Every finding on record at Prn Medical Staffing, Inc.

Based upon the findings of an unannounced onsite Medicare recertification and state relicense survey completed on 4/3/25, PRN Home Health Services. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness

Based on the findings of an unannounced onsite home health agency Medicare recertification survey completed on 4/3/25, PRN Home Health Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of the survey, two (2) condition level deficiencies cited at: 484.55 Comprehensive Assessment of Patients, 484.75 Skilled Professional Services and eighteen (18) standard level deficiencies were cited. No immediate jeopardy situation was identified. The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to ensure the provision of care planning, coordination and quality of care, the provision of services by Skilled Professionals and the inability to organize, manage and administer its resources to attain and maintain the highest practicable functional capacity and provide optimal care.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on reviews of medical records and staff interviews the agency Clinical Manager failed to ensure that treatment or care was furnished by family member hired as agency staff as outline in the plan of care for four (4) of seven (7) active records reviewed. (MR #1, MR#2. MR#3, MR#7) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The physician ordered plan of care requires skilled nursing to be provided up to 12.5 hours a day x 5 days a week and 10 hours of skilled nursing a night seven nights a week. Nursing is to provide a Chest physiotherapy vest (CPT) (A device used to help loosen and clear mucus from the lungs) and cough assist treatments every 4 hours throughout the day and night, along with nebulizer treatments. On 3/20/25 & 3/24/25 there was no documentation that nebulizer treatments had been performed On 3/29/25 & 3/31/25 there was no documentation that nebulizer or cough assist treatments had been performed MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. The physician ordered plan of care requires skilled nursing to be provided 12 hours per night 7 nights per week. Skilled nursing is to administer medications and feeds via gastrostomy tube (G-tube) with a 5 ml flush after medication administration (medications are administered on this shift). The patient is to receive Calcium Carbonate and MiraLAX at night. There was no documentation of medications or flushes having been administered. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The physician ordered plan of care required skilled nursing to be provided for 40 hours per week. Skilled nursing is to provide G-tube (Gastrostomy tube a tube inserted through the abdomen into the stomach to provide nutrition, fluids, and medications) care twice a day and as needed with soap and water. From 2/28/25 through 4/1/25 there is no documentation of what was used to clean the G-tube MR#7 Start of Care 6/2/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The physician ordered plan of care required skilled nursing to be provided for 8 hours a night and 1 hour daily for 7 days a week. The patient has a Gastrostomy and J-tube (Jejunostomy tube is a feeding tube placed into the small intestines to deliver nutrition directly into the small bowel bypassing the stomach) and is to have gauze and Desitin applied to irritated sites. Documentation revealed on 3/4/25 the patient had her tubes removed. The Gastrostomy tube had closed and then reopened. The J tube had never closed and the draining from the tube was causing skin excoriation. On 3/21/25, 3/22/25, 3/23/25, 3/25/25 through 4/2/25 there was no documentation that Desitin was used on the patient’s irritated sites. Interview with the Clinical Manager on 4/2/25 at 11:00 AM confirmed the above findings

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on review of agency policies/procedures, medical records, agency staff interviews, it was determined that the agency failed to ensure a registered nurse completed a comprehensive assessment, included the patients current health, psychosocial, functional, and cognitive status reviewed all medications, included patient's primary caregiver and other available supports including their willingness and ability to provide care, availability and schedules, The patients representative if any and updated the comprehensive assessment the last 5 days of every 60 days. Findings include: Cross Reference: 484.55(b)(1) (Tag 520): Completion of the comprehensive assessment 484.55 (c) (Tag 528) The patients current health, psychosocial, functional, and cognitive status 484.55(c)(5) (Tag 536): Review of all medications the patient is currently using to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. 484.55(c) (6) (Tag 538) The patient's primary caregiver and other available supports including their willingness and ability to provide care, availability and schedules 484.55 (c) (7) (Tag 540) The patients representative if any 484.55(d)(1) (Tag 546) Update of the comprehensive assessment the last 5 days of every 60 days beginning with the start-of-care date The cumulative effect of these systematic problems resulted in the agency's inability to ensure the provision of quality healthcare to the patients. Based on reviews of policies and procedures, medical records, and interview with agency, the agency failed to completed a comprehensive assessment no later than 5 calendar days after the start of care or nine (9) of nine (9) skilled record reviewed. (MR #1 through MR#9) Review of policies and procedures on 4/3/25 at 10:30 AM states, MDS (minimum data set which is an assessment used in skilled nursing facilities) policy: “It is the policy of PRN home health that a comprehensive assessment of each client will be performed no less than 14 days after the date of the skilled admission…Standard of care: a comprehensive assessment of each client will be made using the uniform data set specified by the state and will describe the client’s capacity to perform daily life functions and significant impairments in functional capacity.” Assessment policy states, "PRN home health that all skilled clients will have assessments. Procedure: 1. On admission, quarterly and prn all skilled clients will have the following: A. Body assessment, B. Pain assessment, C. Pressure risk assessment, D. Fall assessment. Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no documentation that any comprehensive assessment updates were performed. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. There was no documentation that any initial comprehensive assessments were performed. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no documentation that any initial comprehensive assessments were performed. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no documentation that any initial comprehensive assessment were performed. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin damage. There was no documentation that any initial comprehensive assessments were performed. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no documentation that any initial comprehensive assessment were performed. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no documentation that any initial comprehensive assessment were performed. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no documentation that any initial comprehensive assessment were performed. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. no documentation that any initial comprehensive assessment were performed. Interview with the Clinical Manager on 4/2/25 at the time of the record reviews confirmed the above findings Based on reviews of medical records, and interview with agency staff, the agency failed to ensure a comprehensive assessment was conducted which accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR#9) Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin damage. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status Interview with the Clinical Manager on 4/2/25 at the time of the record reviews confirmed the above findings Based on a review of medical records (MR), and an interview with the agency staff, the agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for nine (9) of nine (9) clinical records reviewed, (MR#1 through MR#9). Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic Brain damage. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Interview with the Clinical Manager on 4/2/25 at the time of the record reviews confirmed the above findings Based on reviews of medical records, and interview with agency the agency failed to ensure the comprehensive assessment was conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR #9) Based on reviews of medical records, and interview with agency the agency failed to ensure the comprehensive assessment was conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR #9) Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin damage. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no comprehensive assessment conducted noting the patient's primary caregiver, if any, and other available supports, including their willingness and ability to provide care and availability and schedules. Interview with the Clinical Manager on 4/2/25 at the time of the record reviews confirmed the above findings Based on reviews of policies and procedures, medical records, and interview with agency the agency failed to ensure the comprehensive assessment included the patient's representative if any, for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR #9) Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The comprehensive assessment failed to include the patients representative, if any. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. The comprehensive assessment failed to include the patients representative, if any. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The comprehensive assessment failed to include the patients representative, if any. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. The comprehensive assessment failed to include the patients representative, if any. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic Brain damage. The comprehensive assessment failed to include the patients representative, if any. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. The comprehensive assessment failed to include the patients representative, if any. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The comprehensive assessment failed to include the patients representative, if any. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. The comprehensive assessment failed to include the patients representative, if any. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. The comprehensive assessment failed to include the patients representative, if any. Interview with the Clinical Manager on 4/2/25 confirmed the above findings

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on reviews of policies and procedures, medical records, and interview with Clinical Manager, the agency staff (family members) failed to complete a comprehensive assessment no later than 5 calendar days after the start of care or nine (9) of nine (9) skilled record reviewed. (MR #1 through MR#9) Findings include: Review of policies and procedures on 4/3/25 at 10:30 AM states, MDS (minimum data set which is an assessment used in skilled nursing facilities) policy: “It is the policy of PRN home health that a comprehensive assessment of each client will be performed no less than 14 days after the date of the skilled admission…Standard of care: a comprehensive assessment of each client will be made using the uniform data set specified by the state and will describe the client’s capacity to perform daily life functions and significant impairments in functional capacity.” Assessment policy states, "PRN home health that all skilled clients will have assessments. Procedure: 1. On admission, quarterly and prn all skilled clients will have the following: A. Body assessment, B. Pain assessment, C. Pressure risk assessment, D. Fall assessment. Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no documentation that any initial comprehensive assessment updates were performed. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. There was no documentation that any initial comprehensive assessments were performed. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no documentation that any initial comprehensive assessments were performed. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no documentation that any initial comprehensive assessment were performed. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin damage. There was no documentation that any initial comprehensive assessments were performed. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no documentation that any initial comprehensive assessments were performed. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no documentation that any initial comprehensive assessments were performed. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no documentation that any initial comprehensive assessments were performed. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. no documentation that any initial comprehensive assessments were performed. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM identified that all staff caring for the patients were family members and confirmed the above findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on reviews of medical records, and interview with agency staff (family members), the agency failed to ensure a comprehensive assessment was conducted which accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR#9) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin damage. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no comprehensive assessment conducted to accurately reflected the patient's status and included the patient's current health, psychosocial, functional, and cognitive status Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on a review of medical records (MR), and an interview with the agency staff (family members) , the agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for nine (9) of nine (9) clinical records reviewed, (MR#1 through MR#9). Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic Brain damage. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. Contained no documentation that medications were reviewed for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

The patient's representative (if any); CFR(s): 484.55(c)(7) The patient's representative (if any); This ELEMENT is not met as evidenced by: Based on reviews of policies and procedures, medical records, and interview with agency staff (family members) the agency failed to ensure a comprehensive assessment included the patient's representative if any, for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR #9) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The comprehensive assessment failed to include the patient's representative, if any. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. The comprehensive assessment failed to include the patient's representative, if any. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The comprehensive assessment failed to include the patient's representative, if any. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. The comprehensive assessment failed to include the patient's representative, if any. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic Brain damage. The comprehensive assessment failed to include the patient's representative, if any. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. The comprehensive assessment failed to include the patient's representative, if any. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The comprehensive assessment failed to include the patient's representative, if any. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. The comprehensive assessment failed to include the patient's representative, if any. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. The comprehensive assessment failed to include the patient's representative, if any. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on reviews of policies and procedures, medical records, and interview with agency staff (family members) the agency failed to ensure an update of the comprehensive assessment was completed within the last five (5) days of every sixty (60) days beginning with the start of care date for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR#9) Findings include: Review of policies and procedures on 4/3/25 at 10:30 AM states, MDS (minimum data set which is an assessment used in skilled nursing facilities) policy: “It is the policy of PRN home health that a comprehensive assessment of each client will be performed no less than 14 days after the date of the skilled admission…Standard of care: a comprehensive assessment of each client will be made using the uniform data set specified by the state and will describe the client’s capacity to perform daily life functions and significant impairments in functional capacity.” Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no documentation that any comprehensive assessment updates were performed. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. There was no documentation that any comprehensive assessment updates were performed. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no documentation that any comprehensive assessment updates were performed. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no documentation that any comprehensive assessment updates were performed. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brin daamange. There was no documentation that any comprehensive assessment updates were performed. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no documentation that any comprehensive assessment updates were performed. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no documentation that any comprehensive assessment updates were performed. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no documentation that any comprehensive assessment updates were performed. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no documentation that any comprehensive assessment updates were performed. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on review of medical records (MRs) and interview with agency staff (family members) it was determined the agency failed to send a discharge summary to the primary care practitioner or other health care professional with all necessary medical information pertaining to the patient's course of illness or treatment, post discharge goals of care, and treatment preferences, to the receiving health care practitioner to ensure the safe and effective transition of care for two (2) of two (2) discharge records reviewed. (MR#8 & MR#9) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. Patient discharged from agency on 1/8/25. There was no documentation provided that the Discharge Summary that was sent to the physician until 2/5/25 which did not contain all necessary medical information pertaining to the patient's course of illness or treatment, post discharge goals of care, and treatment preferences, to the receive health care practitioner to ensure the safe and effective transition of care MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. Patient discharged from agency on 8/10/24. There was no documentation provided that the Discharge Summary was sent to the physician until 9/4/24 which did not contain all necessary medical information pertaining to the patient's course of illness or treatment, post discharge goals of care, and treatment preferences, to the receiving health care practitioner to ensure the safe and effective transition of care Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

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 reviews of medical records and staff interviews the agency failed to ensure that treatment or care was furnished as ordered for four (4) of seven (7) active records reviewed. (MR #1, MR#2. MR#3, MR#7) Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The physician ordered plan of care requires skilled nursing to be provided up to 12.5 hours a day x 5 days a week and 10 hours of skilled nursing a night seven nights a week. Nursing is to provide a Chest physiotherapy vest (CPT) (A device used to help loosen and clear mucus from the lungs) and cough assist treatments every 4 hours throughout the day and night, along with nebulizer treatments. On 3/20/25 & 3/24/25 there was no documentation that nebulizer treatments had been performed On 3/29/25 & 3/31/25 there was no documentation that nebulizer or cough assist treatments had been performed MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. The physician ordered plan of care requires skilled nursing to be provided 12 hours per night 7 nights per week. Skilled nursing is to administer medications and feeds via gastrostomy tube (G-tube) with a 5 ml flush after medication administration overnight. The patient is to receive Calcium Carbonate and MiraLAX at night. From 3/11/25 through 4/1/25 there was no documentation that medications or G tube flushes had been conducted. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The physician ordered plan of care required skilled nursing to be provided for 40 hours per week. Skilled nursing is to provide G-tube care twice a day and as needed with soap and water. From 2/28/25 through 4/1/25 there is no documentation of what was used to clean the G-tube MR#7 Start of Care 6/2/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The physician ordered plan of care required skilled nursing to be provided for 8 hours a night and 1 hour daily for 7 days a week. The patient has a G and J-tube and is to have gauze and Desitin applied to irritated sites. Documentation revealed on 3/4/25 the patient had her tubes removed. The G tube had closed and then reopened. The J tube had never closed and the draining from the tube was causing skin excoriation. On 3/21/25, 3/22/25, 3/23/25, 3/25/25 through 4/2/25 there was no documentation that Desitin was used on the patient’s irritated sites. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on review of governing body meeting minutes, medical records (MR) and staff interview, the agency failed ensure the plan of care was reviewed by the physician no less frequently than once every 60 days for nine (9) of nine (9) medical records reviewed (MR#1 through MR#9) Findings include: Review of governing body meeting minutes on 4/1/25 st 10:30 AM, dated February 5, 2025, states the following were reviewed, "Plan of care will be updated every 60 days with the physician and the RN Case manager, and a summary sent to the physician for all skilled and primary insurance clients." Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brain damage. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no documentation of a 60 day summary provided to the physician to ensure the plan of care was reviewed by the physician no less frequently than once every 60 days. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on review of policies and procedures, quality assessment and performance improvement documentation and staff interview the agency failed to have at least one performance improvement project either in development, on-going or completed each calendar year for 2 (two) of 2 (two) calendar years reviewed (2024 and 2025) Findings include: Review of policies and procedures on 4/3/25 at approximately 1:00 PM failed to reveal any policies for quality assessment and performance improvement projects Review of quality assessment and performance improvement documentation on 4/1/25 at approximately 11:00 AM revealed the following: The agencies quality assessment and performance improvement plan failed to have any performance improvement projects in development, ongoing or completed each calendar year for 2024 or 2025 Interview with the owner at approximately 1:30 PM confirmed the above findings

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of policies and procedures, quality assessment and performance improvement documentation and staff interview the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program for 2 (two) of 2 (two) calendar years reviewed (2024 and 2025) Findings include: Review of policies and procedures on 4/3/25 at approximately 1:00 PM failed to reveal any policies for quality assessment and performance improvement pertaining to a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases Review of quality assessment and performance improvement documentation on 4/1/25 at approximately 11:00 AM revealed the following: The agencies quality assessment and performance improvement plan failed to have a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases completed each calendar year for 2024 or 2025 Interview with the owner at approximately 1:30 PM confirmed the above findings

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on review of policies/procedures, personnel file reviews and staff interview, it was determined that the agency failed to ensure competency of skilled nursing staff through documentation of competency skill assessments. Findings include: Cross references: 484.75(a) Services by Skilled Professionals: Tag 0702- failed to ensure that skilled nursing staff had pediatric competencies completed upon hire for six (6) out of six (6) files (PF # 1- # 6) 484.75(b) Responsibilities of Skilled Professionals: Tag 710-failed to ensure treatment or care was furnished as ordered for four (4) of seven (7) active records reviewed. (MR #1, MR#2. MR#3, MR#7) The cumulative effect of these systemic problems resulted in the Home Health Agency's inability to ensure the provision of services by Skilled Professionals and quality of care.

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 reviews of medical records and staff interviews the agency failed to ensure that services ordered by the physician were provided for four (4) of seven (7) active records reviewed. (MR #1, MR#2. MR#3, MR#7) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The physician ordered plan of care requires skilled nursing to be provided up to 12.5 hours a day x 5 days a week and 10 hours of skilled nursing a night seven nights a week. Nursing is to provide a Chest physiotherapy vest (CPT) (A device used to help loosen and clear mucus from the lungs) and cough assist treatments every 4 hours throughout the day and night, along with nebulizer treatments. On 3/20/25 & 3/24/25 there was no documentation that nebulizer treatments had been performed On 3/29/25 & 3/31/25 there was no documentation that nebulizer or cough assist treatments had been performed MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. The physician ordered plan of care requires skilled nursing to be provided 12 hours per night 7 nights per week. Skilled nursing is to administer medications and feeds via gastrostomy tube (G-tube) with a 5 ml flush after medication administration overnight. The patient is to receive Calcium Carbonate and MiraLAX at night. From 3/11/25 through 4/1/25 there was no documentation that medications or G tube flushes had been conducted. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The physician ordered plan of care required skilled nursing to be provided for 40 hours per week. Skilled nursing is to provide G-tube care twice a day and as needed with soap and water. From 2/28/25 through 4/1/25 there is no documentation of what was used to clean the G-tube MR#7 Start of Care 6/2/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The physician ordered plan of care required skilled nursing to be provided for 8 hours a night and 1 hour daily for 7 days a week. The patient has a G and J-tube and is to have gauze and Desitin applied to irritated sites. Documentation revealed on 3/4/25 the patient had her tubes removed. The G tube had closed and then reopened. The J tube had never closed and the draining from the tube was causing skin excoriation. On 3/21/25, 3/22/25, 3/23/25, 3/25/25 through 4/2/25 there was no documentation that Desitin was used on the patient’s irritated sites. Interview with the Clinical Manager on 4/2/25 at approximately 11:00 AM confirmed the above findings

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on review of agency policy, personnel records (PRs) and staff interview it was determined the agency failed to ensure 12 hours of in-service training had been completed during each 12 month period for three (3) of three (3) home health aide files reviewed that have been employed with the agency longer than one year. PRs reviewed. (PR# 7, PR #9 and PR# 10) Findings include: Review of policies and procedures on 4/3/25 at approximately 1:00 PM failed to reveal any policies regarding home health aide in-service training Review of PRs conducted on 4/1/25 at 12:00 PM revealed the following: PR#7, Date of hire 9/6/19: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. PR#9, Date of hire 8/23/22: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. PR#10, Date of hire 2/17/17: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. Interview with the office manager 0n 4/3/25 at approximately 1:30 PM confirmed the above findings

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on review of agency policy, personnel records (PRs) and staff interview it was determined the agency failed to ensure documentation of 12 hours of in-service training had been completed during each 12 month period for three (3) of three (3) home health aide files reviewed that have been employed with the agency longer than one year. PRs reviewed. (PR# 7, PR #9 and PR# 10) Findings include: Review of policies and procedures on 4/3/25 at approximately 1:00 PM failed to reveal any policies regarding home health aide in-service training Review of PRs conducted on 4/1/25 at 12:00 PM revealed the following: PR#7, Date of hire 9/6/19: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. PR#9, Date of hire 8/23/22: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. PR#10, Date of hire 2/17/17: There was no documentation in the personnel file which provided evidence the HHA completed 12 hours of in-service training in 2023 or 2024. Interview with the office manager on 4/3/25 at approximately 1:30 PM confirmed the above findings

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of policies/procedures, quality assurance/ performance improvement (QAPI) documentation, and interview with the agency owner the governing body failed to ensure the establishment of policies specific to the patient population serviced and in line with current practices; failed to have written policies requiring an overall evaluation of the agency's total program at least once a year, failed to have the group of professional personnel meet at least annually to advise the agency on professional issues, participate in the evaluation of the agency's program and assist the agency in maintaining liaison with other health care providers in the community. Review of policies and procedures on 4/3/25 at approximately 1:00 PM failed to reveal any policies for quality assessment and performance improvement pertaining to a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases and failed to have written policies requiring an overall evaluation of the agency's total program at least once a year, failed to have the group of professional personnel meet at least annually to advise the agency on professional issues, participate in the evaluation of the agency's program and assist the agency in maintaining liaison with other health care providers in the community Review of quality assessment and performance improvement documentation on 4/1/25 at approximately 11:00 AM revealed the following: The agencies quality assessment and performance improvement plan failed to have a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases completed each calendar year for 2024 or 2025 Interview with the owner at the time of the documentation review confirmed the above findings

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on reviews of medical records and staff interviews the agency failed to implement the plan of care for four (4) of seven (7) active records reviewed. (MR #1, MR#2. MR#3, MR#7) Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. The physician ordered plan of care requires skilled nursing to be provided up to 12.5 hours a day x 5 days a week and 10 hours of skilled nursing a night seven nights a week. Nursing is to provide a Chest physiotherapy vest (CPT) (A device used to help loosen and clear mucus from the lungs) and cough assist treatments every 4 hours throughout the day and night, along with nebulizer treatments. The plan of care was not implemented on 3/20/25 & 3/24/25 there was no documentation that nebulizer treatments had been performed The plan of care was not implemented on 3/29/25 & 3/31/25 there was no documentation that nebulizer or cough assist treatments had been performed MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebral palsy. The physician ordered plan of care requires skilled nursing to be provided 12 hours per night 7 nights per week. Skilled nursing is to administer medications and feeds via gastrostomy tube (G-tube) with a 5 ml flush after medication administration overnight. The patient is to receive Calcium Carbonate and MiraLAX at night and the G-tube to be monitored for redness and infection. The plan of care was not implemented From 3/11/25 through 4/1/25 there was no documentation that medications or G tube flushes had been conducted. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. The physician ordered plan of care required skilled nursing to be provided for 40 hours per week. Skilled nursing is to provide G-tube care twice a day and as needed with soap and water. The plan of care was not implemented From 2/28/25 through 4/1/25 there is no documentation of what was used to clean the G-tube MR#7 Start of Care 6/2/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. The physician ordered plan of care required skilled nursing to be provided for 8 hours a night and 1 hour daily for 7 days a week. The patient has a G and J-tube and is to have gauze and Desitin applied to irritated sites. Documentation revealed on 3/4/25 the patient had her tubes removed. The G tube had closed and then reopened. The J tube had never closed and the draining from the tube was causing skin excoriation. The plan of care was not implemented on 3/21/25, 3/22/25, 3/23/25, 3/25/25 through 4/2/25 there was no documentation that Desitin was used on the patient’s irritated sites. Interview with the Clinical Manager on 4/2/25 at approximately 11:30 PM confirmed the above findings

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on reviews of policies and procedures, medical records, and staff interview, the agency failed to ensure the patient had a current comprehensive assessment documented for nine (9) of nine (9) skilled record reviewed. (MR #1 through MR #9) Review of policies and procedures on 4/3/25 at 10:30 AM states, MDS (minimum data set which is an assessment used in skilled nursing facilities) policy: “It is the policy of PRN home health that a comprehensive assessment of each client will be performed no less than 14 days after the date of the skilled admission…Standard of care: a comprehensive assessment of each client will be made using the uniform data set specified by the state and will describe the client’s capacity to perform daily life functions and significant impairments in functional capacity.” Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#1 Start of Care 2/1/18, certification period 3/5/25-5/3/25. Primary diagnosis: Other reduction deformities. There was no documentation that a current comprehensive assessment has been performed. MR#2 Start of Care 8/28/17, certification period 3/11/25-5/9/25. Primary diagnosis: Spastic diplegic cerebal palsey. There was no documentation that a current comprehensive assessment has been performed. MR#3 Start of Care 6/12/16, certification period 2/28/25-4/28/25. Primary diagnosis: Hypoplastic Left heart syndrome. There was no documentation that a current comprehensive assessment has been performed. MR#4 Start of Care 11/27/17, certification period 3/22/25-5/20/25. Primary diagnosis: Other specified congenital abnormalities. There was no documentation that a current comprehensive assessment has been performed. MR#5 Start of Care 5/20/20, certification period 3/2/25-4/30/25. Primary diagnosis Anoxic brain damage. There was no documentation that a current comprehensive assessment has been performed. MR#6 Start of Care 11/24/23, certification period 3/18/25-5/16/25. Primary diagnosis: Lennox-Gastaut syndrome. There was no documentation that a current comprehensive assessment has been performed. MR#7 Start of Care 6/12/16, certification period 3/21/25-5/19/25. Primary diagnosis: Gastroparesis. There was no documentation that a current comprehensive assessment has been performed. MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. There was no documentation that a current comprehensive assessment has been performed. MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. There was no documentation that a current comprehensive assessment has been performed. Interview with the Clinical Manager on 4/2/25 at approximately 11:30 PM confirmed the above findings

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 review of medical records (MRs) and interview with agency staff it was determined agency failed to send a discharge summary 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 home health agency (HHA) within five (5) business days of the date of the discharge from the responsible physician two (2) of two (2) discharge records reviewed. (MR#8 & MR#9) Findings include: Review of medical records on 4/2/25 PM at approximately 11:00 AM revealed: MR#8 Start of Care 8/1/24, certification period 12/8/24-2/5/25. Primary diagnosis: Hereditary spastic paraplegia. Patient discharged from agency on 1/8/25. Documentation provided showed the Discharge Summary was not sent to the physician until 2/5/25. (28 days total, 19 business days) MR#9 Start of Care 7/6/24, certification period 7/1/24-8/29/24. Primary diagnosis: Genetic susceptibility. Patient discharged from agency on 8/10/24. Documentation provided showed the Discharge Summary was not sent to the physician until 9/4/24. (25 days total, 16 business days) Interview with the Clinical Manager on 4/2/25 at approximately 11:30 PM confirmed the above findings

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted April 12, 2022 through April 15, 2022, PRN Home Health Services, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite home health agency Medicare recertification survey conducted April 12, 2022 through April 15, 2022, PRN Home Health Services, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on review of policies and procedures, Medical records(MR) and interviews with agency staff (EMP), it was determined that the agency failed to ensure discharge communication and discharge summary in one (1) of seven (7) medical records reviewed. (MR # 6) Findings include: Review of Review of PRN Home Health Services Discharge from Skilled Care Policy and Procedure on 4/15/22 at approximately 11:10 AM revealed: Policy statement: PRN Home Health Services recognizes the formal discharge process from skilled care includes discharge due to meeting goals, transfer to another service/agency, or death. In the event of discharge, the following will occur within five (5) days: Order will be sent to the ordering physician with the client's name, discharge as of a certain date, and reason for discharge. A letter will be sent to the client or responsible party listing discharge date, reason for discharge and the name and phone number of the referring doctor for follow-up. Documentation will occur in the electronic medical record stating date of discharge, reason for discharge and any follow-up instructions. Reviews of medical records conducted on 4/12/22 at approximately 12:00 PM revealed the following: Medical record(MR) #6; Start of care(SOC) 7/9/21: certification period: 7/9/21-8/30/21: No documentation noted of skilled nurse discharge summary. No documentation that client's mother or physician were notified of discharge. Agency Administrator stated on 4/15/22 at approximately 9:30 AM: "We never did an official discharge on him because his mom stated that they started with another agency and she also placed him back in daycare because our staff member was unreliable and mom couldn't afford to lose her job, if we needed to do something different please teach us." An interview with the agency administrator conducted on 4/15/22 at approximately 11:30 AM confirmed the above findings. Reviews of medical records conducted on 4/12/22 at approximately 12:00 PM revealed the following: Medical record(MR) #6; Start of care(SOC) 7/9/21: certification period: 7/9/21-8/30/21: No documentation noted of skilled nurse discharge summary. No documentation that client's mother or physician were notified of discharge. Agency Administrator stated on 4/15/22 at approximately 9:30 AM: "We never did an official discharge on him because his mom stated that they started with another agency and she also placed him back in daycare because our staff member was unreliable and mom couldn't afford to lose her job, if we needed to do something different please teach us."