Every finding on record at Prodigy Home Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/15/25. 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 08/15/25. Standard level deficiencies cited. Abbreviations: # = Number Pt. = Patient RN = Registered Nurse OASIS = Outcome and Assessment Information Set .

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Agency’s Error Summary report and Staff interview, it was determined for 37 of 400 reports submitted in the last 12 months, the Agency failed to submit reports within 30 days of completing the assessment. Finding include: 1. The Agency’s Error Summary report for 08/01/24 thru 07/31/25, was reviewed on 08/15/25 at 12:00 PM. The report included an error code for late submissions. 9.25% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 08/15/25 at 12:15 PM.

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 review of clinical records, and staff interview, for 1 of 1 (Pt. #3) clinical records reviewed with Aide services, the Agency failed to ensure the RN conducted Aide supervision onsite every 14 days. Findings include: 1. Pt. #3 was admitted to Home Health Services on 11/11/24 with the diagnosis of Urinary Tract Infection, Site not specified. The clinical record was reviewed on 08/12/25. The clinical record included a plan of care dated 07/09/25, that required the Aide services 1 time a week for 9 weeks. On 08/13/25 at 12:15 PM, during the interview with the Agency Supervisor, it was stated the Aide supervisory visits on 07/19/25 and 07/31/25 were conducted by telephone. The last RN onsite-supervisory visit was conducted on 07/07/25 (recertification). The RN failed to conduct an onsite-supervisory visits in the patient’s residence every 14 days. 2 . The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 08/14/25 between 1:00 PM and 1:30 PM.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan, review of personnel files, policy review and staff interview, it was determined the Agency failed to provide Emergency Preparedness staff training. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 5/4/22 at 10:30 AM. The Plan lacked documentation the Agency conducted staff training upon orientation, and for the years 2020 and 2021. 2. The binders titled “Clinical In-services” and “HHA In-services” were reviewed on 5/4/22 at 11:00 AM. The in-service binders lacked documentation of any Emergency Preparedness staff training for the years 2020 and 2021. 3. The personnel files of employees were reviewed on 5/4/22 beginning at 11:50 AM: Staff #1. Date of Hire 2/5/18. Staff #2. Date of Hire 10/1/20. Staff #3. Date of Hire 3/11/19. Staff #4. Date of Hire 4/25/11. Staff #5. Date of Hire 10/30/15. Staff #6. Date of Hire 6/1/21. The personnel files lacked documentation the Agency provided any Emergency Preparedness staff training during orientation and for the years 2020 and 2021. 4. The Agency policy titled "Emergency Management Plan" was reviewed on 5/4/22 at 11:30 AM. The policy required: “ Orientation and Education Program for Those who participate in implementing the plan: Personnel will attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency…” 5. During an interview with the Administrator on 5/4/22 at 11:45 AM, the Administrator confirmed the Agency failed to provide Emergency Preparedness staff training during orientation and for the years 2020 and 2021.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC = Start of care Pt. = Patient AM = Morning PM = Afternoon RN = Registered Nurse HHA= Home Health Aide

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that written Pt. care instructions provided to the HHA were based on Pt. care needs. This was found in 2 of 2 (Pt. #1 and #2) clinical records reviewed, wherein the Pt. received HHA services. Findings include: 1. Pt. #1. SOC 3/19/22. Principal Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/3/22 at 10:30 AM. The record contained a document “HHA Care Plan” completed by the RN on 3/22/22. The Plan required the HHA to provide a bath as needed but lacked to specify the type of bath based on Pt. needs. Pt. #1’s HHA notes dated 4/16/22, 4/23/22 and 4/23/22 also lacked to specify the type of bath that was provided by the HHA to Pt. #1. 2. Pt. #2. SOC 3/13/22. Principal Diagnosis: Bilateral Primary Osteoarthritis of Knee. A home visit was conducted with the HHA on 5/2/22 at 3:30 PM. Pt. #2 stated that a bed bath has been provided by the HHA since admission because Pt. #2 has been bed bound since March 2022. The clinical record was reviewed on 5/3/22 at 11:52 AM. The record contained a document “HHA Care Plan” completed by the RN on 3/13/22. The Plan required the HHA to provide a bath, but lacked to specify the type of bath based on Pt. needs, and, also, lacked the frequency of when the services should be provided. Pt #2’s HHA notes dated 3/14/22, 3/18/22, 3/21/22, 3/25/22, 3/28/22, 4/1/22, 4/4/22, 4/8/22, 4/11/22, 4/14/22, 4/18/22, 4/21/22, 4/25/22, 4/28/22 and 5/2/22 also lacked to specify the type of bath that was provided to Pt. #1. 3. During an interview with the Administrator and Director of Nursing on 5/4/22 at 2:30 PM, the Director of Nursing stated the type of baths and frequencies are determined based on the assessment of the RN during the SOC; the type of bath and the frequencies for the services should be specified based on those assessments. During the same interview, both confirmed the above findings.