Every finding on record at Tracy L Donahue

Purpose of the visit: Recertification survey. Entrance conference date was 01/07/2026. The census was 70 Licensed and Certified Home Health patients. The agency was in compliance with the emergency preparedness conditions of participation for home health agencies.

Purpose of the visit: Recertification survey. Entrance conference date was 01/07/2026. The census was 70 Licensed and Certified Home Health patients. Abbreviations: CFR- Code of Federal Regulations CMS- Center for Medicare and Medicaid Services HH COPs - Home Health Conditions of Participation QA- Quality Assurance OASIS – Outcome and Assessment Information Set POC – Plan of Care DON – Director of Nurses / Supervising Nurse HHA- Home Health Agency PT- Physical Therapy

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 interview, the agency failed to encode and electronically transmit each completed OASIS assessment (a standardized comprehensive patient assessment completed at prescribed intervals to measure patient outcomes and compare to other agencies) to the CMS system (collector of assessments for quality and outcome measurements), regarding each beneficiary as required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary in 11.98% of OASIS assessments submitted to CMS from 11/01/2024 – 11/01/2025. Patients are subjected to poor quality of care and outcomes when the assessments of care are not submitted at the regular required times. The surveyor reviewed the CMS report detailing the timeliness of transmission of required OASIS assessment data on 01/07/2025 as part of the presurvey assessment of the agency’s quality of care. The report documented that the agency submitted 11.98 percent of the required OASIS assessment more than 30 days after the date of the assessment. The report documented 167 assessments were processed in the report period 11/01/2024 to 11/01/2025. An interview was conducted on 01/07/2026 at 10:30 AM with the Administrator, DON, and QA Director. The surveyor reviewed the findings of the late assessments. The surveyor asked why the assessments were late. The Administrator stated: “We are new to Medicare.” The surveyor asked about the policy and procedures for OASIS collection, encoding and transmission. The Administrator stated: The referral comes into intake and is reviewed, and a nurse is scheduled and sees the patient within 48 hours. The nurse completes the assessment in 5 days, and they go to the DON to review and then they are reviewed for QA and coded. The surveyor asked if that was a 100 percent review or a sample. The Administrator stated it was 100 percent. The surveyor asked the DON how long the DON had to review the assessments. The DON stated 48 hours and then if returned to the staff for changes they had 3 days to return the reviewed assessment. The Administrator stated: the assessment then went to the biller who submitted completed assessments multiple times per week. There are reports sent weekly to Administration and compliance. The surveyor asked if the agency was aware the assessments were late. The QA Director stated that QA is starting to look at these this year and the agency just transitioned to a new electronic medical record system. The QA stated the agency had done extensive training on OASIS collection. The surveyor asked about the effect on the patients of the deficient practice. The Administrator stated they were in the learning curve as they transitioned from the previous electronic medical record to the new one. Agency policy and procedures: “Timelines IM.35 Page 1 of 3 HCL / IM.35 Last Reviewed: 010126” read in part “Purpose To establish timely parameters for all medical record information. Policy The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations…Policy- All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…”

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: Based on observation, record review, and interviews, the agency failed to ensure the plan of care for 1 (Patient 2) of 3 patients who the surveyor made home visits with included all pertinent diagnoses and all medications. The outcome was an incomplete plan of care and potential for poor quality care and patient harm due. Review of Patient 2’s Plan of Care for the start of care 12-01/2025 for certification period 12/02/2025 to 01/30/2026 revealed one diagnosis - Displaced fracture of left tibial spine, subsequent encounter for closed fracture with malunion (routine care during the healing phase after a bone fracture that is healing in an abnormal position). The Plan of Care contained no other diagnoses. The plan of care did not contain any medication. Review of the start of care assessment dated 12/02/2025 by PT A documented history of falls, elevated fall risk, weakness, difficulty with transfers, compromised balance, history of irregular heart rate and hypertension (high blood pressure), and a pain level of 5 out of 10. The care plan did not contain additional diagnoses for the issues documented in the start of care assessment and no medications to treat or alleviate the problems documented. An observation visit was conducted on 01/08/2026 at 12:45PM with Patient 2 and a family member. The surveyor observed a medical splint on Patient 2’s left leg, a healing surgical scar on the left leg, a curved shape to Patient 2’s left leg. The surveyor observed Patient 2 using a cane and assistance from a family member with ambulation. Patient 2 reported health problems of irregular heart rate and high blood pressure, pain, difficulty walking, history of falls, his left leg not healing straight after recent surgery after a fall. Patient 2 stated he may need a total knee replacement surgery. Patient 2 said his family member helped with medications for his blood pressure and irregular heart rate and pain. Patient 2 stated he did not know the names of his medications, and medications were not made available for the surveyor during the visit. The surveyor observed PT A provide part of the home visit with Patient 2. The PT stated they did not realize they were to complete the start of care assessment until the PT was in the home the first time. The PT stated they looked at the referral information for other diagnoses and medications when completing the POC, and there were none listed in the referral received. PT A said they should put pertinent diagnoses and medications on the POC and thought the agency would add that information during the review process. The PT stated they did not normally do start of care assessments for this agency, just therapy evaluations and services. An interview was conducted with the DON and the Administrator on 01/12/2026 at 1:22 PM. The surveyor asked about the lack of diagnoses and medications on Client 2s plan of care. The DON stated they did not know Client 2’s diagnoses and medications. The surveyor asked about the policy and procedures when the PT admits a patient. The DON stated the expectation is the PT is expected to put all pertinent diagnoses and medications in the assessment and plan of care. The surveyor asked about the effect to the patient of the failure to put in the diagnoses and medications. The DON stated “that’s how we can teach and monitor them. All the medications need to be evaluated for interactions. It is very important to have all the information in the records. The Administrator stated, “we need to ensure all contractors are living up to expectations.” The surveyor asked how the process went from referral to the plan of care. The Administrator stated the agency does use a few contractors to complete admissions when staff are needed. The contract staff are notified by agency intake staff they are to complete the start of care assessment. The surveyor asked about the outcome for the patient of the deficient practice. The Administrator stated the POC is not complete. The surveyor asked if the agency would expect all pertinent diagnoses and medications to be included on the POC. The Administrator stated “Yes, 100 percent they should be there.” The surveyor asked about the process after the PT admits the patient. The DON stated the assessment and POC go to QA to be reviewed and then the DON signs the POC. The DON said this deficient practice should have been caught by QA before it was sent to the DON for signature. Review of Agency policy and procedures: “Plan of Care PC.35 Page 1 of 4 HCL / PC.35 Last Reviewed: 010126” read in part: “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems… Policy I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs… Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment …The individualized Plan of Care must include the following: 1. All pertinent diagnoses…10. All medications and treatments…”

A recertification and complaint survey was initiated on 1/20/2023. The census was: LCHH-48 LHH-0 PAS-108 Total agency census: 156 Intakes: 347449 362577 353664 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and complaint survey was initiated on 1/20/2023 The census was: LCHH-48 LHH-0 PAS-108 Total agency census: 156 Abbreviations LHH-Licensed Home Health LCHH-Licensed and Certified Home Health

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff in 2 (Patients #2 & #3) of 2 patients' home folders reviewed during home visits. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availability of the patients. Findings included: Patient #2: Record review contained a plan of care for the period of 12/19/2022 through 2/16/2023 with a start of care of 12/19/2022. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. During a home visit with Patient #2 on 1/26/2023 at 10:30 am, no documentation was found in the agency home folder provided to Patient #2 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #2 said “No.” The surveyor asked if Patient #2 had been provided with a written schedule of visits to be made by the skilled nurse. Patient #2 said, "No." Patient #3: Record review contained a plan of care for the period of 11/28/2022 through 1/26/2023 with a start of care of 9/29/2022. The frequency for the skilled nurse was ordered 1 time a week for 9 weeks. During a home visit with Patient #3 on 1/26/2023 at 11:00 am, no documentation was found in the agency home folder provided to Patient #3 of written information outlining a visit schedule including frequency of visits to be made by the skilled nurse. The surveyor asked if anything had been removed from the folder. Patient #3 said “No.” The surveyor asked if Patient #3 had been provided with a written schedule of visits to be made by the skilled nurse. Patient #3 said, "No." An interview was conducted on 1/26/2023 at 4:10 pm with The Administrator and the Alt. Adm/Supervising Nurse. The surveyor reviewed the above findings and asked why Patient #2 and #3 were not provided with a written visit schedule. The Administrator said, “The nurses forgot to leave one in the home.”