Suburban Home Health Care, Inc.

“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 record review and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 8 patients (#2, #4, #5, #7, #8, #3, #10, and #13), out of a total sample of 14 patients. Findings include: 7. Patient #3 was admitted to the agency in September 2025 with a diagnosis of aftercare following joint replacement surgery. a. Review of the clinical record indicated a physician ordered POC for certification period 9/25/25 through 11/23/25 indicated the following: SN: 1-2 times a week for 9 weeks with 3 as needed (prn) visits. Physical Therapy (PT): 1-2 times a week for 9 weeks, then 1-2 times a week for 3 weeks. Review of the clinical record indicated the SN and PT visit notes were not signed/dated on the day services were rendered: *9/25/25 SN visit, note completed 9/30/25 *9/25/25 PT visit, note completed 9/28/25 b. Review of the clinical record indicated a physician ordered POC for certification period 11/24/25 through 1/22/26 indicated the following: SN: 1-2 times a week for 8 weeks. Review of the clinical record indicated the SN visit notes were not signed/dated on the day services were rendered: *1/7/26 SN visit, note completed 1/12/26 c. Review of the clinical record indicated a physician ordered POC for certification period 1/23/26 through 3/23/26 indicated the following: SN: 1-2 times a week for 10 weeks with 3 PRN visits. Review of the clinical record indicated the SN visit notes were not signed/dated on the day services were rendered: *1/28/26 SN visit, note completed 2/2/26 8. Patient #10 was admitted to the agency in March 2024 with a diagnosis of diabetes mellitus type 2. a. Review of the clinical record indicated a physician ordered POC for certification period 11/20/25 through 1/18/26 indicated the following: PT: 1 time a week for 1 week, 1-2 times a week for 1 week, 1-2 times a week for 1 week, then 1-2 times a week for 8 weeks. Review of the clinical record indicated the PT visit notes were not signed/dated on the day services were rendered: *12/11/25 PT visit, note completed 12/16/25 *12/18/25 PT visit, note completed 12/22/25 *12/24/25 PT visit, note completed 12/30/25 *1/2/26 PT visit, note completed 1/5/26 *1/3/26 PT visit, note completed 1/6/26 *1/8/26 PT visit, note completed 1/13/26 *1/10/26 PT visit, note completed 1/13/26 *1/15/26 PT visit, note completed 1/20/26 b. Review of the clinical record indicated a physician ordered POC for certification period 1/19/26 through 3/19/26 indicated the following: PT: 1-2 times a week for 9 weeks Review of the clinical record indicated the PT visit notes were not signed/dated on the day services were rendered: *1/22/26 PT visit, note completed 2/27/26 *1/24/26 PT visit, note completed 2/27/26 *1/29/26 PT visit, note completed 2/2/26 During an interview on 2/9/26 at 8:36 A.M., Nurse #1 said the expectation for submission of clinical documentation is same day, but within 48 hours the latest. During an interview on 2/9/26 at 12:34 P.M., the ED said home health personnel enter information on the day of the visit and once it’s signed it’s complete. She said being signed and submitted meant the same thing and the agency probably needed to clarify their policy. 6. Patient #13 was admitted to the agency in November 2024 with a diagnosis of hypertension and Hodgkin Lymphoma a. Review of the Physician ordered Plan of Care (POC) for certification periods 11/15/25 through 1/13/26 indicated the following: *SN 1 time per week for 10 weeks and 3 as needed (PRN) visits for exacerbation of disease process. Review of the clinical record indicated the following: *SN visit on 12/19/25 with visit note completed on 12/23/25. *SN visit on12/24/25 with visit note completed on 12/30/25. b. Review of the Physician ordered POC for certification period 1/14/26 through 3/14/26, indicated the following: *SN visit 1/21/26, note completed on 1/26/26. *SN visit 1/28/26, note completed on 2/2/26. *SN visit 2/4/26, note completed on 2/9/26. During an interview on 2/9/26 at 10:40 A.M. Nurse #3 said that documentation is completed 24-48 hours after the visit is completed. During an interview on 2/9/26 at 12:40 P.M. Nurse #2 said that documentation should be completed after the visit is done but sometimes you are waiting to speak with a provider or physician, so that case you would wait to write your note, but no later than the next day. Review of the agency policy, titled Entries into the Clinical Record, Policy No. 5-006, not dated, included the following: *Documentation in the clinical record will be timely, detailed, accurate, and reflect the care of services provided. *Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned into the office in a timely manner. 1. Patient #2 was admitted to the agency in May 2025 with a diagnosis of Heart Failure. a. Review of the Physician ordered Plan of Care (POC) for certification period 11/12/25 through 1/10/26 indicated the following: Skilled Nursing (SN) visits 1 to 3 times a week for 9 weeks, with three as needed (PRN) visits for exacerbation. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *12/8/25 visit, note completed on 12/14/25 *12/10/25 visit, note completed on 12/15/25 *12/13/25 visit, note completed on 12/16/25 *12/24/25 visit, note completed on 12/29/25 *1/2/26 visit, note completed on 1/5/26 b. Review of the Physician ordered POC for certification period 1/11/26 through 3/11/26, indicated the following: SN visits 1 to 3 times a week for 10 weeks, with 3 PRN visits for exacerbation. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *1/19/26 SN visit, note completed on 1/26/26 *1/21/26 SN visit, note completed on 1/26/26 *1/26/26 SN visit, note completed on 2/2/26 *1/31/26 SN visit, note completed on 2/3/26 2. Patient #4 was admitted to the agency in January 2025 with a diagnosis of Diabetes and CKD (chronic kidney disease). a. Review of the Physician ordered POC for certification period 11/10/25 through 1/8/26 indicated the following: SN visits 1 to 3 times a week for 9 weeks, with 3 PRN visits for exacerbation. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *12/9/25 SN visit, note completed on 12/15/25 *1/1/26 SN visit, note completed on 1/5/26 b. Review of the Physician ordered POC for certification period 1/9/26 through 3/9/26 indicated the following: SN visits 1 to 3 times a week for 10 weeks, with 3 PRN visits for exacerbation. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *1/20/26 SN visit, note completed on 1/26/26 *1/27/26 SN visit, note completed on 2/2/26 3.Patient #5 was admitted to the agency in December 2025 with a diagnosis of Benign Paroxysmal Vertigo (inner ear disorder that causes a spinning sensation) and Hypertension. Review of the Physician ordered POC for certification period 12/17/25 through 2/14/26 indicated the following: SN visits 1 to 2 times a week for 4 weeks, with 3 PRN visits for complications/medication changes. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *12/22/25 visit, note completed on 12/27/25 *12/26/25 visit, note completed on 12/29/25 *12/29/25 visit, note completed on 12/31/25 *1/2/26 visit, note completed on 1/5/26 4. Patient #7 was admitted to the agency in October 2025 with a diagnosis of Hypertensive CKD (chronic kidney disease). Review of the Physician ordered POC for certification period 10/29/25 through 12/7/25 indicated the following: SN visits 1 times a week for 9 weeks. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *11/6/25 SN visit, note completed on 11/10/25 *11/13/25 SN visit, note completed on 11/18/25 *11/20/25 SN visit, note completed on 11/25/25 5. Patient #8 was admitted to the agency in March 2025 with a diagnosis of Type 2 Diabetes. Review of the Physician ordered POC for certification period 11/1/25 through 12/20/25 indicated the following: SN visit 1 time a week for 10 weeks. Review of the clinical record indicated the following SN visits were not dated/signed on the day services were rendered: *11/12/25 SN visit, note completed on 11/17/25 *11/17/25 SN visit, note completed on 11/24/25 During an interview on 2/5/26 at 1:02 P.M. the Executive Director (ED) said documentation should ideally be entered on the same day but sometimes clinicians are waiting on something and will submit later. She said she would not expect all disciplines to be consistently late with submitting documentation.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated the last five days of every 60 days beginning with the start of care date for one patient (#3), out of a total sample of 14 patients. Findings include: Review of the agency’s policy titled Care Planning Process, undated, indicated but was not limited to the following: *A written plan of care will be initiated within five (5) days of the start of care and updated at least every 60 days, or as a patient’s condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. Patient #3 was admitted to the agency in September 2025 with a diagnosis of aftercare following joint replacement surgery. Review of the clinical record indicated a physician ordered Plan of Care for certification period 11/24/25 through 1/22/26. Patient #3 remained on service into a subsequent certification period beginning 1/23/26. Further review of the clinical record indicated an Outcome and Assessment Information Set (OASIS-tool used to collect data on patient outcomes and quality of care) recertification assessment for Patient #3, dated 1/20/26. A comprehensive assessment (including OASIS data elements) to reflect the patient’s current health status was not updated or revised in the last 5 days of every 60 days by a skilled nurse until discharged as required. During an interview on 2/9/26 at 12:47 P.M., the Director of Nursing, after reviewing Patient #3’s clinical record, said an updated comprehensive assessment was not completed within the required timeframe.”