Medical Services of America Home Health

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review, and staff interview, the agency failed to ensure the Condition of Participation for Quality Assessment/Performance Improvement (QA/PI) requirement was met by failing to ensure implementation of a Quality Assessment Program to monitor effectiveness, safety of services, and quality of care as well as develop, implement, evaluate, and maintain an effective, ongoing, Home Health Agency (HHA)-wide, data-driven program. Cross Reference G0644: Based on record reviews and interviews, the home health agency failed to ensure that quality indicator data collected was used to monitor the effectiveness, safety and quality of services provided, and failed to identify opportunities for improvement based on this data. Cross Reference G0658: Based on record review and staff interviews, the agency failed to conduct and document performance improvement projects to improve the quality of services provided with the potential to affect all patients. Cross Reference G0720: Based on QAPI program documents and interviews the home health agency failed to ensure all skilled staff including both direct employees and contracted staff provided input and participated in the implementation of the agency’s QAPI program. Cross Reference G0684: Based on record review and interview the home health agency failed to coordinate an agency wide infection control program as a part of the home health agency’s QAPI program”

“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 staff interview, and medical record review, the agency failed to ensure they encoded and electronically transmitted a completed OASIS (Outcome and Assessment Information Set) assessment to CMS (Centers for Medicare and Medicaid Services) system within 30 days of completing the assessment for 5 out of 12 patients sampled for medical records review, (#1, #4, #5, #6, #10) and failed to ensure a discharge OASIS was completed for a patient who had deceased, (#11). The findings include: Survey preparation review revealed that for the year 2024, the agency failed to ensure they encoded and electronically transmitted a completed OASIS (Outcome and Assessment Information Set) assessments to the CMS (Centers for Medicare and Medicaid Services) system within 30 days of completing the assessment for 72 out of 896 assessments made, with an error rate of 8.04%. Further review revealed a year to date (from January 1, 2025, thru January 31, 2025) error rate of 6 assessments out of 76, with an error rate of 7.89%. A review of twelve patient medical records revealed the agency failed to ensure they encoded and electronically transmitted a completed OASIS (Outcome and Assessment Information Set) assessment to the CMS (Centers for Medicare and Medicaid Services) system within 30 days of completing the assessment of the patient for five patients from a sample of twelve patient medical records reviewed: Patient #1: OASIS assessment completed 8/23/24; submitted to CMS 9/27/24; Patient #4: OASIS assessment completed 11/20/24; submitted to CMS 12/24/24; Patient #5: OASIS assessment completed 6/3/24; submitted to CMS 9/24/24; Patient #6: OASIS assessment completed 11/19/24; submitted to CMS 12/24/24; Patient #10: OASIS assessment completed 11/29/24; submitted to CMS 12/30/24; During an interview with Employee C (Clinical Manager) on 1/31/25 at 12:20pm, she was asked if she was aware of the late submission error rate, and if so, why were the assessments submitted late. She stated, “Yes, I am aware we have late submissions. First the chart goes to (an outside coding company) for coding, they are not always very quick to respond. It could be 2 or 3 days for the coding to get done. Then I’m the one who does the QA (Quality Assurance), then I send it to the clinician to sign, ask them to agree or disagree with any changes, then the clinician re-signs it and sends it back to me, then it gets packaged to be processed and sent in and exported to CMS. I am the only person doing this. I run about a month behind, because I am only one person. I was actually only running about 2 weeks behind when you all arrived, not 2 weeks late, but 2 weeks behind. I feel like if I could code myself in house, I could get it done faster, but that’s not how it’s done.” Patient #11 A review of the electronic medical record (EMR) for patient #11 revealed she was admitted to the agency on 8/19/24 for Hemiplegia (paralysis or weakness on one side of the body) following cerebral infarct (Stroke) of right dominant side. She was non-verbal and required assistance with all transfers, bed mobility, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and was non-ambulatory, her assist level is Max Assist and all transfers performed with total assist using a hoyer (a specialized medical device used to safely lift and transfer patients) lift. She was ordered to have physical therapy 2 visits a week for 4 weeks then 1 visit a week for 5 weeks. The EMR revealed the patient had visits on 8/19/24; 8/21/24; 8/28/24; 9/4/24; 9/11/24; 9/26/24; 9/30/24 and 10/07/24 by the Physical Therapist (PT) or the Physical Therapy Assistant (PTA). After the visit on 10/7/24 there is no further documentation of visits. There was no discharge summary or other discharge information noted in the EMR. On 10/16/24 the home health agency became aware that patient #11 had passed away on 10/8/24 when staff member A, Medical Records/Pre-biller spoke with the physician’s office. (cross reference G0430) On 1/29/24 at 11:11 AM an interview was conducted with the Clinical Manager during which the patient’s medical record was reviewed. She stated that there should have been a discharge OASIS for the patient because she had passed away. She stated that the visits are noted in the computer and stated that in looking at the visit list the last visit noted in the record was on 10/7/24. She verified that there was not a discharge OASIS.”

“Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: Based on staff interviews, medical record reviews, and agency policy review, it was determined that the agency failed to develop and implement an effective discharge planning process for 2 of 7 patients sampled for discharge, (#9, #10). A review of Patient #9’s medical record revealed he was discharged from skilled Physical Therapy (PT) services on 10/11/24 with the “reason for discharge: Discharge at this time to recover from scabies”. The medical record noted Patient #9 was a 75-year-old with diagnoses that included Alzheimer’s Disease, type 2 diabetes, back pain, history of falls, and other chronic pain. He was admitted to the agency for skilled physical therapy services on 4/15/24 and was recertified for skilled physical therapy services on 6/13/24 and 8/13/24. Further review revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15 at time of discharge that indicated he had severe cognitive impairment. An assessment noted he was at high risk for falls. Review of the patient’s medical record revealed he had pain level rated at 0/10 by the patient on 9/5/24 at 30-day evaluation. At time of discharge on 10/11/24, the medical record revealed a pain level rated at 5/10 by the patient with 3/6 unmet therapy goals and assessed as a high risk for falls. At time of discharge, no other therapy services were set up for the patient, with a plan, “Will discharge at this time for patient to fully recover from it.” During an interview with therapy Employee Q on 1/29/25 at 3:15 PM, she stated, “Yes, he was my patient. He was supposed to be discharged because they were trying to figure out if he had scabies. He kept getting rashes and was treated for scabies. They had dermatology involved and a wound care specialist but they couldn’t determine what he had. We had to make sure we used personal protective equipment to prevent any contamination. It was more an issue of infection control, and we had to discharge. He kept getting rashes, so we decided to discharge until they could determine the issue, so we wouldn’t risk any infections.” She noted the patient had not reached his therapy goals at time of discharge and the agency had not restarted therapy services for the patient after his discharge on 10/11/24. During an interview with Employee C (Clinical Manager Registered Nurse) on 1/30/25 at 10:30 AM, she stated, “He was discharged at that time for patient to fully recover from scabies.” Employee C reviewed the patient’s medical record and talked about his therapy goals. She explained his goals were, “partially met. Not all his goals were met, improved balance, increased gait 300-500 feet, improved functional lower extremity strength were not met.” She confirmed he was not referred to any other therapy services at time of discharge. She discussed his discharge and reported it was not an appropriate discharge, “ As a nurse, there are preventive measures that can be provided, so I don’t think that was a reason for discharge. If it were me, I would not have allowed this discharge, I would have asked to add nursing to come in and assist with the case.” A review of the agency’s Discharge/Transfer Policy titled “Criteria for Discharge- Transfer Summary (revised 2/2024) revealed: Purpose: To ensure a standardized process for discharging patients from MSA Home Health Agency. Policy: Any discontinuation of care, treatment, and/or services should be done in an appropriate manner and in such a way as to prevent harm to the patient. The patient’s continuing care, treatment, and service needs should be assessed at discharge. Patients who have a continuing care need should receive written and verbal instructions and should be informed of available community resources that may be utilized to meet those needs. On 1/28/25 at 2:30 PM, a review of the list of discharged patients provided by the agency noted an entry where patient #10 was discharged at the request of the Assisted Living Facility’s (ALF) Coordinator. In an interview with staff C, Clinical Manager/Registered nurse (RN), on 1/28/25 at 2:40 PM, she stated patient #10 was discharged at the request of the ALF Administrator. Staff C stated the Administrator was the building owner but clarified was not the patient’s representative. On 1/28/25 at 2:50 PM, record review for patient #10 indicated her daughter as an emergency contact and that she did not have a designated representative listed. Patient #10 had signed her own consent. A communication note dated 1/23/25 at 2:34 PM, written by staff Q, physical therapist (PT) to staff C noted that staff J Registered nurse (RN) went to complete a recertification visit with patient #10 but the ALF administrator informed the agency’s services were no longer needed. Staff J completed a discharge and a nursing visit note, dated 1/16/25 that documented a plan to recertify the patient and discharge when all goals were met. Review of the medical record noted patient #10 had unmet goals to include therapy goals as documented in a PT visit/re-evaluation by staff member Q. On 1/17/25, staff member Q, documented 4 unmet goals that read, “Patient will safely perform transfers from any seat surfaces within the facility with stand by assist to supervision in 7-8 weeks- progress 60%, Patient will adhere to medication treatment regimen within certification period- progress 70%, Patient and caregivers will manage lower extremity edema and control lower extremity edema and prevent any skin impairment in 8 weeks- progress 60% and Patient will gait train with 4WW (4 wheel walker) with supervision to modified independent 170-200 with improved gait speed 0.1 meters/second or better to go to church or MD (medical doctor) appointments safely- progress 60%.” Under clinical statement of assessment findings and recommendations, staff Q wrote, “With history of prior falls with injuries, MAHC-10 (fall risk assessment tool) score of 10/10, slow gait speed as noted by the 10 feet gait speed, patient was a high fall risk. Without skilled PT services, patient was at risk for further decline and falls. Daughter and caregivers wanted the patient to get stronger, improve independence with transfer and ambulation around the facility and reduce fall risk. They also wanted to manage lower extremity edema and prevent any wounds/blisters. Patient and daughter agreed to plan of care.” On 1/30/25 10:20 AM, during a telephone interview with staff Q, she stated it was their plan to recertify patient #10, but was told by staff C, that at the recertification appointment the ALF administrator told staff J they didn’t require their services any longer. With that information, Staff J discharged the patient from the agency. Staff J acknowledged the patient was alert and oriented and was not involved in the decision to discharge, Staff J confirmed the ALF was not the healthcare surrogate and did not have any legal right to make decisions on behalf of the patient. Staff J recalled the patient #10 said she was disappointed that she would not be coming back. On 1/30/2511:11AM during patient #10’s record review with staff C, she confirmed there was no alternative discharge plan in place for patient #10 to receive PT or skilled nursing services upon discharge.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record reviews and interviews, the home health agency failed to ensure quality indicator data collected was used to monitor the effectiveness, safety and quality of services provided, and failed to identify opportunities for improvement based on this data. On 1/28/25 at 12:12 PM the Clinical Manager was asked about their Quality Assurance Performance Improvement (QAPI) meeting agendas and sign in sheets. She replied that she had a log for weekly meetings she had with staff to discuss patients. The Performance Improvement Trending Sheet for the Agency dated January 16, 2025, was presented for review as their QAPI program information. She stated they did not meet to discuss the Agency’s Performance Measures. When directed to the information on the form presented for review and asked if they met and followed up on data as presented for review i.e. quarterly average of 82% improvement in bed transfer with a goal of 98%, a quarterly average of 87.6%, improvement in ambulation with a goal of 95%, a quarterly average of 68.6%, improvement in oral meds with a goal of 100%, a quarterly average of 87.6%, improvement in dyspnea with a goal of 97% and a quarterly average of 88.6%, she stated, “No.” She acknowledged they did not have any PIPs (performance improvement plans) in place for any of the quality measures listed. When asked if they met at least quarterly to discuss performance and quality issues and how patient care could be improved, she stated she had not been involved with a meeting like that, despite the fact the Performance Improvement Trending Sheet was dated 12 days prior. A review of the Pre-board meeting preparation report, which was presented as the agency’s QAPI meeting, identified attendees to include Executive Vice President, Chief Operations Officer, Chief Financial Officer, Executive Operations Manager, Vice President of Sales, Area Vice President of Sales, Regional Director of Marketing (DOM), and Area Vice President Operations only. The Regional DOM had been identified as the current interim administrator but was not identified as such on the report. The Clinical Manager was not listed as being present and no other skilled professional staff was documented as present or having participated. A review of the agency’s policy titled, “QAPI HH5002” revised 10/2024 revealed a Purpose: To define the Quality Assessment (QA) Performance Improvement (PI) process (QAPI) program. The agency develops, implements, evaluates, and maintains an effective, ongoing, HHA-wide, data driven QAPI program. It is the policy of (the agency) to measure process outcomes in order to facilitate improvement in the quality of patient care. Performance measures are selected based on their impact on patient/client care, age friendly criteria, services offered (includes all HHA services, including those services provided under contract or by arrangement), risk and safety, clinical practice, fiscal accountability, cost effectiveness and addresses the HHA’s performance across the spectrum of care, including prevention and reduction of medical errors. The program will be capable of showing measurable improvement indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. During a phone interview with Area Vice President (AVP) on 1/29/25 at 3:35 PM, she stated they had a QAPI program in place. She noted that the preboard meeting report that was given to the survey team represented the agency’s QAPI program meeting. She verified they did not have any meetings to discuss clinical data that was collected to determine areas to improve the quality of care and patient outcomes, or where processes were measured to determine the effectiveness of those processes.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review, and interview, the home health agency failed to conduct and document performance improvement projects (PIPs) to demonstrate measurable improvement indicators for which there was evidence that improvement in those indicators would improve health outcomes, patient safety and quality of care. On 1/28/25 at 12:12 PM the Clinical Manager was asked about their Quality Assurance Performance Improvement (QAPI) meeting agendas and sign in sheets. She replied that she had a log for weekly meetings she had with staff to discuss patients. The Performance Improvement Trending Sheet for the Agency dated January 16, 2025, was presented for review as their QAPI program information. She stated they did not meet to discuss the Agency’s Performance Measures. When directed to the information on the form presented for review and asked if they met and followed up on data as presented for review i.e. quarterly average of 82% improvement in bed transfer with a goal of 98%, a quarterly average of 87.6%, improvement in ambulation with a goal of 95%, a quarterly average of 68.6%, improvement in oral meds with a goal of 100%, a quarterly average of 87.6%, improvement in dyspnea with a goal of 97% and a quarterly average of 88.6%, she stated, “No.” She acknowledged they did not have any PIPs (performance improvement plans) in place for any of the quality measures listed. When asked if they met at least quarterly to discuss performance and quality issues and how patient care could be improved, she stated she had not been involved with a meeting like that, despite the fact the Performance Improvement Trending Sheet was dated 12 days prior. A review of the Pre-board meeting preparation report, which was presented as the agency’s QAPI meeting, identified attendees to include Executive Vice President, Chief Operations Officer, Chief Financial Officer, Executive Operations Manager, Vice President of Sales, Area Vice President of Sales, Regional Director of Marketing (DOM), and Area Vice President Operations only. The Regional DOM had been identified as the current interim administrator but was not identified as such on the report. The Clinical Manager was not listed as being present and no other skilled professional staff was documented as present or having participated. A review of the agency’s policy titled, “QAPI HH5002” revised 10/2024 revealed a Purpose: To define the Quality Assessment (QA) Performance Improvement (PI) process (QAPI) program. The agency develops, implements, evaluates, and maintains an effective, ongoing, HHA-wide, data driven QAPI program. It is the policy of (the agency) to measure process outcomes in order to facilitate improvement in the quality of patient care. Performance measures are selected based on their impact on patient/client care, age friendly criteria, services offered (includes all HHA services, including those services provided under contract or by arrangement), risk and safety, clinical practice, fiscal accountability, cost effectiveness and addresses the HHA’s performance across the spectrum of care, including prevention and reduction of medical errors. The program will be capable of showing measurable improvement indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. During a phone interview with Area Vice President (AVP) on 1/29/25 at 3:35 PM, she stated they had a QAPI program in place. She noted that the preboard meeting report that was given to the survey team represented the agency’s QAPI program meeting. She verified they did not have any meetings to discuss clinical data that was collected to determine areas to improve the quality of care and patient outcomes, or where processes were measured to determine the effectiveness of those processes.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate a coordinated and systematic agency-wide program for the surveillance, identification, prevention, and control of infections and failed to identify and treat infections for 1 of 12 (#12) patients reviewed. A review of the Agency’s policy entitled Infection Control Program HH4001 last revised on 10/2023 revealed Purpose: To reduce the risk of acquired or transmitted infections among (Home Health Agency) patients and staff through a formalized, coordinated, agency-wide program for surveillance, infection, prevention, control, and investigations of infections to reduce those risks. (The Home Health Agency) has established a comprehensive Infection Control Program to ensure that there is a functioning coordinated process in place, to reduce the risk of acquired and transmitted infections among patients and staff, and to optimize the use of resources. . . Monitoring is achieved through: infection control committee interaction with agency departments, functions, systems, and processes, daily job functions of the risk Manager, comparisons of current statistical information, historical data, and benchmarking on regular basis; regular policy and procedure reviews to ensure that infection control practices are incorporated into the appropriate policies and procedures; internal and external surveys and inspections. A review of the infection control program was conducted with the Clinical Manager on 1/30/25 at 4:29 PM. She stated that she is responsible for the Infection Control Program for the home health agency. She offers that she offers education to staff on hand washing, infection logs, bag technique, barriers, wound care, following sterile technique, and care of catheters. Any infections, physician orders for antibiotics and follow-up are reported on infection logs which are submitted by the nursing staff. The logs come to her “hot box” (an electronic system) then she logs the infection in her infection book or if patients are placed on antibiotics she puts it in the book. At this time, she presented a three-ring binder that had the months of October, November, and December, in separate tabbed sections. For October there was one infection noted for a Urinary tract infection (UTI), November had 4 infections 2 of which were UTIs, and December had one infection also noted to be a UTI. She reported that if staff do not submit the infection logs, she is not notified, she reported that there are no triggers or alerts in the electronic medical records system so if the staff do not report she is not aware. When asked how she tracks infections she stated that she was not aware of any system to track infections. She was asked if she had identified a pattern of infections, and she stated that she had not. When asked what she does with the infection control data she collected she had no response. At this time the Clinical Manager did offer an example of how infections were tracked in the agency. She referred the surveyor to patient #12 who she stated was known for having multiple urinary tract infections, but did not appear on the infection logs. At this time the patient’s EMR was reviewed which revealed an order dated 12/13/24 for a STAT (immediate) urinalysis. Further review of the record revealed the result had been returned to the Home Health Agency on 12/14/24 at 8:08 AM with the following result Clarity noted as Hazy, Leukocyte Esterase 3+; Protein 1+; Blood 3+; Ketones Trace; RBC (Red Blood Cell) 115 (H); WBC (White Blood Count)116 (H); Squamous Epithelial Cells 1; Bacteria 1+; Mucus Occasional. Together with the clinical Manager, a fax receipt was viewed demonstrating that the results had been faxed by the medical records staff to the physician on 12/16/24 at 8:25 AM. The Clinical Manager attempted to locate an order for antibiotics or communication with the physician related to the results and/or follow-up after the urinalysis had been faxed. However, she was unable to find this information to which stated the nurse should have followed up with the physician.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on staff interviews, medical record review, and agency policy review, ithe agency failed to obtain the patient’s or legal representative’s signature to confirm they had received a copy of the notice of rights and responsibilities for 1 of 12 sampled patients, (9). Findings: On 1/28/25, a skilled nursing home care visit observation was made of Patient #9, an ALF (Assisted Living Facility) resident, along with Employee J, a Registered Nurse. Employee J stated the patient’s signed paperwork for the home health agency was kept in his chart. She noted, “we can ask the ALF nurse.” On 1/28/25 at 11:50 AM, the ALF Wellness Director/Coordinator (a Licensed Practical Nurse) was asked for the written agreement and consent for Patient #9. A review of the patient’s home packet and booklet revealed all forms were left blank and unsigned. The ALF Wellness Director/Coordinator was asked if they had a copy of the signed written agreement/consent. She went through his chart and stated, “No, we don’t have it.” On 1/28/25 at 1:00 PM, Employee I was unable to locate the signed written agreement and consent for Patient #9. She stated, “No, Employee C and I both looked, it’s not here.” On 1/28/25 at 1:20 PM, Employee I presented a written agreement and consents for Patient #9 which were signed/initialed by unknown person. This form was signed on 1/10/25 on each section of the agreement and consent. Employee I was unable to determine whose initials were on the forms, and thought possibly a nurse from the ALF. She stated they just found the forms and removed them from the patient’s physical chart. During an interview with Employee C (Clinical Manager) on 1/30/25 at 10:13 AM, she was asked if ALF staff were allowed to sign written agreement and consents for patients. She stated, “No, it needs to be the patient or the patient’s power of attorney.” She stated they were unable to determine who signed the patient’s written agreement and consents on 1/10/25. She said, “That is not someone who works here. I don’t know who that is.” She explained their physical therapist, Employee G would have turned in the signed written agreements and consents dated 1/10/25. During a second interview with the ALF Wellness Coordinator/Director on 1/30/25 at 12:40 PM, she was asked who signed the written agreement and consents for patients when they entered into an agreement with a home care agency. She stated, “That would be either the patient or their power of attorney. Patient #9 is incapacitated, he is on the memory care unit, so either his wife or his son will sign his paperwork for him. His wife lives at this ALF, but not on the Memory Care Unit.” She was asked if the ALF staff signed any written agreements or consents and she replied, “No, they should not be signing any agreements or consents, or sign as witness to any of these.” She was asked if there was anyone working at her ALF whose initials matched the ones on the form. She stated, “Yes, we do, she is our LPN, and she may have signed his paperwork. She stated the LPN was new and may not have known she wasn’t supposed to sign or witness any agreements or consents for the residents.” On 1/31/25 at 1:30 PM, Employee G, stated he completed the start of care visit for Patient #9 on 1/10/25. He recalled he had signed for the written agreement and consents and noted, “I believe I signed them. The ALF nurse also signed them. He stated, “My approach is with dementia patients, I try to get the patient to sign, and a family member if one is available or a staff member to sign.” He was asked if the patient had a family member available to sign his written agreement and consents during the start of care visit. He stated no. He stated, “ideally, we’re trying to get a patient signature or a family member signature and if neither are available then get a staff signature at minimum.” A review of the written agreement and consent for Patient #9 revealed a section titled “Patients Rights and Advanced Directives” which read: I acknowledge receipt of a copy of my patient’s bill of rights and all rules and regulations governing patient conduct. This is observed to be checked “yes” with the initials from the ALF staff. A review of an agency policy titled “Electronic Signature of the Patient/Caregiver” (revised 8/2023) revealed: Purpose: An electronic signature of the patient and/or the patients’ caregiver is obtained in order to validate that the visit was made, and pertinent material was reviewed with them. Policy: If the patient is in an Assisted Living Facility and is unable to sign the tablet, an employee of the facility will be asked to sign the tablet to verify the visit was made by the home health clinician. If the patient has been declared incompetent or is unable to sign with full knowledge, the designated health care power of attorney or guardian can sign the documents. In the event the patient is physically unable to sign, or the signature was not obtained, documentation will be included in the medical record to explain the difference.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, record review, staff interview and agency policy review, the Home Health Agency failed to alert the physician of changes in the patient’s condition for 3 of 12 sampled patients, (Patients #s 11, 7 and 12). 1.Review of the medical record noted patient #11 was documented to be bedbound and in need of maximum assistance with all ADL’s. Documentation also noted patient to be alert and oriented but did not speak and on most visits patient was documented to be in and out of sleep with poor demonstration and awareness. The medical record noted on three occasions (9/26/24, 9/30/24 and 10/7/24), notes by the PTA documented the patient as “unresponsive” without clarification of the word “unresponsive”. On 1/29/24 at 11:11 AM, an interview was conducted with the Clinical Manager during which patient #11’s medical record was reviewed with the Clinical Manager. The Clinical Manager was asked if she could locate anywhere in the record where the PTA had notified the physician, the office or the PT regarding documentation of patient’s “unresponsive” condition. Review of the three notes in question and the communication notes section of the EMR did not find evidence where PTA had informed anyone, and clinical manager stated that he should have. 2. On 1/28/25 on and around 10:00 AM a home visit was conducted at the home of patient #7 with staff member E, Registered Nurse (RN). The patient was admitted to the Home Health Agency on 1/21/25 with a diagnosis to include Malignant Neoplasm of Prostate. During the home visit the family reported the patient had lost weight and provided a notebook which listed the patient’s daily weights. January 21st = 183.6 January 22nd = 178.4 January 23rd = 177.4 January 25th = 170.9 January 26th = 170.1 January 27th = 170.8 January 28th = 169.3 At this time staff member E, RN verbalized that review of the notebook noted patient had lost 14 pounds since admission and that he would call the MD today (1/28/25). Review of patient #7’s medical record for 1/28/25, post visit, revealed staff member E, RN did not document the patient’s weight loss in the visit note and did not find documentation of any communication with the office or the physician regarding family’s concern with patient’s weight loss. The medical record was checked for documentation of communication/notification on 1/29/25 at 3:30 PM, and 1/30/25 at 9:00 AM, but again did not find any documentation. On 1/29/25 at 5:30 PM, a telephone interview was conducted with the daughter of patient #7 regarding the patient’s weight loss and she stated she had not heard back from the nurse regarding whether or not the doctor had recommendations about patient #11’s weight loss or if they should be concerned. Daughter continued to say they went to their oncologist yesterday and he made a few recommendations, however, the home health nurse had said he was going to call the primary care physician (PCP) but she had not heard back from him yet. On 1/30/25 at 10:08 AM, an interview was conducted with the Clinical Manager regarding patient #7’s noted weight loss of 14 pounds in 7 days. She stated that patient was a terminal cancer patient so they would anticipate weight loss. Clinical Manager then stated nurse E had called her yesterday to discuss patient’s weight loss and she instructed the nurse to observe the patient being weighed, to validate it was done correctly. Clinical Manager stated the nurse was waiting for a return call from the physician, but she indicated Nurse E had called him. The Clinical Manager stated that she had not documented the conversation between her and Nurse E about the weight loss in the EMR but that the nurse should have done a communication note after he contacted the physician. After further review of the EMR, Clinical Manager verified there was no documentation in the record Nurse E had contacted the physician and review of the note written by the nurse on the day of the home visit verified the nurse did not document anything regarding the weight loss. Interview via phone on 1/30/25 at 11:33 AM, with staff member E, RN noted he had not yet notified the physician of the patient’s weight loss and also had not notified the office of the weight loss concern. He stated he would be seeing the patient on 1/31/25 and would address it then. 3. During the infection control interview with the Clinical Manager conducted on 1/31/25 at 4:29 PM, she offered an example of how infections were tracked at the agency. She referred the surveyor to patient #12 who was known for having multiple urinary tract infections (UTIs). At this time the patient’s Electronic Medical Record (EMR) was reviewed with the Clinical Manager which revealed that on 12/13/24 the nurse obtained a STAT (immediate) order for a urinalysis. The record revealed the result had been returned to the Home Health Agency on 12/14/24 at 8:08 AM, with the following result: Clarity noted as Hazy, Leukocyte Esterase 3+; Protein 1+; Blood 3+; Ketones Trace; Red Blood Count (RBC) 115 (H); White Blood Count (WBC) 116 (H); Squamous Epithelial Cells 1; Bacteria 1+; Mucus Occasional. Together with the clinical Manager, a fax receipt was viewed that showed the results had been faxed to the physician on 12/16/24 at 8:25 AM. The Clinical Manager attempted to locate an order for antibiotics and a communication note the physician had been contacted with the results or for follow-up after the urinalysis had been faxed but she was unable to find this information. She stated the nurse should have followed up with the physician. On 1/31/24 at 1:28 PM, an interview was conducted staff member J, RN, who had ordered the STAT urinalysis for patient #12. She stated that when orders were obtained for urinalysis it was documented in the EMR and the office should follow up on the results. She stated she would ask the patient on the next visit what the results were but the office would follow up with the physician. She stated the patient had a catheter and a history of UTI (urinary tract infections) and lived with her grandson. She reported she did not see the patient after she ordered the urinalysis so she did not follow up. Review of the policy “Coordination of Services HH2020” last approved and revised on 10/2024. Under Purpose: “To ensure effective and appropriate coordination and continuity of care, treatment and/or services to promote positive patient outcomes.” “To uphold patient rights.” “To ensure patients and caregivers active involvement in a fluid care plan.” “To support the goals and objectives outlined in the plan of care.” “To prevent duplication and conflict of care, treatment and/or services.” On page 3 of 4 it states that MSA Home Health Agency staff promptly contact the physician: When there are changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. Communication and coordination will occur with all physicians involved in the patient treatment even if they are not signing the plan of treatment. Coordination of patients’ care may involve notification of changes and updates to more than one physician. Integration of services to assure the identification of patients’ needs and factors that directly affect patients’ safety and treatment. . .”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on Quality Assurance Performance Improvement (QAPI) program documents and interviews, the home health agency failed to ensure all skilled staff including both direct employees and contracted staff provided input and participated in the implementation of the agency’s QAPI program. On 1/28/25 at 12:12 PM the Clinical Manager was asked about their Quality Assurance Performance Improvement (QAPI) meeting agendas and sign in sheets. She replied that she had a log for weekly meetings she had with staff to discuss patients. The Performance Improvement Trending Sheet for the Agency dated January 16, 2025, was presented for review as their QAPI program information. She stated they did not meet to discuss the Agency’s Performance Measures. When directed to the information on the form presented for review and asked if they met and followed up on data as presented for review i.e. quarterly average of 82% improvement in bed transfer with a goal of 98%, a quarterly average of 87.6%, improvement in ambulation with a goal of 95%, a quarterly average of 68.6%, improvement in oral meds with a goal of 100%, a quarterly average of 87.6%, improvement in dyspnea with a goal of 97% and a quarterly average of 88.6%, she stated, “No.” She acknowledged they did not have any PIPs (performance improvement plans) in place for any of the quality measures listed. When asked if they met at least quarterly to discuss performance and quality issues and how patient care could be improved, she stated she had not been involved with a meeting like that, despite the fact the Performance Improvement Trending Sheet was dated 12 days prior. A review of the Pre-board meeting preparation report, which was presented as the agency’s QAPI meeting, identified attendees to include Executive Vice President, Chief Operations Officer, Chief Financial Officer, Executive Operations Manager, Vice President of Sales, Area Vice President of Sales, Regional Director of Marketing (DOM), and Area Vice President Operations only. The Regional DOM had been identified as the current interim administrator but was not identified as such on the report. The Clinical Manager was not listed as being present and no other skilled professional staff was documented as present or having participated. A review of the agency’s policy titled, “QAPI HH5002” revised 10/2024 revealed a Purpose: To define the Quality Assessment (QA) Performance Improvement (PI) process (QAPI) program. The agency develops, implements, evaluates, and maintains an effective, ongoing, HHA-wide, data driven QAPI program. It is the policy of (the agency) to measure process outcomes in order to facilitate improvement in the quality of patient care. Performance measures are selected based on their impact on patient/client care, age friendly criteria, services offered (includes all HHA services, including those services provided under contract or by arrangement), risk and safety, clinical practice, fiscal accountability, cost effectiveness and addresses the HHA’s performance across the spectrum of care, including prevention and reduction of medical errors. The program will be capable of showing measurable improvement indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. During a phone interview with Area Vice President (AVP) on 1/29/25 at 3:35 PM, she stated they had a QAPI program in place. She noted that the preboard meeting report that was given to the survey team represented the agency’s QAPI program meeting. She verified they did not have any meetings to discuss clinical data that was collected to determine areas to improve the quality of care and patient outcomes, or where processes were measured to determine the effectiveness of those processes.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interview, the HHA’s (Home Health Agency) Administrator failed to be responsible for the day-to-day operations of the HHA to ensure continuous managerial oversight of therapy services by failing to ensure contracts for therapy services were current and ensure active Quality Assurance and Performance Improvement and Infection Control Programs were ongoing. On 1/27/25 at approximately 1:25 PM an interview was conducted with the Interim Administrator, Clinical Manager, staff member H, the clinical manager from the Ormond/Jacksonville office and staff member I, the Alternate Administrator from the Ormond/Jacksonville office. During this interview the Interim Administrator stated she became the Interim Administrator when the previous Administrator left unexpectantly in October. On 1/29/25 at 11:57 AM an interview was conducted with the Area Vice President who confirmed that the Interim Administrator is the current administrator. A review of the agreement/contract for therapy services dated July 10, 2019, for physical therapists (PTs), Occupational Therapists (OT) and Speech Therapists (ST) that provide direct patient care revealed that the agency was to exercise professional responsibility and control over the services provided to patients, including maintaining the clinical record, maintaining liaison with the attending physician, assuring physician review, certification and recertification of the plan of treatment, and performing utilization review of the services provided hereunder. Agency’s Director of Professional Services or professional designee will review the delivery of care by the Contractor by performing supervisory visits to patients on a schedule determined appropriate by Agency. The agreement/contract Term/Termination section 5.1 states “The term of this Agreement shall be for a period of one (1) year commencing on the date hereof and shall automatically renew for four successive terms of one (1) year each unless earlier terminated in accordance with the terms hereof”, noting expiration date to be July 2024. Review of the infection control program was conducted with the Clinical Manager on 1/30/25 at 4:29 PM. When asked how she tracks infections she stated she was not aware of any system to track infections but had not identified any patterns of infections. When asked what she did with the information she collected she had no response. Interviews with the Area Vice President, Interim Administrator, and the Clinical Manager also revealed the lack of development or implementation of coordinated agency-wide programs for surveillance, identification, prevention, control and investigation for infection control and/or performance improvement plans. Concerns about care and services provided to the home health agency’s patients, responsibility for the day-to-day operations of the HHA ensuring continuous managerial oversight to include the expired Therapy Services Contract, the lack of systematic infection control program, and lack of improvement projects were discussed on 1/31/2025 during a conference call at 3:45 PM and again during the exit conference on the same day at 5:45 PM. Attendance during these discussions included the Area VP, the Corporate Compliance Officer, a Paralegal, Director of Clinical Services of Home Health Division, the Chief Financial Officer, Executive Vice President, and the General Counsel for the home health agency and the Interim Administrator who was also present in the conference room during the call. There was no evidence presented by Interim Administrator and other management staff in attendance to demonstrate active and effective responsibility of day-to-day operation of the HHA.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on review of documents and interviews, the home health agency failed to ensure a current Therapy contract or agreement was in place for Physical therapists (PTs), Occupational Therapists (OT), and Speech Therapists (ST) who provide direct patient care, when they failed to identify the contact had expired in July of 2024. A “Medical Staffing Contract” between the Home Health Agency and the therapy contract company dated July 10, 2019, was provided for review. The Contract states they shall furnish Physical Therapists, Occupational Therapists and Speech Therapists. It was noted that each will be paid for visits, evaluations and meeting times and conferences (as noted in Exhibit A). Item 2.3 states “In providing services, Contractor will immediately provide and will direct its employees to provide the Agency’s designated representative with oral notice of any changes, in or other significant occurrence with respects to each patient’s condition or services. Contract will supplement such oral notice with a written report of same to the patient’s file. Any changes in the plan of care may only be made after consultation with the patient’s physician, patient’s family (if applicable) and in consultation with the contractor and the agency together. The contractor will participate in discharge planning for the Agency patients as requested by Agency. Agency will perform all admission and planned discharge visits on nursing cases. The Term/Termination section 5.1 stated “The term of this Agreement shall be for a period of one (1) year commencing on the date hereof and shall automatically renew for four successive terms of one (1) year each unless earlier terminated in accordance with the terms hereof. (2031 days 5.5 calendar years). On 1/30/25 at 9:06 AM a telephone interview was conducted with the Area Vice President (AVP) during which she was asked if the contract provided for review was the most current and if she could provide the address of contractor. She stated she was unsure where the contracted therapy office was located but said she would look in her folder for the newest contract. She indicated that she oversees the contracts, but they come from legal who reviews them. On 1/30/25 at 9:34 AM a follow-up interview was conducted with the AVP during which she stated that the contract provided to the survey team was the most current copy. She was asked about the renewal of the contract, and said it had an automatic annual renewal until terminated by the Home Health Agency. She was directed to item 5. Term/Termination and asked to define 5.1 which read “The term of this Agreement shall be for a period of one (1) year commencing on the date hereof and shall automatically renew for four (4) successive terms of one (1) year each unless earlier terminated in accordance with the terms hereof.” She stated that this would indicate the contract expired in July of 2024.”

“Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to retain overall responsibility for therapy services provided to their patients when they did not ensure they had a valid and current contract and by failing to fully investigate a contracted Physical Therapist (PT) who submitted erroneous documentation for 1 of 12 records reviewed (#11) for a recertification therapy visit dated 7 days after the patient had passed away and resulted in the lack of awareness of a second visit made by the Physical Therapy Assistant 8 days after the death of the same patient. A review of the electronic medical record (EMR) for patient #11 revealed she was admitted to the agency on 8/19/24 for Hemiplegia (paralysis or weakness on one side of the body) following cerebral infarct (Stroke) of right dominant side. She was non-verbal and required assistance with all transfers, bed mobility, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and was non-ambulatory. She was ordered to have physical therapy 2 visits a week for 4 weeks then 1 visit a week for 5 weeks. The EMR revealed the patient had visits on 8/19/24; 8/21/24; 8/28/24; 9/4/24; 9/11/24; 9/26/24; 9/30/24 and 10/07/24 by the Physical Therapist (PT) or the Physical Therapy Assistant (PTA). After the visit on 10/7/24 there was no other documentation of a visit on the visit log and there was no discharge summary or other discharge information noted in the EMR. Further review of patient #11’s EMR revealed that on 10/22/24 there was a Patient Communication note created by staff member A, Medical Records/Pre-Biller noting “I called Mobile Physician Services on 10/16/24 and left a voicemail to my orders signed for the patients and on 10/17/24 they called back and I explained I needed the plan of care signed because we need to do a recertification. She had let me know the patient expired on 10/8/24 but they will send out the plan of care for signature. I did notice as well that there was a visit done on 10/15/24 with a signature on it by one of our therapists, I made sure to report it to our office administration.” In an interview with Staff member A on 1/28/2025 at approximately1:00 PM, he reported that he had reached out to the physician to obtain signatures on the POC for the recert (recertification) and stated that during the call he was surprised to hear the patient had passed away and realized that there was a recertification done with documentation after the patient had passed away. He stated that he told the Administrator the visit had been conducted with dates and times of the visit and verified the presence of initials in the box where family signatures go on the GPS data within (the agency’s EMR). On 1/29/24 at 11:11 AM an interview was conducted with the Clinical Manager during which the patient’s medical record was reviewed. She stated that there should have been a discharge OASIS for the patient because she had passed away. She stated that the visits are noted in the computer and stated that in looking at the visit list, the last visit noted in the record was on 10/7/24 and verified there was not a discharge OASIS. At this time, she was asked about a visit made by the PT after the patient had died. She stated that she had heard discussions between staff member O, Administrator, and staff member A, Medical Records about the PT conducting a recertification visit 7 days after the patient had passed away but had just started in her position at that time and was not involved in the discussion or the investigation. She stated that staff member O, former administrator, who left unexpectedly, had started the investigation, but she was not aware of the outcome. A review of the deleted documentation for the visit that was conducted after the patient had passed away revealed a copy of the (Home Health Agency’s EMR) Verified Visit for patient #11 for an OASIS-E Recertification PT visit indicating it was made on 10/15/24 from 1800-1845 (6:00 PM to 6:45 PM). The address listed on the form was different from the address listed in the admission paperwork for the patient and the address verified by patient #11’s father and there were initials noted in the box where families/caregivers sign to verify a visit. A review of the OASIS-E Recertification (PT) dated 10/15/24 with the “Time in time was noted as 1800 (6:00 PM) and the Time Out time was noted as 1845 (6:45 PM) by staff M, PT. The OASIS-E documented an Episode Start date of 10/18/24. All fields on the form were blank except for the last page titled “Task Details” that revealed the OASIS-E Recertification for PT was “deleted”. Review of the work log documented that the patient signature was created on 10/15/24 at 1841(6:41) by staff member M, PT and the recertification was deleted by the former Administrator on 10/24/24, at 1521 (3:21 PM). Further review of the record revealed a Patient Medication Record with a list of Current Medications which had a detailed list of the patient’s medications. The form states “Medication Review Acknowledgement: All medications the patient is currently using have been reviewed for potential adverse events and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.” This note was digitally signed by staff member N, PTA on 10/16/24, 8 days after the patient’s death. A follow up interview was conducted with the Area Vice President (AVP) on 1/29/25 at 3:32 PM during which she stated that they do not have a copy of the investigation for the concerns with patient #11. She stated that the pervious administrator who had conducted the investigation had not provided copies to her or legal. She also stated that there had not been staff in-services directly related to the concerns related to the PT conducting a visit after the patient was deceased. A copy of the facility’s Therapy contract was provided for review which noted an expiration date of July 2024. Review of the therapy contract was conducted noting section 7.3…The agency (the Home Health Agency) shall at all times exercise professional responsibility and control over the services provided to patients, including maintaining the clinical record, maintaining liaison with the attending physician, assuring physician review, certification and recertification of the plan of treatment, and performing utilization review of the services provided hereunder. The Agency’s Director of Professional Services or professional designee will review the delivery of care by the Contractor by performing supervisory visits to patients on a schedule determined appropriate by Agency. Contractor will ensure that the provisions of services the agency patients receive will at all times comply with all statutes, rules, and regulations established by all applicable federal, state, and local agencies with jurisdiction over the Agency or Contractor. Agency may perform field inspections of Contractor’s personnel at any time without notice. On 1/30/25 at 9:34 AM a follow-up interview was conducted with the AVP during which she stated the contract provided was the most current copy. The AVP continued to say that the Clinical Manager should be doing supervisory visits for patients not the contracted staff. The supervisory visits should be an employee of Home Health Agency not another contracted employee. She was asked about the renewal of the contract, and she said it had an automatic annual renewal until terminated by the HHA. She was directed to item 5. “Term/Termination” which read… “The term of this Agreement shall be for a period of one (1) year commencing on the date hereof and shall automatically renew for four (4) successive terms of one (1) year each unless earlier terminated in accordance with the terms hereof.” The AVP, after reading the terms, stated that this would indicate the contract expired in July of 2024 and that when the concerns came up with patient #11 there would not have been a current contract in place for therapy services.”

“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 record reviews and interviews, the home health agency failed to ensure all required items were in the clinical record to include accurate, legible, and clear information in clinical notes and assessments, to include signatures of patients and/or families verifying visits and signing consents for services for 4 of 12 patients sampled (#11, #7, #10, and #6). Patient #10 01/28/25 10:14 AM During a home visit a home chart review was conducted. There was no consent for services signed by the patient present. 01/28/25 1:00 PM A medical record review was completed in the office and no consent could be located. In the patient’s electronic medical record under the tab “consent” there was no document. 01/28/25 PM Staff I stated she could not locate a consent in the patient’s medical record. 1/28/25 3:30 PM In an interview with Staff C, she was shown the “consent” area of the EMR and asked where else the consent could be located. Staff C responded if there was a signed consent this is where it would be. The findings include: Patient #11 On 1/29/25 at 1:55 PM an interview was conducted with the father of patient #11. He stated that his daughter had strokes, he had been happy with the care they had been receiving, and that staff were coming out twice a week. He stated that she was awake but in bed and that her death was unexpected. He said “they” came to their home for their regular visit after she had passed away this is when they learned she had passed away but otherwise no one had contacted them. He was asked to provide the address of their home and it was consistent with all documentation as to the location of the home not an ALF. A review of the electronic medical record (EMR) for patient #11 revealed she was admitted to the agency on 8/19/24 for Hemiplegia (paralysis or weakness on one side of the body) following cerebral infarct (Stroke) of right dominant side. She was non-verbal and required assistance with all transfers, bed mobility, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and was non-ambulatory. She was ordered to have physician therapy 2 visits a week for 4 weeks then 1 visit a week for 5 weeks. The EMR revealed the patient had visits on 8/19/24; 8/21/24; 8/28/24; 9/4/24; 9/11/24; 9/26/24; 9/30/24 and 10/07/24 by the Physical Therapist (PT) or the Physical Therapy Assistant (PTA). After the visit on 10/7/24 there is no other documentation of a visit on the visit log and there was no discharge summary or other discharge information noted in the EMR. Further review of patient #11’s EMR revealed that on 10/22/24 there is a Patient Communication note created by staff member A, Medical Records/Pre-Biller “I called Mobile Physician Services on 10/16/24 and left a voicemail to my orders signed for the patients and on 10/17/24 they called back and I explained I needed the plan of care signed because we need to do a recertification she had let me know the patient expired on 10/8/24 but they will send out the plan of care for signature. I did notice as well that there was a visit done on 10/15/24 with a signature on it by one of our therapist, I made sure to report it to our office administration.” On 1/28/24 at approximately 1:00 PM an interview was conducted with staff member A, Medical Records/Pre-Biller during which he reported that he had reached out to the physician to obtain signatures on the POC for the recert (recertification). He stated that during the call he was surprised to hear the patient had passed away but realized that there was a recertification done with documentation after the patient had passed away. He stated that he had told the Administrator but the visit had been conducted with dates and times of the visit. He verified the presence of a family signature on the GPS data within (the agency’s EMR). On 1/29/24 at 11:11 AM an interview was conducted with the Clinical Manager during which the patient’s medical record was reviewed. She stated that there should have been a discharge OASIS for the patient because she had passed away. She stated that the visits are noted in the computer and stated that in looking at the visit list the last visit noted in the record was on 10/7/24. She verified that there was not a discharge OASIS. She was also shown the three notes which documented the patient was “unresponsive” on 9/26/24, 9/30/24 and 10/7/24 and was asked if she could locate anywhere in the record where the PTA had notified the physician, the office or the PT. She reviewed the three notes in question and the communication notes section of the EMR and stated that she did not see evidence that he had informed anyone. She stated that he should have. At this time she was asked about visit made by the PT after the patients had died she stated that she had heard discussions between staff member O, Administrator and staff member A, Medical Records about the PT conducting a recertification visit 7 days after the patient had passed away but had just started in her position at that time and was not involved in the discussion or the investigation. She stated that staff member O, former administrator had started the investigation but she was not aware of the outcome. She stated that she had taken over staff member O’s responsibilities but had not followed up on this issue despite staff member O leaving in October unexpectantly. A review of the deleted documentation for the visit that was conducted after the patient had passed away on 10/8/24 revealed a copy of the (Home Health Agency’s EMR) Verified Visit for patient #11 for an OASIS-E Recertification PT visit was made on 10/15/24 from 1800-1845 (6:00 PM to 6:45 PM). The address listed on the form was different from the address listed in the admission paperwork for the patient and the address verified by patient #11’s father. There were initials that appeared to be that of the patient in the box where families/caregivers sign verifying visit. A review of the OASIS-E Recertification (PT) dated 10/15/24 with the “Time in time noted as 1800 (6:00 PM) and the Time Out time noted as 1845 (6:45 PM) by staff M, PT. The OASIS-E documented an Episode Start date of 10/18/24. All fields on the form were blank except for the last page titled “Task Details” that reveals the OASIS-E Recertification for PT was “deleted”. Review of the work log documents that the patient signature was created on 10/15/24 at 1841(6:41) by staff member M, PT and the recertification was deleted by the former Administrator on 10/24/24 at 1521 (4:21 PM). Further review of the record revealed a Patient Medication Record with a list of Current Medications which had a detailed list of the patient’s medications. The form states “Medication Review Acknowledgement: All medications the patient is currently using have been reviewed for potential adverse events and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.” This note is digitally signed by staff member N, PTA on 10/16/24 (8 days after the patient’s death). On 1/29/25 at 11:57 AM an interview was conducted with the Area Vice President (VP). She stated she is a registered nurse and had been with the Home Health Agency since September. She was asked about the investigation into the PT conducting a recertification visit 7 days after the patient had passed away. She confirmed she headed the investigation and found that the PT had falsified the visit. She stated they had discovered the patient had expired prior to the recert visit. She offered that she got a call from legal and compliance who directed her to notify the contracted therapy company to report that the PT had falsified information. She stated that she was told by legal and compliance that the agency that employed him was to report him to the licensing board since he was not “our employee”. But then stated that the Home Health Agency is responsible for the actions of the contracted staff member. She stated that she had not conducted a review of the patient’s chart as part of her investigation as the previous administrator had done that. She offered that she had notified the contracted agency on 10/15/24 via email of the falsified record but when asked how she could have notified the agency at that time as the Medical Records staff had not been told until 10/17/24, she stated she was mistaken and they had been notified at 10/17/24. At this time she was asked to provide the email notification to the contracted therapy company for review and a copy of the investigation, she stated she would. She stated that the investigation had been closed before the pervious administrator had left and found that only one employee had falsified the record. The outcome of the investigation had been to notify the therapy contract company and ask them to report the employee to the board. She stated that the employee is no longer working for this home health agency and that she believes he had been terminated. She was unsure if he was reported to the board. At this time she was asked about a Medication Reconciliation that had been conducted by staff member N, PTA on 10/16/24. She stated she was not aware of this. She was also asked if the investigation had found that the patient was documented by the PTA as being “unresponsive” on three visits prior to her passing. She stated the previous administrator and “legal” had reviewed the chart so she was not aware of this but that it is her expectation that if a patient has a change in condition the PTA should report it to the PT and the physician. She was asked about the recertification not appearing in the electronic medical record to which she stated that this had been brought to her attention that it had been removed but she could not explain why. She was asked if there had been any staff education regarding this incident to which she stated that there had been in-services in case conferences since then related to documentation and she would forward this to the survey team. A follow up interview was conducted with the Area VP on 1/29/25 at 3:32 PM during which she stated that they do not have a copy of the investigation for the concerns with patient #11. She stated that the pervious administrator had conducted the investigation and had not provided copies to her or legal. She also stated that there had not been staff in-services directly related to the concerns related to the PT conducting a visit after the patient was deceased and that in-services conducted during case conference were generic related to documentation and not specific to this concern. By the time of survey exit (1/31/25) a copy of the email notifying the contracted therapy provided of the fraudulent visit had not been provided. On 1/29/25 at 1:55 PM an interview was conducted with the father of patient #11. He stated that his daughter had strokes, he had been happy with the care they had been receiving, and that staff were coming out twice a week. He stated that she was awake but in bed and that her death was unexpected. He said “they” came to their home for their regular visit after she had passed away this is when they learned she had passed away but otherwise no one had contacted them. He was asked to provide the address of their home and it was consistent with all documentation as to the location of the home not an ALF. A review of the in-services and Case Conference/in-service sign-in sheets for 10/30/24; 11/6/24; 11/20/24; 1/8/25; 1/15/25 – failed to reveal that contract staff attended the meetings. Patient #7 On 1/28/25 beginning at 10:00 AM a home visit was conducted at the home of patient #7 with staff member E, Registered Nurse (RN). The patient had been admitted to the Home Health Agency on 1/21/25 for Malignant Neoplasm of Prostate. During the home visit the family reported the patient had lost weight and provided a notebook which listed the patient’s daily weights. The review revealed the patient had a 14 pound weight loss between January 21, 2025 and January 28, 2025 (cross reference G0590). During the visit staff member E, Registered Nurse (RN) verbalized that the patient had lost 14 pounds since admission and that he would be calling the physician today (1/28/25) A review of the patient’s medical record for 1/28/25 revealed staff member E, RN had not documented the patient’s weight loss in the visit note and there was no documentation of communication with the office or the physician. The record was checked on 1/29/25 at 3:30 PM and again on 1/30/25 at 9:00 AM no documentation of the weight loss or notification of the physician could be located. On 1/29/25 at 5:30 PM a telephone interview was conducted with the daughter of patient #7 regarding the patient’s weight loss and she stated she had not heard back from the nurse regarding whether or not the doctor had recommendations about what to do about his weight loss or if they should be concerned. She stated they went to their oncologist yesterday and he made a few recommendations but the nurse was going to call his primary care physician (PCP) but she had not heard back from him yet. On 1/30/25 at 11:33 AM staff member E, RN stated in a cellular conversation that he had not notified the physician of the patient’s weight loss and had not notified the office of the concern. He stated he is seeing the patient tomorrow (1/31/25) and would address it then. He clarified at 1:01 PM that he had not spoken to anyone in the office yesterday (1/29/25) regarding the patient’s weight.”