Every finding on record at Preferred Home Health Agency Inc

During the recertification survey conducted on 2/9/2026 to 2/12/2026 at Preferred Home Health Agency Inc, a Home Health Agency, Emergency Preparedness was reviewed. Preferred Home Health Agency Inc is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on 2/9/2026 to 2/12/2026 at Preferred Home Health Agency Inc. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies, Requirements for Home Health Agencies.

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 observation and interview, the home health agency registered nurse (RN), Staff A, failed to follow standard precautions during a home visit with Sample Patient (SP) #1. The findings include: During a home visit on 2/10/2026 that started at 7:36 AM, the surveyor observed that Staff A failed to follow standard precautions more than once: Staff A placed a red bio-hazard bag that contained a brown plastic sharps container, his personal bag, and his medical equipment on SP #1’s dining table without first laying down a barrier; Staff A failed to wash or sanitize hands prior to starting patient care; Staff A failed to apply gloves prior to starting patient care; Staff A failed to sanitize medical equipment before taking SP #1's vital signs; Staff A failed to sanitize medical equipment before returning the equipment to his personal bag; and the medical equipment did not belong to SP #1. During an interview with the Administrator on 2/11/2026 at 2:25 PM, the Administrator said it will be worked on.

During the recertification survey conducted on 09/11/2023 to 09/13/2023 at Preferred Home Health Agency Inc., a Home Health Agency, Emergency Preparedness was reviewed. Preferred Home Health Agency Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

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 record review and interview, the home health agency failed to demonstrate that an initial training in emergency preparedness policies and procedures was provided to all new and existing staff consistent with their expected roles and provide emergency preparedness training at least every 2 years thereafter for 4 out of 11 sample active staff. (Staff C, Staff D, Staff E and Staff F) Findings include: Personnel record review conducted on 09/11/23 to 09/13/23 revealed the Physical Therapist (Staff C) was hired on 04/06/2023, the Physical Therapist Assistant (Staff D) was hired on 04/06/2023, the Occupational Therapist (Staff E) was hired on 08/24/2023 and the Occupational Therapist Assistant (Staff F) was hired on 08/24/2023. The Staff C, Staff D, Staff E and Staff F are currently providing care to patients of the home health agency. Further review of the personnel files for Staff C, Staff D, Staff E and Staff F revealed no documentation of receiving initial training upon hire. Interview was conducted with the Administrator on 09/13/2023 at approximately 2:35 PM acknowledged the provider is not able to demonstrate Staff C, Staff D, Staff E and Staff F received initial emergency plan training as required from the provider.

A recertification survey was conducted on 09/11/2023 to 09/13/2023 at Preferred Home Health Agency Inc. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to complete a comprehensive resumption of care (ROC) assessment within 48 hours of the patient's return to the home from a hospital admission in 1 out of 7 Sampled Patients (SP). SP#7 Findings include: Closed clinical record review conducted on 09/11/23 to 09/13/23 of SP#7 revealed a Plan of Care for certification period of 06/05/23 to 07/04/23 that showed the patient received nursing service for intravenous medication administration every 12 hours. Review of the clinical record showed the last nursing service note completed on 06/26/23, no nursing service provided from 06/27/23 to 07/01/23, and nursing service resumed on 07/02/23. Further review of the clinical record revealed a missed visit nursing notation dated 06/27/23 that revealed “patient refer to ER (emergency room) hospital to check the PICC (peripherally inserted central catheter) line, RN (registered nurse) couldn’t flushed the IV (intravenous) line, patient complained with pain”. Interview conducted on 09/13/23 at 2:07 PM with the Administrator stated that patient was admitted to the hospital due to complications with the intravenous line, the registered nurse sent the patient to the hospital. The surveyor presented the clinical record to the Administrator for review, and the Administrator acknowledged that a ROC was not completed. Review of the provider Policy and Procedure titled "Reassessment" under section "Procedure" reads "1. For Medicare: The comprehensive assessment must be updated and revised (including the administration of the OASIS)[Outcome and Assessment Information Set] as frequently as the patient’s condition warrants due a major decline or improvement in the patient’s health status, but not less frequently than: b. Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic test or on physician or allowed practitioner-ordered resumption date.”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the home health agency failed to complete a discharge (DC) comprehensive assessment in a timely manner in 1 out of 7 Sampled Patient (SP). SP#7 Findings include: Closed clinical record review conducted on 09/11/23 to 09/13/23 of SP#7 revealed a Plan of Care for certification period of 06/05/23 to 07/04/23 that showed the patient received nursing service for intravenous medication administration every 12 hours. Review of the clinical record showed the last visit made by the skilled nurse was on 07/03/23 and omitted a discharge comprehensive assessment completed for SP#7. A physician order dated 07/04/23 reads “discharge RN (registered nurse) skilled services for this period by the MD (medical doctor) recommendation for the laboratory resulted. Patient continuing hha (home health aide) services with the LTC (long term care) for personal care”. An interview was conducted on 09/13/23 at 2:07 PM with the Administrator. The surveyor presented the clinical record to the Administrator for review, and the Administrator acknowledged that a DC was not completed. Review of the provider Policy and Procedure titled "Reassessment" under section "Procedure" reads "1. For Medicare: The comprehensive assessment must be updated and revised (including the administration of the OASIS)[Outcome and Assessment Information Set] as frequently as the patient’s condition warrants due a major decline or improvement in the patient’s health status, but not less frequently than: c. At discharge.”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to coordinate care delivery to meet the patient's needs for 2 out of 7 Sampled Patients (SP). SP#1 and SP#7 Findings include: Clinical record reviews were conducted on 09/11/23 to 09/13/23 of SP#1 and SP#7. Record review of SP#1 revealed the patient was admitted on 08/18/2023 and the Plan of Care reads for Physical and Occupational Therapies services. The Physical Therapy initial evaluation was completed on 08/23/23 and the frequency reads for 2wk1 (two times a week for one week), 3wk3 (three times a week for three weeks), 2wk1(two times a week for one week). The Occupational Therapy initial evaluation was completed on 08/24/23 and the frequency reads for 1wk1 (one time a week for one week), 2wk3 (two times a week for three weeks). Further review of the service notes for date range 08/23/23 to 09/13/23 revealed the occupational therapy service notes for scheduled date(s) 08/29/23, 08/31/23 and 09/05/23 reflected as not started as of 09/12/23. A modify order dated 09/06/23 reads “Partial discharge OT (occupational therapy) services. Agency inform to physician the OT was stopped services due caregiver request to continue physical therapy only to the patient rehabilitation. Las OT services was 09/05/2023”. On 09/13/23 the status of the occupational therapy service notes for scheduled date(s) 08/29/23, 08/31/23 and 09/05/23 reflected as “missed visits”. During a home visit made to SP#1 on 09/12/23 at 3:50 PM, the patient’s caregiver stated that occupational therapy was provided for a couple of visits, but it just stopped. An interview was conducted with the Administrator on 09/13/23 at 2:04 PM. The Administrator was informed of the Modify order dated 09/06/23 that reads OT last visit made 09/05/23; the patient’s caregiver stating OT visits were made; and the service notes reflect as “missed visits”. The Administrator acknowledged that the provider is unable to demonstrate care coordination of the services provided by others under contractual arrangements, ensuring that all care provided is delivered in accordance with the plan of care. A closed clinical record review conducted on 09/11/23 to 09/13/23 revealed the patient was admitted to service on 06/05/23 and the Plan of Care reads “Physical therapist to evaluate and submit plan of treatment. Occupational therapist to evaluate and submit plan of treatment”. The clinical record contained the Physical Therapy initial evaluation completed on 06/06/23 with (3) follow up visits completed; last visit documented on 06/15/23. The clinical record omitted documentation reason for not providing Occupational Therapy.

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 record review and interview, the home health agency failed to demonstrate that 4 out of 11 active staff received annual in-service on infection control. (Staff C, Staff D, Staff E and Staff F) Findings include: Record review revealed the provider provided infection control education in-service on 03/17/2023 to its employees. Further record review revealed no documentation to show that active Staff C, Staff D, Staff E and Staff F participated in the infection control education in-service. Interview was conducted with the Administrator on 09/13/2023 at approximately 2:35 PM acknowledged that the Staff C, Staff D, Staff E and Staff F are providing physical and occupational therapy services to patients of the home health agency and have not received infection control education in-service from the provider.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional for 2 out of 7 Sampled Patients (SP). SP#1 and SP#2 Findings included: Electronic clinical record reviews were conducted of active SP#1 and SP#2 on 09/11/23 to 09/13/23. The SP#1 contained a Plan of Care with a Certification Period of 08/18/23 to 10/16/23 that revealed the patient is receiving Skilled Nursing (SN) and Home Health Aide (HHA) services. The home health agency failed to demonstrate that HHA supervisions were conducted every 14 days between date range 08/18/23 and 09/13/23, which is an interval of 26 days. The SP#2 contained a Plan of Care with a Certification Period of 07/19/23 to 09/16/23 that revealed the patient is receiving Skilled Nursing (SN) and Home Health Aide (HHA) services. The home health agency failed to demonstrate that HHA supervisions were conducted every 14 days between the date range 07/19/23 and 09/11/23, which is an interval of 54 days. Review of the home health agency’s policy and procedures titled “Supervisory Visits” reads “1. All supervisory visits will be on-site visits conducted by a registered nurse or other appropriate skilled professional as follows: b. For Home Health Aide: 2. At least every 14 days, if the patient is receiving home health aide services along with skilled services. The home health aide does not have to be present during supervisory visit”. An interview was conducted with the Administrator on 09/13/23 at 2:15 PM. The Administrator acknowledged no supervisions completed for SP#1 and SP#2.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that the Registered Nurse (RN) conducted a supervisory visit of the Home Health Aide (HHA) while the HHA is providing patient care, no less frequently than every 60 days, who is not receiving skilled care service in 2 out of 7 Sample Patients (SP). SP#5 and SP#6 Findings include: Electronic clinical record reviews were conducted of active SP#5 and SP#6 on 09/11/23 to 09/13/23. The SP#5 is receiving home health aide services for assistance with personal care, homemaker, and companion. Further review of the clinical record revealed supervisory visits were conducted on 07/01/23 and then on 09/12/23, which is an interval of 73 days. The SP#6 is receiving home health aide services for assistance with personal care, homemaker, and companion. Further review of the clinical record revealed supervisory visits were conducted on 05/08/23 and then on 07/17/23, which is an interval of 70 days. Review of the home health agency’s policy and procedures titled “Supervisory Visits” reads “1. All supervisory visits will be on-site visits conducted by a registered nurse or other appropriate skilled professional as follows: b. For Home Health Aide: 3. If the patient is not receiving skilled services, the registered nurse must make an onsite visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care”. An interview was conducted with the Administrator on 09/13/23 at 2:15 PM. The Administrator acknowledged no supervisions completed for SP#5 and SP#6.

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 record review and interview, the home health agency is unable to demonstrate a completed discharge summary for 1 out of 7 Sampled Patients (SP). SP#7 Findings include: A closed record review of SP#5 was conducted on 09/11/23 to 09/13/23. The clinical record for SP#7 omitted a discharge summary that includes such as listing the reason for admission to home health; the type of services provided and frequency of services; any Lab data (as applicable); and complete summary of care/outcomes in meeting the goals in the Plan of Care. An interview was conducted with the Administrator on 09/13/2023 at approximately 2:35 PM acknowledged that the clinical record for SP#7 is incomplete, missing the required notations as previously mentioned.