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 07/03/25. 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 07/03/25. Standard level deficiencies cited. Abbreviations: # = number SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients VS = Vital signs PCG = Patient caregiver POC = Plan of Care

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 a review of the Agency's Pt. admission folder, observation and interview during home visits, clinical record reviews, and staff interviews, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator for 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/30/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 06/30/25 and 07/01/25: Pt. #1. SOC 05/09/25 Pt. #2. SOC 05/15/25 Pt. #3. SOC 06/18/25 Pt. #4. SOC 05/09/25 Pt. #5. SOC 06/21/25 Pt. #6. SOC 05/22/25 Pt. #7. SOC 05/12/25 During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Administrator. 3. The following clinical records were reviewed from 06/30/25 to 07/02/25: Pt. #1. SOC 05/09/25 Pt. #2. SOC 05/15/25 Pt. #3. SOC 06/18/25 Pt. #4. SOC 05/09/25 Pt. #5. SOC 06/21/25 Pt. #6. SOC 05/22/25 Pt. #7. SOC 05/12/25 Pt. #8. SOC 05/05/25 Pt. #9. SOC 05/09/25 Pt. #10. SOC 04/04/25 Pt. #11. SOC 05/22/25 Pt. #12. SOC 03/26/25 Pt. #13. SOC 05/08/25 Pt. #14. SOC 05/20/25 Pt. #15. SOC 04/11/25 Pt. #16. SOC 04/04/25 Pt. #17. SOC 04/14/25 The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. On 07/02/25, during multiple separate interviews between 10:06 AM to 4:00 PM, with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) and E#6 (Office Manager), E#2 (Director/Administrator) confirmed the above findings.

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: Based on clinical record review, policy review and staff interviews, the Agency failed to ensure care and services were provided as ordered by the Physician in the POC for 3 of 17 (Pts. #7, 9 and 12) clinical records reviewed. Findings include: 1. Pt. #7 was admitted to home health services on 05/12/25 with the diagnosis of but not limited to Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Other Site Stage 2, and End Stage Chronic Kidney Disease. The clinical record was reviewed on 07/01/25 and included the POC effective 05/12/25. The POC required, “Notify Physician if VS (vital sign) parameters out of range: Pulse greater than 120 or less than 55.” The Nursing Routine Visit note dated 05/19/25 in the record included the documentation: “Pulse: 52. Physician Contact: No contact required/made. Case Coordination: Not applicable this visit.” The record lacked Physician notification of the vital sign which was out of range. The POC also required, “Wound Care to: Between left great toe and second toe: Cleanse with saline, pat dry. Apply Hydrofera blue, dry gauze and secure with tape. To be done twice weekly and prn (as needed) for drainage by PCG or SN at visit…” The Nursing Routine Visit note dated 05/26/25 in the record included the documentation, “Between left great and second toe site location…Dressing Changed this Visit: Dressing changed as described: Cleansed with saline, pat dry. Apply this layer of triad paste and leave open to air.” The wound treatment was not in accordance with the POC. 2. Pt. #9 was admitted to home health services on 05/09/25 with the diagnosis of but not limited to, Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic ulcer of Other Part of Right Foot with Bone Involvement Without Evidence of Necrosis. The clinical record was reviewed on 07/02/25 and included the POC effective 05/09/25. The POC required, “Wound Care to - right 3rd toe daily and as needed for soilage by PCG/SN. Cleanse with saline or wound cleanser. Pat dry. Apply Iodosorb gel. Cover with gauze. Secure with tape; left hallux pressure ulcer daily and as needed or soilage by PCG/SN. Cleanse with wound cleanser. Pat dry. Apply Medihoney. Cover with gauze. Secure with tape.” The Nursing Routine Visit note on 5/12/25 included the following documentation, “Right 3rd toe site location…Dressing changed this visit: Dressing changed as described: Cleansed with saline or wound cleanser. Pat dry. Applied Xeroform. Covered with gauze and secure with tape…Left Hallux site location… Dressing changed this visit: Dressing changed as described: Cleanse with saline or wound cleanser. Pat dry. Applied Xeroform. Covered with gauze and secure with tape. Medihoney not in home at this time…. Care coordination, not applicable. Physician contact: No contact required/made.” The wound treatment was not in accordance with the POC. 3. Pt. #12 was admitted to home health services on 03/26/25 with the diagnoses of but not limited to Non-pressure Chronic Ulcer of Right Calf with Fat Layer Exposed, Non-pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed and Heart Failure. The clinical record was reviewed on 07/02/25. The POC effective 05/25/25 required, “Weigh every visit, if stable and able…Notify Physician for weight gain of 2 pounds in a day or 5 pounds in a week…” The Nursing Routine Visit Notes for the following dates: 05/02/25, 05/15/25, 05/27/25 and 06/26/25 lacked documentation of the patient's weight; Weekly weight gain monitoring and reporting was not implemented. 4. The Policy, “Wound Care Guidelines: Home Health” dated 2/2022 was reviewed on 07/02/25, and required, “1. Wound Care is to be performed per physician orders.” 5. The Policy, “Physician Participation in Plan of Care” dated 11/2024 was reviewed on 07/02/25 and required, “The care will be provided in compliance with his/her therapeutic and diagnostic orders and accepted standards and practice…” 6. During an interview with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) on 07/03/25 at 3:30 PM, the above findings were confirmed.

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 observation during home visits, clinical record reviews, policy review and staff interviews, the Agency failed to ensure Plans of Care for 2 of 17 (Pts. # 7 and 9) clinical records reviewed included all the requirements. Findings include: 1. Pt. #7 was admitted to home health services on 05/12/25 with the diagnosis of but not limited to Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Other Site Stage 2, and End Stage Chronic Kidney Disease. A home visit was conducted on 07/01/25 with E#1 (Home Health Aide). During the home visit, it was observed the Pt. had contractures on the left elbow and hand and bilateral lower extremities; the Pt. also had an arteriovenous shunt/access on the right upper arm covered with a dressing, and an off-loading heel and ankle foam boot on the left foot. During the home visit, E#1 stated that the off-loading boot has been used by the Pt. "for a long time", and the contractures have been present “for a long time.” The clinical record was reviewed on 07/01/25 and the POC lacked documentation of the interventions, use and care of the off-loading boot, safety measures and Pt./care giver education, for the arteriovenous shunt/access, Pt. and caregiver education, specific interventions for Pt.’s contractures. 2. Pt. #9 was admitted to home health services on 05/09/25 with the diagnosis of but not limited to, Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic ulcer of Other Part of Right Foot with Bone Involvement Without Evidence of Necrosis. The clinical record was reviewed on 07/02/25. The clinical record included the POC effective 05/09/25 which lacked documentation of Pt./caregiver education on blood glucose parameters to report to the clinician or Physician. 3. The Policy, “Physician Participation in Plan of Care” dated 11/2024 was reviewed on 07/02/25 and required, “Physician…orders will be individualized, based on patient’s needs and include: B. Treatments and/or procedures needed, including…goals…D. A description of equipment and related supplies provided by the organization…” 4. During an interview with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) on 07/03/25 at 3:30 PM, the above findings were confirmed.

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 clinical record reviews, policy review and staff interviews, the Agency failed to ensure that wound treatment provided for 2 of 17 (Pts. #9 and #12) was ordered by the Physician. Findings include: 1. Pt. #9 was admitted to home health services on 05/09/25 with the diagnosis of but not limited to, Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic ulcer of Other Part of Right Foot with Bone Involvement Without Evidence of Necrosis. The clinical record was reviewed on 07/02/25. The Nursing Routine Visit note in the clinical record dated 5/27/25 included documentation, “right shin, site location…right 3rd toe, site location… Dressing Changed this visit: Dressing changed as described: Cleansed with saline, pat dry. Vaseline gauze applied to wound with adhesive bordered foam.” The Nursing Routine Visit note dated 06/03/25 included the documentation, “left shin site location, Dressing Changed this visit: Dressing changed as described: Cleansed with saline, pat dry. Vaseline gauze to wound and covered with bordered gauze.” The Nursing Routine Visit note dated 06/27/25 included the documentation for a new wound onset, “left mid shin site location, Dressing Changed this visit: Dressing changed as described: Cleansed with wound cleanser, pat dry. Applied border foam dressing.” The clinical record lacked documentation the Physician was notified of new onset of wounds and lacked documentation Physician orders were obtained for the use of the above-mentioned wound treatment. 2. Pt. #12 was admitted to home health services on 03/26/25 with the diagnoses of but not limited to Non-pressure Chronic Ulcer of Right Calf with Fat Layer Exposed, Non-pressure Chronic Ulcer of Other Part of Left Lower Leg with Fat Layer Exposed and Heart Failure. The clinical record was reviewed on 07/02/25. The clinical record included Nursing Routine Visit notes. The Nursing Routine Visit notes dated 05/23/25 and 05/27/25 included documentation the wound on the right posterior calf was healed. The Nursing Routine Visit notes dated 05/30/25 included the documentation of the recurrence of the wound, “right posterior calf, site location: Dressing Changed this Visit, Cleansed with saline, pat dry. Hydrofera Blue ready applied to wound and covered with dry gauze, rolled gauze, secured with tape and Tubi grip.” The clinical record lacked documentation the Physician was notified of the recurrence of the wound that had previously healed and lacked documentation Physician orders were obtained for the use of the above-mentioned wound treatment. 3. The Policy, “Wound Care Guidelines: Home Health” dated 02/2022 was reviewed on 07/02/25, and required, “1. Wound Care is to be performed per physician orders.” 4. During an interview with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) on 07/03/25 at 3:30 PM, the above findings were confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission booklet, observation during home visits, clinical record reviews, and staff interviews, the Agency failed to provide the Pt./patient's representative the Agency Clinical Manager's name for 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 06/30/25. The folder lacked the name of the Agency Clinical Manager. 2. The following home visits were conducted on 06/30/25 and 07/01/25: Pt. #1. SOC 05/09/25 Pt. #2. SOC 05/15/25 Pt. #3. SOC 06/18/25 Pt. #4. SOC 05/09/25 Pt. #5. SOC 06/21/25 Pt. #6. SOC 05/22/25 Pt. #7. SOC 05/12/25 During the home visits, the Pt. admission folders were observed, and lacked the name of the Agency Supervisor. During the home visits, the Pt/patient’s representative was not aware of the Agency Clinical Manager's name. 3. The following clinical records were reviewed on 06/30/25 and 07/02/25: Pt. #1. SOC 05/09/25 Pt. #2. SOC 05/15/25 Pt. #3. SOC 06/18/25 Pt. #4. SOC 05/09/25 Pt. #5. SOC 06/21/25 Pt. #6. SOC 05/22/25 Pt. #7. SOC 05/12/25 Pt. #8. SOC 05/05/25 Pt. #9. SOC 05/09/25 Pt. #10. SOC 04/04/25 Pt. #11. SOC 05/22/25 Pt. #12. SOC 03/26/25 Pt. #13. SOC 05/08/25 Pt. #14. SOC 05/20/25 Pt. #15. SOC 04/11/25 Pt. #16. SOC 04/04/25 Pt. #17. SOC 04/14/25 The clinical records lacked documentation that the Pt./patient's representative was provided the name of the Agency Clinical Manager. 4. On 07/02/25, during multiple separate interviews between 10:06 AM to 4:00 PM, with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) and E#6 (Office Manager), E#2 (Director/Administrator) confirmed the above findings.

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 the onsite observations, Policy review and staff interviews, the Agency failed to ensure in 1 of 7 home visits (Pt.#7) that Standard Precautions were followed. Findings include: 1.A home visit was conducted on 07/01/25 with E#1 (Home Health Aide) for Pt. #7. It was observed E#1 failed to change gloves between tasks on the same patient. During the same home visit, it was observed that E#1 used the same gloves, towel, and water when cleaning and rinsing the Pt. during the bed bath. 2. The Policy, “Standard Precautions” dated 11/2024 was reviewed on 07/02/25, and required, “…1. Gloves: … 11…C. Gloves are to be changed: 1. Between tasks and procedures on the same patient 2. After changing or cleaning an incontinent patient…” 3. During an interview with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) on 07/03/25 at 3:30 PM, the above findings were confirmed.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on the onsite observations, policy review and staff interviews, the Agency failed to ensure in 1 of 9 Pts. (Pt.#7) with Home Health Aide services, that the written patient care instructions were individualized. Findings include: 1. A home visit was conducted on 07/01/25 with E#1 (Home Health Aide) for Pt. #7. Pt. #7 was admitted to home health services with the diagnosis of but not limited to End Stage Renal Disease and was observed to have a dialysis access/arteriovenous shunt (AV Shunt) on the right upper arm. It was observed the E#1 failed to properly take the blood pressure reading. E#1 was observed to use the patient's right forearm. The Aide Care plan lacked individualized instructions regarding how the Aide should take the blood pressure reading for a patient on dialysis with an AV shunt. 2. The Policy, “Home Health Aide Plan of Care” dated 11/2024 was reviewed on 07/02/25, and required, “… POLICY Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide.” 3. During an interview with the E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) on 07/03/25 at 3:30 PM, the above findings were confirmed.

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 clinical record review and staff interview, the Agency failed to ensure that the Physician was sent a copy of the Discharge summary for 2 of 5 (Pts. #14 and 16) discharged clinical records reviewed. Findings include: 1. Pt. #14 was admitted to home health services on 05/20/25 with the diagnosis of Atrioventricular Block, First Degree. The clinical record was reviewed on 07/02/25. The record included a discharge summary indicating Pt. #14 was discharged from the Agency on 06/18/25. The discharge summary lacked documentation that it was sent to the Physician. 2. Pt. #16 was admitted to home health services on 04/04/25 with the diagnosis of Urinary Tract Infection, Site not Specified. The clinical record was reviewed on 07/01/25. The record included a discharge summary indicating Pt. #16 was discharged from the Agency on 05/13/25. The discharge summary lacked documentation that it was sent to the Physician. 3. During an interview with E#2 (Director /Administrator), E#3 (Agency Supervisor/Nurse Manager), E#4 (Nursing Supervisor/Nurse Manager), E#5 (Therapy Supervisor) and E#6 (Office Manager) on 07/02/25 between 1:30 PM and 2:20 PM, E#2 (Director/Administrator) confirmed the above findings.