Every finding on record at Prime Home Health Services, LLC

This Statement of Deficiencies is the result of an on-site complaint investigation of complaint IQIES #2565892, conducted at Prime Home Health Services, LLC, located at 3125 Emmons Avenue, Brooklyn, NY 11235 from 08/19/2025 to 08/20/2025 as authorized by CMS (Centers of Medicare and Medicaid Services) to evaluate the Certified Home Health Agency's compliance with Federal Conditions of Participation (CoP): 0406 Patient Rights; (CoP) 0510: Comprehensive Assessment of Patients; (CoP) 0570: Care Planning, Coordination, Quality of Care; (CoP) 0750: Home Health Aide Services; (CoP) 0940: Organization and Administration of Services. The active census at the time of the survey was 2,878. The investigation consisted of a review of three (3) clinical records and four (4) personnel records. Additionally, the Certified Home Health Agency's Policy: Coordination of Patient Care and Services, complaints logs for June 2025 and July 2025, and Admission Packet were reviewed. The Administrator, Director of Patient Services, and Senior Director of Education and Quality Improvement were interviewed. Findings were reviewed at the exit conference on 08/20/2025. The Provider is considered to be in substantial compliance with the following Conditions of Participation: (CoP): 0406 Patient Rights (CoP) 0510: Comprehensive Assessment of Patients (CoP) 0570: Care Planning, Coordination, Quality of Care (CoP) 0750: Home Health Aide Services (CoP) 0940: Organization and Administration of Services. The complaint is substantiated. The following Standard deficiencies were identified as a result of the on-site complaint investigation: G- 0614 Visit Schedule G- 0808 Onsite Supervisory Visit Every 14 Days

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the agency failed to provide patients with a written visit schedule that is consistent with the patient's plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient #3). Failure to provide patients with a written visit schedule that is consistent with the patient's plan of care has the potential for negative patient outcomes. The finding is: 1. Patient #3 has a Start of Care Date of 06/24/2025, a discharge date of 07/18/2025, with diagnoses of Pressure Ulcer of Left Heel, Stage 3, Strain of Left Quadriceps Muscle, Fascia and Tendon, and Unspecified Fall documented on the Home Health Certification and Plan of Care with a Certification Period from 06/24/2025 to 08/22/2025. The Home Health Certification and Plan of Care with a Certification Period from 06/24/2025 to 08/22/2025 documents the following ordered services: 06/24/2025 - 07/13/2025 - SN 3 week 3 (Skilled Nurse three (3) times a week for three (3) weeks), 06/26/2025 - 07/13/2025 - PT 1 week 1; 2 week 2 (Physical Therapy one (1) times a week for one week, then two (2) times a week for two (2) weeks), 06/26/2025 - 07/13/2025 - Aide 2 week 1; 3 week 2 (Aide two (2) times a week for one (1) week, then three (3) times a week for two (2) weeks). There is no documented evidence of the patient being provided with a written home visit schedule of when the patient can expect visits from Skilled Nursing, Physical Therapy, and aide services based on the patient's plan of care. On 08/20/2025 at 12:55 PM, the Administrator was interviewed and stated, the Case Manager tells them verbally and they receive a 485 (Home Health Certification and Plan of Care) by mail.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to provide supervision of the Home Health Aide no less frequently than every 14 days. This was evident for one (1) of three (3) clinical records reviewed (Patient #3). Failure to supervise the Home Health Aide no less frequently than every 14 days has the potential for negative patient outcomes. The finding is: 1. Patient #3 has a Start of Care Date of 06/24/2025, a discharge date of 07/18/2025, with diagnoses of Pressure Ulcer of Left Heel, Stage 3, Strain of Left Quadriceps Muscle, Fascia and Tendon, and Unspecified Fall documented on the Home Health Certification and Plan of Care with a Certification Period from 06/24/2025 to 08/22/2025. The clinical record documents Home Health Aide services began on 06/27/2025 and the last day of Home Health Aide services was on 07/16/2025. The clinical record documents one Home Health Aide supervision on 07/16/2025, nineteen days after Home Health Aide Services started on 06/27/2025. There is no documented evidence of a Home Health Aide supervision being conducted no less frequently than every 14 days after Home Health Aide services started on 06/27/2025. On 08/20/2025 at 10:50 AM, the Administrator was interviewed and did not provide an explanation.

This Statement of Deficiencies is a result of an on-site investigation of complaint 62969 and a focused Infection Control related to Healthcare Worker COVID vaccinations, conducted at Prime Home Health Services, LLC., located at 3125 Emmons Avenue, Brooklyn, NY 11235 on 05/02/2022. The active patient census was 1155. The investigation consisted of a review of three (3) clinical records (identified as Patients #1, #2, and #3), three (3) personnel records (Employees #1, #2, and #3), the agency's complaint, accident/incident report and interviews with the Administrator, the Director of Compliance and Education, the Manager of Quality, and the Manager of Human Resource. Pre-survey activities consisted of review on 4/29/2022 of the agency's Health Commerce System account. Findings were reviewed at the exit conference. The allegation is Unsubstantiated due to lack of sufficient evidence. The following deficiencies are being cited as result of the survey: G- 0687 - COVID-19 Vaccination of Home Health Agency staff

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on a review of the policy and procedure, documentation of vaccination status, personnel record, and staff interviews, the governing authority failed to ensure development of policy and procedure that include the contingency plan for unvaccinated staff. Failure to ensure that a policy and procedure that include the contingency plan for unvaccinated staff has the potential for negative patient outcomes. The findings are: Employee #2 has a hire date of 9/22/2013. The Vaccination Status Log documents: Employee #2 with (Medical) exemption. On 05/02/2022 at 2:30pm, the Administrator and the Manager of Human Resource were interviewed and stated, “Employee #2 continues to provide patient care.” The agency’s policy and procedure lacks documented evidence of a contingency plan including mandatory routine COVID-19 testing in accordance with OSHA and CDC guidelines, physical distancing from co-workers and patients, re-assignment or modification of duties, etc., for staff who are not fully vaccinated for COVID-19, including staff with medical exemption. On 05/02/2022 at 4:00pm, the Administrator was interviewed and did not provide an explanation for the findings.