Spectrum Nurses, 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 Agency’s Error Summary report and Staff interview, the Agency failed to submit timely reports for 88 of 655 reports submitted for the last 12 months. Finding include: 1. The Agency’s Error Summary report for 07/01/2024 through 06/30/2025, was reviewed on 07/22/25 at 10:10 AM. The report included 88 of 655 (13.52%) of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Director of Nursing, on 07/22/25 between 11:30 AM and 2:00 PM.”

“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 a review of clinical records, Agency policy, and Staff interviews, in 5 of 7 (Pts. #1, 3, 4, 6, and 7) clinical records reviewed, the Agency failed to ensure Staff provide service, as required on the POC and ordered by the Physician. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The clinical record included the POC for the certification period of 05/15/25 to 07/13/25. The POC required the SN to provide service “1wk9 …Notify physician of… Pulse greater than (>) 120 or less than () 180 or less than ( Diastolic BP greater than (>) 90 or less than ( The SN visit notes dated 06/03/25 and 06/10/25 included “BP 101/56”, the SN visit note dated 06/24/25 included “Pulse 55”. The record lacked documentation the SN notified the Physician for Pulse and BP outside the stated parameters in the POC. The SN “Missed Visit Form” competed by the SN and dated 05/27/25 lacked documentation the Physician was notified of the missed visit, or that the SN attempted to reschedule the visit during the week of 05/25/25 to 05/31/25. 2. Pt. 3 was admitted for Home Health services on 04/30/24 with a diagnosis of, but not limited to “Pulmonary Fibrosis, Unspecified. The clinical record was reviewed on 07/22/25. The clinical record included the POC for the certification period of 04/24/25 to 06/22/25 that required the SN to provide service “1wk9 … Notify physician of: Temperature greater than (>) 101 or less than ( Pulse greater than (>) 120 or less than (Systolic BP greater than (>) 180 or less than ( Diastolic BP greater than (>) 90 or less than ( The SN visit note dated 05/27/25 lacked documentation the SN assessed the patient’s temperature, pulse, or BP. The SN “Missed Visit Form” competed by the SN and dated 06/12/25 lacked documentation the Physician was notified of the missed visit, or that the SN attempted to reschedule the visit during the week of 06/08/25 to 06/14/25. 3. Pt. #4 was admitted to Home Health services on 10/14/24 with the diagnoses of Essential Hypertension and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 07/22/25. The clinical record included PsOC dated 04/07/25 and 06/06/25, that required the SN to assess the patient 1 time a week for 9 weeks. The SN failed to visit the weeks of 05/07/25 (week #5) and 05/14/25 (week #6). 4. Pt. #6 was admitted to Home Health services on 01/27/23 with the diagnoses of “Hyp Hrt & Chr Kdny Dis w Hrt Fail and stg 1-4/unsp chr kdny”. The clinical record was reviewed on 07/22/25. The clinical record included a POC dated 07/20/24, that required the OT to evaluate the patient. The OT evaluation included orders to assess the patient 1 time a week for 8 weeks. The OT failed to visit the weeks of 08/03/24 (week #2) and 09/05/24 (week #7). 5. Pt. #7 was admitted to Home Health services on 05/03/24 with the diagnosis of “Carcinoma in situ of rectosigmoid junction”. The clinical record was reviewed on 07/22/25. The clinical record included a POC dated 08/31/24, that required the SN to assess the patient 1 time a week for 9 weeks. The SN failed to visit the patient after 09/27/24. 6.The Agency’s policy titled “Missed Visit Report” was reviewed on 07/23/25 at 10:00 AM and included “…SPECIAL INSTRUCTIONS… 3. Notify the Physician and the Agency…” 7.The above findings were confirmed, during an interview with the Director of Nursing, Nursing Supervisor and QA RN on 07/23/25 between 8:58 AM and 11:30 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 interviews, in 4 of 7 (Pts. #1, 3, 5 and 7) clinical records reviewed, the Agency failed to ensure the clinical records were complete and accurate. 3. Pt. #5 was admitted to the Home Health services on 04/22/25 with the diagnosis of Multiple Sclerosis. The clinical record was reviewed on 07/22/25. The clinical record included a POC dated 04/22/25, that included the SN services 1 times a week for 9 weeks. The records lacked the SN visit notes after 07/02/25. On 07/22/25 at 11:00 AM, during the interview with the Director of Nursing, it was stated the SN visits were conducted and the SN notes were not yet completed. 4. Pt. #7 was admitted to the Home Health services on 05/03/24 with the diagnosis of “Carcinoma in situ of rectosigmoid junction”. The clinical record was reviewed on 07/22/25. On 07/23/25, 11:00 AM, during the interview with the Director of Nursing, it was stated the patient refused the Home Health Care visits and wanted hospice care. The clinical notes were incomplete and lacked the documentation of patient’s request for hospice care. 5. The above findings were confirmed, during an interview with the Director of Nursing, Nursing Supervisor and QA RN on 07/23/25 between 8:58 AM and 11:30 AM. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The clinical record included the “Notice of Medicare Non-Coverage” form completed by the SN and signed by the patient’s caregiver on 05/15/25. The CMS form required the Agency to document the effective date that services will end. This section on the form was left blank. 2. Pt. #3 was admitted for Home Health services on 04/30/24 with a diagnosis of, but not limited to “Pulmonary Fibrosis, Unspecified. The clinical record was reviewed on 07/22/25. The clinical record included the undated “Notice of Medicare Non-Coverage” form completed by the SN and signed by the Pt. The CMS form lacked the effective date that services will end.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of clinical records, and Staff interview, in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to obtain a referral to initiate service. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The Agency lacked a referral to initiate service on 05/15/25. 2. Pt. #2 was admitted for Home Health services on 06/30/20 with a diagnosis of, but not limited to Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 07/22/25. The Agency lacked a referral to initiate service on 06/30/20. 3. During an interview with the Director of Nursing, Nursing Supervisor and QA RN on 07/23/25 at 8:58 AM, all confirmed the Agency failed to initiate service within 48 hours of receipt of a referral.”

“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 a review of clinical records and Staff interview, in 2 of 7 (Pts. #1, and 3) clinical records reviewed, the Agency failed to complete the assessment for Pt. Pneumonia and Influenza vaccines. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The clinical record included the Agency’s form titled, “Influenza/Pneumonia Vaccine” completed by the SN and dated 05/15/25. The form lacked an inquiry regarding the need for the Pneumonia vaccine during the SOC visit. 2. Pt. #3 was admitted for Home Health services on 04/30/24 with a diagnosis of, but not limited to “Pulmonary Fibrosis, Unspecified. The clinical record was reviewed on 07/22/25. The clinical record included the SOC assessment form completed by the SN and dated 04/30/24. The form contained a section titled; “Most Recent Immunizations” that included an inquiry for the Pneumonia and Flu (Influenza) vaccines. The SN responded “No” to both vaccines. The form lacked documentation to indicate whether “No” was intended that the Pt. refused the vaccines, or the vaccines were not needed. 3. During the entrance interview with the Administrator, Director of Nursing, and Nursing Supervisor #1 on 07/21/25 at 1:00 PM, Nursing Supervisor #1 stated that an inquiry regarding the patient’s need for the Influenza and Pneumonia vaccines is initially conducted during the SOC visit and is documented in the SOC assessment form, and/or the vaccine form in the clinical record. 4. During an interview with the Director of Nursing, Nursing Supervisor and the QA RN on 07/23/25 at 8:58 AM, all confirmed the SN failed to complete the assessment for Pneumonia and/or Influenza vaccines during the SOC visits.”

“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 a review of clinical records, Agency policy, and Staff interview, in 1 of 3 (Pt. #1) clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure the Home Health Aide followed the directions on the Home Health Aide Care Plan. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The clinical record included the “Aide Care Plan” completed by the RN on 05/15/25. The Aide Care Plan included, “Vital Sign Notification… Pulse >120 The Home Health Aide visit notes dated 05/23/25 (Pulse 56), 06/23/25 (Pulse 52), 06/27/25 (Pulse 48), and 06/30/25 (Pulse 58), lacked documentation the Home Health Aide notified the RN and/or Agency of the Pulse rates outside the stated parameters in the Aide Care Plan. The Home Health Aide visit note dated 06/13/25 included, “Patient has some small skin abrasions near her right knee”. The Home Health Aide visit note dated 06/16/25 included “Skin tares near right knee”. The Home Health Aide visit notes/record lacked documentation the Home Health Aide notified the RN and/or Agency of the abrasions and skin tares. The SOC assessment form dated 05/15/25 and ROC assessment form dated 05/23/25, all completed by the RN; and weekly RN visit notes from 05/27/25 to 07/01/25 lacked documentation of any skin breakdown for Pt. #1. 2. The Agency policy titled; Home Health Aide Job Description” was reviewed on 07/23/25. The policy required, “… The Home Health Aide participates in caring for clients by… Recording care given, including observations and treatments; Informing supervisor of changes in client’s condition...” 3. During an interview with the Director of Nursing, Nursing Supervisor and the QA RN on 7/23/25 at 8:58 AM, Nursing Supervisor #1 stated the Home Health Aide is trained to notify either her or the Agency when new areas of skin breakdown is observed. During the same interview, the Director of Nursing and Nursing Supervisor confirmed the above findings.”

“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 a review of clinical records and Staff interviews, in 2 of 3 (Pts. #1 and 5) clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. 2. Pt. #5 was admitted to the Home Health services on 04/22/25 with the diagnosis of Multiple Sclerosis. The clinical record was reviewed on 07/22/25. The clinical record included a POC dated 04/22/25, with Aide services 2 times a week for 9 weeks. The records lacked documentation of the Aide supervision by the RN in the patient’s home on 05/01/25 (week #3) and on the week of 07/16/25 (week #4). During the interview with the Director of Nurses, it was stated the supervision was conducted by telephone. 3. The above findings were confirmed, during an interview with the Director of Nursing, Nursing Supervisor and QA RN on 07/23/25 between 8:58 AM and 11:30 AM. Findings include: 1. Pt. #1 was admitted for Home Health services on 05/15/25 with a diagnosis of, but not limited to Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 07/22/25. The clinical record included the Home Health Aide visit notes for 1 to 2 times a week from 05/15/25 to 06/30/25 that indicated care was provided. The record lacked documentation the RN supervised the Home Health Aide from 05/15/25 to 06/30/25.”