Active Home Health Care Services, LLC

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of the Home Health Agency’s policy, record review and interview, the Home Health Agency failed to provide Home Health Aide supervision every 2 weeks for 1 of 7 sampled patients who required Home Health Aide care and services (Patient #7). The findings included: Review of the Home Health Agency’s policy titled, “Home Health Aide Supervision” revealed, “When skilled services are being provided to a patient, a Registered Nurse/Therapist must make a supervisory visit to the patient’s residence at least every two (2) weeks (either when the Home Health Aide is present to observe and assess care delivery, or when the Home Health Aide is absent) to assess relationships and determine whether goals are being met.” Record review revealed Patient #7 was referred to the Home Health Agency on 04/29/25 with a start of care date of 04/30/25 for a diagnosis requiring home health care and services. Record review conducted on 08/06/25 for the certification period 06/29/25-08/27/25 revealed Home Health Aide supervisory visits were due on 07/15/25 and 07/28/25 as the patient was receiving skilled nursing and home health aide services for this certification period. An interview was conducted with the Director of Nurses (DON) on 08/07/25 at 10:30 AM who was asked if there were any outstanding visits that were not in the Electronic Medical Record (EMR) for Patient #7; she did not have anything more to add and stated there should have been (Home Health) Aide supervisory visits for Patient #7 on 07/14/25 and 07/28/25.”

“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 the Home Health Agency’s policy review, record review and interview, the Home Health Agency failed to timely include all clinical documentation in the Electronic Medical Record (EMR) for 3 of 7 sampled clinical records reviewed (Patient #2, #3, and #7). The findings included: 1) Review of the Home Health Agency’s policy titled, “Clinical Documentation” revealed, “All skilled services provided by Nursing, Therapy, or Social Services will be documented in the clinical record.” “Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record with (72) hours after the care has been provided.” Record review revealed Patient #2’s Start of Care was 03/16/25 with the certification period review 07/14/25-09/11/25 and a diagnosis requiring Home Health Agency care and services. Further review revealed no evidence of a “disaster plan” document for Patient #2 included in the EMR. 2) Patient #3’s Start of Care was 04/14/25 with the certification period reviewed 04/14/25-06/12/25 and a diagnosis requiring Home Health Agency care and services. A review of the EMR revealed the patient’s admission information, consents, and disaster plan were not in the EMR. An interview was conducted with a Registered Nurse (RN) on 08/06/25 at 12:20 PM, Staff A, the nurse who provided care and services at the patient’s start of care on 04/14/25 and was responsible for the documentation to be included in the EMR, when asked about the documentation being absent in the EMR, Staff A stated she was very busy and had not had time to put in the visits in the EMR yet. A review of the Skilled Nurse visits for 07/15/25 and 07/22/25 conducted by Staff B, RN, revealed they were not in the EMR. 3) Patient #7’s Start of Care was 04/30/25 with the certification period reviewed 06/29/25-08/27/25 and a diagnosis requiring home health care and services. A review of the EMR for Patient #7 revealed the admission information, consents and disaster plan for 06/29/25 were not included in the EMR and the “Start of Care” was done by Staff A. The Skilled Nursing visits dated 07/03/25, 07/09/25, 07/17/25, 07/21/25, and 07/29/25 were not included in the EMR. Further review revealed the “Home Health Certification and Plan of Care” document, with a target date of 06/29/25 was not included in the EMR. This document is used to record the physician’s plan of care, certification, and re-certification for patients receiving home health services, signed by the physician overseeing the patient’s care and serves as the service plan for the patient, detaining clinical orders and interventions. An interview was conducted with the Director of Nurses (DON) on 08/07/25 at 10:30 AM regarding the missing visit notes in the EMR who stated that they lost their previous EMR on 01/31/25 and the new EMR started on 02/08/25, she has been focused on revenue instead of reviewing the timeliness of putting documentation in. An interview was conducted with the Administrator on 08/06/25 at 3:00 PM who was informed that there was documentation that was not in the EMR, stated he was aware, and he has tried a lot of ways to have the nurses put in the documentation timely, but it has not worked and stated he was aware that this was a problem.”