Excell 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 review of the Error Summary report and staff interview, it was determined that in 20 of 133 reports submitted for the last 12 months, the Agency failed to submit the report within 30 days after the assessment was completed resulting in a warning. Findings include: 1. The OASIS Error Summary report for 10/01/24 to 12/19/25 was reviewed on 01/13/26. The report included a warning for the error: 20 of the 133 assessments were submitted late; 15.04 % of the OASIS reports were submitted more than 30 days after the assessment was completed. 2. During staff an interview with the Agency Supervisor, on 01/14/26 at 2:30 PM, the above findings were confirmed.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy and staff interviews, for 6 of 7 (Pts. #1, 2, 3, 4, 5 and 7) clinical record reviews, the Agency failed to ensure that services were provided in accordance with accepted standards of practice. Findings include: 1. The following documents, “Lippincott Manual”, and journals from the National Library of Medicine of the National Institute of Health, “Vital Signs Assessment” and “Nursing Fundamentals” were reviewed on 01/15/26 and included documentation: “Normal Ranges: Temperature Range: 97.9 F to 99.5 F (Fahrenheit) Heart Rate/Pulse: 60 to 100 bpm (beats per minute) Respiratory Rate: 12 to 20 (cycles per minute) Systolic Blood Pressure: 120 to 140 (millimeters of Mercury/mmHg) Diastolic Blood Pressure: 80 to 90 (mmHg) Oxygen: 94 to 98 %” 2. The following clinical records were reviewed 01/13/26: Pt. #1 - SOC 12/30/25. Pt. #2 – SOC 10/08/25. Pt. #3 – SOC 12/01/25. Pt. #4 - SOC 08/01/25. Pt. #5 – SOC 09/09/25. Pt. #7 – SOC 06/06/25. The above-mentioned clinical records included a POC that required the following: “Orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range: Heart Rate: greater than 100 bpm, less than 60 bpm Temperature: greater than 102 F, less than 70 F Respiratory Rate: greater than 30, less than 15/minute Pain Level: greater than 10/10 Oxygen saturation: less than 80 % Systolic Blood Pressure: greater than 200 mmHg, less than 60 mmHg Diastolic Blood Pressure: greater than 100 mmHg, less than 50 mmHg 3. The Agency policy “Skilled Nursing Scope of Services” was reviewed and required, “3. Skilled nursing services will be carried out in accordance with accepted standards of practice of professional associations as well as any regulatory bodies impacting presently or in the future on the practice of skilled nursing…” 4. During an interview conducted with the Agency Supervisor on 01/14/25 from 2:00 PM and 3:00 PM, it was confirmed that the vital signs parameters are to be based on accepted standards of practice and Agency policy. During the same interview, the above findings were confirmed.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy and staff interview, for 3 of 7 (Pts. #4, 5, 6) clinical records reviewed, the Agency failed to ensure the clinical record was complete. Findings include: 1. Pt. # 4 was admitted for home health services on 08/01/25 with a diagnosis of Type 2 diabetes mellitus. The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 11/20/25, 12/19/25, 12/26/25 and 01/02/26 have not been incorporated in the clinical record. 2. Pt. #5 was admitted for home health services on 09/09/25 with a diagnosis of Type 2 diabetes mellitus with other circulatory complication. The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 12/26/25 and 12/31/25 have not been incorporated in the clinical record. 3. Pt. #6 was admitted for home health services on 05/12/25 with a diagnosis of Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, affecting both eyes (bilateral). The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 11/26/25, 12/10/25 and 01/02/26 have not been incorporated in the clinical record. 4. The Agency policy titled “Clinical Documentation” was reviewed on 01/15/26 and required, “8. Required documentation for each service provided must be completed on the day of service is rendered and filed in the clinical record within seven (7) days… When a client is discharged from care, clinical record shall be completed…within 14 days.” 5. During an interview conducted with the Agency Supervisor on 01/14/26 at 2:00 PM, the above findings were confirmed.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observation and interviews during a home visit, clinical record review and staff interview, for 6 of 7 (Pts. #1, 4, 5, 6, 2 and 3) clinical records reviewed, the Agency failed to ensure the clinical record included all interventions, services and patient responses. 5. Pt. #2 was admitted for home health services on 10/08/25 with the diagnosis of Bilateral primary osteoarthritis of knee. The clinical record was reviewed on 01/13/26. The record included the following SN visits: 12/10/25, 12/17/25, 12/26/25, and 12/31/25, completed by the RN for the certification period of 12/07/25 to 02/04/26 that lacked the visit narratives. 6. Pt. #3 was admitted for home health services on 12/01/25 with the diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. The clinical record was reviewed on 01/13/26. The record included the following SN visits: 12/03/25, 12/05/25, 12/10/25, 12/17/25, 12/29/25, and 01/07/26, completed by the RN for the certification period of 12/01/25 to 01/29/26 that lacked the visit narratives. 7. During staff interview with the Agency Supervisor on 01/14/26 at 2:00 PM, and 3:00 PM, the Agency Supervisor confirmed the above findings. Findings include: 1. Pt. #1 was admitted for home health services on 12/30/25 with the diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 01/02/26 and 01/07/26 which lacked documentation of any Pt. education/interventions implemented during the visit. 2. Pt. #4 was admitted for home health services on 08/01/25 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training notes dated 12/05/25 and 12/12/25 which lacked documentation of any Pt. education/interventions implemented during the visit. 3. Pt. #5 was admitted for home health services on 09/09/25 with the diagnosis of Type 2 Diabetes Mellitus with other circulatory complications. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 12/10/25 and 12/17/25 which lacked documentation of any Pt. education/interventions implemented during visit. 4. Pt. #6 was admitted for home health services on 05/012/25 with the diagnosis of Type 2 Diabetes Mellitus with mild non-proliferative diabetic retinopathy without macular edema, affecting both eyes (bilateral). The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 11/13/25 and 01/02/26 which lacked documentation of any Pt. education/interventions implemented during the visit.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records and staff interview, for 1 of 2(Pts. #7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. 1. Pt. #7 was admitted for home health services on 06/06/25 with the diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 01/13/26. The record included the discharge summary completed by the SN dated 12/01/25. The record lacked documentation that a copy of the summary was sent to the Physician. 2. During staff interview with the Agency Supervisor on 01/14/26 at 2:00 PM, and 3:00 PM, the Agency Supervisor confirmed the above findings.”