Pro-Health Nursing Services, Inc.

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency failed to: Ensure that the required in-person encounter with the patient during a home visit was conducted to complete the Recertification Outcome and Assessment Information Set (OASIS) (G0370) and Ensure the accuracy of the encoded OASIS Data without benefit of required in-person encounter with the patient during a home visit (G0374). The cumulative effect of these systemic practices resulted in the Home Health Agency inability to ensure that the patients’ needs would be met. The findings Include: 1) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-! for Patient #1 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 05/23/2025 and electronically signed by the Administrator documents that a “Visit” on 05/23/2025 that “”Started” at 8:30 AM and “Ended” at 9:15 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Muscle Wasting and Atrophy NEC (Not Elsewhere Classified). Continued review of the Comprehensive Assessment and OASIS E-1 Recertification dated 05/23/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; the patient has “at least 1 unhealed Pressure Ulcer at Stage 2 or higher designated as unstageable” but the Norton Pressure Score Risk Assessment is blank; the heading for Prognosis Supportive Assistance, Safety Measures, Sensory Assessment, Pain Assessment, Integumentary (Skin) Status, Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, Musculoskeletal Assessment are left blank.” Further review of the “Functional Status for Grooming” documents that the “Patient depends entirely upon someone else for grooming needs although the “Caregiver Status” is left blank. Continued review reveals the Neurological Assessment documents the patient is “oriented to person, place and time but the “Mental and Cognitive Status” is left blank. Further review reveals all areas of “Dressing Ability,” Bathing/Toileting” and “Self-Care” documents dependence, “ Patient depends entirely upon another person to dress, eat, bathe and toilet;” for Transferring, Ambulation/Locomotion; documentation reveals the patient is “bedfast,” with Functional Limitations left “blank” and all areas of “Mobility” document “dependence” although the question, “Does the patient use a wheelchair and or scooter”, documents, “Yes.” Documentation reveals that the patient can “wheel 50 feet with two turns; once seated in the wheelchair/ scooter, the ability to wheel at least at least 50 feet and make two turns.” Continued review reveals no evidence of documentation of an Endocrine/Hematological, Nutritional/Nutritional Requirements Assessment. Patient #1 was contacted via telephone 12/06/2025 at 11:30 AM and the family member was asked if the RN/Administrator has ever been to the patient’s home to perform a Comprehensive Assessment including OASIS and stated, “No.” 2) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-1 for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 09/02/2025 and electronically signed by the Administrator documents that a “Visit” on 09/02/2025 that “”Started” at 10:00 AM and “Ended” at the same time, 10:00 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Multiple Sclerosis, Gastro-Esophageal Reflux Disease without Esophagitis, Hypothyroidism, Other Abnormalities of Gait and Mobility, and Anemia Unspecified. Continued review of the Comprehensive Assessment and OASIS E-1 Recertification dated 09/02/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; for “Potential Risk For Infection Assessment” documentation reveals “Poor Mobility, no risk for infection; “Supportive Assistance, no willing or able caregiver to assist;” the heading for Integumentary Status documents, “No problems identified; “Norton Pressure Sore Risk Assessment documents, “fair for physical condition’” Activity, “walks with help, mobility is slightly impaired;” Pressure Ulcer, no;” Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, “No problems identified;” Musculoskeletal Assessment documents, “Joint pain, poor balance, shuffling gait, high risk for falls, muscle weakness, unsteady gait.” Further review of the “Functional Status for Grooming” documents that “someone must assist the patient to groom self;” Continued review reveals all areas of “Dressing Ability Upper and Lower Body reveals, “Someone must help patient.” Bathing/Toileting” and “Self-Care” documents the requirement of another person to assist; able to trans to transfer with minimal human assistance or with the use of an assistive device; Ambulation/Locomotion; documentation reveals the patient requires the use of a two-handed device to walk alone on a level surface and or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces; Functional Limitations, ambulation, dyspnea with moderate exertion and endurance; Eating ability documents, “needs supervision or assistance; toileting hygiene, needs partial to moderate assistance;” Patient #2 was contacted via telephone 12/08/2025 at 3:30 PM and asked her if the RN/Administrator has ever been to their home to perform a Comprehensive Assessment including OASIS and stated “No, however, she has called a few times and asked some questions.” During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-! for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 11/01/2025 and electronically signed by the Administrator documents that a “Visit” on 11/01/2025 that “”Started” at 10:30 AM and “Ended” at 11:30 AM, reveals the exact same documentation from the “Visit” on 09/02/2025 except for the time. During an interview on 12/08/2025 at 11:00 AM, the Administrator was shown both Comprehensive Assessment and OASIS documents and had no comment as to the similarity.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency failed to: Ensure that the required in-person encounter with the patient during a home visit was conducted to complete the Comprehensive Assessment (G0510) and Ensure the completion of the Comprehensive Assessment to provide a complete picture of the patient’s status thereby assisting in the development of the patient’s plan of care (G0528). The cumulative effect of these systemic practices resulted in the Home Health Agency inability to ensure that the patients’ needs would be met. The findings Include: 1) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment for Patient #1 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment Recertification dated 05/23/2025 and electronically signed by the Administrator documents that a “Visit” on 05/23/2025 that “”Started” at 8:30 AM and “Ended” at 9:15 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Muscle Wasting and Atrophy NEC (Not Elsewhere Classified). Continued review of the Comprehensive Assessment Recertification dated 05/23/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; the Norton Pressure Score Risk Assessment is blank; the heading for Prognosis Supportive Assistance, Safety Measures, Sensory Assessment, Pain Assessment, Integumentary (Skin) Status, Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, Musculoskeletal Assessment are left blank.” Further review of reveals the “Caregiver Status” is left blank. Continued review reveals the Neurological Assessment documents the patient is “oriented to person, place and time but the “Mental and Cognitive Status” is left blank. Continued review reveals no evidence of documentation of an Endocrine/Hematological, Nutritional/Nutritional Requirements Assessment. There is no evidence of a “Medication Status, Medication Review, Durable Medical Equipment, Patient Rights Assessment and Visit interventions,” Patient #1 was contacted via telephone 12/06/2025 at 11:30 AM and the family member was asked if the RN/Administrator has ever been to the patient’s home to perform a Comprehensive Assessment including OASIS and stated, “No.” 2) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment Recertification dated 09/02/2025 and electronically signed by the Administrator documents that a “Visit” on 09/02/2025 that “”Started” at 10:00 AM and “Ended” at the same time, 10:00 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Multiple Sclerosis, Gastro-Esophageal Reflux Disease without Esophagitis, Hypothyroidism, Other Abnormalities of Gait and Mobility, and Anemia Unspecified. Continued review of the Comprehensive Assessment Recertification dated 09/02/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; for “Potential Risk For Infection Assessment” documentation reveals “Poor Mobility, no risk for infection; “Supportive Assistance, no willing or able caregiver to assist;” the heading for Integumentary Status documents, “No problems identified; “Norton Pressure Sore Risk Assessment documents, “fair for physical condition’” Activity, “walks with help, mobility is slightly impaired; Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, “No problems identified;” Musculoskeletal Assessment documents, “Joint pain, poor balance, shuffling gait, high risk for falls, muscle weakness, unsteady gait.” Further review of the Functional Limitations documents ambulation, dyspnea with moderate exertion and endurance. Patient #2 was contacted via telephone 12/08/2025 at 3:30 PM and asked her if the RN/Administrator has ever been to their home to perform a Comprehensive Assessment including OASIS and stated “No, however, she has called a few times and asked some questions.” During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment E-! for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator Review of the Comprehensive Assessment Recertification dated 11/01/2025 and electronically signed by the Administrator documents that a “Visit” on 11/01/2025 that “”Started” at 10:30 AM and “Ended” at 11:30 AM, reveals the exact same documentation from the “Visit” on 09/02/2025 except for the time. During an interview on 12/08/2025 at 11:00 AM, the Administrator was shown both Comprehensive Assessment and OASIS documents and had no comment as to the similarity.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency failed to ensure that the required in-person encounter with the patient during a home visit was conducted to complete the Recertification Outcome and Assessment Information Set (OASIS) and that the OASIS data transmitted to the Centers For Medicare And Medicaid (CMS) is consistent with the current status of the patient at the time the OASIS was completed for 2 of 6 sampled patients (Patient #1 and #2). The findings Include: 1) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-1 for Patient #1 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 05/23/2025 and electronically signed by the Administrator documents that a “Visit” on 05/23/2025 that “”Started” at 8:30 AM and “Ended” at 9:15 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Muscle Wasting and Atrophy NEC (Not Elsewhere Classified). Continued review of the Comprehensive Assessment and OASIS E-1 Recertification dated 05/23/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; the patient has “at least 1 unhealed Pressure Ulcer at Stage 2 or higher designated as unstageable” but the Norton Pressure Score Risk Assessment is blank; the heading for Prognosis Supportive Assistance, Safety Measures, Sensory Assessment, Pain Assessment, Integumentary (Skin) Status, Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, Musculoskeletal Assessment are left blank.” Further review of the “Functional Status for Grooming” documents that the “Patient depends entirely upon someone else for grooming needs although the “Caregiver Status” is left blank. Continued review reveals the Neurological Assessment documents the patient is “oriented to person, place and time but the “Mental and Cognitive Status” is left blank. Further review reveals all areas of “Dressing Ability,” Bathing/Toileting” and “Self-Care” documents dependence, “ Patient depends entirely upon another person to dress, eat, bathe and toilet;” for Transferring, Ambulation/Locomotion; documentation reveals the patient is “bedfast,” with Functional Limitations left “blank” and all areas of “Mobility” document “dependence” although the question, “Does the patient use a wheelchair and or scooter”, documents, “Yes.” Documentation reveals that the patient can “wheel 50 feet with two turns; once seated in the wheelchair/ scooter, the ability to wheel at least at least 50 feet and make two turns.” Continued review reveals no evidence of documentation of an Endocrine/Hematological, Nutritional/Nutritional Requirements Assessment. Patient #1 was contacted via telephone 12/06/2025 at 11:30 AM and the family member was asked if the RN/Administrator has ever been to the patient’s home to perform a Comprehensive Assessment including OASIS and stated, “No.” 2) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-1 for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 09/02/2025 and electronically signed by the Administrator documents that a “Visit” on 09/02/2025 that “”Started” at 10:00 AM and “Ended” at the same time, 10:00 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Multiple Sclerosis, Gastro-Esophageal Reflux Disease without Esophagitis, Hypothyroidism, Other Abnormalities of Gait and Mobility, and Anemia Unspecified. Continued review of the Comprehensive Assessment and OASIS E-1 Recertification dated 09/02/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; for “Potential Risk For Infection Assessment” documentation reveals “Poor Mobility, no risk for infection; “Supportive Assistance, no willing or able caregiver to assist;” the heading for Integumentary Status documents, “No problems identified; “Norton Pressure Sore Risk Assessment documents, “fair for physical condition’” Activity, “walks with help, mobility is slightly impaired;” Pressure Ulcer, no;” Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, “No problems identified;” Musculoskeletal Assessment documents, “Joint pain, poor balance, shuffling gait, high risk for falls, muscle weakness, unsteady gait.” Further review of the “Functional Status for Grooming” documents that “someone must assist the patient to groom self;” Continued review reveals all areas of “Dressing Ability Upper and Lower Body reveals, “Someone must help patient.” Bathing/Toileting” and “Self-Care” documents the requirement of another person to assist; able to trans to transfer with minimal human assistance or with the use of an assistive device; Ambulation/Locomotion; documentation reveals the patient requires the use of a two-handed device to walk alone on a level surface and or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces; Functional Limitations, ambulation, dyspnea with moderate exertion and endurance; Eating ability documents, “needs supervision or assistance; toileting hygiene, needs partial to moderate assistance;” Patient #2 was contacted via telephone 12/08/2025 at 3:30 PM and asked her if the RN/Administrator has ever been to their home to perform a Comprehensive Assessment including OASIS and stated “No, however, she has called a few times and asked some questions.” During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment including OASIS (Outcome And Assessment Information Set) E-1 for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator Review of the Comprehensive Assessment and OASIS E-1 Recertification dated 11/01/2025 and electronically signed by the Administrator documents that a “Visit” on 11/01/2025 that “”Started” at 10:30 AM and “Ended” at 11:30 AM, reveals the exact same documentation from the “Visit” on 09/02/2025 except for the time. During an interview on 12/08/2025 at 11:00 AM, the Administrator was shown both Comprehensive Assessment and OASIS documents and had no comment as to the similarity.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency failed to: ensure the accuracy of the Comprehensive Assessment Data without the benefit of a required in-person encounter with the patient during an on-site home visit for 2 of 6 sampled patients (Patient #1 and #2). The findings Include: 1) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment for Patient #1 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment Recertification dated 05/23/2025 and electronically signed by the Administrator documents that a “Visit” on 05/23/2025 that “”Started” at 8:30 AM and “Ended” at 9:15 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Muscle Wasting and Atrophy NEC (Not Elsewhere Classified). Continued review of the Comprehensive Assessment Recertification dated 05/23/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; the Norton Pressure Score Risk Assessment is blank; the heading for Prognosis Supportive Assistance, Safety Measures, Sensory Assessment, Pain Assessment, Integumentary (Skin) Status, Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, Musculoskeletal Assessment are left blank.” Further review of reveals the “Caregiver Status” is left blank. Continued review reveals the Neurological Assessment documents the patient is “oriented to person, place and time but the “Mental and Cognitive Status” is left blank. Continued review reveals no evidence of documentation of an Endocrine/Hematological, Nutritional/Nutritional Requirements Assessment. There is no evidence of a “Medication Status, Medication Review, Durable Medical Equipment, Patient Rights Assessment and Visit interventions,” Patient #1 was contacted via telephone 12/06/2025 at 11:30 AM and the family member was asked if the RN/Administrator has ever been to the patient’s home to perform a Comprehensive Assessment including OASIS and stated, “No.” 2) During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator. Review of the Comprehensive Assessment Recertification dated 09/02/2025 and electronically signed by the Administrator documents that a “Visit” on 09/02/2025 that “”Started” at 10:00 AM and “Ended” at the same time, 10:00 AM. Further review reveals evidence that documents that the patient’s primary diagnosis is Multiple Sclerosis, Gastro-Esophageal Reflux Disease without Esophagitis, Hypothyroidism, Other Abnormalities of Gait and Mobility, and Anemia Unspecified. Continued review of the Comprehensive Assessment Recertification dated 09/02/2025 and electronically signed by the Administrator documents no evidence of vital signs taken; for “Potential Risk For Infection Assessment” documentation reveals “Poor Mobility, no risk for infection; “Supportive Assistance, no willing or able caregiver to assist;” the heading for Integumentary Status documents, “No problems identified; “Norton Pressure Sore Risk Assessment documents, “fair for physical condition’” Activity, “walks with help, mobility is slightly impaired; Respiratory Assessment, Cardiac Assessment Genitourinary Assessment, Gastrointestinal Assessment, “No problems identified;” Musculoskeletal Assessment documents, “Joint pain, poor balance, shuffling gait, high risk for falls, muscle weakness, unsteady gait.” Further review of the Functional Limitations documents ambulation, dyspnea with moderate exertion and endurance. Patient #2 was contacted via telephone 12/08/2025 at 3:30 PM and asked her if the RN/Administrator has ever been to their home to perform a Comprehensive Assessment including OASIS and stated “No, however, she has called a few times and asked some questions.” During an Interview on 12/02/2025 at 10:00 AM and again on 12/08/2025 at 11:00 AM, the Administrator/Registered Nurse (RN) and Chief Operating Officer (COO) both stated and acknowledged that the Comprehensive Assessment E-! for Patient #2 was conducted by the Administrator completely without benefit of an in person, in home visit and were conducted by telephone only by the Administrator Review of the Comprehensive Assessment Recertification dated 11/01/2025 and electronically signed by the Administrator documents that a “Visit” on 11/01/2025 that “”Started” at 10:30 AM and “Ended” at 11:30 AM, reveals the exact same documentation from the “Visit” on 09/02/2025 except for the time. During an interview on 12/08/2025 at 11:00 AM, the Administrator was shown both Comprehensive Assessment and OASIS documents and had no comment as to the similarity.”