Every finding on record at Prime Healthcare Home Care and Hospice, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/31/2025. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 07/31/2025. The Agency was not in compliance with the standards for Home Health Agencies, 42 CFR 484, for this survey.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on document review, patient interview, and staff interview, it was determined in 7 of 7 (Pt #1 , Pt. #2, Pt. #3, Pt. #4, Pt. #5, Pt. #6 and Pt #7) patient records reviewed and home visits observed, the Home Health Agency (HHA) failed to ensure the patient was advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. Findings include: 1. The following clinical records were reviewed: On 7/29/2025 during a home visit for Pt. #1 the HHA admission booklet was reviewed in the home. It was determined the admission booklet did not contain information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This was verbally confirmed with Pt. #1 who stated she was not made aware of the hot line, how to contact it, it’s hour of operation, and its purpose. On 7/29/2025 during a home visit for Pt. #2 the HHA admission booklet was reviewed in the home. It was determined the admission booklet did not contain information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. Pt. #2 is non-verbal and was not able to verbally confirm she was not made aware of the hot line, how to contact it, it’s hour of operation, and its purpose. On 7/29/2025 during a home visit for Pt. #3 the HHA admission booklet was reviewed in the home. It was determined the admission booklet did not contain information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This was verbally confirmed with Pt. #3 who stated she was not made aware of the hot line, how to contact it, it’s hour of operation, and its purpose. On 7/29/2025 during a home visit for Pt. #7 the HHA admission booklet was reviewed in the home. It was determined the admission booklet did not contain information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This was verbally confirmed with Pt. #4 who stated he was not made aware of the hot line, how to contact it, it’s hour of operation, and its purpose. On 7/29/2025 during a home visit for Pt. #4 the HHA admission booklet was reviewed in the home. It was determined the admission booklet did not contain information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This was verbally confirmed with Pt. #1 who stated she was not made aware of the hot line, how to contact it, it’s hour of operation, and its purpose. During the home visit, the Registered Nurse, E #5, added a contact information page, page 77, with the required information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs and educated the patient on its contents. On 7/30/2025 during a home visit for Pt. #5 the Physical Therapy Assistant (PTA), E #11, added a contact information page, page 77, with the required information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs to Pt. #5’s admission booklet and educated the patient on its contents. During an interview with the Pt. #5 he confirmed he was not aware of the hotline prior to the education provided by E #11 during the home visit. On 7/30/2025 during a home visit for Pt. #6 the Occupational Therapy Assistant (OTA), E #9, added a contact information page, page 77, with the required information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs to Pt. #6’s admission booklet and educated the patient on its contents. During an interview with the Pt. #6 he confirmed he was not aware of the hotline prior to the education provided by E #9 during the home visit. 2. An interview as conducted on 7/29/25 at approximately 1:30PM, with the Senior Manager, E #1. During discussion about advising patients of state toll free hotline E #1 verbally confirmed the required information on the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs is not in their admission booklet. E #1 noted page 77 was omitted from the booklet by the printers and was able to provide the missing page and its contents.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 6/30/2022. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements and the COVID-19 Staff Vaccination survey on 6/30/2022. The Agency was in compliance with the requirements for Emergency Preparedness and COVID-19 Staff Vaccination for this survey. The Agency was not in compliance with the standards for for Home Health Agencies 42 CFR 484, as evidenced by. Abbreviations: E- Employee CBC- Complete Blood Count PICC- Peripherally Inserted Central Catheter Pt- Patient SOC- Start of Care

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, document review and interview, it was determined for 4 of 10 records reviewed, the Agency failed to follow accepted standards of practice to prevent the transmission of communicable diseases. This has the potential to affect all pstient who receive care by the Agency with a current census of 153 patients. Findings include: 1. During a home visit on 6/29/22 at approximately 1:30 PM, E#4 (Registered Nurse) was observed to donn a non-medical grade mask throughout Pt #3's visit. Pt #3 stated "My (wife/husband) has had cold-like symptoms for a few days and has not had any energy. I told (her/him) to go get one of those tests (COVID-19). (She/He) is getting that (COVID-19 test) done today." During the visit, 3 family members were observed to enter the house and visit with the (wife/husband) in the kitchen area. 2. Pt #3 Start of Care (SOC): 11/20/21 Diagnosis: Diabetes Mellitus with skin ulcer right ankle. The record was reviewed on6/29/22 at approximately 12:00 PM. The COVID-19 screening tool dated 6/29/22 noted "Do you have a close contact that is currently experiencing any of the following... none..." The record lacked documentation Pt #3's (wife/husband) was being tested for COVID on 6/29/22 or the supervisor was notified. 3. The following records lacked documentation a COVID-19 screen was conducted prior to the home visit: a) Pt #3, 3/25/22 through 6/1/22, 21 of 28 visits lacked a pre-visit screen; b) Pt #5, 1/8/22 through 6/29/22, 27 of 34 visits lacked a pre-visit screen; c) Pt #6, 4/21/22 through 6/27/22, 26 of 26 visits lacked a pre-visit screen; d) Pt #9, 3/10/22 through 6/20/22, 4 of 11 visits lacked a pre-visit screen. 4. During an interview on 6/30/22 at approximately 11:00 AM, E#5 (Clinical Nursing Supervisor) stated "We don't do pre-visit screens anymore. Staff should call the supervisor and report any symptoms the patient may be experiencing and the supervisor would track the patient and notify the interdisciplinary team. We don't track care givers. It's not our responsibility. We are there to take care of the patient." 5. During a phone interview on 6/30/22 at approximately 12:30 PM, E#6 (Quality Director) stated "The COVID screen is done as part of the admission process and every visit as well as the patients are educated about when and what symptoms should be reported. The COVID screening tool was eliminated because it was outdated but the expectation is to conducted an assessment (COVID symptoms) during the home visit... A surgical mask is required to be worn by all staff during the home visits at all times. If there is a person of interest in the home, we ask they stay at least 3 foot from the patient and wear a mask. If a person of interest has a test conducted, we would recommend the patient be tested as well before the next visit.

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 document review and interview, it was determined for 1 of 10 (Pt #9) patients records reviewed, the Agency failed to ensure the interdisciplinary team conducted an ongoing assessment of the patient. This has the potential to affect all patients who receive care by the Agency with a current census of 153 patients. Findings include: 1. Pt #9 Start of Care (SOC): 3/10/22 Diagnosis: Stage 4 Pressure Ulcer. The record was reviewed on 6/28/22 at approximately 2:55 PM. The Skilled Nurse Assessment dated 5/16/22 authored by E#2 (Registered Nurse) noted "Gastrointestinal Last Bowel Movement: 05-16-2022 Detailed Gastrointestinal: No further detail Abdomen: Abdomen soft, non tender, Active bowel sounds all 4 quadrants, Regular bowel pattern..." The Clinical Notes dated 05/16/2022 authored by E#2 noted "Family reports patient has been having very dark stools and new orders received for CBC (Complete Blood Count) to be drawn this visit." The Skilled Nurse Assessment and Clinical Note dated 05-25-2022 (the next skilled nurse visit after the 5/16/22 visit) authored by E#3 (Registered Nurse) lacked documentation the dark stools were assessed or the CBC results were followed up on. 2. During an interview on 6/29/22 at approximately 3:00 PM, E#1 (Director of Home Health) reviewed Pt #9's record and stated "They (nurses) are supposed to review the previous Skilled Nurse Assessment and Clinical Note prior to the visit." E#1 verbally agreed the 5/16/22 Gastrointestinal Assessment was not accurately documented and the 5/25/22 visit lacked documentation the dark stools were followed up on and should have been.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 1 of 1 (Pt #3) patient record reviewed with a Peripherally Inserted Central Catheter (PICC), the Agency failed to ensure the PICC line was assessed per policy. This has the potential to affect all patients with a PICC line. Findings include: 1. The policy titled "Peripheral Inserted Central Catheter (PICC) Maintenance Guideline" (dated 5/21/21) was reviewed on 6/29/22 at approximately 12:00 PM. The policy noted "Measure the length of the external catheter with weekly dressing changes." 2. Pt #3 Start of Care (SOC): 11/20/21 Diagnosis: Diabetes Mellitus with skin ulcer right ankle. The record was reviewed on 6/29/22 at approximately 12:00 PM. The Skilled Nurse's note dated 5/2/22, 5/9/22, 5/17/22 and 5/23/22 noted the PICC line dressing was changed although lacked documentation the length of the external catheter was measured. 3. During an interview on 6/30/22 at approximately 9:30 AM, E#1 (Director of Home Health Agency) reviewed Pt #3's record and verbally agreed the length of the external catheter had not been measured and should have been.