Every finding on record at Safeway Healthcare Services Inc

A recertification survey and a self-reported investigation #1003797 was conducted 07/07/2026 The census was: Licensed and Certified – 45 License and Home Health - 0 Personal Attendant Services – 221 The agency was in compliance with Home and Community Support Services Agencies with no deficiencies.

A recertification survey and a self-reported investigation #1003797 was conducted 07/07/2026. The census was: Licensed and Certified – 45 License and Home Health - 0 Personal Attendant Services – 221 Acronyms used: CMS – Center for Medicare and Medicaid Services IM – Internal Memorandum iQIES - Internet Quality Improvement and Evaluation System JCC- J Consulting Company M0090 – Official OASIS assessment form 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 record review and interviews, the agency failed to encode and electronically submit each completed OASIS assessment (a tool used by CMS to collect certain patient information) to the CMS system within 30 days of completing the assessment of the beneficiary for 215 OASIS assessments submitted during 07/06/2025 to 07/06/2026 for 215 patients. This failure meant insufficient care could not be identified by the agency or CMS subjecting patients to inadequate continuity of care. FINDINGS INCLUDE: Record review of the agency’s OASIS errors report in iQIES (a CMS data-based system for patient analysis of care trends) on 07/06/2026 which documented the agency had submitted 215 comprehensive assessments more than 30 days after the date of the assessment. The report listed 215 patient names as being affected by the late transmission of their comprehensive assessments from 07/06/2025 to 07/06/2026. In an interview with the Office Manager on 07/09/2026 3:30 PM, the surveyor inquired about the OASIS assessment transmission being late. The Office Manager stated she was responsible for the transmission entries and sending the assessments. The Office Manager stated there have been many “kicked back” causing the ultimate OASIS assessment error. The office manager stated most of the time she got the initial reports sent into CMS. She stated she was not sure what the error percentage was, but she knew she had to deal with a lot of “Re-Do’s”. The Office Manager stated that not getting the admissions turned into CMS on time can negatively impact on the clients, interfering with their services. In an interview with the Alternate Administrator on 02/12/2025 3:40 PM, it was revealed the Alternate Administrator was aware the OASIS assessment submissions being late due to the iQIES error reports that the Office Manager discussed at the agency meetings. The Alternate Administrator stated the ultimate responsibility for the OASIS admission reports being turned in, on time was the ultimate responsibility of the Administrator and Alternate Administrator. The Alternate Administrator stated it was in the State regulations and in the agency policy to encode the OASIS admissions within 30 days. The Alternate Administrator stated negative outcomes could include interruptions to client care. Record review of the agency’s policy dated 07/09/2026, Administrative Policy Manual, IM.9 Timeliness, JCC 063025 L&C Page 2 of 2, 17. Read in part …Encoding and transmission of OASIS data to CMS (Centers for Medicare and Medicaid) is performed at least monthly and prior to billing. The Oasis is required to be transmitted to CMS within 30 days of the date the assessment is completed (M0090).

A recertification inspection survey was conducted on 07/11/2023. The licensed and certified home health services census was 48. No deficiencies were cited.

A recertification inspection survey was conducted on 07/11/2023 with investigation of Intakes IQ95366 and IQ98368. The licensed and certified home health services census was 48. Abbreviations/Acronyms: Adm-Administrator Alt Adm -Alternate Administrator DON-Director of Nursing ADON-Alternate Director of Nursing PAS Sup-Personal Assistant Services Supervisor Registered Nurse (RN) Licensed Vocational Nurse (LVN) Physical Therapist (PT) Occupational Therapist (OT) EHR- Electronic Health Record POC- Plan of Care SOC- Start of Care HHA- Home Health Agency SN- Skilled Nursing CMS- Center for Medicare and Medicaid Services 485-Plan of Care form number OASIS -outcome and assessment information set ESRD- End Stage Renal Disease

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure that patients had the administrators name in order to receive complaints for three (Patients # 1, 2, and 3) of three patients who received a home visit. The failure caused the patients not to have the agency administrators’ name to receive complaints and could place the patients at risk for abuse, neglect and exploitation. Findings included: Review of the agency’s sample admission packet revealed that the packet had the agency’s business address and business phone number. The sample packet did not reveal that it included the Adm/ADON’s name. Patient # 1 Review of Patient # 1’s EHR revealed a POC with a SOC date of 01/14/2022 and certification period 07/08/2023 to 09/05/2023. The POC was signed by RN A on 07/07/2023 and contained an order for SN visits one time per week for nine weeks. During a home visit on 07/13/2023 at 12:00 noon, the surveyor reviewed and observed Patient # 1’s admission home folder. The home folder included the same information as the sample admission packet, which included the agency’s business address and business phone number. The folder did not include administrator’s name. The surveyor asked Patient # 1 if he knew the administrator’s name in order to voice complaints. Patient # 1 stated that he did not know the name of the Adm/ADON. Patient # 2 Review of Patient # 2’s EHR revealed a POC dated 06/15/2023 and signed by RN A for certification period 06/18/2023 to 08/16/2023. The POC contained an order for SN visits one time per week for nine weeks and hha visits two times per week for nine weeks. During a home visit on 07/13/2023 at 1:00 p.m., the surveyor reviewed and observed Patient # 2’s admission home folder. The home folder included the same information as the sample admission packet, which included the agency’s business address and business phone number. The folder did not include administrator’s name. The surveyor asked Patient # 2 if she knew the administrator’s name in order to voice complaints. Patient # 2 stated that she did not know the name of the Adm/ADON. Patient # 3 Review of Patient # 3’s EHR revealed a POC dated 05/11/2023 and signed by the Adm/ADON for certification period 05/11/2023 to 07/09/2023. The POC included an order for SN visits one time per week for one week, two times per week for eight weeks, PT to evaluate and treat. During a home visit on 07/13/2023 at 11:00 a.m., the surveyor reviewed and observed Patient # 3’s admission home folder. The home folder included the same information as the sample admission packet, which included the agency’s business address and business phone number. The folder did not include administrator’s name. The surveyor asked Patient # 3 if she knew the administrator’s name in order to voice complaints. Patient # 3 stated that she did not know the name of the Adm/ADON. During an interview with the Adm/ADON and DON/PAS Sup on 07/14/2023 at 3:21 p.m., the surveyor discussed the findings and asked why the agency had not given Patients # 1, 2, and 3 the administrator’s name in order to receive complaints. The Adm/ADON replied, “I did not know that it had to be there. I tell the nurses to write their name there.” The Adm/ADON also state that he was responsible for ensuring that the admission packet and home folder included the required information. During an interview on 07/14/2023 at 3:30 p.m. the Adm/ADON stated that the agency’s processes were based on agency policies and regulations. Review of agency policy titled “RI.1 Patient Bill of Rights and Responsibilities/Rights of the Elderly” revised 01/29/2019 read in part: “…Procedure…Notice of Rights...A. During the initial visit, in advance of furnishing care to the patient, legal representative…is provided the following information…2. Contact information for the Agency Administrator, including the administrator’s name, business address, and business phone number in order to receive complaints…”

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 record review and interview the agency failed to ensure that the individualized plan of care was reviewed and revised by the physician or allowed practitioner who was responsible for the home health plan of care and the HHA no less frequently than once every 60 days, beginning with the start of care date for one (Patient # 3) of two records reviewed in which the patient received a home visit and was receiving physical therapy. The failure could cause a decline the patient’s health status and mobility. Findings include: Clinical Record # 3: On 07/12/2023 review of Patient # 3’s EHR revealed a POC with a SOC date of 05/11/2023 and a certification period of 05/11/2023 to 07/09/2023. The POC was signed by the Adm/ADON and dated 05/11/2023. The POC included a primary diagnosis of Hereditary factor VIII deficiency (Is also known as Hemophilia A and is a hereditary bleeding disorder caused by a lack of blood clotting factor VIII. Without enough factor VIII, the blood cannot clot properly to control bleeding) and a secondary diagnosis of Chronic Obstructive pulmonary disease (Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems). The POC included an order for SN visits one time per week for one week, two times per week for eight weeks, PT to evaluate and treat. The POC for Patient # 3 listed the Adm/ADON as clinical manager. The record also included a PT evaluation dated 06/23/2023 and singed by PT A. The PT evaluation had start and end dates of 05/11/2023 to 07/09/2023 and included an order for PT visits one time per week for one week and two times per week for two weeks. Further review of Patient # 3’s EHR did not reveal an updated POC or PT evaluation. The record contained a task list for certification period 07/10/2023 to 09/07/2023. Review of the task list revealed a task for CMS 485 (POC) that was due 07/10/2024 and the “status” was listed as “Not due Yet.” During an interview on 07/12/2023 at 12:50 p.m. with the Adm/ADON the surveyor requested a home visit scheduled with Patient # 3. The Adm/ADON stated that “the RN has not done the recert (60-day recertification).” He also that that “we have five days to get it done.” At approximately 1:30 p.m. RN A stated that she could not do the recertification because she could not find Patient # 3. During a home visit and interview with Patient # 3 on 07/13/2023 at approximately 11:00 a.m., she stated that she had received a letter for authorized visits for PT, but PT A stated that he could not start yet. Patient # 3 stated that she was out of town in June 2023 but was back home by July 1, 2023. She stated that she needed PT so that her muscles “won’t lock up.” Review of Patient # 3’s EHR on 07/13/2023 did not reveal an updated POC or PT evaluation. Further review of the EHR revealed a patient communication note with a date of contact of 07/10/2023 and signed on 07/12/2023 by Intake Coordinator C. The communication note read in part: “Agency received a call from patient…Agency called [RN A] to infromed her patient was wondering what day she would be coming to get the process going again RN informed agency to tell her she would be there tomorrow 7/11/2023 in the morning for her recertification…” Continued review of the record revealed a patient communication note with a date of contact of 07/11/2023 and signed on 07/12/2023 by Intake Coordinator C. The communication note read in part: “Agency received a call from RN that patient was not opening the door like it was infromed to her that the RN would be going, agency then tried giving her a call before the nurse left her house agency called her multiple of times and the emergency contacted listed and no answer was made RN not able to do recertification on her and we will not have to ask another RN to go out so that the patient can continue with HH.” On 07/17/2023 the surveyor reviewed Patient # 3’s EHR and the record revealed a POC that signed by RN A and dated 07/08/2023. During an interview on 07/17/2023 at approximately 12:00 noon, the surveyor discussed the findings and asked why the POC for Patient # 3 was not updated no less that every 60 days (due no later than 07/09/2023). The Adm/ADON stated that RN A stated that she could not contact the patient. The surveyor also asked why Patient # 3’s record contained a POC that was dated 07/08/2023 (was not in the EHR on 07/12/2023). The Adm/ADON stated that he believed it (the date) was a mistake. During an interview on 07/14/2023 at 3:30 p.m. the Adm/ADON stated that the agency’s processes were based on agency policies and regulations. Review of agency policy titled, “TX.6 Plan of Care” revised 01/01/20 read in part: “Purpose[:] To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific needs according to state and federal regulations. Policy[:] A. Each patient will receive an individualized written plan of care, including any revisions or additions…d. The plan of care must be reviewed, revised and signed by the physician…who established and approved the plan of care…no less frequently than once every 60 days, beginning with the start of care date…I. The Clinical Manager will ensure the development, implementation, and updates of the individualized plan of care…” Review of agency policy titled Patient Reassessment/recertification… PE.4” revised 03/01/05 read in part: “…Policy…II. The recertification/Follow-up Comprehensive assessment which includes OASIS data set, will be updated and revised: A. During the last five days of the episode…”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to coordinate care with a physician, outpatient facility, and involve the patient in the coordination of care activities for one (Client # 1) of two clients with a diagnosis of kidney disease who received a home visit. The agency failed to coordinate with the primary physician and outpatient hemodialysis center patient specific care interventions for the hemodialysis access site care and treatment. The failure placed the client at risk to not have the necessary care and treatment by the agency’s SN staff. FINDINGS INCLUDED: Clinical Record # 1: Record review of the EHR for Client # 1 revealed a POC with a SOC date of 01/14/2022. The POC had a certification period 05/09/2023 thru 07/07/2023 and a primary diagnosis of Essential (primary) hypertension and a secondary diagnosis of End stage renal (kidney disease). The POC was signed by the RN A and dated 05/05/2023. The POC contained an order for SN visits one time per week for nine weeks. Client # 1’s POC read in part “…Medical Necessity…has ESRD on dialysis. The POC did not include a diagnosis for hemodialysis. The POC also did not include the location and type of the dialysis access site, an order for SN to assess site for infection or occlusion, or who was responsible for the care of the access site. The record did not include any documentation that indicated the agency had coordinated services for the care and treatment of the dialysis access site with the primary care physician and the outpatient dialysis center. Review of OASIS E dated 05/05/2023 read in part (page 16/21); “…Interventions[:] Does patient have IV access? [Yes] Type: CVC RT SC [Central Venus Catheter right Subclavian, is an indwelling device inserted into a large, central vein, like the subclavian vein]. Date of Insertion: 11/01/2022. Date of Last Dressing Change: 12/27/2022…” Review of POC dated 07/08/2023 and signed by RN A for treatment period 07/08/2023 to 09/05/2023 also did not include a diagnosis for hemodialysis, the location and type of the dialysis access site, an order for SN to assess site for infection or occlusion, or who was responsible for the care of the access site. The POC(s) for Client # 1 listed the Adm/ADON as clinical manager. Review of OASIS E dated 07/07/2023 documented “Is patient on dialysis-Yes-Right Chest-On hold” (on page 12/21). Review of SN visit notes (signed by LVN A) for certification period 05/09/2023 to 07/07/2023 did not reveal any documentation of assessment, teaching, or care of Patient # 1’s hemodialysis catheter site. During a home visit with Client # 1 and LVN A on 07/13/2023 at 12:00 noon, the surveyor observed a bandage to Client # 1’s right chest on the upper quadrant. The surveyor asked if that was the location of the access for dialysis. Client # 1 replied, “Yes.” He also stated that he received outpatient dialysis three times per week. The surveyor asked if the agency nurse provided any care or treatment to the site. Client # 1 stated that the agency nurse did not do anything with the site or any teaching about care of the site. Client # 1 also stated that the dressing was changed during dialysis treatment. During an interview on 07/17/2023 at 11:52 a.m., with the Adm/ADON and DON/PAS Sup, the surveyor asked who was responsible for documenting coordination of services with physician’s and outpatient facilities. The Adm/ADON stated that the agency had not designated a specific person. The surveyor discussed the findings and asked why the agency had not coordinated services for the care and treatment of Client # 1’s dialysis access site with the primary care physician and the outpatient dialysis center. The DON/PAS Sup replied, “I don’t remember why we didn’t.” She stated that she did not think the agency had “anything from the physician that says what to do.” The Adm/ADON stated that he did not think the agency needed a specific order, “unless it was invasive. I take responsibility for that.” During an interview on 07/14/2023 at 3:30 p.m. the Adm/ADON stated that the agency’s processes were based on agency policies and regulations. Review of agency policy titled, “Monitoring Client Care/Coordination of Care TX.8” revised 06/01/06 read in part: “Purpose[:] To ensure coordination of patient care/treatment…Policy…Agency will collaborate with other organizations providing services (i.e.…outpatient clinics…) physicians…to ensure appropriate coordination of care for the patient. Procedure…4. When other organizations are involved in the patient care, Agency staff members notify them of significant changes in the patient’s overall care. This communication is documented in the medical record. 5. Agency staff are expected to contact the agency to inform of patient needs and changes. This will be documented on a communication note and will serve as coordination of care.” Review of agency policy titled, “TX.6 Plan of Care” revised 01/01/20 read in part: “Purpose[:] To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific needs according to state and federal regulations. Policy[:] A. Each patient will receive an individualized written plan of care, including any revisions or additions…I. The Clinical Manager will ensure the development, implementation, and updates of the individualized plan of care…C. The individualized Plan of Care will specify care and services necessary to meet patient specific needs as identified in the comprehensive assessment…The POC will contain the following elements: 1. All pertinent diagnoses…14. Patient-specific interventions and education…” Review of National Institute of Diabetes and Digestive and Kidney Disease website https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis on 07/21/2023 revealed that “Hemodialysis is a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in your blood…[Hemodialysis] Catheter for temporary access-If your kidney disease has progressed quickly, or you have not had a vascular access placed before you need dialysis, you may need a venous catheter—a small, soft tube inserted into a vein in your neck, chest…—as a temporary access…Take care of your access-Your access is your lifeline. You will need to protect your access. Wash the area around your access with soap and warm water every day. Check the area for signs of infection, such as warmth or redness. When blood is flowing through your access and your access is working well, you can feel a vibration over the area. Let your dialysis center know if you can’t feel the vibration. Take care of your access-Your access is your lifeline. You will need to protect your access. Wash the area around your access with soap and warm water every day. Check the area for signs of infection, such as warmth or redness. When blood is flowing through your access and your access is working well, you can feel a vibration over the area...”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to make an onsite hha supervisory visit to the patient's home no less frequently than every 14 days for one (Patient # 2) of one patient record reviewed in which the patient received hha visits. The failure could place the patient’s health and safety at risk of the hha was not performing the assigned tasks safely, competently, and in accordance with the plan of care. Findings include: Clinical Record # 2: Review of Patient # 2’s EHR revealed a POC with a SOC date of 10/21/2022 and a certification period of 06/18/2023 to 08/16/2023. The POC was signed by RN A and dated 06/15/2023. The POC included a primary diagnosis of Gastrointestinal hemorrhage and a secondary diagnosis of type two diabetes with diabetic chronic kidney disease. The POC included an order for SN visits one time per week for nine weeks and hha visits two times per week for nine weeks. Patient # 2’s record also included a POC for the certification period of 04/19/2023 to 06/17/2023 with a primary diagnosis of open wound to left lesser toe and a secondary diagnosis of type two diabetes with diabetic chronic kidney disease. The POC was signed by RN A and dated 04/14/2023. The POC included an order for SN visits three times per week for nine weeks and hha visits two times per week for nine weeks. Continued review of the EHR for Patient # 2 did not reveal that an agency RN had conducted onsite hha supervisory visits no less frequently than every 14 days. Review of the SN visit notes did not reveal any hha onsite hha supervisory visits. During an interview with the Adm/ADON and DON/PAS Sup on 07/17/2023 at 12:00 noon, the surveyor discussed the findings and asked why the agency had not conducted the hha onsite supervisory visits. The DON/PAS Sup replied, “I think that’s the last portion of the OASIS itself. That’s how we do it, with every recert (every 60 days].” The surveyor discussed why the agency had not conducted the visits based on agency policy and regulations. The Adm/ADON stated that he thought the updated OASIS software was all that was needed. During an interview on 07/14/2023 at 3:30 p.m., the Adm/ADON stated that the agency’s processes were based on agency policies and regulations. Review of agency policy titled, “HR.11 Employee Supervision” revised 11/29/19 read in part: “Purpose[:] To ensure employee supervision is performed in accordance with applicable federal and state laws and regulations. To ensure the patient is receiving appropriate care, treatment, and services according to the Plan of Care. Policy…C. Agency will provide supervision of the following employees by qualified individuals: 1. Home Health Aide supervision will be provided…a. By…(Registered Nurse) who is familiar with the patient, the patient’s plan of care, and the written patient care instructions no less than every 14 days when skilled nursing…is performed in addition to home health aide services….”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that all entries in the patients’ clinical records were completed and appropriately authenticated, dated, timed with a primary author’s signature and title, who had reviewed and approved the entry, in two (Patients # 4 and 5) of four patient records reviewed for authentication whose certification period ended in July 2023. The failure could place the patient at risk of harm if care and treatment were not reviewed, approved, and authenticated by the primary author (an agency registered nurse). Findings included: Clinical Record # 4: Review of Patient # 4’s record revealed a POC for the certification period of 05/23/2023 to 07/21/2023 with a SOC date of 11/19/2021. The POC included a primary diagnosis cerebral infarction (also called a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it which can cause parts of the brain to die). The POC included an order for SN visits two times per week for nine weeks and for PT and OT to evaluate and treat. The POC was not signed, dated, timed, or titled by the primary author. Clinical Record # 5: Review of Patient # 5’s record revealed a POC for the certification period of 05/16/2023 to 07/14/2023 with a SOC date of 11/17/2022. The POC included a primary diagnosis of pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) back, buttock and hip, stage 2. The POC included an order for SN visits two times per week for nine weeks. The POC was not signed, dated, timed, or titled by the primary author. During an interview on 07/17/2023 at approximately 12:15 p.m., the surveyor discussed the findings and asked why the POC(s) for Clients # 4 and 5 had not been authenticated by an agency RN. The Adm/ADON and DON/PAS Sup reviewed the agency’s EHR and stated that the task was assigned to RN A. The Adm/ADON called RN A and asked why the POC(s) were not signed, [dated, timed, or titled]. The Adm/ADON stated that RN A stated that she did not know why the POC(s) were not [authenticated]. During an interview on 07/14/2023 at 3:30 p.m. the Adm/ADON stated that the agency’s processes were based on agency policies and regulations. Review of agency policy titled IM.8 Authorization and Authentication of Medical Record Entries” revised 04/17/19 read in part: “Purpose[:] To identify the authors of medical record entries…Policy[:] A. All entries are legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and title…of a primary author who had reviewed and approved the entry…”