Advance Home Health Care, Ltd

“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 the review of the Agency’s Error Summary report and Staff interview, the Agency failed to submit timely reports for 188 of 1023 reports submitted for the last 12 months. Finding include: 1. The Agency’s Error Summary report for 09/01/2024 thru 08/31/2025, was reviewed on 09/23/25 at 2:40 PM. The report included 18.38% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator, on 09/24/25 at 10:43 AM.”

“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 the clinical records reviewed and Staff interview, the Agency failed in 2 of 7 (Pts. #4 and 6) clinical records reviewed, to ensure the patient care was provided as ordered in the plan of care. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 07/02/25 with the diagnosis of Orthostatic Hypotension. The clinical record was reviewed on 09/23/25. The clinical record contained a POC dated 07/02/25, that required the SN to visit the patient 2 times a week for 2 weeks and 1 time a week for 7 weeks, to complete a physical assessment each visit with emphasis on orthostatic hypotension. The SN failed to assess the patient for orthostatic hypotension on admission 07/02/25 and on revisit 07/04/25 (week #1). The ortho BP was not assessed until the 3rd visit 07/09/25 (week #2). 2. Pt. #6 was admitted to the Home Health Services on 04/23/25 with the diagnosis of Acute Post Hemorrhagic Anemia. The clinical record was reviewed on 09/23/25. The clinical record contained a POC dated 06/16/25, that required the SN and Aide to visit the patient 1 time a week for 9 weeks. The SN failed to visit during the week of 6/25/25 (week #1). The Aide failed to visit during the week of 08/14/25 (week #8). 3.The findings were confirmed during the interview with the Administrator and Director of Nursing on 09/24/25 between 9:30 AM and 11:00 AM.”

“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 a review of clinical records, and staff interview, for 5 of 7 (Pts. #1, 2, 3 and 4 and 5) clinical record reviewed, the Agency failed to ensure forms and records were complete and accurate. Findings include: 1. The following clinical records were reviewed on 09/22/25 to 09/23/25 and included the form “Notice of Medicare Non-Coverage.” The forms were signed by the Pt. or Pt. representative at the SOC. The forms were incomplete. Pt. #1. SOC: 08/06/24 –The section, “The Effective Date Coverage of Your Current Home Health Services Will End” was blank. Pt. #2. SOC: 07/03/25 - The section, “The Effective Date Coverage of Your Current Home Health Services Will End” was blank. Pt. #3. SOC: 08/18/25 – The section, “The Effective Date Coverage of Your Current Home Health Services Will End” was blank. Pt. #4. SOC: 07/02/25 – The section, “The Effective Date Coverage of Your Current Home Health Services Will End” was blank. Pt. #5. SOC: 07/03/25 – The section, “The Effective Date Coverage of Your Current Home Health Services Will End” was blank. 2. During an interview with the Agency Supervisor on 09/23/25 at 1:45 PM, it was stated that the form is to be filled out once the Agency has determined the effective date Medicare will not pay for the services, and not to be filled out at the SOC. During the same interviews, the above findings were confirmed.”

“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, policy review and staff interviews, for 3 of 7 (Pts. #1, 2 and 5) clinical records reviewed, the Agency failed to ensure Plans of Care included all the requirements. Findings include: 1. Pt. #1 was admitted for Home Health Services on 08/06/24 with the diagnosis of Pressure Ulcer Left Buttock Stage 2. The clinical record was reviewed on 09/22/25. The POC effective 01/01/25 included documentation “Home Health Aide to provide assistance with personal care, ADLs as indicated by limitations on functional and physical status impeding self-care.” The POC lacked documentation of the frequency and duration of the Home Health Aide. 2. Pt. #2 was admitted for Home Health Services on 04/02/25 with the diagnosis of Urinary Tract Infection. The clinical record was reviewed on 09/22/25. The SN notes for from 08/05/25 through 09/16/25 included documentation that Pt. #2 had a urinary catheter and that Home Health, and that the urinary catheter was changed on 09/02/25. The POC effective 07/31/25 lacked procedure and equipment for urinary catheter use, removal and replacement. 3. Pt. #5 was admitted for Home Health Services on 07/23/25 with the diagnoses of, but not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 Unspecified Chronic Kidney, Type 2 Diabetes Mellitus and Unspecified Diastolic Congestive Heart Failure (CHF). The clinical record was reviewed on 09/23/25. The POC effective 09/01/25 lacked documentation of interventions related to monitoring weight and fluids for CHF. 4. The undated Agency Policy titled “Congestive Heart Failure Policy” was reviewed on 09/23/25 at 2:00 PM and required, “Purpose: To clinically guide the care of the heart failure patients and standardize the practice to quickly identify the problems to ultimately prevent hospitalizations and exacerbations. Policy and Procedure: 2. Fully explain the procedure of weighing every skilled nursing visit and daily for the patient is necessary on this type of condition…4.The doctor should be notified if the condition of the patient restricts him/her in taking weight and create an order for the doctor to sign. 5. During an interview with the Administrator and Director of Nursing on 09/23/25 at 1:45 PM, it was stated that patients with CHF are to be weighed. During the same interviews, it was stated that the POC should include all of the required items, and the above-mentioned findings were confirmed.”