Advent Home Health Services, Inc.

“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 Error Summary report and staff interview, for 61 of 343 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed, which resulted in a warning. Findings include: 1. The Error Summary report for 06/01/25 to 06/24/26 was reviewed on 07/06/26 at 9:30 AM. The report included “Error # -3330” for 61 of 343 late submissions, which was 17.78% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 07/08/26 at 3:00 PM, it was confirmed the error occurred.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, clinical records, observation during home visits and staff interviews, in 7 of 7 (Pts. #1 - 7) clinical records reviewed, the Agency failed to ensure Pts. and/or patients’ representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1. The patient’s admission folder was reviewed on 07/07/26 and included the form titled, “Admission Service Agreement”. The Agency requires the SN to complete the Agreement form during the SOC visit. The form lacked a section that includes the disciplines to provide services and the frequency of their visits. 2. The clinical records were reviewed from 07/07/26 to 07/08/26 and included documentation that the following services were provided: Pt. #1. SOC 03/14/26. SN and PT. Pt. #2. SOC 04/08/26. SN. Pt. #3. SOC 06/01/26. PT and OT. Pt. #4. SOC. 01/01/26. SN. Pt. #5. SOC 02/16/26. SN. Pt. #6. SOC 08/07/25. PT. Pt. #7. SOC 10/15/26. SN and MSW. The records included the form titled, “Admission Service Agreement” completed by the RN, signed by the Pt./patient’s representative, and dated with the SOC date. The records lacked documentation that the Pt. or Pt.’s representative was notified of each discipline to provide services and frequency of visits, prior to providing Pt. care and services. 3. Home visits were conducted on the following Pts. on 07/07/26: Pt. #1. SOC 03/14/26. Pt. #2. SOC 04/08/26. During the home visits, the patients’ admission folders were reviewed and lacked the discipline and the frequency of the services to be provided. 4. During an interview with the Administrator on 07/08/26 at 2:45 PM, the above findings were confirmed.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on a review of clinical records, and staff interviews, for 4 of 7 (Pts. # 4, 5, 6 and 7) clinical record reviews, the Agency failed to ensure Pts. are advised in writing, of their out-of-pocket cost for services, if any, at SOC. Findings include: 1. The clinical records of the Pts. listed below were reviewed from 07/07/26 through 07/08/26. The records contained a form titled: “Admission Service Agreement Home Health.” The forms were signed by the Pts. or representative and dated upon admission, but the section” Liability for payment…I understand that services provided to me by this organization will be billed as follows…” were left blank. Pt. #4 SOC: 01/01/26 Pt. #5 SOC: 02/06/26 Pt. #6 SOC: 08/07/25 Pt. #7 SOC: 10/15/25 2. The above findings were confirmed during an interview with the Administrator on 07/08/26 at 3:00 PM.”

“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 review and staff interviews, for 2 of 7 (Pt. #5 and 7) clinical record reviews, the Agency failed to ensure that the PsOC included all the requirements. Findings include: 1. Pt. #5 was admitted to home health services on 02/06/26 with the diagnosis of Type 2 Diabetes Mellitus with diabetic polyneuropathy. The clinical record was reviewed on 07/08/26 and included a POC effective 06/05/26. The POC lacked documentation of parameters for notifying the physician of blood glucose results. 2. Pt. #7 was admitted to home health services on 10/15/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 07/08/26 and included a POC for the certification period of 12/14/25 to 02/11/26. The POC lacked documentation of parameters for notifying the physician of blood glucose results. 3. During an interview with the Administrator on 07/08/26 at 3:00 PM, the above findings were confirmed.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical review and staff interview for 1 of 7 clinical records reviewed (Pt. #5), the Agency failed to ensure that needs and concerns identified are communicated with other staff involved in the patient’s care. Findings include: 1. Pt, #5 was admitted to home health services on 02/06/26 with the diagnosis of Type 2 Diabetes Mellitus with diabetic polyneuropathy. The clinical record was reviewed on 07/08/26. The comprehensive assessment completed on 06/04/26 included documentation the RN identified the need for the Pt. to be referred to MSW, “Pt. will benefit for SW (Social Worker) on education, safety of home environment, including infection prevention, cleanliness and items falling…”. The clinical record lacked documentation that the need for MSW services was communicated to the Administrator or Director of Nursing. 2. During an interview conducted with the Administrator on 07/08/26 at 3:00 PM, it was confirmed that the need for a MSW services was not communicated between the SN and the Administrator or Director of Nursing, and therefore there was no MSW referral.”