Every finding on record at Refined Home Health and Personal Care LLC

Based on a recertification survey conducted from March 9, 2026, through March 11, 2026, it was determined that the home health agency was not in compliance with the Conditions of Participation for Emergency Preparedness, as outlined in 42 Code of Federal Regulations 484.22 and 484.102, and a deficiency was cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the agency did not participate in a full-scale exercise that was community-based within the past two years. Findings include: On March 10, 2026 at 4:47 PM, the surveyor interviewed the agency’s assistant administrator and the acting administrator. The acting administrator stated that the agency did not participate in a full-scale, community-based exercise within the last two years. On March 11, 2026, surveyors completed a review of the agency's emergency preparedness documentation. There was no documented evidence of a full-scale community-based exercise in the last two years.

Based on a recertification survey conducted from March 9, 2026, through March 11, 2026, it was determined that the agency was not in compliance with the Conditions of Participation for Home Health Services, as outlined in 42 Code of Federal Regulations Part 484. A deficiency was cited in the area of 484.50 Patient Rights.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff did not report incidences or circumstances of neglect to other appropriate authorities in accordance with state law. Specifically, for 1 of 7 sample patients, agency staff did not report suspected neglect to the state survey agency as required by Utah state statute 26B-2-243(2)(a). (Patient identifier: 1.) Findings include: On October 17, 2025 an agency nurse completed an initial assessment of Patient 1 and documented that they had a surgical wound. On October 25, 2025, eight days after the nurse identified the wound, wound care orders for daily dressing changes to Patient 1’s surgical wound were initiated after the agency’s quality assurance nurse determined that orders had not been obtained. The agency identified the error on October 25, 2025 and immediately began an investigation, and notified adult protective services, but not the state survey agency, as required by state statute.

Based on a recertification survey conducted 10/31/22 through 11/3/22, it was determined that Charter Home Health of West Jordan was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited.

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 interview and record review, the home health agency failed to provide skilled professional services that met the needs of patients. Specifically, the agency failed to provide social work (SW) services for 1 of 7 sampled patients. (Patient identifier: 5) Findings include: Patient 5’s medical record was reviewed on 10/31/22. Patient 5 was admitted to the agency on 10/21/22, with a diagnosis of hemathrosis (bleeding in a joint). In an occupational therapy (OT) note dated 10/28/22, it was documented by the therapist that, “…(patient 5) stated some suicidal ideation. OT notified HH (home health) team re pt’s (patients) statements.” There was no further documentation regarding the patient speaking of suicide. When surveyors requested further information, the agency provided and email chain regarding patient 5’s statements. Review of the emails revealed the following: On Friday 10/28/22 at 12:59 PM, OT 1 emailed five members of the care team. The email stated, “I am a little concerned about this cute lady. She has some suicidal ideation. Please please please do not let her know that I shared this. I told her I needed to let the team know and she became very anxious and asked me not to. She takes lorazepam for anxiety but her doctor won’t prescribe it for her anymore. I asked her to speak with her doctor about possibly getting on a different anti-depressant and she’s going to see her doctor on Monday at 2:30.” At 1:14 PM, RN 1 replied, “I saw patient this morning. She was pleasant, seemed happy with a big smile on her face. I asked her about medications and concerns. She did not share that with me…[name], (Director of nursing) (DON) how do we act in this case? Do we need to get [name] (SW) involved?” At 2:19 PM, the DON replied, “Yes but lets follow up with her on Monday and see how the visit went, if he changed any meds, then we can send [name] (SW), im (sic) afraid she will be upset if we send [name] (SW) out first thing.” At 3:03 PM, the physical therapist (PT) replied, “…she has not shared that with me…I asked her to honestly speak to her doctor on Monday…” At 4:29 PM, RN 1 replied, “It sounds a good plan (sic)” At 4:37 PM, OT 1 replied, “She initially stated she wish she would just fall over and die. When I inquired further she said she’s had a good life and she’s ready to go…She said if she knew lorazepam and alcohol would do it, she would go that route. Let’s see what happens Monday…” There was no documented evidence that the SW had been notified of patient 5’s suicidal ideation. There was also no documentation of following up with patient 5 for her safety for over 48 hours. On 11/1/22 at 9:37 AM, an interview was conducted with OT 1. OT 1 stated patient 5 had been talking about suicide. OT 1 stated the patient had lost interest in things she had previously enjoyed. OT 1 stated she discussed with patient 5 a SW coming to speak with her. OT 1 stated patient 5 got upset about the idea of other people knowing, “So we waited.” OT 1 stated she did not follow up with patient 5 for her safety. On 11/1/22 at 9:45 AM, an interview was conducted with RN 1. RN 1 stated patient 5 had seemed okay during her visit on Friday 10/28/22. RN 1 stated that as a team they felt that a SW visit would have been, “Too aggressive of an approach”. RN 1 stated as far as she knew there had not been any follow up visits for patient 5 over the weekend. On 11/1/22 at 10:12 AM, an interview was conducted with the DON. The DON stated they as a team thought the patient was more upset about her medications and the patient had an appointment on Monday. The DON stated that patient 5 did not want anyone to know about her feelings. The DON stated they were not sure if patient 5’s statements about suicide were real or not. When asked if suicidal statements was something they should be sure about, the DON stated yes.