patient’s records were kept, the Adm/DON stated the agency used the EMR software from Vendor B in the past “But it was getting expensive.” The Adm/DON stated the agency was going through the process of transitioning to an EMR system through Vendor C. When asked when services from Vendor B was discontinued, the Adm/Don stated, “about a year.” The Adm/DON stated she would contact Vendor B by phone to access discharged patient records. The Adm/DON stated the agency printed some of the patients’ records before discontinuing the EMR services provided by Vendor B and the Adm/DON would try and locate the records. The Adm/DON stated the agency’s records were “disorganized” due to the agency’s recent move to the agency’s new location and some patient records were still located at the agency’s previous location. The surveyor informed the Adm/DON that the patients’ records had to be available within 8 hours of the surveyor’s request if stored at another location. On 2/12/2026 12:23pm the Adm/DON stated she received a call from Vendor B and “they (Vendor B) were drafting an invoice for me (the Adm/DON) to pay so you (the surveyor) can gain access (to the EMR system). I will let you know once I receive the invoice and pay it.” An end of the day conference was conducted with the Adm/DON on 2/12/2026 at 5:00pm. When asked about the status of gaining access to the agency past EMR system through Vendor B. The Adm/DON stated Vendor B “wanted an additional three thousand dollars” for surveyor access to the discharged patient records. The Adm/DON did not confirm that she was going to pay the three thousand dollars for access to the online records. The surveyor informed the Adm/DON that the patients’ records had to be retained for the time frame stated in the agency’s policy and be available for the surveyor to review. The surveyor requested the clinical records for discharged Patients 2,3, and 4 from the Adm/DON/Agency owner on 2/13/2026 at 9:00am. The agency’s receptionist provided the clinical records for discharged Patients 2,3, and 4 on 2/13/2026 at 1:02pm. Record review of discharged Patient 2’s “Home Health Certification and Plan of Care” for period 9/10/2023 to 11/08/2023 signed by the Adm/DON revealed a SOC date of 3/14/2023, a primary diagnosis of non-pressure chronic ulcer (a slow-healing or nonhealing sore on the skin caused by injury, infection, nerve damage or poor blood circulation) of other part of left foot,” and a nurse visit frequency of twice a week for 9 weeks. Records contained Patient 2’s discharge summary dated 11/08/2023 signed by the Adm/DON. Record review of discharged Patient 2 revealed an undated daily visit record signed by the Adm/DON. The daily visit record contained an entry by the Adm/DON dated 9/12, 9/15, 9/19. 9/22, 9/26, 9/29, 10/3, 10/7, 10/10, 10/12, 10/17, 10/20 and 10/27. Record review of discharged Patient 2 revealed an undated “Vital Signs Log” signed by the Adm/DON. The log contained Patient 2’s temperature, pulse, respiration rate, blood pressure, and random blood sugar reading for dates 9/12, 9/15, 9/19, 9/22, 9/26, 9/29, 10/3, 10/7, 10/10, 10/12, 10/17, and 10/20. Record review of discharged Patient 2 revealed completed nurse visit notes with assessments dated 9/15, 9/19, 9/22, 10/06, 10/13, 10/20, 10/24 and 10/27 signed by the Adm/DON. Patient 2’s paper records did not contain nurse visit notes dated 9/12, 9/26, 9/29, 10/3, 10/10, and 10/17. Record review of discharged Patient 3’s “Home Health Certification and Plan of Care” for period 10/28/2023 to 12/26/2023 signed by the Adm/DON revealed a SOC date of 10/28/2023, a primary diagnosis of Pressure Ulcer of right buttocks (“bottom” or two rounded muscular parts of the body used for sitting and hip movements) stage 2 (a shallow open wound or blister cause by unrelieved pressure), and a nurse visit frequency of twice a week for 2 weeks than once a week for 7 weeks. Records contained a 5-day discharge notice with a discharge date of 12/26/2023. Record review of discharged Patient 3 revealed an OASIS start of care assessment dated 10/28/2023 and signed by the Adm/DON. The paper records did not contain any visit notes, coordination notes, or a discharge summary after 10/28/2023. Record review of discharged Patient 4’s “Home Health Certification and Plan of Care” for period 5/27/2023 to 07/25/2023 signed by the Adm/DON revealed a SOC date of 3/28/2023, a primary diagnosis of Non-pressure chronic ulcer of the other foot with necrosis (death of cells caused by injury, infection, toxins, or lack of blood supply) of muscle, and a nurse visit frequency of “daily or every other day if daily not tolerated.” The paper records did not contain a discharged date. Record review of discharged Patient 4 revealed an OASIS start of care assessment dated 03/28/2023 signed by the Adm/DON. The paper records did not contain any visit notes, coordination notes, recertification assessments, or a discharge visit/summary after 03/28/2023. An interview was conducted with the Adm/DON/Agency Owner on 2/20/2026 at 1:18pm. When asked about the agency’s policy on the contents of the patient’s medical record. The Adm/DON stated that the patient’s records contained “the admission consents, orders, 485 (Home Health Certification and Plan of Care), PT and OT visit notes, OASIS assessments, communication notes, the history and physical (from the hospital or patient’s doctor), and sometimes we(the agency) have a slot (in the patient’s records) for (documentation of) wounds.” When asked about the agency’s policy on the retention of records for discharged patients, the Adm/DON stated the agency retained records for “10 years.” The surveyor shared the findings for Patient’s 2, 3, and 4. When asked about the missing visit notes, assessments, coordination notes and discharge documentation, the Adm/DON stated she completed the visit notes, assessments and documentation for Patient’s 2,3 and 4 in the EMR system. The Adm/DON stated “I probably didn’t print them (the visit notes, assessments, and coordination notes) from” the EMR system “before I stopped services” with Vendor B. When asked about the agency’s process of retrieving records from the past EMR system upon a patient’s request for records. The ADM/DON stated, “I would contact” Vendor B to arrange a payment for those records. When asked about the potential patients’ outcomes due to the agency’s failure to retain the discharged patients’ records per the agency’s policy, the Adm/DON did not respond to the question or provide any additional information. Review of the agency’s policy “Medical Record Information Retention and Destruction” with last reviewed date of 05/01/2024 read in part,” The Agency will maintain all medical records for a minimum of 10 years after the discharge of the patient/client unless state law stipulates a longer period of time, and for any additional time as deemed necessary in the event of an audit, litigation or other dispute. Records will be retained for longer periods of time as required by state laws and payers. Records for Medicare managed care beneficiaries will be retained for 10 years. Access to related billing records will be maintained for at least 10 years. The final disposition/responsibility for the patient's/client’s medical record will rest with the Agency Administrator and Governing Body. In the event that the Agency ceases to exist, all charts will be maintained in safekeeping for at least 10 years. If the Agency discontinues operation, it will inform the state agency where clinical records will be maintained. The State will be notified in writing of closure of the Agency, the location of the medical records and the name and address of the medical record custodian. Procedure. Process: Retention of Information. An inactive patient/client medical record may be stored as a signed paper record, an electronically signed computer record, or a combination. The Agency may preserve and retain a signed paper record electronically, including on microfilm, optical disc, or computer disk. The Agency may maintain a signed paper record by preserving its electronic duplicate in the electronic record for an inactive patient/client. If the electronic record is readily accessible and systematically organized, the signed paper record, after it is duplicated does not have to be retained… Medical records whether in paper, electronic or combination format will be stored so as to protect them from damage, loss, and/or theft. Inactive medical records will be accessible during normal working hours. If a medical record is removed, the appropriate sign-out form is completed, and all medical records are returned by the end of the business day. Inactive patient/client information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours.”

A recertification inspection survey was conducted on 01/25/2023. The L & CHHS census was 4. A deficiency was cited. Abbreviations/Acronyms: Adm/DON-Administrator/Director of Nursing Office Mgr.-Office Manager EP-Emergency Preparedness COO-Continuity of Operations

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable Federal, State, and local emergency preparedness requirements, in that the agency failed to maintain a comprehensive emergency preparedness program that was reviewed and updated at least annually, per state regulations and agency policy, for the calendar years 2021 and 2022. The failure could place the agency’s patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. FINDINGS INCLUDED: Review of the Texas Administrative Code Title 26 Part 1 §558.256 (j)- Emergency Preparedness Planning and Implementation revealed that, “An agency must complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.” Agency policy titled “Emergency Preparedness and Response Plan-Addendum EC.40-TX” reviewed 012023 read in part, “…Purpose I. In addition to Purpose statement in the Emergency Preparedness and Response Plan policy…the purpose is: A. To ensure the Agency reviews and updates the plan at least annually…” Review of the emergency preparedness plan binder, policies, and procedures on 01/25/2023 did not identify any records to establish that the agency had conducted annual reviews and updates of the agency’s emergency preparedness plan and response plan for the years 2021 and 2022. Continued review of The EP binder provided by the Adm/DON revealed the following: 1. A nine page “Continuity of Operations (COO) Business Plan Revised date 01/04/2019.” The COO business plan was signed on page nine, by the Adm/DON and dated 01/08/2019. The Adm/DON wrote on the bottom of page nine, “Reviewed: No changes signed: [Adm/DON] 01/08/2020. 2. A incomplete/blank nine-page COO business plan. Pages one through nine had not been complete, except on the bottom of page nine read in part “…Completed by: [Adm/Don] 2021 Signature: [signed by Adm/DON] reviewed 2/23/2022].” 3. Two “Agency Business Recovery Plan Checklist[s].” One plan checklist was completed with check marks, where indicated on the checklist and was dated 01/08/2020 and signed by the Adm/Don. The other plan checklist was not completed, there were no check marks on the check list and was dated 01/13/2021 and signed by the Adm/DON. 4. An “Unduplicated Census” dated 02/23/2022. The unduplicated patient census was listed as 10 and only one patient (Patient # 1) on the list was an active patient of the agency. The binder did not reveal any records that indicated the agency had conducted an internal review of the EP and response plan for 2021 and 2022. On 02/07/2023 at 2:00 p.m. the surveyor reviewed the above findings with the Adm/DON and Office Mgr. and asked why the agency had not conducted annual internal reviews and updates of the emergency preparedness plan for calendar years 2021 and 2022. The Adm/DON just looked at the surveyor and did not answer. The office Mgr. replied, “2022 was tough. It was a tough year.”

A recertification inspection survey was conducted on 01/25/2023. The L & CHHS census was 4. Deficiencies were cited. Abbreviations/Acronyms: Adm/DON-Administrator/Director of Nursing Office Mgr.-Office Manager L & C- Licensed and Certified LHH- Licensed Home Health EHR- Electronic Health Record POC- Plan of Care SOC- Start of Care HHA- Home Health Agency PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement SN- Skilled Nursing AC AV- autologous arteriovenous dialysis access ESRD-End Stage Renal Disease PRN-As Needed Wk-Week

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide written notice of the HHA's transfer and discharge policies in two (Patients # 1 and # 3) of two home visits conducted. The failure could affect patients’ health and safety and result in harm due to lack of comprehensive discharge planning in the patients post discharge needs. FINDINGS INCLUDED: Review of 42 Code of Federal Regulations Part 484.50 (d) revealed that, “…The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge…” On 01/25/2023 the agency's sample "Medicare" patient admission packet did not include any written notice for the HHA's transfer and discharge policies. Clinical Record # 1: Record review of the hard copy clinical record and EHR for Client # 1 revealed a POC with a SOC date of 12/03/2022. The POC had a treatment period 12/03/2022 thru 01/31/2023 and a primary diagnosis of Fracture of left foot…with routine healing. The POC was signed by the Adm/DON and dated 12/03/2022. During a home visit conducted on 01/30/2023 at approximately 12 noon., observation of Patient # 1's home folder revealed that the folder did not include written notice of the HHA's transfer and discharge policies. Patient # 1 stated the folder included all the written information that was provided by the agency. Clinical Record # 3: Record review of the hard copy clinical record and EHR for Client # 3 revealed a POC with a SOC date of 10/14/2022. The POC had a treatment period 12/13/2022 thru 02/10/2023 and a primary diagnosis of Cerebrovascular Disease. The POC was signed by the Adm/DON and dated 12/12/2022. During a home visit conducted on 01/30/2023 at approximately 10:15 a.m., observation of Patient # 3's home folders (there were two folders in the home) revealed that the folders did not include written notice of the HHA's transfer and discharge policies. On 02/07/2023 at approximately 2:25 p.m., the surveyor discussed the above findings with the Adm/DON. The surveyor asked why the agency had not provided Patients # 1 and # 3 written notice of the HHA's transfer and discharge policies. The Adm/DON replied, “I usually talk to them[about] the criteria for discharge.” The Adm/DON also stated that she was not aware of the requirement to provide written notice of the HHA's transfer and discharge policies.

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 clinical record review and interview, the agency failed to ensure that the individualized plan of care included the frequency and/or duration of visits to be made in five (Patients, # 1, # 2, # 3, # 4, and # 6) of seven clinical records reviewed for SN visit frequency. The agency also failed to ensure that the plan of care included the pertinent diagnosis of hemodialysis with patient specific intervention for hemodialysis treatment, in one (Patient # 2) one patient receiving hemodialysis. The failure placed the patients at risk to not have the necessary care and treatment if visits were not scheduled and/or missed by the agency’s SN staff. FINDINGS INCLUDED: Clinical Record # 1: Record review of the hard copy clinical record and EHR for Patient # 1 revealed a POC with a SOC date of 12/03/2022. The POC had a certification period 12/03/2022 thru 01/31/2023 and a primary diagnosis of Fracture of left foot…with routine healing. The POC was signed by the Adm/DON and dated 12/03/2022. The POC did not contain an order for SN visit frequency for the certification period. The POC contained an order for PT to evaluate and treat three times per week for six weeks. Further review Patient # 1’s clinical records revealed a “consent for service…” that was dated 12/03/2022 and signed by Patient # 1 and the Adm/DON. The consent for service listed the SN visit frequency “As per POC.” Continued review of the clinical records revealed the following SN visit notes that were signed and dated by the ADM/DON: (SN visit notes were dated: 12/08/2022; 12/15/2022; 12/22/2022; 12/29/2022; 01/05/2023; 01/12/2023, and 01/19/2023). Clinical Record # 2: Record review of the hard copy clinical record and EHR for Patient # 2 revealed a POC with a SOC date of 01/21/2023. The POC had a certification period 01/21/2023 thru 03/21/2023 and a primary diagnosis of Essential (primary) hypertension. The POC was signed by the Adm/DON and dated 01/21/2023. The POC did not contain an order for SN visit frequency for the certification period of 01/21/2023 thru 03/21/2023. Further review Patient # 2’s clinical records revealed a “consent for service…” that was dated 01/21/2023 and signed by Patient # 2 and the Adm/DON. The consent for service listed the SN visit frequency of one time per week for nine weeks. Continued review of the clinical records revealed an “activity calendar.” The activity calendar revealed a projected schedule for skilled nurse visits for one time per week for nine weeks. Patient # 2’s POC included a diagnosis of Encounter for adequacy testing for hemodialysis. The POC read in part “…Medical Necessity…has ESRD on dialysis 3 times a week via Right AC AV fistula…” The POC did not include a diagnosis for hemodialysis. The POC also did not include an order for SN to assess Patient # 2’s right AC AV fistula for infection or occlusion. The POC also did not have a SN order to avoid taking pressure readings on the right arm. Clinical Record # 3: Record review of the hard copy clinical record and EHR for Patient # 3 revealed two POC(s) with a SOC date of 10/14/2022. POC dated 10/14/2022 had a certification period of 10/14/2022 thru 12/12/2022. POC dated 12/12/2022 had a certification period 12/13/2022 thru 02/10/2023. The POC(s) had a primary diagnosis of Cerebrovascular disease. The POC(s) were signed by the Adm/DON. The POC(s) did not contain orders for SN visit frequency for the certification periods of 10/14/2022 thru 12/12/2022 and 12/13/2022 thru 02/10/2023. Further review of Patient # 3’s clinical records revealed a “consent for service…” that was dated 10/14/2022 and signed by Patient # 3 and the Adm/DON. The consent for service listed the SN visit frequency one time per week for nine weeks. During an interview at a home visit on 01/30/2023 at approximately 10:15 a.m., Patient # 3 stated that the Adm/DON visited time per week. Clinical Record # 4: Record review of the hard copy clinical record and EHR for Patient # 4 revealed two POC(s) with a SOC date of 11/07/2022. POC dated 11/07/2022 had a certification period of 11/07/2022 thru 01/05/2023 and a primary diagnosis of Dementia with unspecified severity. POC dated 01/05/2023 had a certification period 01/06/2023 thru 03/06/2023 and had a primary diagnosis of Hemiplegia affecting left non-dominate side, following a cerebral vascular infarction. The POC(s) were signed by the Adm/DON. The POC(s) did not contain orders for SN visit frequency for the certification periods of 11/07/2022 thru 01/05/2023 and 01/06/2023 thru 03/06/2023. Further review of Patient # 4’s clinical records revealed a “consent for service…” that was dated 11/07/2022 and signed by Patient # 4 and the Adm/DON. The consent for service listed the SN visit frequency as one time per week for nine weeks. Continued review of the clinical records revealed the following SN visit notes that were signed and dated by the ADM/DON: (SN visit notes were dated: 11/10/2022; 11/14/2022; 11/18/2022; 11/23/2022, and 01/12/2023). Patient # 4’s clinical records also contained an activity calendar that revealed a projected visit schedule for one time per week for nine weeks for certification period 01/06/2023 – 03/06/2023. Clinical Record # 6: Record review of the hard copy clinical record and EHR for Patient # 6 revealed two POC(s) with a SOC date of 11/03/2021. The POC(s) were signed by the Adm/DON. POC dated 11/03/2021 had a certification period of 11/03/2021 thru 01/01/2022 and a primary diagnosis of Non-pressure chronic ulcer of right calf with necrosis of muscle. The POC dated 11/03/2021 read in part; “…SN to perform wound care on stasis ulcer of posterior right lower extremity wound weekly…” The 11/03/2021 POC did not include the duration of the weekly SN visits. POC dated 12/30/2021 had a certification period 01/02/2022 thru 03/02/2022 and had a primary diagnosis of Chronic venous hypertension with ulcer and inflammation of right lower extremity. The POC dated 12/30/2021 read in part: “…Home health to change dressing two times a week, Nurse practitioner at wound clinic will see patient one times a week on Tuesdays. Frequency 4 weeks…” Further review of Patient # 6’s clinical records revealed a physician’s order dated 12/30/2021 and signed by the Adm/DON. The physician’s order read in part: “…Frequency: SN change dressing 2 X Wk [two times per week] for 4 weeks, 1W5, [one time per week for five weeks] PRN X 2 [two as needed visits] visit anticipated, NP [nurse practitioner] 1 X WK [one time per week] on Tuesdays…” The 12/30/2021 POC did not include the SN visit frequency and duration as ordered on 12/30/2021 by the physician (Identifier 100). Patient # 6’s clinical records also contained an activity calendar certification period 01/02/2022 thru 03/02/2022 that revealed SN visits were conducted by the Adm/DON two times per week for one week; three times per week for three weeks; two times per week for three weeks, one time per week for one week, and two times per week for one week. The activity calendar revealed SN visits were not conducted according to the frequency and duration as ordered on 12/30/2021 by the physician (Identifier 100). During an interview on 02/07/2023 at approximately 2:35 p.m., the surveyor discussed the above findings and asked why the POC's for Patients #1, # 2, # 3, # 4, and # 6 did not include the frequency and/or duration of visits to be made. The Adm/DON replied, “Then I have to pay attention to EHR (Identifier 500), it is supposed to pull it over.” The surveyor also asked why the POC for Patient #2 did not include the pertinent diagnosis of hemodialysis with patient specific intervention for hemodialysis treatment. The Adm/DON replied, “That’s very important. I thought I put it on there. I am going to make a correction ” Review of agency policy titled "Plan of Care PC.35" last reviewed 121021, read in part "...Procedure .I. The appropriate licensed professional staff member, with physician and/or non-physician practitioner participation, is responsible for developing the plan of care within three to five days of the initial assessment. A. A Registered Nurse initiates the plan of care for skilled nursing care and for personal hygiene/activities of daily living care...III. Each patient/client must receive an individualized written plan of care…A. The individualized plan of care must include the following...1. All pertinent diagnoses…4. The frequency and duration of visits to be made...14. Patient/Client-specific interventions…" According to Davita Dialysis (2011), an AV graft “is an artificial vein that is used for needle placement and blood access during hemodialysis. Hemodialysis filters the blood by removing it from the body and passing it through a filter.”(retrieved from http://www.davita.com/kidney-disease/preparing-for-dialysis/planning -for-a-vascular-access/arteriovenous-av-fistula-BD-the-gold-standard-hemodialysis-access/e/5032). Further review of Patient #2's POC failed to contain orders to assess AV graft and to abstain from taking blood pressure on arm due to AV graft. According to Davita Dialysis (2011), measures should be taken to avoid any restriction of blood flow that could cause clotting in the AV graft. These include avoiding tight clothing, jewelry and blood pressure cuffs that could put pressure in the access area.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: The is a continuing deficiency cited at G 0658 at survey dated 02/21/2020. Based on record review and interview, the agency failed to conduct and document Performance Improvement Projects for the calendar years 2020 and 2022, that reflected the scope, complexity, and past performance of the agency's services and operations. The failure could place patients’ health and safety at risk if the agency did not identify health and safety concerns and develop improvement projects to address the concerns. FINDINGS INCLUDED: During the entrance conference with the Adm/DON on 01/25/2023, at approximately 12:25 p.m., the surveyor requested the agency QAPI binders/reports/documents. Agency business and QAPI binders were provided. 01/25/2023 3:12 p.m. the business and QAPI binders contained the following: 1. “1st Biannual Report to the Governing Board 2021.” The report was undated. The Report was signed by the Adm/DON and the PAS Supervisor. The Report documented a PIP for 1st Biannual 2021. 2. Annual Evaluations for 2020 and 2021. The binder did not include any documentation that showed the agency had any performance improvement project either in development, on-going or completed for the years 2020 and 2022. On 02/07/2023 at 2:30 p.m. the surveyor reviewed the above findings with the Adm/DON and Office Mgr. and asked why the agency had not conducted performance improvement projects in the QAPI program that reflected the scope, complexity, and past performance of the agency's services and operations, as required by federal regulations, for the years 2020 and 2022. The Adm/DON replied, “I don’t know why.” Agency policy titled "Quality Assessment Performance Improvement Program QAPI.5" reviewed 011318 read in part: "PROCEDURE...III...E...Performance Improvement Projects 1. The number and scope of distinct improvement projects conducted annually which reflect the scope, complexity and past performance of the Agency's services and operations. 2. The agency will document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects..."