Every finding on record at Patient Care Professionals Inc

A partial extended survey for Medicare recertification for the home health provider was completed on 01/29/2026. The provider had 60 current patients. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/29/2026. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of personnel files, policy review, and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire and every two years in three of three personnel records reviewed (Employees #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's undated policy titled, "Emergency Disaster Plan Orientation and Training," showed in part the following: - All employees will be oriented to the Emergency Disaster Plan (EDP), including their responsibilities in carrying out the plan, upon hire, and will participate in the in-service educational sessions annually; - Initial EDP will be provided to individuals providing services under arrangement consistent with their expected roles; and - Attendance and demonstration of staff knowledge will be notated in the employee’s personnel file. EMPLOYEE #1: Review of Employee #1’s personnel file showed in part: - The employee’s position was registered nurse; - Orientation in-service training took place on 09/02/2025; and - The personnel file failed to contain evidence that EDP training was completed upon hire. EMPLOYEE #2: Review of Employee #2’s personnel file showed in part: - The employee’s position was physical therapist; - Orientation in-service training took place on 12/30/2025; and - The personnel file failed to contain evidence that EDP training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part: - The employee’s position was (contract) occupational therapist; - Orientation in-service training took place on 09/27/2024; and - The personnel file failed to contain evidence that EDP training was completed upon hire. During an interview on 01/29/2026 at 10:00 AM, the home health administrator stated that: - Emergency Preparedness (EP) training was not completed during orientation or annually (only required during orientation and every two years) for several years; - He/she thought training was done in 2024 but he/she was unable to locate the sign-in sheets (last EP training sign-in sheets for provider was dated 2022); and - Employee's #1, #2, and #3 personnel folders failed to include EP training.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that a registered nurse (RN) completed an initial assessment on the patient in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider's policy titled, "Registered Nurse," dated 09/2006, showed the RN performs comprehensive assessments of client status, including physical, psychosocial, and environmental parameters. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the skilled nurse visit note, dated 06/02/2025, showed the visit was completed by a licensed practical nurse (LPN). Review of the skilled nursing visits, dated 06/02/2025 - 06/20/2025, showed three LPN visits a week for three weeks. The RN failed to perform a visit on the patient. During an interview on 01/29/2025, the clinical manager stated that he/she could not locate any RN visits for this patient, and he/she would expect the RN to do a comprehensive assessment and supervise the LPN.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on OASIS E (Outcome and Assessment Information Set; a standardized data collection tool) Guidance Manual review, record review, and interview, the home health provider failed to ensure that the OASIS assessment was completed by a registered nurse (RN) in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the OASIS-E Guidance Manual, dated 01/01/2023, showed in cases involving nursing, the RN is responsible for completing the start of care comprehensive assessment, including OASIS if applicable. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the referral order, dated 05/01/2025, showed the patient was being referred to home health for registered nursing, physical therapy, and occupational therapy. Review of the OASIS-E1 Start of Care Assessment, dated 06/02/2025, showed the assessment was completed by a physical therapist (PT). A RN did not complete the OASIS assessment. During an interview on 01/29/2025 at 11:15 AM, the home health clinical manager stated that they thought if therapy was ordered, the therapist could complete the OASIS assessment to meet the start of care date.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure nursing services were provided under the supervision of a registered nurse (RN) in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 06/02/2025 with a primary diagnosis of pressure ulcer to the left heel, stage four (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a caregiver. Review of the initial skilled nurse visit note, dated 06/02/2025, showed the visit was completed by a licensed practical nurse (LPN). Review of the skilled nursing visits dated 06/02/2025 through 06/20/2025, showed three LPN visits a week for three weeks. The RN failed to perform a visit on the patient. Review of the clinical record failed to show a RN supervised the LPN. During an interview on 01/29/2025, the clinical manager stated that he/she could not locate any RN visits for this patient, and he/she would expect the RN to supervise the LPN.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/01/20233. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 02/01/2023. The agency had 72 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. One standard level deficiency was identified.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on the agency's current patient rights information, home visit observation, and interview, the agency failed to provide the patient and representative (if any) correct contact information for the current home health agency administrator, to receive complaints in, but not limited to, three (Records/Patients #1, #2, and #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's, undated, admission folder left in the patient's home showed no name and contact information of the home health agency administrator. RECORD/PATIENT #1: Observation on 01/31/2023 at 9:45 AM, during the patient's home visit, showed review of the admission packet left in the home, failed to include the current administrator's name and contact information to receive complaints. RECORD/PATIENT #2: Observation on 01/30/2023 at 2:30 PM, during the patient's home visit, showed review of the admission packet left in the home, failed to include the current administrator's name and contact information to receive complaints. RECORD/PATIENT #3: Observation on 01/31/2023 at 11:35 AM, during the patient's home visit, showed review of the admission packet left in the home, failed to include the current administrator's name and contact information to receive complaints. On 01/30/2023 at 2:00 PM and 02/01/2022 at 1:36 PM, the findings were reviewed with the director of clinical services. He/she acknowledged the findings and no additional information was provided.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the patient's current health status was assessed and documented in two (Patients/Records #2 and #3) of five records reviewed. This deficient practice has the potential to affect the identification of patient needs for all patients on service with the agency. PATIENT/RECORD #2: Review of the POC (plan of care) dated 01/21/2023 to 03/21/2023 showed the following: - An other pertinent diagnosis of unspecified cystostomy (a surgical creation of an opening into the bladder, often used to refer to a suprapubic catheterization made to drain the bladder) status; and - Suprapubic catheter changed by “named Doctor” every 3-4 (three to four) weeks. Review of the recertification comprehensive assessment dated 01/20/2023 showed: - Catheter and suprapubic marked under Section H- Bladder and Bowel; and - It failed to contain documentation of a skin assessment at the suprapubic insertion site. During an interview on 02/01/2023 at 2:00PM the Director of Clinical Services stated that it (skin assessment at suprapubic insertion site) should be documented that they are monitoring. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency 11/19/2022 with a diagnosis included, but not limited to paraplegia (paralysis of the legs and lower body), unspecified fracture of T11-T-12 (thoracic compression fracture of the spine), and Parkinson’s disease (progressive disease of the nervous system). Review of the comprehensive assessment dated 11/19/2022 showed the agency failed to provide the location of pain the patient rated a three (using a scale from zero to ten, zero representing no pain and ten the worst pain possible). The assessment also failed to include what level of pain was acceptable to the patient. During an interview on 02/01/2023 at 2:00 PM, the director of clinical services (clinical manager) stated that he/she expects the nurse to assess and document a complete assessment including where a patient’s pain is located and what pain level is tolerable for the patient.

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, record review, home visit observation and interview, the agency failed to ensure an accurate medication review and/or update of the patient medications was completed in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to adversely affect the accurate administration of medications to all the agency’s patients. Findings included: Review of the agency’s policy titled, “Pharmacy Rule” (Policy No: 107.30(a)), revised 9/2006 showed: - Patient medication will be monitored every visit to ensure that all medication ordered by the physician is available for the patient to take in the prescribed manner; - The nurse providing care for each patient will be responsible for checking medication and follow through on new prescriptions to assure that they have been filled and are available to the patient; - The RN (registered nurse) will post a complete list of all medications on the medication profile following the initial visit; - The medication profile will be reviewed and signed by the RN in charge of the case- a minimum of every sixty days and updated as soon as new medications are added; - The RN will check medication bottles for the purposes of refills within three days of obtaining the prescription; - Purpose: To provide the safe handling and distribution of medication and to provide an accurate comprehensive tracking of all medication distributed; and - Policy: It is the policy of “named agency” to maintain a complete record of all medications ordered by the patient’s physician. RECORD/PATIENT #1: Review of a clinical summary from a local rehabilitation facility dated 01/20/2023 showed, in part: - Aspirin 81mg (milligram) oral enteric coated 1 tablet by mouth daily; and - Cholecalciferol (vitamin D3 2000 intl (international) units oral 1 capsule by mouth daily. Review of the plan of care dated 01/21/2023 showed: - Aspirin 325mg delayed release oral tablet administered by mouth 1 tablet 1x/day (one time a day) in am (morning); and - Vitamin D3 50mcg (micrograms) 2,000 u (units)) oral capsule administered by mouth 2 tabs 1x/day in am. Further review of the clinical record failed to show physician orders to clarify the aspirin or Vitamin D3 dosage discrepancies. Observation on 01/31/2023 at 9:30 AM, during the patient’s home visit, showed the following: - RN B questioned patient regarding medication and any changes; - RN B failed to look at the medication bottles and review with the medication list; and - This surveyor reviewed the medication bottles with the current medication profile provided by the agency and noted the aspirin bottle contained 81mg enteric coated tablets, and cholecalciferol 2000 iu capsules. Per interview conducted with the patient during the home visit observation, as this surveyor was comparing the current med profile list to the medication bottles the patient stated that he/she: - Is taking one of the aspirin 81mg enteric coated daily (plan of care and current medication profile showed 325mg); and - Takes one vitamin D3 2,000 iu daily (plan of care and current medication profile showed take two tabs daily). During an interview on 01/31/2023 at 11:45 AM the Director of Clinical Services (Director) stated that; - The aspirin dose is incorrect, it should be 81mg; - At some point he/she was taking two tablets of the vitamin D3 to equal 2,000 iu; and - “I see why they thought it was two tablets a day (as he/she looked at the referral information), I corrected the 485 (plan of care). It hadn’t been sent out yet to the physician.”

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 policy review, record review, and interview, the agency failed to ensure the individualized plan of care included all of the required elements in, but not limited to, two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective care to all patients served by the agency. Findings included: Review of the agency’s policy titled “Physician’s Plan of Treatment/Change Orders” (Policy No: 105.2), revised 10/2007 showed: - The physician’s plan of treatment is an individualized plan of care and treatment prepared by the patient’s physician with assistance from the nurse and/or therapist who establish the plan based on the current assessment of the patient; - At the time of recertification , a written summary of the patient’s current status and the services being provided are submitted with the plan of treatment shall relate to the diagnosis and must be considered reasonable and necessary treatment for that diagnosis; - The plan of treatment shall include but not be limited to: *Diagnosis- primary and secondary; * Types, amount, frequency and duration of services; * Functional limitations; safety precautions; * Orders for treatments and treatment modalities; * Goals/Rehabilitation potential/Discharge plans; and - Modifications to the plan of treatment deemed necessary shall be made in consultation with the physician, and the physician’s signature shall be obtained within 60 (sixty) days after any modification of the medical plan of treatment. RECORD/PATIENT #1: Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set (a standardized assessment form)) dated 01/21/2023 showed: - Item M1610 Urinary Incontinence or Urinary Catheter (tube inserted into the bladder to drain urine) Presence was marked 02- Patient requires a urinary catheter, and other marked with self-cath (self-catheterize: involves inserting a thin, hollow tube called a catheter into the bladder through the urethra to drain urine from your bladder) 3-4x/day documented; and - Under the cardiovascular status section other was marked with fistula (irregular connection between an artery and a vein-a surgical procedure done to be utilized when administering dialysis (procedure done to remove waste products and excess fluid from the blood when the kidneys stop working properly)) to L (left) arm from past dialysis prior + (positive/present) thrill and bruit (vibration and sound caused by blood flowing through a fistula) documented. Review of the POC dated 01/21/2023 showed: - It failed to include the patient was to be completing self-catheterization 3-4 times daily; and - It failed to include the diagnosis of the AV fistula (an irregular connection between an artery and a vein, a surgical procedure done to be utilized when administering dialysis) to the left arm. RECORD/PATIENT #2: Review of the recertification OASIS dated 01/20/2023 showed: - Section H- Bowel and Bladder with catheter and suprapubic marked (a surgical creation of an opening through the abdomen into the bladder to drain urine from the bladder); and - The musculoskeletal section marked limited ROM (Range of motion: how far and in what direction you can move a joint or muscle) with r (right) sided hemi paralysis (paralysis/inability to move one side of the body) bilateral legs documented. (The patient was a paraplegic (unable to move/paralysis of both legs) Review of the POC dated 01/21/2023 to 03/21/2023 showed: - An other pertinent diagnosis of unspecified cystostomy (a surgical creation of an opening into the bladder, often used to refer to a suprapubic catheterization made to drain the bladder) status; - An other pertinent diagnosis of hemiplegia (paralysis of one side of the body); - Suprapubic catheter changed by “named Doctor” every 3-4 (three to four) weeks; and - It failed to contain the need to monitor or care for the suprapubic catheter site as well as the appropriate interventions/goals related to such; and - It failed to contain the need to monitor and educate regarding the potential for skin breakdown due to decreased mobility as well as the appropriate interventions/goals related to such. During an interview on 02/01/2023 at 2:00 PM the Director of Clinical Services stated that: - The patient is a paraplegic, not a hemiplegic, "I will get that fixed"; - The plan of care should include the preventative skin measures due to the paralysis as well as the care/assessment of the suprapubic with interventions and goals; and - It (the preventative skin measures and suprapubic catheter assessment/care) failed to be added on the new OASIS E. It had been on the prior OASIS and flowed over to the plan of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to obtain physician orders to ensure services were administered, as only ordered by a physician in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Coordination of Care," revised 9/2006 showed, in part, the following: - Care coordination occurs in order to assure continuity of care and services for the patient/family from admission through discharge; and - The purpose of coordinating care or services provided by a home health organization including patient referral and liaison with others including the patient’s physician. RECORD/PATIENT #3: Review of the referral record showed: - The hospital discharge summary showed admission date 10/21/2022 and discharge date of 11/12/2022 to home and printed by the administrator on 11/11/2022 at 2:10 P.M.; and - An ambulatory referral to home care dated 11/08/2022 at 2:21 PM: * Diagnoses included spinal stenosis (narrowing of he spinal canal) in cervical (neck) region, cervical myelopathy (compression of the spinal cord in the neck) and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors); * The patient was discharged stable to home with aspiration precautions (accidental breathing in of food or fluid into the lungs), spinal precautions, and medication changes; - Physical therapy, occupational therapy, and speech therapy for two to three times a week for six weeks; - Home health aide and social worker as needed; and - There was no orders for skilled nursing. Review of an OASIS (Outcome and Assessment Information Set - a required set of assessment data submitted to Medicare or Medicaid Services) start of care comprehensive assessment, dated 11/19/2022, completed by the skilled nurse showed the patient was discharged from a skilled nursing facility on 11/12/2022 (seven days after the patient was referred to the home health agency). The clinical record failed to show a physician order for the start of care on 11/19/2022. During an interview on 01/31/2023 at 12:50 PM, the director of clinical services stated that the patient’s referral was received on "11/13/2022"; the patient was not admitted to the agency because he/she was going to outpatient therapy. The agency notified the patient’s physician the start of care was not done. (There was no documentation of the notification). The physician later called (no date given) and asked why the agency had not admitted the patient and sent another referral. He/she was not able to find the referral. The physician’s office asked why the agency could not use the referral from "11/13/2022". There was no physician order for the skilled nurse start of care for 11/19/2022.

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 policy review, observation, and interview, the agency failed to ensure staff followed acceptable standards of practice for infection control in one (Record/Patient #2) of three home visit observations; and failed to continue implementing their program to protect visitors and staff who entered the home health agency office, from those employees that had chosen not to be vaccinated against Covid-19. These deficient practices have the potential to adversely affect infection control needs for all visitors/non-employees, employees and patients served by the agency. Findings included: Review of the agency’s policy titled “Bag Technique” (Policy No: 110.7) dated revised 10/2007 showed, in part: - Upon entering the home, place the bag on a clean surface. A sheet of newspaper or some paper towels can be used to create a clean area for the bag if necessary. Open the bag near the area where care will be given. It should be near the water supply if possible; - Remove the hand cleanser and/or hand sanitizer and some paper towels. Place a trash bag neat the set up for the disposable wastes; - Using soap and water, wash the hands thoroughly. Dry hands with paper towels. Remove all other bag items, which will be needed for the visit. Place them on the newspaper or one of the paper towels, which has been placed near the bag. Close the bag; - If additional items are needed after care has started, wash the hands before re-entering the bag; and - After completing patient care, clean any soiled items, which will be returned to the bag. Place them on a clean newspaper or clean paper towel. Wash hands or may use hand sanitizer and return equipment to the bag. Close bag. Review of the agency’s policy titled “PCOVID -19”, dated December 1, 2021 showed unvaccinated employees with exemption must: - Follow universal precautions at all times; - Must take temperature daily; and - Gloves and masks must be worn at all times. RECORD/PATIENT #2: Observation on 01/30/2023 at 3:15 PM, during the patient’s home visit, showed RN A failed to remove gloves and sanitize hands prior to returning vital sign equipment to bag. Observation on 01/30/2023 showed the unvaccinated employee (E-2) unmasked and ungloved throughout the office. During an interview on 02/01/2023 at 2:00 PM the Director stated that he/she would expect the clinician: - To sanitize their hands before re-entering their bag; and - Not to go in the bag with gloves on. During an interview on 02/01/2023 at 3:00 PM the administrator stated that: - The unvaccinated employee was nervous and forgot to wear the mask; and - He/she was going to change the policy and remove the part about the gloves.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee file review and interview, the agency failed to ensure staff were provided infection control training annually for one (Employee #4/RN A) of four employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled “Infection Control Program” (Policy No: 110.1), dated revised 9/2006 showed: - In an effort to promote safe, competent patient care and reduce risks for infections in patients and staff members by identifying work practice controls that should be used to eliminate or minimize employee exposure to blood borne pathogens and communicable diseases; - The organization has developed a written exposure plan including: the exposure determination; the procedures for evaluating the circumstances surrounding an exposure incident; and the schedule and method for implementing sections of the standard covering the methods of compliance; and - Every employee with patient contact will be instructed in universal precautions during orientation. This instructions will be repeated at least annually. Employee #4 (E-4)/RN A: Review of E-4’s employee file: - Showed date of Hire: 06/26/05; and - Failed to include annual infection control in-service training. During an interview on 02/01/2023 at 12:17 PM the Director of Clinical Services (Director) stated that he/she did not see the annual infection control in-service training in the employee file.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the skilled professional assumed responsibility for an ongoing interdisciplinary assessment of the patient, in one (Record/Patient #3) out of five records reviewed. This deficient practice has the potential to affect the safety and changing needs of all the agency's patients. Findings included: Review of the agency's policy titled, "Coordination of Care," revised 09/2006, showed, in part, care coordination occurs in order to assure continuity of care and services for the patient/family from admission through discharge. The primary nurse is responsible for coordinating for the home health patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 11/19/2022, with diagnoses including paraplegia (paralysis of the legs and lower body), unspecified fracture of T11-T-12 (thoracic compression fracture of the spine), and Parkinson’s disease (progressive disease of the nervous system that affects movement). Review of occupational therapy (OT) visit note dated 12/14/2022, showed the patient reported, “I have a headache today, it hurts where I fell on it” and he/she pointed to the back of his/her head. The patient reported a pain level of four out of ten (zero represents no pain and ten represents the worst pain possible). The pain was described as acute and dull and at the back of head where he/she fell, and he/she woke up with the pain. The OT failed to document notification to the physician regarding the patient’s fall. Further review of the OT visit note dated 12/14/2022 showed the patient was discharged from OT during the visit, and care was coordinated with physical therapy (PT). The OT failed to document communication with PT regarding the patient’s fall. Review of the PT evaluation dated 12/16/2022 showed the patient had multiple falls and fractures. The patient did not report any falls (OT documented fall on 12/14/2022) and had not experienced a fall since the last visit (PT did an evaluation on 12/12/2022). During an interview on 01/31/2023 at 11:35 AM, the patient stated that he/she had a fall in December of 2022, and sustained a bump on the back of his/her head, and pointed to the back of his/her head. His/her spouse stated that the patient also sustained a bruise to his/her left outer leg from the same fall in December. During an interview on 01/31/2023 at 1:30 PM, the director of nursing stated that the fall on 12/14/2022 was not reported to the physician because OT stated that the patient was talking about another fall prior to admission (11/19/2022). There was no late documentation to show this clarification. There was no further information provided.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on employee file review, and interview, the agency failed to ensure staff were provided with annual agency in-service training in one (Employee #4/RN A) of four employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Employee #4 (E-4)/RN A: Review of E-4’s employee file: - Showed date of Hire: 06/26/05; and - Failed to include annual agency in-service training. During an interview on 02/01/2023 at 12:17 PM the Director of Clinical Services (Director) stated that he/she did not see the annual agency in-service training in the employee file.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on nationally-recognized standards, policy review, employee file review and interview, the agency failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire on one (Employee #2) of four employee files reviewed, and failed to ensure all staff had the Family Care Safety Registry (FCSR) checked prior to date of first patient contact in one (Employee #2) of four employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” Review of the agency’s policy titled, “Background Checks” (Policy No: 1103.5), revised 9/2006 showed: - All “Named Agency” employees providing direct patient care are required to have a criminal history check, EDL, and Family Care Registry; and - Prior to employment, a prospective employee will be checked through EDL and the copy of the results must be received by the agency. Employee #2 (E-2): Review of the Director of Clinical Services (Director) (E-2) showed: - Date of hire: 02/04/2022; - Date of first patient contact: 02/04/2022; - EDL results: 02/08/2022; and - FCSR results: 02/08/2022. During an interview on 01/31/2023 at 1:00 PM the administrator stated that; - The EDL and FCSR had been done over the phone prior to hire and he/she was clear; - He/she remembers doing it on 01/31/2023, but didn’t receive the paperwork until later; and - I do them monthly but don’t always print them out, if I don’t I will have to set up a whole new log in and password.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a complete transfer and discharge summary (containing relevant information) was sent to the patient's receiving health care facility within two business days of the agency becoming aware of the patient's transfer, for one (Record/Patient #5); and five business days of he patient's discharge, for one (Record/Patient #6) of two transfer/discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Patient Transfer,” revised 09/2006, showed in part the following: - If a patient must be transferred, the home health registered nurse will complete a discharge/transfer summary form; - Send to the receiving health care provider(s) a copy of the patient record that the patient has given written consent to release, together with the completed discharge/transfer summary; and - Place a copy of the competed discharge/transfer summary form in the patient’s clinical record. Review of the agency’s policy titled, “Discharge Policy,” revised “10/207”, showed, in part the following: - A skilled nurse will complete a discharge instructions and summary; - A discharge will be completed and documented on the appropriate forms in the following ways: * Discharge to self- remains in the community * Discharge or transfer to inpatient facility - When the patient is transferred to another facility, relevant information regarding the patient’s condition and care requirements will be provided either verbally or in writing to the facility, if requested, within 48 hours of the agency becoming aware of the transfer; - The discharge summary shall include, but not limited to the following: * Reasons for discharge * Status of problems identified at admission and subsequently * A narrative summary of services provided * The patients’ course and progress or deterioration * The status of the patient at the time of discharge; and * Any continuing care needs instruction or referrals regarding the needs. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 11/03/2022. Diagnoses included, but not limited to, unspecified open wound to the left lower leg, cellulitis left lower extremity, and local infection of the skin and subcutaneous tissue (the wound to lower left leg was infected). Review of a transfer without discharge comprehensive OASIS (Outcome and Assessment Information Set - a required set of assessment data submitted to Medicare or Medicaid Services) dated 11/23/2022, showed in part, the patient’s son notified the agency on 11/28/2022 that the patient was admitted to the hospital on 11/23/2022 for urinary tract infection and mental status changes. The patient will transfer to a long-term care facility today (11/28/2022) for rehabilitation and to finish intravenous antibiotic. The agency failed to send a completed transfer summary to the receiving facility. During an interview on 02/01/2023 at 2:06 PM, the director of clinical services stated that the agency was notified on 11/28/2022 the patient transferred to the hospital on 11/23/2022, and then transferred to the skilled nursing facility on 11/28/2022. There was no transfer summary completed and sent to the receiving facility. RECORD/PATIENT #6 Review of the clinical record showed the patient was admitted to the agency on 11/02/2022. Diagnoses included, but not limited to, type two diabetes mellitus (impairment in the way the body regulates and uses sugar as fuel), cardiac pace maker, non-pressure chronic ulcer to the right heel; atherosclerosis heart disease (affects arteries that carry bold to the heart muscle), cerebral infarction (stroke), and dementia. Review of a transfer with discharge comprehensive OASIS dated 11/28/2022, showed the speech therapist went to do a discharge visit and found the patient lethargic with hypotension (low blood pressure). The patient was transferred to an in-patient facility and discharged from the agency. During an interview on 01/31/2023 at 10:00 AM, the director of clinical services stated that the patient was being discharged from the agency when the speech therapist was doing his/her discharge visit, found the patient with a change in condition, and the patient was sent to the emergency room. The clinical manager stated that the speech therapist sends the discharge summary to the director of clinical services for review and then the director of clinical services sends the discharge summary to the receiving facility. The director of clinical services tried to call the emergency room and give report, and they stated that they would get the report from the paramedics. The clinical manager called the emergency department later and was informed the patient opted for hospice. He/she offered to send a discharge summary and the hospital refused. He/she was unable to find a discharge summary from the speech therapist. There was no transfer/discharge summary completed and sent to the receiving facility.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure plan of care orders were authenticated with physician signature and date in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency’s policy titled “Physician’s Plan of Treatment/Change Orders” (Policy No: 105.2), revised 10/2007 showed: - The physician’s plan of treatment is an individualized plan of care and treatment prepared by the patient’s physician with assistance from the nurse and/or therapist who establish the plan based on the current assessment of the patient; - At the time of recertification , a written summary of the patient’s current status and the services being provided are submitted with the plan of treatment shall relate to the diagnosis and must be considered reasonable and necessary treatment for that diagnosis; - The plan of treatment shall be in writing within 14 (fourteen days) of assessment and shall be signed within a reasonable time period by the attending physician; and - The agency will contact the MD (medical doctor) office by phone or send an additional request for MD signature on any plan of treatment not received in a timely manner. RECORD/PATIENT #2: Review of the clinical record showed: - A recertification OASIS (Outcome and Assessment Information Set (a standardized assessment form)) dated 11/21/2022; and - A plan of care dated 11/22/2022 to 01/20/2023 that failed to have a physician signature documented. During an interview 02/01/2023 at 11:38 AM, the Director of Clinical Services stated that the POC dated 11/22/2023 to 01/20/2023 was not back signed yet. During an interview 02/01/2023 at 11:40 AM, the Intake-Administrative Assistant was unable to locate any dates for when the POC was sent to the physician for signature. During an interview 02/01/2023 at 12:45 PM, the Director of Clinical Services stated that he/she expected the physician to sign the POC within 30 days.