Essential Preventive Health Care, LLC

“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 review of the Error Summary report and staff interview, for 385 of 588 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days after the assessment was completed. Findings include: 1. The Error Summary report for 10/01/24 to 12/19/25, was reviewed on 01/20/26 at 2:30 PM. The report included 385 of 588 late submissions, 65.48% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 11:30 AM, it was confirmed that the error occurred.”

“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 and staff interviews, for 2 of 7 (Pts. #3, and #6) the Agency failed to ensure the POC was followed. Findings include: 1. Pt. #3 was admitted for home health services on 08/15/25 with the diagnoses of but not limited to Pressure Ulcer of sacral region stage 2 and Type 2 Diabetes mellitus without complications. The clinical record was reviewed on 01/21/26. The POC effective 12/13/25 required, “SN: Assessment…of patient with…Type 2 diabetes mellitus without complications… Notify physician of Fasting Blood Sugar greater than 200 or less than 60…Random blood sugar greater than 250 or less than 60...“ The SN visit notes lacked documentation that the patient’s blood glucose was assessed and recorded on the clinical record by the SN. 2. Pt. #6 was admitted for home health services on 4/29/25 with the diagnosis of anxiety disorder. The clinical record was reviewed on 01/21/26 and included a POC for the certification period of 04/09/25 to 06/27/25. The POC required, “Orders and Treatments… SN: 1wk 9...” The record lacked documentation of an SN visit for the week of 05/25/25 to 05/31/25. 3. During an interview conducted with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 11:30 AM, the above findings”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on onsite observations and interviews during home visits, clinical record reviews and staff interviews, for 2 of 2 Pts. (Pt.#1 and 2) reviewed receiving Home Health Aide services, the Agency failed ensure that the written Pt. care instructions were based on RN assessment of the Pts. 2. Pt. #2 was admitted to home health services on 09/09/25 with the diagnosis of Phantom limb syndrome with pain. The clinical record was reviewed on 01/21/26. A home visit was conducted with HHA (Home Health Aide) on 01/21/26. During the home visit, the Pt. stated “the HHA comes twice a week to give me a shower”. The Aide Care plan reviewed prior to the visit documents under personal care: Complete bath and not a shower as stated by the pt. 3. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 10:15 AM and 11:40 AM, the Nursing Supervisor stated that the baths provided should be only either a complete bath or partial bath, or shower based on the assessment of the RN and that if during the home visit something changes, then the Aide Care Plan should be updated. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for skilled home health on 01/07/26 with a primary diagnosis of Type 2 Diabetes mellitus with diabetic polyneuropathy. A home visit was conducted with the PT on 01/22/26. During the home visit, the Pt. was asked regarding the type of bath the HHA provides and states, “gives me a shower, and I sit on the bench…” The clinical record was reviewed on 01/22/26 and included an Aide Care Plan that required the HHA to provide the Pt with both a “Complete bath” and a “Partial bath” during the same visit. The record lacked an individualized Aide Care Plan that was based on the assessment of the RN.”

“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 clinical record review and staff interviews, for 2 of 7 (Pts. #4 and 1) clinical records reviewed, the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for home health care services. 2. Pt. #1 was admitted for home health services on 01/07/26 with a diagnosis of Type 2 Diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 01/22/26. The record contained a Physician order dated 12/29/25 for “SN, PT, HHA…” The initial assessment was conducted by the RN on 01/07/26. The record lacked documentation the Agency started care/services within 48 hours of the referral date. 3. During an interview with the Assistant Administrator and Nursing Supervisor on 01/22/26 at 12:00 PM it was stated that the initial assessment should be conducted within 48 hours of the referral date. During the same interview, the above findings were confirmed. Findings Include: 1. Pt. #4 was admitted for home health services on 10/21/25 with the diagnosis of Dysphagia, oropharyngeal phase. The clinical record was reviewed on 01/21/26. The referral for home health services signed by Physician on 10/07/25 and received by Agency on 10/09/25 documents: “ Attached is a referral for home health services for Pt. #4, who will be returning home on 10/16. She will need PT/OT/ST/RN.” The record lacked documentation the Agency initiated service within the required time frame.”