N.o.s. Healthcare 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 clinical record reviews and Staff interviews, it was determined that in 2 of 7 (Pts.# 3 and 6) clinical records reviewed, the Agency failed to ensure Staff provide care as ordered in the POC. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record contained a POC effective 03/28/25 to 05/26/25, required: “Notify Physician of vital sign parameters out of range:….Diastolic Blood Pressure:….less than (The record lacked documentation the SN rechecked Pt. #3’s blood pressure or reported to the Physician, the Diastolic Blood Pressure readings of less than 60, as ordered. 2. Pt. #6 was admitted to Home Health Services on 01/29/24 with the Diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Abdominal Pain, Other Chest Pain, Type 2 Diabetes Mellitus without complications, Fibromyalgia and Spinal Stenosis. The clinical record was reviewed on 05/13/25. The record contained a POC effective 03/29/24 to 05/27/24, required: “Notify Physician of vital sign parameters out of range:….Pain Level: Greater Than (>) 6….Blood sugar, Fasting…Greater Than (>180) Less Than ()200 Less Than ( 3. During an interview with the Clinical Manager/Director of Nursing on 05/15/25 at 9:45 AM, the Clinical Manager confirmed the above findings.”

“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 Staff interview, it was determined that in 5 of 7 (Pts. # 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. Findings include: 1. Pt. #3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 2. Pt. #4 was admitted to Home Health Services on 01/30/25 with the Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25 and 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 3. Pt. # 5 was admitted to Home Health Services on 11/12/24 with the Diagnosis of Hemiplegia following other Cerebrovascular Disease affecting right dominant side. The clinical record was reviewed on 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 4. Pt. # 6 was admitted to Home Health Services on 01/29/24 with the Diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. 5. Pt. #7 was admitted to Home Health Services on 10/19/24 with Diagnoses of Type 2 Diabetes Mellitus Without Complications. The clinical record was reviewed on 05/14/25. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Patient. The form contained blank sections regarding the Agency that the Pt. transferred from and reason for transfer and effective transfer date. Pt #7 clinical record also contained a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained blank sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. 6. During interviews with the Clinical Manager / Director of Nursing on 05/15/24 between 9:45 AM and 10:30 AM. The findings of the incomplete clinical records were confirmed.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical records review, and staff interviews, it was determined that in 3 of 7 (Pts. #1, 2 and 3) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. The clinical records and home visits were conducted on 05/13/25 and 05/14/25 for the following Pts.: Pt. #1. SOC 05/12/25. Pt. #2. SOC 01/27/25. Pt. #3. SOC 01/27/25. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact information of the Administrator to file a complaint or grievance. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Administrator to file a complaint and/or grievance. 2. During an interviews with the Clinical Manager/Director of Nursing on 05/15/25 at 9:45 AM and at 10:30 AM, the Clinical Manager/Director of Nursing confirmed the above findings.”

“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 clinical record reviews and Staff interviews, it was determined that in 5 of 7 (Pts. #3, 4, 5, 6 and 2) clinical records reviewed, the Agency failed to ensure the POC contained specific interventions related to Pt.’s diagnoses and medications. 5. Pt. # 2 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Bilateral Primary Osteoarthritis of Knee and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25. The record contained POC effective 03/28/25 to 05/26/25 that included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range: Fasting Blood Sugar greater than (>) 180mg/dl less than () 200 mg/dl less than ( 6. During interviews with the Clinical Manager / Director of Nursing on 05/15/25 between 9:45 AM and 10:30 AM., the findings related to the PsOC not including pertinent patient specific interventions were confirmed. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record contained POC effective 03/28/25 to 05/26/25, included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar….Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not indicated for Pt. #3’s diagnosis. The POC effective 03/28/25 to 05/26/25, included the following medications: “Biofreeze Cool The Pain…. Hydrocholorothiazide…. Tizanidine…. Amlodipine Besylate….Aspirin…. Losartan Potassium….Rosuvastatin Calcium….Metoprolol…. and Trazodone….” A home visit was conducted with Employee #4 (Registered Nurse) on 05/14/25 at 9:00 AM. During the home visit, Pt. #3, stated that she has been taking “Tylenol Extra Strength” for pain. The medication bottle labeled “Tylenol Extra Strength” was observed. Pt. #3 and Employee #4 confirmed that Pt. #3 has been taking the medication for more than a month. The POC was inaccurate. 2. Pt. # 4 was admitted to Home Health Services on 01/30/25 with the Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25 and 05/14/25. The POC effective 03/13/25 to 05/29/25, included: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar: greater than (>)180mg/dL less than ()200 mg/dl less than ( 150 mg/dl or >250 mg/dl or 3. Pt. # 5 was admitted to Home Health Services on 11/12/24 with the Diagnosis of Hemiplegia following other Cerebrovascular Disease affecting right dominant side. The clinical record was reviewed on 05/14/25. The POC effective 03/12/25 to 05/10/25, included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar….Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not indicated for Pt. #5’s diagnosis. 4. Pt. # 6 was admitted to Home Health Services on 01/29/24 with the Diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25. The PsOC effective 01/29/24 to 03/28/24 and 03/29/24 to 05/27/24, included: “Notify Physician of vital sign parameters out of range:….Blood Sugar, Fasting: Greater Than (>)180 less than ()200 Less Than ( 150 mg/dl or >250 mg/dl or”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy review and Staff interview, it was determined that in 6 of 7 (Pts. # 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status per Agency policy. Findings include: 1. During the entrance interview on 05/13/25 at 9:30 AM, the Clinical Manager stated that the Influenza and Pneumonia vaccination assessment are completed at the SOC, using the Agency standardized form. 2. The following clinical records were reviewed on 05/13/25 and 05/14/25, and lacked an Influenza and /or Pneumonia vaccination assessment: Pt. #2 SOC 01/27/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 01/27/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 01/30/25 - lacked Influenza and Pneumonia vaccination assessment. Pt. #5 SOC 11/12/24 – lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 01/29/24 – lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 10/19/24 – lacked Influenza and Pneumonia vaccination assessment. 3. The Agency policy was reviewed on 05/15/25. The policy titled: “Flu Vaccination” required, clinicians upon Start of Care, will obtain patient information regarding the patient’s flu vaccination status, will document where and when patient obtain their vaccination….The following shall be considered to be documentation….individual patient record entries identifying the assessment for the need of vaccination; date of offer or referral; patient response; administration, contraindication, or refusal; and any follow up activities….standardized check-off form recording patient specific information including assessment for the need of vaccination; date of offer or referral; patient response; administration, contraindication, or refusal; and any follow up activities .” The policy titled: “Pneumonia Vaccination” required, clinicians upon Start of Care obtain patient information patient information regarding the patient’s pneumonia vaccination status, will document where and when patient obtain their vaccination….The following shall be considered to be documentation….individual patient record entries….standardized check-off form….” 4. During interviews with the Clinical Manager/ Director of Nursing on 05/15/25 from 9:45 AM and at 10:30 AM, the Clinical Manager/ Director of Nursing confirmed the above findings.”