Every finding on record at USA We Care Home Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/20/25. Standard deficiencies cited.

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), §485.542(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: Based on review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure that the Emergency Preparedness Plan was established based on a risk assessment using an all-hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 06/17/25. The Emergency Preparedness Plan lacked documentation that a facility-based and/or community-based risk assessment was completed for 2024 and 2025. 2. During an interview with the Administrator and Director of Nursing on 06/18/25 at 11:50 AM, the Administrative staff confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Program/Plan, and staff interview, it was determined the Agency failed to ensure the Agency conducted the required individual and/or community exercises bi-annually to ensure the effectiveness of the Emergency Preparedness Plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 06/18/25. The Plan lacked documentation that full-scale community or individual testing exercises were conducted by the Agency for the year 2023 and 2024. 2. During an interview with the Administrator and Director of Nursing on 06/18/25 at 11:50 AM, the Administrative staff confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 06/20/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse OT = Occupational Therapy/Therapist PT = Physical Therapy/Therapist SOC = Start of Care POC = Plan of Care PsOC = Plans of Care AM = morning PM = afternoon lbs. = pounds >= more than mg = milligram/milligrams MD = Medical Doctor % = percent OASIS = Outcome and Assessment Information Set

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 103 of 181 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 05/01/24 to 05/23/25 was reviewed on 06/16/25 at 12:30 PM. The report included error # -3330 for 103 of 181 late submissions and 56.91 % of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Administrator, and Director of Nursing on 06/18/25 at 11:00 AM, it was confirmed that the error occurred.

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 clinical record review and staff interviews, it was determined that for 5 of 7 (Pts. #1, 5, 6, 7 and 4) clinical records reviewed, the Agency failed to ensure that the RN conducted the initial comprehensive assessment within 48 hours of the referral. Findings include: 1. Pt. #1 was admitted to home health services on 05/23/25 with the diagnosis of Crohn’s Disease. The clinical record was reviewed on 06/17/25. The clinical record contained a Physician script with orders for SN, PT and OT dated and received via fax by the Agency on 05/20/25. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 2. Pt. #5 was admitted to home health services on 04/24/25 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 06/17/25. The clinical record contained a Physician Encounter document with the service date of 04/09/24 with orders for SN and received via fax by the Agency on 04/15/25. The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician-ordered SOC date. 3. Pt. #6 was admitted to home health services on 07/08/24 with the diagnosis of Anemia. The clinical record was reviewed on 06/17/25. The clinical record contained a Physician script with orders for SN and PT dated 06/20/25. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 4. Pt. #7 was admitted to home health services on 01/24/25 with the diagnosis of Other Specified Urinary Incontinence. The clinical record was reviewed on 06/17/25. The clinical record contained a Physician Encounter Note with orders for PT dated 01/12/25 and received via fax by the Agency on 05/13/25. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 5. Pt. #4 was admitted to home health services on 05/02/25 with the diagnosis of Hemiplegia following Cerebral Infarction Right Dominant Side. The clinical record was reviewed on 06/17/25. The clinical record included a Physician script dated 04/24/25, indicating a referral for RN and PT services. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 6. During interviews with the Administrator and Director of Nursing on 06/18/25 between 10:15 AM and 11:50 AM, the Director of Nursing confirmed the above findings.

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 a review of clinical records, and staff interviews, it was determined that in 2 of 7 (Pts. #2 and 5) clinical records reviewed, the Agency failed to ensure staff provide service/treatment as indicated in the PsOC. 2. Pt. #5 was admitted to home health services on 04/24/25 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 06/17/25 and included the POC effective 04/24/25 which required, “Orders for Discipline and Treatments…SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy, coordinate care with physician for need to change plan of care…” The SN visit notes dated 04/26/25 and 05/08/25 lacked documentation of the patient’s blood glucose level. 3. During interviews with the Administrator and the Director of Nursing on 06/18/25 from 10:15 AM to 12:00 PM, the Director of Nursing stated that interventions on the PsOC should be implemented. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services on 04/18/25 with the diagnoses of Paroxysmal Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure and Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 06/17/25. The clinical record included a POC effective 04/18/25 to 06/16/25, which required: “Orders for Discipline and Treatments….SN to weigh patient weekly and report to MD for weight gain of > 5 lbs /week OR 2 lbs/day….” The clinical record included SN visits 1 – 2 times per week from 04/21/25 to 06/03/25, that lacked weight assessments.

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 a review of clinical records, and staff interviews, it was determined that in 2 of 7 (Pts. #2 and 6) clinical records reviewed, the Agency failed to ensure the PsOC, included an accurate list of medications and patient-specific interventions. 2. Pt. #2 was admitted to home health services on 07/08/24 with the diagnoses of but not limited to Anemia and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 06/18/25. The POC for the certification period of 11/05/24 to 01/03/25 lacked parameters for weight monitoring. 3. During staff interviews with the Administrator and Director of Nursing on 06/18/25 from 10:15 AM to 12:00 PM, it was stated that the POC should include all the requirements and during the same interviews, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services on 04/18/25 with the diagnoses of Paroxysmal Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure and Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 06/17/25. The clinical record included a POC effective 04/18/25 to 06/16/25, and included Medications: “….Donepezil 10 mg 1 at night at night By mouth….”. with same medication and dosage, listed twice. The POC contained an inaccurate medication list.

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 record review, Agency policy review and staff interview, it was determined that in 3 of 7 (Pts. # 1, 4 and 7) clinical records reviewed, the Agency failed to ensure Pts. were assessed for the status of Influenza and Pneumonia vaccination. Findings include: 1. The following clinical records were reviewed on 06/17/25 and 06/18/25: Pt. #1. SOC 05/23/25. Lacked inquiry for Pneumonia vaccine. Pt. #4. SOC 05/02/25. Lacked inquiry for Pneumonia vaccine. Pt. #7. SOC 01/24/25. Lacked inquiry for Influenza and Pneumonia vaccine. 2. The Agency Policy, titled “Vaccinations” was reviewed on 06/18/25, required: “….Influenza...The agency shall annually administer or arrange for administration of vaccination against influenza to each client/patient....unless vaccination is medically contraindicated or the client/patient refused the vaccine....For all clients who are provided services between November 1 and February 28, the home health agency shall document in the client's medical record that an annual vaccination against influenza was administered, arranged, refused, or medically contraindicated... The following shall be considered to be documentation approaches:..a. Individual client record entries identifying the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication or refusal, and any follow up-activities. b. Standard check-off form recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow-up activites....Pneumococcal Pneumonia….The agency shall administer or arrange for administration of pneumococcal vaccination…. to each client/patient who is age 65 or over and who has not received the immunization prior to or upon service initiation, unless the client/patient refuses the offer for vaccination or vaccination is medically contraindicated….The agency shall document in each client’s medical record that a vaccination against pneumococcal pneumonia was offered and administered, arranged, refused, or medically contraindicated or that the client is no a member of a vaccination priority population….The following shall be considered to be documentation approaches: a. Individual client record entries....b. Standard check-off form...." 3. During staff interviews with the Administrator and Director of Nursing on 06/18/25 between 10:15AM and 11:50 AM, the Director of Nursing confirmed the above findings.

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 review of the Agency's Pt. admission folder and staff interviews, it was determined in 5 of 7 (Pts. # 2, 4, 5, 6, and 7) the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 06/16/25. The folder lacked information identifying the Clinical Manager's name and contact information. 2. The clinical records of the following Pts. were reviewed from 06/17/25 to 06/18/25: Pt. #2. SOC 04/18/25 Pt. #4. SOC 05/20/25 Pt. #5. SOC 04/29/25 Pt. #6. SOC 07/08/24 Pt. #7. SOC 01/24/25 The clinical records reviewed lacked information identifying the Clinical Manager's name and contact information. 3. During interviews with the Administrator and Director of Nursing on 06/18/25 from 10:15 AM to 11:50 AM, it was indicated the same folder is given to all Patients. During the same interview, the Administrative staff confirmed the above findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined that for 2 of 7 (Pts. #5 and 3) clinical record reviews, the Agency failed to ensure the information contained in the clinical records were complete and accurate. 2. Pt. #3 was admitted to home health services on 05/31/25 with the diagnosis of Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 06/18/25. The POC effective 05/31/25 to 07/29/25, required SN frequency of 1 time a week for 9 weeks. The clinical record lacked SN notes for the week of 06/01/25 to 06/07/25. During an interview with the Director of Nursing on 06/18/25 at 11:50 AM, the Director of Nursing confirmed that an SN visit was conducted and lacked the SN note documentation. 3. During staff interviews with the Administrator and Director of Nursing on 06/18/25 between 10:15 AM and 11:50 AM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #5 was admitted to home health services on 04/24/25 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 06/17/25. The clinical record included SN clinical notes dated 04/26/25, 05/08/25, 05/22/25 and 05/24/25 that contained the following documentation: “Wound 1, Location: Center of Head, Onset: 11/03/23, Wound Type: Trauma, Measurement: 2 cm, Treatment: Educated to maintain clean and dry. Can shower and can remain open to air…” The SOC Comprehensive Assessment completed by the RN on 04/25/25 did not include documentation of the above-mentioned wound. During an interview with the Director of Nursing on 06/18/25, it was stated that the wound was from the previous admission and the notes were most likely copied from there and confirmed that the clinical records were inaccurate.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, the Agency failed to ensure a copy of the discharge summary was sent to the physician for 2 of 2 (Pts. # 6 and 7) discharged patients reviewed. Findings include: 1. Pt. #6 was admitted to home health services on 07/08/24 with the diagnosis of Anemia. The clinical record was reviewed on 06/17/25. The record contained a discharge comprehensive assessment dated 01/03/25, indicating that Pt. #6 was discharged from the Agency. The record lacked documentation that a copy of the Pt.'s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home health services on 01/24/25 with the diagnosis of Other Specified Urinary Incontinence. The clinical record was reviewed on 06/17/25. The record contained a discharge comprehensive assessment dated 03/19/25, indicating that Pt. #7 was discharged from the Agency. The Discharge Summary was completed by the RN on 06/02/25. The record lacked documentation that a copy of the Pt. #7’s discharge summary was sent to the Physician within 5 days of the discharge. 3. During an interview with the Administrator and Director of Nursing on 06/18/25 at 10:30 AM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: wk = week # = number AM = morning (>) = greater than SN = Skilled Nurse POC = Plan of care SOC = Start of care BP = Blood Pressure PM = afternoon/evening Pt./ Pts. = Patient/Patients

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on the review of clinical records and Staff interview, it was determined that the Agency failed to ensure the Staff followed the POC. This was found in 2 of 7 (Pts. # 5 and 6) clinical records reviewed. 2. Pt. #6. SOC 12/11/21. Diagnoses: Acute on Chronic Diastolic (Congestive) Heart Failure and Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 03/22/22 at 1:30 PM. The POC dated 12/11/21 required the SN: “….Notify Physician of vital sign parameters out of range:…. Systolic BP Greater Than (>) 160….” On 01/24/22, the SN assessed a blood pressure of 164/76. The record lacked any documentation regarding Physician notification of BP finding, as ordered. 3. During an interview with the Administrator and Director of Nursing on 03/22/22 from 2:00 PM to 3:15 PM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #5. SOC 01/07/22. Diagnoses: Atherosclerotic Native Artery Left leg with Ulcer Other Part Lower Leg and Non-ST elevation Myocardium Infarction. The clinical record was reviewed on 03/22/22 at 11:30 AM. The POC dated 01/07/22 required the SN to notify the Physician if the heart-rate was below 60. On 02/18/22, the SN assessed an heart-rate of 56 and on 02/22/22 a heart-rate of 58 and did not notify the patient’s physician, as ordered.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: A. Based on the review of clinical records, policy review and Staff interview, it was determined that the Agency failed to ensure the Staff supervised the Occupational Therapy Assistant services. This was found in 1 of 1 (Pts. # 4) clinical records reviewed with the Occupational Therapy Assistant services. Findings include: 1. Pt. #4. SOC 02/10/22. Diagnoses: Encephalopathy Unspecified and Unspecified Atrial Fibrillation. The clinical record was reviewed on 03/22/22 at 11:00 AM. The clinical record included orders for the Occupational Therapy services, 2 times a week for 5 weeks. The Occupational Therapist conducted the evaluation on 02/17/22 (week #1). The eight (8) follow-up visits: 02/19/22, 02/22/22, 02/25/22, 03/02/22, 03/06/22, 03/08/22, 03/11/22 and 03/14/22 were conducted by the Occupational Therapy Assistant. The Agency lacked the requirement of the Occupational Therapy Assistant supervision by the Occupational Therapist. 2. The Agency's policy titled "Clinical Supervision" was reviewed on 03/22/22 at 2:00 PM. The policy required "...8. When a Licensed Physical Therapy Assistant or Occupational Therapy Assistant performs home therapy services, the Physical Therapist or Occupational Therapist will make a supervisory visit every 4 - 6 visits. 3. The above findings related to the lack of Occupational Therapy Assistant supervision by the Occupational Therapist were confirmed with the Administrator and Director of Nursing on 03/22/22 between 2:00 PM and 3:15 PM.