American Excel Home Health Care

“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 observation, interview and record review, the agency failed to ensure the Plan of Care (POC) were specific to the care needs for three of seven sampled patients (Patient 4, Patient 5, and Patient 6) when the Clinical Supervisor (CS) did not complete all nursing interventions during the home visits for Patient 4, 5 and 6. These deficient practices had the potential to lead to unmet care needs. During a review of Patient 4’s clinical record, the POC for the certification period 7/5/26 to 9/2/26 indicated, Patient 4 had a start of care on 5/6/26 with a diagnosis including Dementia ( a condition that causes problems with memory and thinking), Parkinsonism (a condition that causes slow movement, muscle stiffness, shaking, and difficulty with balance or walking), Diabetes Mellitus Type 2 (DM2- a condition where the body does not use insulin properly, causing too much sugar to build up in the blood.) During a concurrent observation and record review, of Patient 4’s home visit on 8/6/26 at 1 p.m., with CS, CS did not complete all the nursing interventions listed on Patient 4’s POC. During a review of Patient 4’s clinical record, the nursing interventions were not person centered, and no documented evidence that all the nursing interventions were completed from the home visit conducted on 8/6/26. During an interview on 8/7/26 at 11:40 a.m., with CS, the CS stated that the POC is not individualized because the software provides generic interventions. CS indicated he did not modify the POC to make it person centered for Resident 4. CS further stated that he did not complete all nursing interventions listed during Resident 4’s home visit. CS stated that not following POC can lead to unmet care needs. During a review of agency’s Policy and Procedure (P&P) titled, “Care Planning Process” undated, the P&P indicated,” will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver… Individualized patient needs and resultant problems related to care, functional status, and family/caregiver support systems... The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. …” During a review of Patient 5’s clinical record, the Plan of Care (POC) for the certification period 7/30/26-9/27/26 indicated Patient 5. Patient 5 had a start of care date 7/30/26 with several diagnosis including Type 2 Diabetes with diabetic chronic kidney function (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During review of a Skilled Nurse (SN) Visit note from 8/6/26 indicated, done with documentation that indicated, “No blood sugar check. Has medication controlled.” During a concurrent observation and record on 8/6/2 at 11:40 a.m., observed a home visit at the Walnut House (a skilled nursing facility) with the Clinical Supervisor (CS), the CS did not complete all the interventions on the plan of care including, “SN to instruct patient caregiver on all aspects of diabetic management to include the disease process... glucometer use and preparation and administration of diabetic medications disorder by physician.” During an interview on 8/7/26 at 11:27 a.m. with the CS, the CS confirmed that he did not do all the interventions on the plan of care including diabetic teaching. He stated that he is not sure if the assisted living facility does blood sugar checks or checks Patient 5’s lab work regarding her diabetes. He further stated that the care plans are computer generated and not person centered. During an interview on 8/7/26 at 11:41 a.m. with the Administrator (ADM), the ADM stated the expectation is the plan of care (POC) should be person centered and updated. If the POC is not person centered, it may indicate the clinician is not providing care to meet the patient’s individualized needs and it is not best practice. During a review of agency’s Policy and Procedure (P&P) titled, “Care Planning Process” undated, the P&P indicated,” will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver… Individualized patient needs and resultant problems related to care, functional status, and family/caregiver support systems... The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. …” During a review of Patient 6’s clinical record, the POC for the certification period of 7/27/26 through 9/24/26 indicated Patient 6 had a start of care (SOC) of 1/28/26 with a diagnosis of urinary tract infection (UTI- an infection in the bladder/urinary tract). During a concurrent observation and record review of Patient 6’s home visit on 8/6/26 at 10 a.m., with Clinical Supervisor (CS), CS did not complete all nursing interventions listed on Patient 6’s POC. During an interview on 8/7/26 at 11:41 a.m. with the Administrator (ADM), the ADM stated the expectation is the POC should be person centered and updated. If the POC is not person centered, it may indicate the clinician is not providing care to meet the patient’s individualized needs and it is not best practice. During an interview on 8/7/26 at 11:55 a.m., with CS, the CS stated that the POC is not individualized because the software provides generic interventions. CS indicated he did not modify the POC to make it person centered for Resident 6. CS further confirmed that he did not complete all nursing interventions listed during Resident 6’s home visit. CS stated that not following POC can lead to unmet care needs. During a review of agency’s Policy and Procedure (P&P) titled, “Care Planning Process” undated, the P&P indicated,” will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver… Individualized patient needs and resultant problems related to care, functional status, and family/caregiver support systems... The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. …””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to complete comprehensive assessment within 5 days from start of care for two out of seven sampled patients (Patient 1 and Patient 2). These failures had the potential for Patient 1 and Patient 2 not to receive needed health care services. Findings: 1a. A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 3/7/26 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting left nondominant side and other speech/language deficits. A review of Patient 1’s home health referral order, dated 3/3/26, indicated, “MAY DISCHARGE HOME WITH FAMILY ON 3.6.2026 WITH HOME HEALTH TO FOLLOW WITH RN (Registered Nurse)/PT (Physical Therapist)/OT (Occupational Therapist).” A review of Patient 1’s frequency order, dated 3/7/26, indicated, “...Occupational Therapy (OT): for eval [evaluate]. and treat.” A review of Patient 1’s OT evaluation (assessment) was done on 3/13/26, which was more than 5 days from the start of care. 1b. A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the HHA on 9/11/25 and had diagnoses that included cutaneous abscess of buttock (a painful, localized pocket of pus under the skin) and open wound of left buttock. A review of Patient 2’s home health referral order, dated 9/8/25, indicated, “...HOME HEALTH SERVICES AND REFERRAL: RN, PT, OT...HHA (Home Health Aide) ...” A review of Patient 2’s frequency order, dated 9/12/25, indicated, “...OT Q [every] Weekly x 3 [for three times].” A review of Patient 2’s OT evaluation (assessment) was done on 9/17/25, which was more than 5 days from the start of care. During a concurrent interview and record review on 8/6/26 at 12:32 p.m. with the Administrator (Adm), Patient 1 and Patient 2’s clinical records were reviewed. The Adm confirmed that Patient 1 and Patient 2’s OT evaluations (assessments) were both not done within 5 days from their start of care. The Adm stated she would expect evaluations to be completed within 5 days from start of care date to complete the comprehensive assessment unless there was a valid order to move the evaluation date. A review of the agency’s undated policy and procedure (P&P) titled, “INITIAL AND COMPREHENSIVE ASSESSMENT”, indicated, “...To provide guidelines for the initial assessments of patients admitted to service and for completing plans of care...A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care.””

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation, interview and record review the agency failed to ensure the care giver responsible for assisting Patient 4 and Patient 5 received necessary teaching and instruction when: Medication reconciliation and teaching was not done with the caregiver for Patient 5. Medication teaching for nitroglycerin (treatment for heart-related chest pain) and blood glucose (sugar) monitoring was provided to Patient 4. These failures reduced the agency’s 2) During a review of Patient 4’s clinical record, the Plan of Care (POC) for the certification period 7/5/26 to 9/2/26 indicated, Patient 4 had a start of care on 5/6/26 with a diagnosis including Dementia, Parkinsonism (a condition that causes slow movement, muscle stiffness, shaking, and difficulty with balance or walking), Diabetes Mellitus Type 2 (DM2- a condition where the body does not use insulin properly, causing too much sugar to build up in the blood.) The POC directed teaching nitroglycerin use and blood sugar monitoring to Patient 4. The caregiver was not identified in the POC as a recipient of the teaching. Further review of the Clinical record (CR) indicated, no documented evidence that teaching or instruction related to nitroglycerin use and blood glucose monitoring were provided to the caregiver who was responsible for performing these aspects of Patient 4’s care. During a concurrent observation and record review, of Patient 4’s home visit on 8/6/26 at 1 p.m., with Clinical Supervisor (CS), CS performed an assessment of Patient 4. CS asked orientation questions, and Patient 4 was unable to correctly answer the orientation questions. Patient 4 was oriented to name only. No teaching or instruction related to nitroglycerin use or how to do blood glucose monitoring were observed and provided to the patient and or to the caregiver. During an interview on 8/6/26 at 1:45 p.m. with caregiver (CG)1, CG stated, she manages Patient 4’s medication and performs Patient 4’s blood sugar checks daily and as needed. CG 1 stated, “…he has dementia, and he does not remember anything.” During an interview on 8/7/26 at 11:40 a.m., CS confirmed care plan indicated that teaching was directed to the patient and did not include the caregiver. CS further stated, care plan teaching must include the caregiver since Patient 4 has dementia and confusion. During a review of the facility’s policy and procedure titled. “ Patient Education Process,” undated, indicated, “…Patient and family/caregivers will receive education in verbal, visual, and written format…scope of teaching will be determined by assessing the needs, abilities, learning preferences and readiness to learn…” 1. During a review of Patient 5’s clinical record, the Plan of Care (POC) for the certification period 7/30/26 through 9/27/26 indicated Patient 5. Patient 5 had a start of care date 7/30/26 with several diagnosis including Type 2 Diabetes with diabetic chronic kidney function (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Hypertension (High blood pressure) and Congestive heart failure (a condition where the heart does not pump blood well). During a review of Patient 5’s POC indicated, a Skilled Nursing (SN) Intervention of, “SN to instruct Patient/Caregiver side effects to report to Skilled Nurse (SN) or physician and SN to determine if the patient slash caregiver is able to identify the correct dose route and frequency of each medication.” During an observation of the home visit at the Walnut House (an assisted living facility) on 8/6/26 at 11:40 a.m., with the Clinical Supervisor (CS), the CS read a list of the medications that Patient 5 was taking to Patient 5. The CS did not discuss side effects to report to SN or physician and did not discuss the medications with the caregivers at the facility. During an interview on 8/7/26 at 11:27 a.m., with the CS, the CS confirmed that he did not discuss side effects with Patient 5 or reconcile medications with the caregivers at the facility. The CS stated that Patient 5 does not manage her own medications, and he believes the medical assistant administers the medications, but he is not sure. During an interview on 8/7/26 at 12:18 a.m. with the Administrator (ADM), the ADM stated the expectation is that the SN reconcile the medications with the facility staff. A potential problem is that the SN may miss patient side effects of medications and not communicate to provider. This could be a break in coordination of care. Review of the agency’s Policy and Procedure (P&P) titled, “Patient Education Process” undated, the P&P indicated, “ the patient and family/caregiver will receive instructions on…medication management and administration…documentation of patient and family/caregiver education will consist of…describing the patient’s response to teaching including the level of understanding.””

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide home health aide services as ordered by a physician for one out of seven sampled patients (Patient 2). This failure had the potential for Patient 2 not to receive needed home health aide services and continuity of needed patient care. Findings: A review of Patient 2’s clinical records indicated Patient 2 had a start of care date with the HHA on 9/11/25 and had diagnoses that included cutaneous abscess of buttock (a painful, localized pocket of pus under the skin) and open wound of left buttock. A review of Patient 2’s home health referral order, dated 9/8/25, indicated, “...HOME HEALTH SERVICES AND REFERRAL: RN, PT, OT...HHA (Home Health Aide) ...” A review of Patient 2’s frequency order, dated 9/12/25, indicated, “...HHA Q [every] weekly and as needed.” During a concurrent interview and record review on 8/6/26 at 12:32 p.m. with the Administrator (Adm), Patient 2’s clinical records were reviewed. The Adm confirmed that there were no home health aide services provided to Patient 2. The Adm stated the home health aide services should have been provided to Patient 2 since it was ordered. During a concurrent interview and record review on 8/7/26 at 1:44 p.m. with the Assistant Administrator (AAdm), Patient 2’s clinical records were reviewed. The AAdm confirmed that there were no home health aide services provided to Patient 2. The AAdm stated there should have been an order to discontinue the home health aide referral if the services would not be provided. A review of the agency’s policy and procedure (P&P) titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE”, undated, indicated, “...A physician will direct the care of every home health patient admitted for service. The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically required for the patient...The attending physician will sign the plan of care/treatment within 30 days of the start of care, unless otherwise specified by applicable state law and regulation...” A review of the agency’s P&P titled, “ORIENTATION OF ASSIGNED PERSONNEL”, undated, indicated, “...Home Health Aides...Personal care and support services provided will be based on the initial and ongoing assessments of patient needs, as conducted by a nurse or therapist in the patient’s home...””

“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 interview and record review, the home health agency (HHA) failed to ensure that discharge summary for one out of seven sampled patients (Patient 3) was sent to their primary care practitioner (PCP) within 5 business days of their discharge from the agency. This failure had the potential for Patient 3 not to receive continuous treatment and care after their discharge from the agency. Findings: A review of Patient 3’s clinical records indicated Patient 3 had a start of care date with the HHA on 5/6/26 and had diagnoses that included Liver cirrhosis (a late-stage liver scarring where healthy tissue is permanently replaced by scar tissue, impairing blood flow and organ function) and Hepatitis C (a viral infection that causes liver inflammation). A review of Patient 3’s discharge document titled, “Discharge Summary”, dated 6/25/26, indicated that Patient 3 was discharged from the agency on 6/25/26. During a concurrent interview and record review on 8/6/26 at 12:32 p.m. with the Administrator (Adm), Patient 3’s clinical records were reviewed. The Adm confirmed that Patient 3 was discharged from their agency on 6/25/26. The Adm further confirmed that there was no documentation that Patient 3’s discharge summary was sent to the patient’s physician. The Adm stated that it was in their process to send the patient’s discharge summary to the patient’s physician within 5 business days after their discharge from the agency. A review of the agency’s policy and procedure (P&P) titled, “DISCHARGE SUMMARY”, undated, indicated, “...Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record...A copy of the discharge summary will be provided to the patient’s physician...””