Advanced Home Health Care Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 2 of 10 sampled patients. (Patient #1 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. 2. Patient #1 had a Start of Care date of 2/20/25. Clinical record review and associated agency staff interviews revealed the following: a. Plan of Care, dated 8/19/15 to 10/17/25, included orders for Skilled Nurse frequency of 1 time per week with orders for medication set up and identified the patient had a diagnosis that included Diabetes Mellitus. b. The POC included medication orders for Loratadine 10 milligrams (mg) daily as needed for allergy symptoms. c. During a home visit observation visit on 9/23/25 at 9:00 AM with Staff C, Registered Nurse, the surveyor identified the RN included Loratadine 10 mg tablet in the medication planner on a daily schedule. During an interview at the same home visit, the RN and patient stated Laratadine had been set up daily The clinical record lacked documentation the physician was notified of the variance in the medication frequency identified on the POC. The above findings were reviewed with the Administrator and Clinical Manager. Findings: According to the agency policy, titled Plan of Care, dated 10/16/24, the plan of care is composed of the types of services, supplies and equipment needed; frequency and duration of visits made; identification of patient needs and problems, disciplines, patient-specific goals and interventions necessary to meet those goals; and medication profile that is updated whenever there are changes in the patient’s prescribed medication regimen and treatments. 1. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and order for skilled nursing to remove left hip dressing on 8/5/25, incision to be left open to air and may be washed with antibacterial soap and water then patted dry. b. Skilled nursing visit, dated 8/8/25, included documentation the patient had a non-removable dressing to the left hip wound and the dressing was dry and intact. The skilled nurse failed to remove the left hip dressing as ordered.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record reviews and agency policy review, the home health agency failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards of practice for 4 of 7 sampled patients receiving home health aide services (Patients #3, #4, #7 and #9). Failure to ensure all documentation was completed and appropriately authenticated decreased the ability of the home health staff to communicate and coordinate patient care effectively and to provide safe, effective home health services to its patients. Findings include: 2. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 8/5/25 and 9/19/25, included aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 8/14/25, 8/22/25, 8/26/25, 9/9/25 and 9/16/25, included aide initials, date and time but failed to include aide signature and credentials. d. Home health aide visit notes, dated 8/9/25, 8/12/25 and 9/6/25, included aide initials, credentials, date and time but failed to include aide signature. Home health aide staff failed to accurately authenticate visit note documentation. 3. Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. Plan of Care, dated 8/25/25 to 10/23/25, included a diagnosis of decubitis ulcer and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 9/2/25, included Staff D, Home Care Aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 9/3, 9/5, and 9/8/25, included Staff E, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 4. Patient #9 had a start of care date of 8/30/25 and discharge date of 10/16/24. Clinical record review revealed the following: a. Plan of Care, dated 8/22/2 to 10/23/25, included a diagnosis of urinary tract infection and orders for skilled nursing and home health aide services. b. Home health aide visit notes, dated 8/24/24 and 10/5/24 included Staff I, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. Tghe above findings reviewed with the Administrator and Clinical Manager. According to the agency policy titled Clinical Records, revised 1/2024, documentation includes the date, time and place or circumstance of the entry and the documentation is signed with first name, last name, title, date and time. 1.Patient #3 had a start of care date of 9/11/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/11/25 to 11/9/25, included a diagnosis of Acute myeloblastic leukemia and included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Home health aide visit notes, dated 9/15/25 and 9/22/25, completed by Staff D, Home Health Aide, included signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. According to the agency policy titled Clinical Records, revised 1/2024, documentation includes the date, time and place or circumstance of the entry and the documentation is signed with first name, last name, title, date and time. 1.Patient #3 had a start of care date of 9/11/25. Clinical record review revealed: a. The Plan of Care (POC), dated 9/11/25 to 11/9/25, included a diagnosis of Acute myeloblastic leukemia and included orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Home health aide visit notes, dated 9/15/25 and 9/22/25, completed by Staff D, Home Health Aide, included signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 2. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 8/5/25 and 9/19/25, included aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 8/14/25, 8/22/25, 8/26/25, 9/9/25 and 9/16/25, included aide initials, date and time but failed to include aide signature and credentials. d. Home health aide visit notes, dated 8/9/25, 8/12/25 and 9/6/25, included aide initials, credentials, date and time but failed to include aide signature. Home health aide staff failed to accurately authenticate visit note documentation. 3. Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. Plan of Care, dated 8/25/25 to 10/23/25, included a diagnosis of decubitus ulcer and orders for skilled nursing, physical therapy and home health aide services. b. Home health aide visit notes, dated 9/2/25, included Staff D, Home Care Aide signature, date and time but failed to include aide credentials. c. Home health aide visit notes, dated 9/3, 9/5, and 9/8/25, included Staff E, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. 4. Patient #9 had a start of care date of 8/30/25 and discharge date of 10/16/24. Clinical record review revealed the following: a. Plan of Care, dated 8/22/2 to 10/23/25, included a diagnosis of urinary tract infection and orders for skilled nursing and home health aide services. b. Home health aide visit notes, dated 8/24/24 and 10/5/24 included Staff I, Home Care Aide signature, date and time but failed to include aide credentials. Home health aide staff failed to accurately authenticate visit note documentation. The above findings were reviewed with the Administrator and Clinical Manager.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and oxygen used by the patient for 2 of 10 sampled patients (Patients #2 and #10). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #10 had a start of care date of 11/16/18 and a discharge date of 10/18/24. Clinical record review revealed the following: a. The POC, dated 8/16/24 to 10/14/24, identified the patient had a diagnosis of hypertensive heart and chronic kidney disease with heart failure. The POC included orders for medications, treatments and the following supplies/equipment used by the patient: wheelchair, tape, bedside commode, catheter insertion kit, gauze pads, grab bars, oxygen, depends, tubigrips, scale, medication planners, pill splitter, compression pumps to lower legs, stand aid, incentive spirometer and ace wraps. b. The recertification visit note, dated 10/10/24, completed by Staff L, RN, identified the patient uses oxygen at 2 liters per nasal cannula. c. Review of the clinical record lacked orders for patient’s use of oxygen. The agency failed to include all orders on the patient’s POC, including oxygen orders required by the patient. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Plan of Care (POC), revised 10/16/24, the POC is composed of several documents which include: the types of services, supplies, and epuipment required and a medication profile that is updated whenever there are changes in the client’s prescribed medication regimen (including dosage, frequency or route of administration) and treatments. 1.Patient #4 had a start of care date of 8/30/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 6/26/25 to 8/24/25 and 8/25/25 to 10/23/25, identified the patinet had diagnosis that included decubitis ulcer and included the following supplies and epuipment used by the patient: Sterile gloves, tape, dressing supplies, grab bars, exam gloves, tub bench, drainage bag, leg bag, ABDs, Chux, alcohol pads, hospital bed, thermometer, power scooter, removable shower head, slide board, reacher, bedside table, life alert, egg crate cushion, emergency alert button, colostomy supplies, prisma, suprapubic catheter, catheter supplies, gloves, incontinent briefs, colostomy supplies, suprapubic catheter and supplies. b. During a home visit observation on 9/23/25 at 10:00 AM, with Staff H, Registered Nurse (RN), the surveyor identified the following supplies and equipment utilized by the patient: bed rails, wheelchair cushion, lift chair and wheelchair ramp. During an interview at the same home visit, the patient stated the equipment utilized including the lift chair. The POC failed to include the suipplies and equipment including bed rails, wheelchair cushion, lift chair and wheelchair ramp.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on agency staff interview, clinical record review and agency policy review, the agency failed to only provide services ordered by the physician for 1 of 4 sampled patients with wounds (Patient #9). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Verbal Orders, revised 10/25/19, verbal orders will be accepted only by personnel authorized to do so by applicable state and federal laws and regulations as well as by the home health agency’s policy. During an interview on 10/1/24 at 1:39 PM, Clinical Manager reported communication with physician’s documented in the communication notes and the expectation for verbal orders and communication notes to be completed (documented) in 7 days. Patient #9 had a start of care date of 8/22/24 and discharge date of 10/16/24. The clinical record review revealed: a. Plan of Care, dated 8/22/24 to 10/20/24, identified the patient had a diagnosis of urinary tract infection and included orders for skilled nursing visits one time a week. b. The skilled nurse visit note at start of care, dated 8/22/24, Staff L, Registered Nurse (RN), included documentation the patient had a large hematoma on the right leg that measured 20 centimeters (cm) length by 14 cm width by 0 cm depth. The note identified the patient used treatment that included elevating the leg and applied ice to reduce inflammation. c. The skilled nurse visit note, dated 9/2/24, Staff M, RN, documented she changed the patient’s right leg dressing due to an increase in drainage. The dressing applied included Vaseline gauze, ABD dressing, kerlix and coban to secure the dressing. d. The skilled nurse visit note, dated 9/3/24, Staff L, RN, documented the patient complained of left sided pain and rated the pain an 8 on a scale from 0 (no pain) to 10 (worse pain imaginable). The patient treated the pain with Tylenol and applied heat with some relief noted. e. Review of the clinical record failed to include physician orders for treatment to the right leg hematoma including application of ice and dressing change and application of heat for complaints of left sided pain. Agency staff failed to include physician verbal orders for treatments administered including ice, heat and dressing change. The above findings were reviewed with the Administrator and Clinical Manager.”

“HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This Element is not met as evidenced by: Based on agency staff interview, clinical record review, personnel file review and agency policy review, the agency failed to ensure 3 of 3 sampled home health aides (Staff I, Staff J and Staff K) assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 7 sampled patients (Patients #9) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently performing the task with a patient. The agency provided home health aide services to 59 patients at the time of the survey and employed 21 home health aides. Failure to ensure home health aides successfully complete a competency evaluation in any assigned extra skills which exceed the level of basic home health aide skills placed the patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task to be performed. According to the agency policy titled Home Care Aide Competency and Supervision, revised 1/2024, the agency ensures that home care aides are competent and proficient to perform the assigned duties. The agency trains and tests aides to ensure the aide is competent to perform skills which exceed the basic skills. During an interview on 9/24/25 at 9:22 AM, Staff B, Clinical Manager, stated the Clinical Manager and/or a Registered Nurse is responsible for training the aide in the skill that exceeds the general basic skills once the extra skill is assigned for a patient. Patient #9 had a start of care date of 10/5/24 and a discharge date of 1/20/25. Clinical record review revealed: a. The aide care plan included Registered Nurse (RN) instructions to the aide to complete home exercise program with the patient. b. Review of the clinical record showed Staff I, Staff J and Staff K, Home Health Aides, provided services independently for Patient #9. c. Staff I, Home Health Aide, had a hire date of 9/12/23. Staff I’s personnel file lacked documentation a RN had observed Staff I competently perform the task of complete home exercise program. d. Staff J, Home Health Aide, had a hire date of 6/5/23. Staff J’s personnel file lacked documentation a RN had observed Staff J competently perform the task of complete home exercise program. e. Staff K, Home Health Aide, had a hire date of 4/26/23. Staff K’s personnel file lacked documentation a RN had observed Staff K competently perform the task of complete home exercise program. The agency failed to ensure home health aides successfully completed a competency evaluation in assigned extra skills prior to performing the extra skills. The above findings were reviewed with the Administrator and Clinical Manager.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on staff interview, policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 7 sampled patients receiving home health aide services (Patients #4 and #7). Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. 2. Patient #4 had a start of care date of 8/30/24. The plans of care (POCs), dated 6/26/25 to 8/24/25 and 8/25/25 to 10/23/25, included physician orders for skilled nursing services 5 days a week and home health aide services 3 times per week to assist with personal care. The POC identified the patient had a diagnosis that included decubitis ulcer. Clinical record review revealed: a. The Aide Care Plan, dated 8/30/24 and last reviewed on 8/21/25, included direction to the aide to perform the following: shower, sponge bath, perineal care, bed bath, shampoo, comb hair, skin care lotion to extremities and back, oral care, assist dress, bed linen change, personal laundry empty trash, wash dishes. b. Home health aide visit notes, dated 9/2, 9/3, 9/5, 9/8, and 9/10/24, failed to include documentation the aide performed a shower and sponge bath or why the task not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: According to the policy, titled Home Care Aide Competency and Supervision, dated January 2024, the home care aides deliver services according to the plan of care. During an interview on 9/23/25 at 10:19 AM the Director of Nursing reported home care aides should document the reason a task on the aide care plan is not completed. 1. Patient #7 had a start of care date of 8/1/25. Clinical record review revealed: a. Plan of Care, dated 8/1/25 to 9/29/25, included diagnosis of aftercare following joint replacement surgery and orders for skilled nursing and home health aide services. b. Home health aide care plan, dated 8/1/25, included the tasks shower and sponge bath – patient only able to sponge bathe until 8/5/25. c. Home health aide visit notes, dated 8/9/25, 8/12/25, 8/22/25 and 9/6/25, identified the tasks shower and sponge bath as completed. Home health aide failed to identify which bath type was actually completed and which bath type was not completed.”