Every finding on record at Takecare Insurance Company, Inc.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of The Centers For Medicaid and Medicare Services (CMS). An unannounced on-site recertification survey conducted at the above named Home Health Agency (HHA) facility from 06/08/26 through 06/10/26 resulted in a finding of substantial compliance respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of The Centers For Medicaid and Medicare Services (CMS). An unannounced on-site recertification survey conducted at the abovenamed Home Health Agency (HHA) facility from 06/08/26 through 06/10/26 resulted in compliance with Condition(s) of Participation respective to applicable CoP under 42 CFR 484 Subparts A through C and the following standard-level deficiencies listed below.

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 policy review, observation, record review, and interview, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for two of ten sampled patients (Patient (P) P3 and P4) reviewed for medication reconciliation. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the Agency's policy titled, "Plan of Care – CMS (Centers for Medicare and Medicaid) #485 Physicians Orders Care Plan" read, "Care and services provided will be provided according to physicians orders. Orders and current and updated." 1. Observation during a homecare visit performed by Registered Nurse (RN) 2 on 06/08/26 at 1:00 PM revealed that P4's "Medication List," found in P4's Electronic Medical Record (EMR), did not accurately reflect the medications being administered to the patient in her home. Oxygen currently being administered to P4 at one to two liters per nasal cannula was not on the Agency's EMR and fluticasone (a nasal spray) one squirt in each nostril, which was indicated on the Agency's current medication list in the EMR had been discontinued on 05/12/26 and was no longer being administered to P4. During an interview on 06/10/26 at 1:30 PM, P4's family member/caregiver confirmed P4 was receiving oxygen one to two liters continuously via his/her nasal cannula and confirmed P4's Fluticasone had been discontinued on 05/12/26. 2. Review of P3's "Medication List" found in the EMR revealed documentation P3 had Clonidine 0.1 milligram (MG) as an ordered medication. There was no documented evidence P3 was taking Eliquis (a medication used to prevent blood clots) 2.5 MG twice daily. During an observation and interview on 06/09/26 at 9:30 AM while conducting a home visit, P3's medications were reviewed. It was noted P3 had Eliquis 2.5 MG twice daily in his/her medications with a prescribed date of March 2026 and there was no Clonidine. P3 confirmed he/she was currently taking the Eliquis and no longer taking the Clonidine. During an interview on 06/10/26 at 11:15 AM, the Nurse Manager confirmed the patients were receiving routine skilled nursing visits and indicated that medications were expected to be reconciled by the nurse at every visit. He/she stated her expectation was the medications being administered to patients in their homes should match the Agency's medication order set.

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 policy review, record review, and interview, the Home Health Agency (HHA) failed to ensure Physicians Orders were reviewed and signed/validated timely for three of ten sampled patients (Patient (P) P3, P6 and P8). This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the Agency's undated policy, "Plan of Care – CMS (Centers for Medicare and Medicaid) #485 Physicians Orders Care Plan" read, "Care and services provided will be provided according to physicians orders. Orders and current and updated;" and "Physician services will be provided by a licensed Doctor of Medicine, Osteopathy or Podiatry and include: -Submitting signed orders for Plan of Care and changes in accordance with required time frames." 1. Record review of P3's "Plan of Care – Initial CMS 485," (initial certification orders patient's following 60 days of care), dated 02/20/26 and found in P3's Electronic Medical Record (EMR), revealed the orders were not reviewed/validated and signed by the patient's physician until 04/29/26 (more than two months after P3 began receiving care by the Agency). 2. Record review of P6's "Plan of Care – Initial CMS 485," dated 04/03/26 and found in P6's EMR, revealed the orders were still not reviewed/validated and signed by the patient's physician as of 06/10/26 (more than two months after P6 began receiving care by the Agency). 3. Record review of P8's "Plan of Care – Initial CMS 485," dated 01/28/26 and found in P3's EMR, revealed the orders were not reviewed/validated and signed by the patient's physician until 04/08/26 (more than two months after P8 began receiving care by the Agency). During an interview on 06/10/26 at 11:15 AM, the Nurse Manager and Administrator confirmed the agency had been having a difficult time tracking physician's down to have them review and sign patient care orders for the initiation and recertification of patient care. The Nurse Manager orders were expected to be reviewed and signed within 30 days of the initiation of the orders.

The following reflects the finding of a Federal recertification survey conducted by federal surveyors on 9/15-23/2022. The agency was found to be in compliance with the requirements.

The following reflects the findings of Federal Surveyors who conducted a Federal Recertification survey on 9/15/22 - 9/23/22. There were 382 unduplicated admissions in the previous 12 months. The sample size was 10 and included four home visits and six record reviews.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: The agency did not assure that the individualized plan of care included functional limitation; nutritional requirements or patient specific interventions or education related to the patients swallowing difficulty, puree diet for one of 10 patients (Pt 4). This deficient practice had the potential for the patient to experience choking while eating. Findings: Patient 4 was 86 years old with diagnoses including but not limited to lung cancer, recent hospitalization for pneumonia caused by COVID-19, and weakness. The diagnoses listed on the Plan of Care which also served as the physician’s order did not include dysphagia. This diagnosis was on the list of diagnoses from the hospital. The POC included orders for puree diet and aspiration precautions (how to position a patient during meals, immediately after meals and during rest to prevent choking). During observation and interviews during a home visit made on 9/20/2022 with a Medical Social Worker (MSW), the MSW offered to order meals to be delivered to the home so that the caregiver (cg) would have the food the patient needed. The MSW said she/he would order a soft diet. The cg stated the patient had recently had difficulty swallowing and would choke when he/she ate, so the cg mashed the patient’s food, “like mashed potatoes.” MSW asked what food the cg was making for the patient that day, the cg stated she/he was making various food including a special cultural soup. The surveyor asked what was in the soup and the cg stated there was soft vegetables and rice. When asked how he/she prepared the soup so that the patient wouldn’t choke, the cg stated she/he did not mash the soup because the vegetables were soft and the rice was small. She/he stated the rest of the meal was mashed like mashed potatoes. When asked if anyone from the Agency had instructed him/her how to make puree food, he/she stated, “No.” When asked if anyone from the Agency had instructed him/her how the patient should be positioned while eating or after eating, the cg stated, “No.” Informed the cg to not give the patient anything to eat until the Agency spoke to him/her. The MSW stated he/she would find out what diet the patient should be on before ordering the delivered meals. When asked if he/she usually checked the diet orders prior to his/her visits, the answer was no. The surveyor then immediately called the Agency and spoke with the Director of Patient Care Services (DPCS) and the Administrator (Admin). The DPCS contacted the case manager (CM – who was a licensed nurse) who admitted the patient and conducted the skilled nursing (SN) visits. The SN stated he/she did instruct the cg about aspiration precautions; however, had not discussed how to prepare puree food. The SN then immediately called the cg and instructed how to prepare puree meals, and found out that the family did not have a blender, so the agency bought a blender and delivered it to the family later that day. Review of the admission assessment and POC dated 9/14/2022 read in pertinent part as follows: “…Functional limitation: ambulation, bowel and bladder incontinence, hearing, endurance, other [difficulty breathing] with moderate exertion.” Difficulty swallowing was not on the list. “Safety measures…aspiration precautions…” “Nutritional requirements: Puree diet” SN orders included the following pertinent instructions: “…Instructions/Teaching Signs and symptoms of respiratory status compromise and appropriate actions to take, when to call 911, Goal: Patient/caregiver will verbalize knowledge of the signs and symptoms of respiratory distress and when to contact agency or 911 within certification period… Order: Observation and Assessment Aspiration precautions, Goal: Patient will be free from aspirations during plan of care… Order: instructions/ Teaching Fiber increase in diet to prevent constipation Goal: [blank]… Order: Observe and Assess Ability Caregiver/Family to provide care for patient, Goal: Patient will receive assistance needed for care during certification period…” Review of the general notes read in pertinent part as follows: “…Explained to patient and [family]... Informed them to monitor for any [signs or symptoms] of respiratory distress and when to call EMS/911. Instructed to continue medication administration as ordered, aspiration precautions, fall safety/precautions, home safety, and to keep all scheduled appointments…” There was no patient specific interventions or education regarding the puree diet or assessment conducted to identify if the family knew how to prepare puree foods.