Every finding on record at Truelife Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 6/6/25. 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 6/6/25. Standard level deficiencies cited. Abbreviations: Pt. = Patient Pts. = Patients POC = Plan of Care SN = Skilled Nurse BP = Blood Pressure MD = Medical Doctor mmHg = millimeter of Mercury lbs. = pounds PM = afternoon AM = morning

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 the review of the Error Summary report and staff interview, it was determined, in the last 12 months, the Agency failed to submit 45 of 71 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 6/1/24 to 5/31/25 was reviewed on 6/4/25 at 1:30 PM. The report included error # -3330 for 45 of 71 late submissions, and 63.38% of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the RN/Agency Supervisor on 6/4/25 at 3:00 PM, it was confirmed that the error occurred.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews, it was determined for 2 of 7 (Pts.#6 and #7) clinical records reviewed, the Agency failed to ensure care and services were provided as ordered by the Physician in the POC. Findings include: 1. Pt. #6 was admitted to home health services on 8/30/24 with the diagnosis of but not limited to, Hemiplegia following Other Cerebrovascular Disease affecting Left Non-Dominant Side. The clinical record was reviewed on 6/4/25 and included the POC for the period of 8/30/24 to 10/28/24 which required, “Orders for Discipline and Treatments…Notify Physician of vital sign parameters out of range: Diastolic BP: Greater than (>) 90, less than (The record included a Skilled Nurse Visit note on 9/3/24, which included documentation: “BP Sitting Left: 150/100 mmHg.” The record lacked Physician notification of the vital sign which was out of range. The POC also required, “SN to assess, observe, instruct and document on hydration status, electrolyte status, pulmonary and cardiovascular status…monitoring of weight loss/gain every shift…” The clinical record lacked documentation of the patient’s weight on the following visits: 9/5/24, 9/12/24, 10/3/24, 10/10/24 and 10/17/24. 2. Pt. #7 was admitted to home health services on 8/22/24 with the diagnoses of but not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and stage 1-4 unspecified Chronic Kidney, Heart Failure and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 6/3/25 and included the POC for the period of 12/20/24 to 2/17/25 which required, “Orders for Discipline and Treatments… Nursing: ...SN to instruct on daily weigh monitoring (if able) and recording and to report to SN/MD weight change of 3 lbs. or more in 24 hours or 5 lbs. or more in 7 days…” The Skilled Nurse Visit note on 12/26/24 recorded a weight of 198 lbs. The Skilled Nurse Visit note on 1/2/24 recorded a weight of 178 lbs. The record lacked documentation the Physician was notified of the weight change. The same POC also requires, “SN to perform finger stick for blood glucose analysis every visit.” The Skilled Nurse Visit note dated 1/16/25 lacked documentation of the patient’s blood glucose level. 3. During an interview with the Owner and Agency Supervisor on 6/4/25 at 3:45 PM, the above findings were confirmed.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Emergency Preparedness plan and staff interview, it was determined the Agency failed develop a risk assessment. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The binder labeled, “Emergency Preparedness” plan was reviewed on 3/28/22 at 11:00 AM. The plan lacked an all-hazards, facility-based and community-based risk assessment. 2. The Agency's policy titled, "Emergency Preparedness Plan Potential Hazards" was reviewed on 3/28/22 at 11:30 AM and required the Agency to "...identify potential hazards that surrounds the client/patient, and shall develop a plan according to the prioritization of the hazardous risks...Natural Disasters, Man-Made Disasters, Technological Failures and Other". 3. During an interview with the Administrator and Alternate Director of Nursing on 3/29/22 at 2:50 PM, both were unable to provide an Emergency Preparedness plan risk assessment.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Preparedness plan, Agency policy and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The "Emergency Preparedness" communication plan was reviewed on 3/28/22 at 11:00 AM. The communication plan lacked the name and contact information of Employee #1 (direct employee), contracted staff/agencies (physical therapy, occupational therapy, speech therapy, medical social worker), and patients’ Physicians. 2. The Agency’s policy titled, “Emergency Preparedness Plan Communications Capabilities” was reviewed on 3/28/22 at 11:20 AM and included: “Procedure… shall maintain the names and contact information of the following as part of the communication plan: 1. Staff 2. Physician 3. Other sources of collaboration: pharmacy, DME companies, et. al…5. Contracting companies with the agency…” 3. During an interview with the Administrator and Alternate Director of Nursing on 3/29/22 at 2:50 PM, both confirmed the Agency’s communication plan was incomplete.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Preparedness Plan, Agency policy and staff interview, it was determined the Agency failed to establish an alternate form of communication. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 3/28/22 at 11:00 AM. The plan lacked documentation that in the absence of the Agency’s primary form of communication, the Agency has an alternate source of communicating with staff, Federal, State, regional and local emergency agencies. 2. The Agency’s policy titled, “Emergency Preparedness Plan Communications Capabilities” was reviewed on 3/28/22 at 11:20 AM and included: “…2. The agency shall maintain communication with other health care providers via phones, faxes and emails if there are no power outage in order to maintain continuity of care…” 3. During an interview with the Administrator and Alternate Director of Nursing on 3/29/22 at 2:50 PM, both confirmed the Agency use phones, faxes and emails as their primary source of communication. During the same interview, both confirmed the Agency lacked an alternate form of communication to contact staff, Federal, State, regional and local emergency agencies, in the event of an emergency or disaster.

Recertification survey completed. Standard level deficiencies cited. SOC = Start of Care SN = Skilled Nurse Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon, Evening PT = Physical Therapy/Therapist OT= Occupational Therapy/Therapist H&P= History and Physical DME = Durable Medical Equipment # = number et. al = and others

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 7 of 7 (Pts. #2, 3, 5 1, 4, 6 and 7) clinical records reviewed. 4. Pt. #1. SOC 3/17/22. Principal Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 3/28/22 at 3:00 PM. The SOC comprehensive assessment documents the SN initiated service for Pt. #1. The referral /"Home Visit" date of service 3/21/22 documents "Weekly RN, PT in progress, OT started…" The referral was faxed from the Physician's office to the Agency on "3/27/22". As of 3/31/22, it cannot be determined whether the SOC was initiated in a timely manner. 5. Pt. #4. SOC 12/2/21. Principal Diagnosis: Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene. The clinical record was reviewed on 3/29/22 at 11:30 AM. The SOC comprehensive assessment documents the SN initiated service for Pt. #2. The referral/ "Physicians Face -to Face Encounter" date of service 11/24/21 documents "Nursing to monitor and PT to increase...." The referral was faxed from the Physician's office to the Agency on "1/5/22". As of 3/31/22, it cannot be determined whether the SOC was initiated in a timely manner. 6. Pt. #6. SOC 1/12/21. Principal Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 3/29/22 at 12:30 PM. The SOC comprehensive assessment documents the SN initiated service for Pt. #6. The referral/ "Physicians Face -to Face Encounter" date of service 1/8/21 documents "Nursing to monitor…" The referral was faxed from the Physician's office to the Agency on "2/11/21". As of 3/31/22, it cannot be determined whether the SOC was initiated in a timely manner. 7. Pt. #7. SOC 5/4/21. Principal Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 3/29/22 at 2:30 PM. The SOC comprehensive assessment documents the SN initiated service for Pt. #7. The referral/ "H&P Established Patients” date of service 5/3/21 documents "Nursing for disease… and PT to evaluate and treat…". The referral was faxed from the Physician's office to the Agency on "5/4/21". As of 3/31/22, it cannot be determined whether the SOC was initiated in a timely manner. 8. During interviews with the Administrator and Alternate Director of Nursing on 3/29/22 at 2:50 PM and 3/30/22 at 10:00 AM both confirmed the above findings. Findings include: 1. Pt. #2. SOC 11/19/21. Diagnoses: Essential Primary Hypertension and Chronic Pain Syndrome. The clinical record was reviewed on 3/29/22 at 10:00 AM. The SOC comprehensive assessment dated 11/19/21 included documentation the SN initiated service for Pt. #2. The referral /"Physicians Face-To-Face Encounter" dated 11/29/21 contained "Nursing to Monitor..." The referral was faxed from the Physician's office to the Agency on "12/22/2021". As of 3/29/22, it can not be determined whether the SOC was conducted in a timely manner. 2. Pt. #3. SOC 11/1/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 3/29/22 at 11:00 AM. The SOC comprehensive assessment dated 11/1/21 included documentation the SN initiated service for Pt. #3. The referral /"Physicians Face-To-Face Encounter" dated 10/29/21 contained "Nursing to Monitor..." The referral was faxed from the Physician's office to the Agency on "11/2/2021". As of 3/29/22, it can not be determined whether the SOC was conducted in a timely manner. 3. Pt. #5. SOC 1/14/22. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 3/29/22 at 9:50 AM. The SOC comprehensive assessment dated 1/14/22 included documentation the SN initiated service for Pt. #5. The referral /"Physicians Face-To-Face Encounter" dated 12/14/21 contained "Nursing to Monitor..." The referral was faxed from the Physician's office to the Agency on "01/28/2022". As of 3/29/22, it can not be determined whether the SOC was conducted in a timely manner.