Every finding on record at Presidente Home Care Inc.

To conduct a relicensure/recertification survey On 05/16/25 at 11:47 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Adm and Alt Admin Census: L&CHHS – 12 LHHS – 8 PAS – 76 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness requirements for Home Health Agencies. Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services DON-Director Of Nurses RN – Registered Nurse QAPI – Quality Assessment Performance Improvement IQIES- Internet Quality Improvement an Evaluation System

Purpose of Survey – To conduct a recertification survey. On 05/16/25 at 11:47 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Adm. Census: L&CHHS – 12 LHHS – 8 PAS – 76 Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services DON-Director Of Nurses RN – Registered Nurse LVN -Licensed Vocational Nurse CMS- Centers for Medicare and Medicaid OASIS – Outcome and Assessment Information Set QA – Quality Assessment IQIES- Internet Quality Improvement an Evaluation System

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 review and interview, the Agency failed to transmit completed OASIS (Outcome and Assessment Information Set: OASIS is a set of core assessment items for adult home care patients. ) Assessments to the CMS system within 30 days of completions for 25 of 177 assessments submitted between 05/01/24 through 05/01/25. This failure prevented the patient’s date from being made available to the Centers for Medicare and Medicaid (CMS) for analysis to identify Agency performance levels in the provision of patient care, which could cause a delay in effective patient care Findings included: Record review of IQIES (IQIES is an Internet -based system that includes survey and certification functions) “Home Health Error by Summary Agency” report generated from the CMS national data system during presurvey preparation on 05/16/25 revealed agency had submitted and processed 177 assessments. The report indicated the Agency had 25 assessments with error-3330 indicating those records were submitted after the 30th date of the M0090 date, which equaled to 14.127% of the total assessments submitted with error -3330. Record review of the Agency OASIS final validation reports with a report period between 05/01/24 through 05/01/25 revealed 177 total assessments were processed by the agency. Further review of the Agency OASIS final validation reports revealed 25 of the 177 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 date. In an interview on 05/21/25 at 10:30 AM, the Adm stated the process for OASIS assessment was to be started when nurse obtained order from physician. The Adm stated nurse had 24 hours to visit client and perform start of care assessment. The Adm stated the nurse had 48 hours to submit OASIS assessment to quality assessment (QA) department for revision. The Adm stated QA would then review the assessment and return the assessment to the nurse if revisions needed to be made. The Adm stated once revisions were made, the nurse would send back to QA for final revisions. The Adm stated after final revisions, QA would then return the assessment back to the nurse for signature and the plan of care would then be ready to go to the physician’s office for physician signature. The Adm stated that the Previous Biller had cut his hours at the agency, and he quit and was not submitting the assessments timely, and the New Biller was learning how to submit the assessments. Also, the Admin stated that there was a new Process from CMS in submitting All patients instead of just the Medicaid patients and they were trying to adjust with the changes. Record review of Agency policy titled, “ IM.10 OASIS Collecting, Encoding and Transmitting”, with revised date noted,01/01/21 and quoted in part, “OASIS information collected encoded and transmitted according to regulation, start of care, resumption of care, follow-up, and transfer to an inpatient facility will be encoded, edited, and locked into the computer system within seven calendar days from the date the assessment is completed. The OASIS information will be sent electronically to the State and will match the data in the clinical record…” “The Agency must Encode and Electronically transmit each Completed OASIS assessment to the CMS system for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary.”

A Recertification Survey entrance conference was conducted on 06/13/22 at 2:15 p.m. with the Administrator/Director of Nursing and the Alternate Administrator. Census: L&C (Licensed and Certified Home Health): 20 LHH (Licensed Home Health): 9 PAS (Personal Assistance Services): 27 An exit conference was conducted on 06/17/22 at 1:25 p.m. with the Administrator/Director of Nursing, the Alternate Administrator, the Alternate Director of Nursing, Office Manager and Clerk. The preliminary findings were discussed. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

A Recertification Survey entrance conference was conducted on 06/13/22 at 2:15 p.m. with the Administrator/Director of Nursing and the Alternate Administrator. Census: L&C (Licensed and Certified Home Health): 20 LHH (Licensed Home Health): 9 PAS (Personal Assistance Services): 27 DME – Durable Medical Equipment LVN –Licensed Vocational Nurse POC –Plan of Care SN -Skilled Nurse CG –Caregiver ADON-Alternate Director of Nursing OASIS-D1 (Outcome and Assessment Information Set-Data) An exit conference was conducted on 06/17/22 at 1:25 p.m. with the Administrator/Director of Nursing, the Alternate Administrator, the Alternate Director of Nursing, Office Manager and Clerk. The preliminary findings were discussed, and written instructions were provided for submitting a plan of correction within ten days of the receipt of the Statement of Deficiencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: (This is a continuing deficient practice that was cited previously at G-0578 on 06/14/19) Based on clinical record review and interview, the agency failed to ensure SN followed the written POC for one of eight active patient's (Patient #’ 5) whose records were reviewed. LVN P performed wound care on Patient #5 without orders from a physician. These failures could place the agency's active patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings included: Review of active Patient #5's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 04/18/22 - 06/16/22, signed and dated by Physician on 06/17/22. The POC revealed a Principal Diagnosis of Acute and Chronic Respiratory Failure, unspecified with Hypoxia or Hypercapnia with other Diagnoses of Encounter for attention to Tracheostomy, Tracheostomy status, Dysphagia, Gastrostomy status. The POC included orders for SN frequency of once a week for nine weeks + 3 PRN (as needed) visits for complications with Trach or GT sites or enteral feeding, signs/symptoms of Hyper-Hypotension, Falls, Injury, Skin breakdown or Medication changes requiring medication review, instruction. Review of active Patient #5’s clinical record revealed a document titled, “Skilled Nurse visit” signed and dated by LVN on 04/21/22. Under the section “Wound 1” the wound is noted to be a sacral pressure ulcer, stage II, 0.3 cm in size. Under the section “Treatment performed”, the note reads as follows: SN using aseptic technique and sterile supplies, cleansed wound with soap and water, rinsed with water, pat dry with gauze and secured with tape. Patient tolerated well. Under the section “Narrative”, the note reads as follows: SN demonstrated wound care to caregiver. Caregiver able to understand and demonstrated well to continue w/c as needed. Continued review of active Patient # 5's clinical record failed to reveal wound care orders. During an interview on 06/17/22 at 11:00 a.m. with the Administrator/Director of Nursing and the Quality Assurance Nurse, the surveyor presented the above findings. The Administrator/Director of Nursing stated “Yes, I see. Maybe, there is an order that came through, let me check”. An order was not provided. Review of the agency's Administrative Policy Manual revealed a policy titled, "Orders for Care", Number: TX.5, dated 010121. The policy read in part the following, "…A. Agency will obtain orders and provide care in accordance with orders which are established prior to initiating patient care and reviewed/revised by the Physician, Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist every 60 days and as warranted..."

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, observation and interview, the agency failed to ensure that Plans of Care included safety measures to protect against injury and activity orders and supplies for four of eight active patients (Patient #’s 2, 3, 5 and 7) and one of two discharged patients (Patient #7) whose records were reviewed. Patient #2's plan of care did not include orders for care of the patient's suprapubic stoma and failed to list suprapubic catheter supplies under DME/Supplies. Patient #3's plan of care did not include orders for patient's left arm not to be used for blood pressure checks or venipunctures due to patient having a Left Arteriovenous Fistula. Patient #5's plan of care did not include orders for wound care that was performed on the patient and failed to include Gastrostomy tube and Tracheostomy care orders and supplies under DME/Supplies. Patient #7's plan of care failed to list Suprapubic catheter care orders supplies and Gastrostomy tube supplies under DME/Supplies. This failure could place the agency's patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes per record reviews and interviews. The findings included: Review of active Patient #2's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 05/15/22 - 07/13/22, signed and dated by Physician on 06/15/22. The POC revealed a Principal Diagnosis of Neuromuscular Dysfunction of Bladder, unspecified with other Diagnoses of Encounter for fitting and adjustment of urinary device, Encounter for attention to other artificial openings of urinary tract, Other Cystostomy status. The POC included orders for SN frequency of once a week for nine weeks + 3 PRN (as needed) visits for signs/symptoms of Hyper-Hypotension, falls, Injury, Skin breakdown, Lesions, problems with urinary catheter or medication changes requiring instruction. Observation during a home visit and review of active Patient #2’s Plan of Care failed to include orders for care of Suprapubic Catheter stoma (opening through which a catheter (tube) is placed to drain urine from the bladder) and failed to include a list of supplies needed for Suprapubic Catheter care under Durable Medical Equipment and Supplies. Review of active Patient #3's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 05/02/22 - 06/30/22, signed and dated by Physician on 05/24/22. The POC revealed a Principal Diagnosis of Pressure Ulcer of Sacral Region, stage 2, with other Diagnoses of Encounter for change or removal of nonsurgical wound dressing, End Stage Renal Disease, Dependence on Renal Dialysis. The POC included orders for SN frequency of once a week for nine weeks + 3 PRN (as needed) visits for signs/symptoms of Hyper-Hypotension, falls, Injury, Skin breakdown, Lesions, problems with urinary catheter or medication changes requiring instruction. Observation during a home visit and review of active Patient #3’s Plan of Care failed to reveal orders for no blood pressure checks or venipunctures to left arm. Review of active Patient #5's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 04/18/22 - 06/16/22, signed and dated by Physician on 06/17/22. The POC revealed a Principal Diagnosis of Acute and Chronic Respiratory Failure, unspecified with Hypoxia or Hypercapnia with other Diagnoses of Encounter for attention to Tracheostomy, Tracheostomy status, Dysphagia, Gastrostomy status. The POC included orders for SN frequency of once a week for nine weeks + 3 PRN (as needed) visits for complications with Trach or Gastrostomy Tube sites or enteral feeding, signs/symptoms of Hyper-Hypotension, Falls, Injury, Skin breakdown or Medication changes requiring medication review, instruction. The POC failed to reveal orders for how enteral nutrition was to be administered, the Gastrostomy tube care that was to be provided, the size of the Trachea tube that was to be used for tracheal tube changes and the care of the Trachea stoma that was to be provided. The POC also failed to reveal orders for wound care that was performed and taught by LVN Q. The POC also failed to include a list of supplies needed for Tracheostomy and Gastrostomy care under DME and Supplies. Review of active Patient #5’s clinical record revealed a document titled, “Skilled Nurse visit” signed and dated by LVN Q on 04/21/22. Under the section “Wound 1” the wound is noted to be a sacral pressure ulcer, stage II, 0.3 cm in size. Under the section “Treatment performed”, the note reads as follows: SN using aseptic technique and sterile supplies, cleansed wound with soap and water, rinsed with water, pat dry with gauze and secured with tape. Patient tolerated well. Under the section “Narrative”, the note reads as follows: “SN demonstrated wound care to CG (caregiver). CG (caregiver) able to understand and demonstrated well to continue w/c as needed.” Continued review of active Patient #5's clinical record failed to reveal wound care orders. Review of discharged Patient #7's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 12/28/21 - 02/25/22, signed and dated by Physician on 01/26/22. The POC revealed a Principal Diagnosis of Pressure ulcer of Sacral region, unstageable, with other Diagnosis of Parkinson’s disease, Dysphagia, oropharyngeal phase, Encounter for attention to Gastrostomy, Retention of Urine, unspecified, Encounter for fitting and adjustment of urinary device, Encounter for change or removal of nonsurgical wound dressing. The POC included orders for SN frequency of twice a week for one week, three times a week for one week + 2 PRN (as needed) visits for changes or complications. Review of discharged Patient # 7's Skilled Nursing Visit notes and Plan of Care failed to reveal orders for care of Suprapubic stoma that was to be provided and failed to include a list of supplies needed for Suprapubic catheter care/changes and Gastrostomy tube care/changes under DME and Supplies. During an interview on 06/17/22 at 11:00 a.m. with the Administrator/Director of Nursing and the Quality Assurance Nurse, the surveyor presented the above findings. The Administrator/Director of Nursing stated “Yes, I see. Maybe, there was an order that came through, let me check.” During a second interview with the Administrator/Director of Nursing, he reviewed the documents and confirmed the findings. Review of the agency's Administrative Policy Manual revealed a policy titled, "Plan of Care", Number: TX.6, dated 070121. The document read in part the following, ... "C. The Individualized Plan of Care (POC) will specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. The POC will contain the following elements: 3. The types of services, supplies, and equipment required; 4. The frequency and duration of visits to be made; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury…"

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 observation, record review and interview, the agency failed to ensure that treatments were performed only as ordered by the physician for one of eight active patients (Patient #5) whose records were reviewed. LVN Q performed wound care without a physician’s order. This failure could place the agency’s patients and future patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings included: Review of active Patient #5's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 04/18/22 - 06/16/22, signed and dated by Physician on 06/17/22. The POC revealed a Principal Diagnosis of Acute and Chronic Respiratory Failure, unspecified with Hypoxia or Hypercapnia with other Diagnosis of Encounter for attention to Tracheostomy, Tracheostomy status, Dysphagia, Gastrostomy status. The POC included orders for SN frequency of once a week for nine weeks + 3 PRN (as needed) visits for complications with Trach or GT sites or enteral feeding, signs/symptoms of Hyper-Hypotension, Falls, Injury, Skin breakdown or Medication changes requiring medication review, instruction. Further review of the POC failed to include orders for skilled nursing to perform wound care. Review of active Patient #5's clinical record revealed LVN Q performed wound care on the following date: 04/21/22. Review of active Patient #5’s clinical record revealed a document titled, “OASIS-D1 (Outcome and Assessment Information Set) Recertification” signed and dated by Alternate Director of Nursing on 04/14/22. The document notes that patient #5 had a small cut in the sacral area that measured 0.3 cm. The document goes on to read that the ADON reported the finding to doctor’s office, with no new orders having been received. Review of active Patient #5’s clinical record revealed a document titled, “Skilled Nurse visit” signed and dated by LVN on 04/21/22. Under the section “Wound 1” the wound is noted to be a sacral pressure ulcer, stage II, 0.3 cm in size. Under the section “Treatment performed”, the note reads as follows: SN using aseptic technique and sterile supplies, cleansed wound with soap and water, rinsed with water, pat dry with gauze and secured with tape. Patient tolerated well. Under the section “Narrative”, the note reads as follows: SN demonstrated wound care to caregiver. Caregiver able to understand and demonstrated well to continue wound care as needed. During an interview on 06/17/22 at 11:00 a.m. with the Administrator/Director of Nursing and the Quality Assurance Nurse, the surveyor presented the above findings. The Administrator stated “Yes, I see. Maybe, there was an order that came through, let me check”. During a second interview with the Administrator/Director of Nursing, he confirmed that there was not an order. Review of the agency's Administrative Policy Manual revealed a policy titled, "Orders for Care", Number: TX.5, dated 010121. The policy read in part the following, "…A. Agency will obtain orders and provide care in accordance with orders which are established prior to initiating patient care and reviewed/revised by the Physician, Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist every 60 days and as warranted..."