Caremax Home Health

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure multidisciplinary visit notes and plan of care (POC) assessments for seven out of seven patients (Patient 1, 2, 3, 4, 5, 6 & 7) were signed accurately and timely according to the policies and procedures (P&P) and facility protocol. These failures had the potential to result in inaccurate data in patients’ clinical records. Findings: During a review of the clinical records conducted from 9/23/25 to 9/25/25, late signatures were identified for: 1. Patient 1 – Physical Therapy (PT) 30-day re-assessment note, dated 9/6/25 was signed on 9/19/25 and Registered Nurse Supervisor (RNS) visit note, dated 9/19/25 was signed 9/23/25. 2. Patient 2 – Home Health Aid (HA) visit note, dated 8/29/25 was signed 9/10/25 and HA visit note, dated 9/5/25 was signed 9/15/25. 3. Patient 3 - RNS visit note, dated 9/5/25 was signed 9/16/25, PT visit note, dated 9/3/25 and 9/8/25 was signed on 9/23/25, HA visit note, dated 8/23/25 was signed 9/10/25, HA visit note, dated 9/6/25 was signed 9/19/25, Skilled Nursing (SN) visit note, dated 8/29/25 was signed 9/9/25, SN visit note, dated 9/9/25 was signed 9/23/25. 4. Patient 4 - RNS visit note, dated 9/11/25 was signed 9/16/25. 5. Patient 5 - HA visit note, dated 9/3, 9/6, & 9/10/25 was signed 9/16/25, HA visit note, dated 9/13/25 was signed 9/17/25. 6. Patient 6 - SN visit note, dated 8/12/25 was signed 8/17/25, SN visit note, dated 8/19/25 was signed 9/23/25. 7. Patient 7 - PT visit note, dated 3/24/25, was signed on 4/3/25, SN visit note. Dated 3/26/25, was signed on 4/23/25, POC dated 4/2/25 was signed by the RN on 3/20/25 and by the MD on 9/24/25. During a review of the facility’s P&P titled, “Entries into the Clinical Record,” dated 4/2011, the P&P indicated, “Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…7. The clinical note will include…D. The date the service was provided (month, day year). E. Signature of clinician and his/her credentials.” Further review of P&P, indicated an addendum stating, “In addition to Entries Into the Clinical record policy and procedure…entries into the clinical record shall be submitted within 48 hours.” During a review of the P&P titled, “Clinical record Review,” dated 5/2024, the P&P indicated, “Clinical records will be reviewed at least annually by qualified organization personnel to assure that documentation entered is reliable, timely, valid and accurate…1. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor Performance Improvement Coordinator, Clinical Director or designees for: A. Timeliness of entries into the clinical record…F. Accuracy of the clinical records.” During a concurrent interview and record review on 9/25/25, at 10:08 a.m. with the Director of Nursing Services (DPCS), the facility’s P&P titled, “Entries in the Clinical Record,” and “Clinical Record Review,” Patient 1, 2, 3, 4, 5, 6 & 7’s’ visit note and the POC assessment were reviewed. The DPCS acknowledged the late signatures and verbalized that all visit notes must be completed on time including signing the document within 48 hours from the date of visit.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the facility failed to develop, implement, and document an effective, ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program for completion of clinical notes and annual tuberculosis (TB) test. These failures had the potential to affect and result in the agency’s substandard quality of care and substantial non-compliance without the necessary measures for identification and implementation of the QAPI program. Findings: 1. During a review of the clinical records conducted from 9/23/25 to 9/25/25, late signatures were identified for: A. Patient 1 – Physical Therapy (PT) 30-day re-assessment note, dated 9/6/25 was signed on 9/19/25 and Registered Nurse Supervisor (RNS) visit note, dated 9/19/25 was signed 9/23/25. B. Patient 2 – Home Health Aid (HA) visit note, dated 8/29/25 was signed 9/10/25 and HA visit note, dated 9/5/25 was signed 9/15/25. C. Patient 3 - RNS visit note, dated 9/5/25 was signed 9/16/25, PT visit note, dated 9/3/25 and 9/8/25 was signed on 9/23/25, HA visit note, dated 8/23/25 was signed 9/10/25, HA visit note, dated 9/6/25 was signed 9/19/25, Skilled Nursing (SN) visit note, dated 8/29/25 was signed 9/9/25, SN visit note, dated 9/9/25 was signed 9/23/25. D. Patient 4 - RNS visit note, dated 9/11/25 was signed 9/16/25. E. Patient 5 - HA visit note, dated 9/3, 9/6, & 9/10/25 was signed 9/16/25, HA visit note, dated 9/13/25 was signed 9/17/25. F. Patient 6 - SN visit note, dated 8/12/25 was signed 8/17/25, SN visit note, dated 8/19/25 was signed 9/23/25. G. Patient 7 - PT visit note, dated 3/24/25, was signed on 4/3/25, SN visit note. Dated 3/26/25, was signed on 4/23/25, POC dated 4/2/25 was signed by the RN on 3/20/25 and by the MD on 9/24/25. During a review of the facility’s P&P titled, “Entries into the Clinical Record,” dated 4/2011, the P&P indicated, “Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…7. The clinical note will include…D. The date the service was provided (month, day year). E. Signature of clinician and his/her credentials.” Further review of P&P, indicated an addendum stating, “In addition to Entries Into the Clinical record policy and procedure…entries into the clinical record shall be submitted within 48 hours.” 2.During a record review on 9/24/25 at 2:46 p.m. it was identified that a Registered Nurse (RN) did not have an updated yearly Tuberculosis (TB – lung infection) Mantoux Test (PPD – Purified Protein Derivative – a substance used in a skin test to detect tuberculosis infection) or chest x-ray (CXR) in their employee personnel file. During an interview on 9/24/25 at 3:01 p.m. with the Office Manager (OM), the OM stated that all employees are required to have yearly PPD tests, and CXR to verify for TB are required every five (5) years. In addition, the OM also confirmed that the RN did not have an updated PPD test located in the employee personnel file. During a review of the facility’s policy and procedure (P&P) titled, “Personnel Record Contents,” dated 1/2019, the P&P indicated in part, “…Homemaker-Home-Health aide services are supervised every fourteen (14) days.” Another facility P&P was reviewed titled, “Missed Visits,” dated 4/2011indicated in part, “New Hire Documents: TB Mantoux Test Documentation or CXR record within 5 years…[agency name] will maintain TB Mantoux Test documentation annually.” During a review of the P&P titled, “Clinical record Review,” dated 5/2024, the P&P indicated, “Clinical records will be reviewed at least annually by qualified organization personnel to assure that documentation entered is reliable, timely, valid and accurate. The record review shall reflect the scope of the QAPI program to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. The frequency and detail of the data collection shall be approved by the organization’s governing body…1. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor Performance Improvement Coordinator, Clinical Director or designees for: A. Timeliness of entries into the clinical record…C. Compliance with organizational policy…F. Accuracy of the clinical records.””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure that supervisory nurse (RN) home visits were implemented no less than 14 days as indicated in the facility policy for one (Patient 3) of 7 patients. This failure had the potential to compromise oversight of patient care, delay identification of changes in condition, and increase the risk of unmet needs. Findings: During a record review on 9/24/25 at 3:57 p.m. it was identified that a supervisory nurse (RN) visit was missed for Patient 3 for the week of 09/14/2025 through 09/20/2025. During an interview on 9/24/25 at 4:08 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed that an RN visit was missed the week of 09/14/2025 through 09/20/2025 and acknowledged that there should have been a supervisory nurse visit during that week. DPCS also verified that there was no documentation indicating that Patient 3’s physician was notified, and there was no evidence of documentation indicating that the RN had attempted to reschedule the missed visit. During a review of the facility’s policy and procedure (P&P) titled, “Supervision,” dated 4/2011, the P&P indicated in part, “…Homemaker-Home-Health aide services are supervised every fourteen (14) days.” During a review of the P&P titled, “Missed Visits,” dated 4/2011, the P&P indicated, “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained….If a visit is missed and not rescheduled, the clinician will: Notify the physician and clinical supervisor of the missed visit and reason for the missed visit.””