Eagletail Health Care LLC

“Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services; This Element is not met as evidenced by: Based on interview and record review, the agency failed to appropriately discharge a patient. Specifically, for 1 of 2 sample patients who were discharged from the agency, the agency did not ensure the physician responsible for the home health plan of care agreed the patient no longer needed services (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 3/4/26. Plan of care orders for the certification period dated 12/3/25 to 1/31/26 revealed a start of care date of 12/3/25; diagnoses included aftercare due to unspecified fracture of lower end of right femur, chronic pain due to trauma, and type 2 diabetes mellitus. Plan of care orders included physical therapy to evaluate and treat and skilled nursing twice per day for medication assistance. a) The agency failed to communicate with the physician prior to discharge to ascertain whether the patient continued to need services. Review of the clinical record revealed a discharge summary completed by a registered nurse (RN) on 1/7/26 with “goals met” as the reason for discharge of Patient #4. Review of the clinical record revealed no visits to Patient #4 had been completed between 12/10/25 and 1/7/25. A communication note written by an RN documented the agency contacted the physician office on 12/23/25 to report Patient #4 had not responded to phone calls or door visits for over five days. No communication regarding a reply from the physician was documented, and no further communication with the physician was documented prior to Patient #4’s discharge on 1/7/26. During an interview with the agency administrator at 2:45 p.m. on 3/5/26, the administrator stated the discharge reason for Patient #4 had not been documented correctly. The administrator stated he had never before encountered a patient who did not respond to calls or open the door for visits, and he had not known how the agency should discharge a patient if that occurred.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to document the existence and resolution of a patient complaint (Patient #2). Additionally, the agency failed to document complaints from January 1, 2026 to March 5, 2026. Findings include: 1. The clinical record for Patient #2 was reviewed on 3/5/26. Plan of care orders for the certification period dated 2/27/26 to 4/27/26 revealed a start of care date of 3/4/25; diagnoses included emphysema and chronic respiratory failure. Plan of care orders included skilled nursing once per week for medication management. a) The agency failed to document the existence and resolution of a complaint for Patient #2. During an interview with Patient #2 at 12:21 p.m. on 3/5/26, Patient #2 stated she had complained to the agency administrator regarding a personality conflict she had experienced with a nurse in 2025. She stated the administrator handled the complaint to her satisfaction by scheduling a different nurse for visits. Review of agency documents revealed the complaint made by Patient #2 was not documented in the log the agency kept for complaints during the year 2025. During an interview with the agency administrator at 12:35 p.m. on 3/5/26, the administrator stated he had resolved the complaint right away by scheduling a different nurse to see Patient #2, and he stated he believed the existence of the complaint did not need to be documented because it was immediately resolved. 2. Agency documents were reviewed on 3/4/26 and 3/5/26. a) The agency failed to document complaints. Review of agency documents revealed no complaint log was kept from January 1, 2026 through March 5, 2026. During an interview with the agency administrator at 2:45 p.m. on 3/4/26, the administrator stated the agency had not had any complaints that needed to be documented in 2026 because issues had been resolved quickly. The administrator stated he had not known all complaints and their resolutions should be documented regardless of how quickly they were resolved.”

“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 agency failed to complete the comprehensive assessment within 5 calendar days from the start of care. Specifically, the agency did not complete a physical therapy assessment as part of the comprehensive assessment, ordered by the referring physician, at the start of care for 1 of 5 sample patients (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 3/4/26. Plan of care orders for the certification period dated 12/3/25 to 1/31/26 revealed a start of care date of 12/3/25; diagnoses included aftercare due to unspecified fracture of lower end of right femur, chronic pain due to trauma, and type 2 diabetes mellitus. Plan of care orders included physical therapy to evaluate and treat and skilled nursing twice per day for medication assistance. a) The agency failed to complete a physical therapy assessment as part of the comprehensive assessment as ordered by the referring physician. Review of the clinical record revealed a physician referral, dated 12/2/25, for home health services for skilled nursing and physical therapy to evaluate and treat Patient #4. Record review revealed a skilled nursing assessment was completed on 12/3/25. Record review did not reveal an assessment by a physical therapist or documentation regarding why the assessment was not completed. During an interview with the agency administrator at 3:15 p.m. on 3/4/26, the administrator stated the physical therapist had tried to set an appointment with Patient #4, but had not been able to reach the patient. The administrator stated the physician should have been notified and the administrator acknowledged the physical therapist’s attempts to reach the patient should have been documented in the chart.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to conform with physician orders. Specifically, the agency did not ensure skilled nursing visits and physical therapy services were provided for 1 of 5 sample patients (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 3/4/26. Plan of care orders for the certification period dated 12/3/25 to 1/31/26 revealed a start of care date of 12/3/25; diagnoses included aftercare due to unspecified fracture of lower end of right femur, chronic pain due to trauma, and type 2 diabetes mellitus. Plan of care orders included physical therapy to evaluate and treat and skilled nursing twice per day for medication assistance. a) The agency failed to ensure skilled nursing and physical therapy visits were completed as ordered. Review of the clinical record revealed no physical therapy visits had been completed during the dates of service, and skilled nursing visits to Patient #4 had been marked as “missed visits” for 27 days from 12/11/25 to 1/7/25 when the patient was discharged. During an interview with the agency administrator at 2:40 p.m. on 3/5/26, the administrator stated on 12/23/25 the physician was notified the consumer was not responding to phone calls or door visits for over five days. The administrator stated he had never before encountered a consumer who did not respond to calls or open the door for visits, and he had not known the agency should document the agency’s attempts to ensure the safety of the consumer and the outcome of each attempt.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure communication with physicians involved in the plan of care. Specifically, for 1 of 5 sample patients, the agency did not document communication with the physician (Patient #4). Findings include: The clinical record for Patient #4 was reviewed on 3/4/26. Plan of care orders for the certification period dated 12/3/25 to 1/31/26 revealed a start of care date of 12/3/25; diagnoses included aftercare due to unspecified fracture of lower end of right femur, chronic pain due to trauma, and type 2 diabetes mellitus. Plan of care orders included physical therapy to evaluate and treat and skilled nursing twice per day for medication assistance. a) The agency failed to document communication with the physician involved in the plan of care. Review of the clinical record revealed a physical therapy assessment was not completed at the start of care and skilled nursing visits were documented as missed for 27 days for Patient #4. A communication note written by a registered nurse documented the agency contacted the physician office on 12/23/25 to report Patient #4 had not responded to phone calls or door visits for over five days. No communication regarding a reply from the physician was documented, and no further communication with the physician was documented prior to Patient #4’s discharge on 1/7/26. During an interview with the agency administrator at 2:45 p.m. on 3/5/26, the administrator stated he did not know if a response had been received from the physician or if other attempts had been made. The administrator stated physicians are sometimes difficult to contact and acknowledged the attempts to contact the physician should all be documented in order to ensure the physicians involved in the plan of care are aware of the patient’s status.”