Every finding on record at Terrace Home Health Springfield, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 03/04/2026. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 03/04/2026. The provider had 127 current patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure that an initial assessment was performed within 48 hours of the referral in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 02/09/2026 with a primary diagnosis of achondroplasia (the most common form of skeletal dysplasia (short-limbed dwarfism) caused by a spontaneous or inherited mutation in the fibroblast growth factor receptor 3 gene, which slows bone growth). The patient lived at home alone. Review of the referral information showed an order dated 01/16/2026 for referral to home health services for physical therapy, occupational therapy, and nursing. Review of the communication note, dated 02/06/2026, showed the home health provider received a verbal order from the primary care provider's office for physical therapy to assess and evaluate the patient. Review of the initial assessment showed the visit was completed by physical therapy on 02/09/2026. During an interview on 03/04/2026 at 8:15 AM, the administrator stated that the patient refused nursing and occupational therapy services, and they got a new order to start physical therapy services on 02/06/2026. The administrator also stated that they got the order on a Friday so they thought they could do the admission on a Monday.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure the comprehensive assessment included information that accurately reflected the patient's health status in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 02/10/2026 with a primary diagnosis of sarcopenia (a progressive loss of skeletal muscle mass, strength, and function). The patient had additional diagnoses of hypertension (HTN; abnormally elevated blood pressure), atrial fibrillation (A-Fib; an abnormal heart rhythm characterized by a rapid irregular heartbeat), chronic kidney disease (CKD; a long-term, irreversible loss of kidney function, causing waste and fluid buildup in the body), and end stage renal disease (ESRD; the final stage of chronic kidney failure). The patient lived in an assisted living facility (ALF). Review of the initial comprehensive assessment titled, "Start of Care (SOC) and Outcome and Assessment Information Set," (OASIS; a mandatory, standardized data collection tool), dated 02/10/2026 at 9:26 AM, showed Employee #3 performed the initial assessment/visit. Employee #3 obtained and documented the patient's pulse, but failed to obtain and document the patient's temperature, respirations, oxygen saturation, and blood pressure as part of the assessment. Observation on 03/03/2026 at 9:30 AM, during a home visit, showed physical therapy assistant (PTA)- A obtained the patient's vital signs. PTA-A obtained and documented the patient's temperature, pulse, respirations, and oxygen saturation, but failed to obtain and document the patient's blood pressure prior to the therapy session. During an interview on 03/03/2026 at 2:00 PM, the clinical manager stated that staff are responsible to obtain a "full set" of patient vital signs during assessments and visits, which includes the patient's temperature, pulse rate, respiration rate, oxygen saturation level, and blood pressure reading.

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, record review, home visit observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services 01/05/2024 with a primary diagnosis of encounter for change or removal of a nonsurgical wound dressing and a secondary diagnosis of necrotizing fasciitis (a rare, life-threatening bacterial infection that rapidly destroys muscles, skin, and fat tissue). The patient lived at home with a family caregiver. Observation and interview on 03/03/2026 at 10:30 AM, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for atorvastatin (a widely used prescription statin that lowers bad cholesterol (low-density lipoprotein-LDL) and triglycerides while raising good cholesterol (high density lipoprotein-HDL) to reduce the risk of heart attacks and stroke) 10 mg tablet, take one tablet by mouth once a day. The patient did not have this medication in the home: -The medication profile showed an order for acetaminophen-oxycodone (a combination of an opioid analgesic (oxycodone) and a non-opioid pain reliever (acetaminophen) used to treat moderate to severe pain) 325 mg-10 mg tablet, take one tablet every six hours as needed for severe pain. The patient did not have this medication in the home; -The patient took the medication Tamsulosin (a prescription alpha-blocker used to treat symptoms of an enlarged prostate) 0.4 mg capsule, take one capsule once a day. This medication was not included on the provider’s medication profile; -The patient took the medication simvastatin (used to lower bad LDL cholesterol and triglycerides while raising good HDL cholesterol) 40 mg tablet, take one tablet once a day. This medication was not included on the provider’s medication profile; -The patient took vitamin B-12 1000 mcg tablet, take one tablet once a day. This medication was not included on the provider’s medication profile; and -The patient took iron (a mineral vital for producing hemoglobin) 65mg tablet, take one tablet once a day. This medication was not included on the provider’s medication log. Findings included: Review of the home health provider’s policy titled, “Medication Reconciliation” dated February, 2022, stated in part: - The Agency will reconcile patient's medications at time of admission and on an ongoing basis 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. - At time of admission, the admitting Registered Nurse (RN), Physical Therapist (PT), or Speech Language Pathologist (SLP), will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; - Any concerns or discrepancies will be reconciled by a RN with the patient's physician/practitioner; - Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; -The agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by Agency staff and staff acting on behalf of the agency; - In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to RN for review, who contacts physician/practitioner if indicated; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 02/10/2026, with a primary diagnosis of sarcopenia (a progressive loss of skeletal muscle mass, strength, and function), and medical diagnosis which included hypertension (HTN; abnormally elevated blood pressure), atrial fibrillation (A-Fib; an abnormal heart rhythm characterized by a rapid irregular heartbeat), chronic kidney disease (CKD; a long-term, irreversible loss of kidney function, causing waste and fluid buildup in the body), and end stage renal disease (ESRD; the final stage of chronic kidney failure). The patient lived in an assisted living facility (ALF). Observation and interview on 02 /03/2025 at 9:30 AM, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for ascorbic acid (vitamin C) 250 milligrams (mg) tablet, take one tablet by mouth twice each day. The patient stated that he/she had not used the medication; -The medication profile showed an order for midodrine (a medication to increase blood pressure) 10 mg tablet, one tablet to be taken by mouth, once each day. The patient stated that the staff at the dialysis clinic administers the medication during his/ her appointment each Monday, Wednesday and Friday; -The medication profile showed an order for Dulcolax (a stimulant laxative medication to treat constipation) 5mg tablet, take one tablet by mouth, once each day. The patient stated that he/she no longer used the medication; -The patient took the medication Warfarin (an anticoagulant "blood thinner") 7.5 mg tablet, take one tablet by mouth, once each day, except Tuesdays- 5 mg taken by mouth, once each day. This medication was not included on the provider's medication profile; -The patient took the medication Lutein (a dietary supplement) 8 mg tablet, take one tablet by mouth, once each day. This medication was not included on the provider's medication profile; -The patient took vitamin B-12 (a vitamin supplement), 1000 micrograms (mcg.) tablet, take one tablet by mouth, once each day. This medication was not included on the provider's medication profile: -The patient took the medication tart cherry (a dietary supplement) 3000 mg tablet, take one tablet by mouth, once each day. This medication was not included on the provider's medication profile; -The patient took the medication Osteo Bi-flex (a dietary supplement) tablet, take one tablet by mouth, twice each day. This medication was not included on the provider's medication profile; -The patient took the medication Metamucil (a dietary fiber supplement) 17-gram (gm) powder mixed with 8 ounces of water, take once each day. This medication was not included on the provider's medication profile; -The patient took the medication Magnesium oxide (a dietary supplement) 400 mg tablet, take one tablet by mouth, once each day. This medication was not included on the provider's medication profile; and -The patient took the medication Tylenol (a pain reliever and fever reducer) 500 mg tablet, take two tablets by mouth, twice each day. This medication was not included on the provider's medication profile. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/08/2026, with a primary diagnosis of perineal adhesions (fibrous bands of scar tissue that form between abdominal tissues or organs, often following surgery, infection, or inflammation), and medical diagnosis which included hypertension (HTN; abnormally elevated blood pressure), and arteriosclerotic heart disease,(ASHD; thickening of the arterial wall that results in decreased supply of blood flow). The patient lived at home with a spouse. Observation and interview on 02/03/2026 at 12:45 PM, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for Ozempic (a medication used to improve blood sugar management in adults with type 2 diabetes and reduces the risk of major cardiovascular events like heart attack or stroke), 4 mg / 3 milliliters (ml) subcutaneous injection (sq; delivers the medication by syringe and needle into the fatty tissue, between the skin and muscle layer). Inject 1 ml sq each week. The patient stated that he/she is not currently taking the medication; -The medication profile showed an order for Tramadol (an opioid pain reliever) 50 mg tablet, take one tablet by mouth every 6 hours. The patient stated that he/she is not currently taking the medication; and -The medication profile showed an order for Imodium (a medication to prevent diarrhea) 2 mg capsule, take one tablet by mouth every 4 hours as needed. The patient stated that he/she is not currently taking the medication. During an interview on 03/03/2026 at 2:00 PM, the clinical manager stated that staff of all clinical disciplines are responsible to compare all current medications in the patient’s home to the medication list at least once each week and/ or during each visit to ensure medication accuracy.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on current Centers for Disease Control (CDC) recommendations, record review, home visit observation, and interview, the home health provider failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases, in one of three home visit observations conducted (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the CDC's current recommendations titled, "CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings," updated 10/2022, showed the following: - Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes) prior to use on another patient or when soiled; - Consult and adhere to manufacturers’ instructions for reprocessing; and - Maintain separation between clean and soiled equipment to prevent cross contamination. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 02/10/2026, with a primary diagnosis of sarcopenia (a progressive loss of skeletal muscle mass, strength, and function). The patient had additional diagnoses of hypertension (HTN; abnormally elevated blood pressure), atrial fibrillation (A-Fib; an abnormal heart rhythm characterized by a rapid irregular heartbeat),chronic kidney disease (CKD; a long-term, irreversible loss of kidney function, causing waste and fluid buildup in the body), and end stage renal disease (ESRD; the final stage of chronic kidney failure). The patient lived in an assisted living facility (ALF). Observation on 03/03/2026 at 9:30 AM, showed physical therapy assistant (PTA)- A placed a protective barrier on the patient's sofa prior to placing a supply bag on the sofa. PTA-A then placed an electronic tablet on the same sofa but failed to place the tablet on the protective barrier. PTA-A used the tablet, had the patient provide a signature for the visit. PTA-A failed to disinfect the tablet after use. During an interview on 03/03/2026 at 2:00 PM, the clinical manager stated that staff of all clinical disciplines are responsible for following infection control standards. This would include the use of placing barriers for bags and supplies and electronic tablets used during each patient visit to prevent the transmission of infections and communicable diseases. Staff are directed to disinfect all the supplies and equipment used during each visit following the visit, to prevent the transmission of infections and communicable diseases.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri statute, policy review, employee file review, and interview, the home health provider failed to ensure that a check of the Employee Disqualification List (EDL) was performed in two of five employee files reviewed (Employees #3 and #4) and failed to ensure Alzheimer’s and dementia training was provided on orientation and annually in five of five employee files reviewed (Employee #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. " Review of the provider’s policy titled, “Employee Orientation,” dated 02/2022, showed orientation for each employee will minimally include training specific to job requirements. Review of the provider’s policy titled, “Personnel Records, dated 02/2022, showed the personnel record for an employee will include agency employee orientation, criminal history check, national sex offender registry, and other data which is directly related to the employment. EMPLOYEE #1: Review of the employee file showed: -Date of hire: 04/07/2025; and -The file failed to show Alzheimer's and dementia training was provided to the employee upon hire. EMPLOYEE #2: Review of the employee file showed: -Date of hire:10/07/2024; and -The file failed to show Alzheimer's and dementia training was provided to the employee upon hire and annually therafter. EMPLOYEE #3: Review of the employee file showed: -Date of hire: 02/09/2024; -The EDL check was received on 12/02/2025 (662 days after hire); and -The file failed to show Alzheimer's and dementia training was provided to the employee upon hire and annually therafter. EMPLOYEE #4: Review of the employee file showed: -Date of hire: 04/21/2025; -The EDL check was received on 04/23/2025 (two days after hire); and -The file failed to show Alzheimer's and dementia training was provided to the employee upon hire. EMPLOYEE #5: Review of the employee file showed: -Date of hire: 09/22/2025; and -The file failed to show Alzheimer's and dementia training was provided to the employee upon hire. During an interview on 03/03/2026 at 10:26 AM, the administrator stated that he/she did not realize that home health was not assigned the Alzheimer’s/dementia training. He/she also stated that the background checks are performed by human resources (HR) and he/she was unsure of why they were not performed prior to hire.