Every finding on record at Silver Cross Home Health

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/11/25. 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 12/11/25. Standard level deficiencies were cited. Abbreviations: Pt./Pts. = Patient/Patients HHA = Home Health Aide SOC = Start of Care RN = Registered Nurse AM = Morning PM = Afternoon SN = Skilled Nursing PT = Physical Therapy OT = Occupational Therapy ST = Speech Therapy MSW = Medical Social Worker

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, the Agency failed to provide the Pt./patient's representative information regarding the Agency's transfer and discharge policies. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/08/25. The folder lacked documentation of the Agency’s policy for transfer and discharge. 2. The following home visits were conducted on 12/08/25 and 12/09/25: Pt. #1. SOC 12/05/25. Pt. #2. SOC 03/13/25. Pt. #3. SOC 11/25/25. Pt. #4. SOC 10/31/25. Pt. #5. SOC 11/28/25. Pt. #6. SOC 11/21/25. Pt. #7. SOC 11/13/25 During the home visits of Pts. #1, 2, 4, 5, and 6, the Pt. admission folder was observed, and lacked documentation of the Agency’s policy for transfer and discharge. During the home visits of Pts. #3 and 7, the Pt./patient’s caregiver was unable to locate the Pt. admission folder. 3. The following clinical records were reviewed between 12/08/25 and 12/10/25. The clinical records lacked documentation of the Agency’s policy of transfer and discharge. Pt. #1. SOC 12/05/25. Pt. #2. SOC 03/13/25. Pt. #3. SOC 11/25/25. Pt. #4. SOC 10/31/25. Pt. #5. SOC 11/28/25. Pt. #6. SOC 11/21/25. Pt. #7. SOC 11/13/25 Pt. #8. SOC 10/29/25. Pt. #9. SOC 11/20/25. Pt. #10. SOC 11/12/25. Pt. #11. SOC 10/31/25. Pt. #12. SOC 06/20/25. Pt. #13. SOC 04/22/25. Pt. #14. SOC 10/15/25. Pt. #15. SOC 06/20/25. Pt. #16. SOC 07/02/25. Pt. #17. SOC 09/18/25 4. During interviews on 12/10/25 at 9:15 AM and 2:35 PM with the Associate Vice-President, Clinical Services and the Director Home Health, both confirmed the Agency failed to provide the Pt./patient's representative information regarding the Agency's transfer and discharge policies. During an interview on 12/11/25 at 8:30 AM with the Director Home Health, the Director of Home Health confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of clinical record reviews, observation during home visits, and staff interviews, the Agency failed to ensure the Pt./patient’s representative was informed of the frequency of visits provided by each discipline. This was found in 12 of 17 (Pts. #1, 2, 3, 8, 4, 5, 6, 7, 13, 14, 15, and 17) clinical records reviewed. 5. Pt. # 4 was admitted to Home Health services on 10/31/25 with the diagnosis of Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN and PT. 6. Pt. # 5 was admitted to Home Health services on 11/28/25 with the diagnosis of Hypertensive and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 Unspecified Chronic Kidney. The clinical record was reviewed on 12/09/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN, PT, OT and HHA. 7. Pt. # 6 was admitted to Home Health services on 11/21/25 with the diagnosis of Encounter for Surgical Aftercare following Surgery on the Digestive System. The clinical record was reviewed on 12/09/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN, PT and OT. 8. Pt. #7 was admitted to Home Health services on 11/13/25 with the diagnosis of Unspecified Fracture of Upper End of Right Ulna. The clinical record was reviewed on 12/09/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN and PT. 9. Pt. #13 was admitted to Home Health services on 04/02/25 with the diagnosis of Abscess of Vulva. The clinical record was reviewed on 12/10/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN. 10. Pt. #14 was admitted to Home Health services on 10/15/25 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 12/10/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN, PT, OT, HHA and ST. 11. Pt. #15 was admitted to Home Health services on 06/20/25 with the diagnosis of Unspecified Fracture Lower End of Right Femur. The clinical record was reviewed on 12/10/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN, PT and OT. 12. Pt. #17 was admitted to Home Health services on 09/18/25 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 12/10/25. The record contained the consent form which included check marks next to the services to be provided but lacked documentation of visit frequencies for SN, PT and OT. 13. During interviews with the Director Home Health on 12/11/25 at 8:30 AM, 9:00 AM and 9:45 AM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to Home Health services on 12/05/25 with the diagnosis of, but not limited to, Epilepsy Unspecified Not Intractable without Status Epilepticus. The clinical record was reviewed on 12/08/25. The clinical record contained the consent form dated 12/05/25 which included a checkmark next to the services to be provided (SN and PT). The clinical record lacked the visit frequency for the SN and PT. A home visit was conducted on 12/08/25 with Employee #4. During the home visit, the patient’s admission folder was observed, and lacked the visit frequency for the SN and PT. 2. Pt. #2 was admitted to Home Health services on 03/13/25 with the diagnosis of, but not limited to, Laceration without Foreign Body Left Lower Leg Subsequent Encounter. The clinical record was reviewed on 12/08/25. The clinical record contained the consent form dated 03/13/25 which included a checkmark next to the services to be provided (SN and PT). The clinical record lacked a visit frequency for the SN and PT. A home visit was conducted on 12/09/25 with Employee #5. During the home visit, the patient’s admission folder was observed, and lacked a visit frequency for the SN and PT. 3. Pt. #3 was admitted to Home Health services on 11/25/25 with the diagnosis of, but not limited to, Unspecified Displaced Fracture of Second Cervical Vertebra Subsequent Encounter for Fracture with Routine Healing. The clinical record was reviewed on 12/09/25. The clinical record contained the consent form dated 11/25/25 which included a checkmark next to the services to be provided (SN and PT). The clinical record lacked a visit frequency for the SN and PT. A home visit was conducted on 12/09/25 with Employee #6. During the home visit, the patient’s admission folder was observed, and lacked a visit frequency for the SN and PT. 4. Pt. #8 was admitted to Home Health services on 10/29/25 with the diagnosis of, but not limited to, Other Speech/Language Deficits following Cerebral Infarction. The clinical record was reviewed on 12/08/25 and 12/09/25. The clinical record contained the consent form which included checkmarks next to the services (SN, PT, OT, ST, and HHA) to be provided. The clinical record lacked a visit frequency for the SN, PT, OT, ST, and HHA.

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 clinical record and staff interviews, for 2 of 5 (Pts. #15 and #16) closed records reviewed, the Agency failed to ensure that staff obtained Physician orders prior to providing procedure or treatment. Findings include: 1. Pt. #15 was admitted to Home Health Services on 06/20/25 with the diagnosis of Unspecified Fracture Lower End of Right Femur. The clinical record was reviewed on 12/10/25. The record included the documentation on Skilled Nurse visit notes “Patient seen (Physician) last week and he forgot to remove two staples from the incision on the right upper thigh that was covered by Steri-Strips. Per Patient’s request, RN removed staples…” The record lacked documentation of a physician order prior to performing the procedure. 2. Pt. #16 was admitted to Home Health services on 07/02/25 with the diagnosis of Infection and Inflammatory Reaction Due to Indwelling Urinary Catheter. The clinical record was reviewed on 12/10/25. The record included documentation on Skilled Nurse visit notes “ 07/29/25: Left Posterior Outer Buttocks/Skin Tear… Additional Note: Xeroform and gauze every other day…Dressing… Per Care Plan… 08/06/25: Left Posterior Outer Buttocks/Skin Tear…. Wound Cleansing and Dressing Change… Per Care Plan... Cleansed with soap and water… Application/Packing…other: Xeroform…” The record lacked documentation of a physician order prior to providing the wound treatment. 3. During an interview with the Associate Vice President Clinical Services (Home Health Administrator) and Director Home Health on 12/10/25 at 2:45 PM, the above findings were confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy review, and staff interviews, the Agency failed to assess the patient’s need for the Pneumonia vaccine. This was found in 16 of 17 (Pts. #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed. 12. Pt. # 6 was admitted to Home Health services on 11/21/25 with the diagnosis of Encounter for Surgical Aftercare following Surgery on the Digestive System. The clinical record was reviewed on 12/09/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment. 13. Pt. #14 was admitted to Home Health services on 10/15/25 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 12/10/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment. 14. Pt. #15 was admitted to Home Health services on 06/20/25 with the diagnosis of Unspecified Fracture Lower End of Right Femur. The clinical record was reviewed on 12/10/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment. 15. Pt. #16 was admitted to Home Health services on 07/02/25 with the diagnosis of Infection and Inflammatory Reaction Due to Indwelling Urinary Catheter. The clinical record was reviewed on 12/10/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment. 16. Pt. #17 was admitted to Home Health services on 09/18/25 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 12/10/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment. 17. The Agency Policy “Pneumococcal Vaccination (PPV) Home Health Patients (reviewed on 04/29/25)” was reviewed on 12/10/25 and required: “Policy: (Agency) will offer/arrange the pneumococcal vaccine (PPV) to all patients who meet immunization criteria and who cannot provide documentation of a previous vaccination. Given that there is no risk in re-vaccination, those who are unsure or do not know their vaccination status will be offered the vaccine. Administration Procedure: A. Each patient’s pneumococcal immunization status will be determined upon admission or soon afterwards and will be documented in the patient’s medical record. B. All patients without a documented history of immunization will be offered or arranged to receive the vaccine. D. Patients may refuse vaccination. Vaccination refusal should be documented by the Agency. 18. During interviews with the Administrator and Director Home Health on 12/10/25 at 2:30 PM and on 12/11/25 at 8:30 AM and 9:15 AM, it was stated the pneumonia status will be assessed on admission and documented in the clinical record. During the same interviews, the above findings were confirmed. 6. Pt. #4 was admitted to Home Health services on 10/31/25 with diagnosis of Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The record lacked Pneumococcal Pneumonia immunization assessment. 7. Pt. #5 was admitted to Home Health services on 11/28/25 with diagnosis of Hypertensive Heart and Chronic Kidney Disease With Heart Failure and Stage 1 Through Stage 4 Chronic Kidney Disease, or Unspecified Chronic Kidney Disease. The clinical record was reviewed on 12/09/25. The record lacked Pneumococcal Pneumonia immunization assessment. 8. Pt. #10 was admitted to Home Health services on 11/12/25 with diagnosis of Displaced Fracture of the Lateral End of the Right Clavicle. The clinical record was reviewed on 12/09/25. The record lacked Pneumococcal Pneumonia immunization assessment. 9. Pt. #11 was admitted to Home Health services on 10/31/25 with diagnosis of Other Intestinal Escherichia Coli Infections. The clinical record was reviewed on 12/11/25. The record lacked Pneumococcal Pneumonia immunization assessment. 10. Pt. #12 was admitted to Home Health services on 06/20/25 with diagnosis of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side. The clinical record was reviewed on 12/11/25. The record lacked Pneumococcal Pneumonia immunization assessment. 11. Pt. #13 was admitted to Home Health services on 06/20/25 with diagnosis of Abscess of Vulva. The clinical record was reviewed on 12/11/25. The record lacked Pneumococcal Pneumonia immunization assessment. Findings include: 1. Pt. #1 was admitted to Home Health services on 12/05/25 with the diagnosis of, but not limited to, Epilepsy Unspecified Not Intractable without Status Epilepticus. The clinical record was reviewed on 12/08/25. The clinical record lacked documentation to indicate whether the Pt. was offered, received, declined or contraindicated to receive the Pneumonia vaccine. 2. Pt. #2 was admitted to Home Health services on 03/13/25 with the diagnosis of, but not limited to, Laceration without Foreign Body Left Lower Leg Subsequent Encounter. The clinical record was reviewed on 12/08.25. The clinical record lacked documentation to indicate whether the Pt. was offered, received, declined or contraindicated to receive the Pneumonia vaccine. 3. Pt. #3 was admitted to Home Health services on 11/25/25 with the diagnosis of, but not limited to, Unspecified Displaced Fracture of Second Cervical Vertebra Subsequent Encounter for Fracture with Routine Healing. The clinical record was reviewed on 12/09/25. The clinical record lacked documentation to indicate whether the Pt. was offered, received, declined or contraindicated to receive the Pneumonia vaccine. 4. Pt. #8 was admitted to Home Health services on 10/29/25 with the diagnosis of, but not limited to, Other Speech/Language Deficits following Cerebral Infarction. The clinical record was reviewed on 12/10/25 and 12/09/25. The clinical record lacked documentation to indicate whether the Pt. was offered, received, declined or contraindicated to receive the Pneumonia vaccine. 5. Pt. #9 was admitted to Home Health services on 11/20/25 with the diagnosis of, but not limited to, Muscle Wasting and Atrophy Not Elsewhere Classified Site Unspecified. The clinical record was reviewed on 12/10/25. The clinical record lacked documentation to indicate whether the Pt. was offered, received, declined or contraindicated to receive the Pneumonia vaccine.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, the Agency failed to provide the Pt./patient's representative information regarding the Director Home Health (Clinical Manager). This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/09/25. The folder lacked the name of the Director Home Health (Clinical Manager). 2. The following home visits were conducted on 12/08/25 and 12/09/25: Pt. #1. SOC 12/05/25. Pt. #2. SOC 03/13/25. Pt. #3. SOC 11/25/25. Pt. #4. SOC 10/31/25. Pt. #5. SOC 11/28/25. Pt. #6. SOC 11/21/25. Pt. #7. SOC 11/13/25 During the home visits of Pts. #1, 2, 4, 5, and 6, the Pt. admission folder was observed, and lacked the name and contact information of the Director Home Health/Clinical Manager. During the home visits of Pts. #3 and 7, the Pt./patient’s caregiver was unable to locate the Pt. admission folder. 3. The following clinical records were reviewed between 12/08/25 and 12/10/25. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact information of the Director Home Health (Clinical Manager). Pt. #1. SOC 12/05/25. Pt. #2. SOC 03/13/25. Pt. #3. SOC 11/25/25. Pt. #4. SOC 10/31/25. Pt. #5. SOC 11/28/25. Pt. #6. SOC 11/21/25. Pt. #7. SOC 11/13/25 Pt. #8. SOC 10/29/25. Pt. #9. SOC 11/20/25. Pt. #10. SOC 11/12/25. Pt. #11. SOC 10/31/25. Pt. #12. SOC 06/20/25. Pt. #13. SOC 04/22/25. Pt. #14. SOC 10/15/25. Pt. #15. SOC 06/20/25. Pt. #16. SOC 07/02/25. Pt. #17. SOC 09/18/25 4. During interviews on 12/10/25 at 9:15 AM and 2:35 PM with the Associate Vice-President, Clinical Services and the Director Home Health, both confirmed the Agency failed to provide the Pt./patient's representative the name and contact information of the Director Home Health (Clinical Manager). During an interview on 12/11/25 at 8:30 AM with the Director Home Health, the Director of Home Health confirmed the above findings.