Seraphic Springs Healthcare

“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 interview and document review, the home health agency failed to ensure an individualized plan of care was reviewed and signed timely by the physician for 1 patient (#7), out of a total sample of 8 patients. Findings include: Review of the agency’s policy titled “Plan of Care (POC) Signing Policy”, undated, included the following: -It is the policy of Seraphic Springs Health Care Agency, Inc. to ensure that all Plans of Care (POCs) are reviewed, approved and signed by the authorized physician in compliance with CMS and Massachusetts requirements. -All POCs must be signed and dated by the authorized physician to certify and authorize patient services. -Initial POC: Signed prior to or shortly after start of care. Patient #7 was admitted to the agency in August 2025 with a diagnosis of pre-eclampsia (persistent high blood pressure that develops during pregnancy or the postpartum period) and required skilled home care services. Review of the Plan of Care, dated 8/8/2025 through 10/6/2025, indicated the physician did not review and sign as required. During an interview on 12/17/25 at 11:20 A.M., the Administrator said all plans of care should be signed by the physician within one week and was unable to provide a reviewed and signed plan of care as required for Patient #7.”

“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 completed and appropriately authenticated and dated in accordance with currently accepted standards of practice for 2 patients (#7 and #3), out of a total sample of 8 patients. 2. Patient #3 was admitted to the agency in October 2025 with a diagnosis of acute kidney failure and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 10/30/25 through 12/28/25, indicated the following: -Skilled Nurse Visit (SNVs): 5 times a week for 9 weeks -Home Health Aide Services: 7 times a week for 9 weeks Further review of the clinical record indicated that documentation for the visits was not completed and incorporated into the patient’s record within 24 hours, per policy, including the following: *The SNV note for 11/1/25 was completed and signed 11/9/25. *The SNV note for 11/3/25 was completed and signed 11/9/25. *The SNV note for 11/10/25 was completed and signed 11/24/25. *The SNV note for 11/11/25 was completed and signed 11/28/25. *The SNV note for 11/12/25 was completed and signed 11/28/25. *The SNV note for 11/14/25 was completed and signed 11/24/25. *The SNV note for 11/24/25 was completed and signed 12/8/25. *The SNV note for 12/3/25 was completed and signed 12/15/25. During an interview on 12/17/25 at 10:15 A.M., the Administrator said all visit documentation should be completed within 24 hours per policy. She said once the visit documentation is completed by the nurse, the Quality Assurance Nurse completes a review and signs off. The Administrator said the Quality Assurance Nurse reviewed the visit documentation late. Findings include: Review of the agency policy titled, Clinical Documentation, undated, indicated the following: -All clinical documentation shall be accurate, timely, complete, legible, and reflective of the care provided. -All clinical documentation must be completed and submitted within 24 hours of the date and time the service is provided. Documentation not completed within this timeframe shall be considered late and subject to review and corrective action. 1. Patient #7 was admitted to the agency in August 2025 with a diagnosis of pre-eclampsia (persistent high blood pressure that develops during pregnancy or the postpartum period) and required skilled services. Review of the physician ordered Plan of Care, dated 8/8/25 through 10/6/25 indicated the following: -Skilled Nurse (SN) visits 2 times per week for 9 weeks and 3 SN visits as needed (PRN). Further review of the clinical record indicated documentation for the visits was not completed and incorporated into the patient’s record within 24 hours, per policy, including the following: -SN visit note for 8/12/25 was completed and signed 9/14/25. -SN visit note for 8/15/25 was completed and signed 9/14/25. -SN visit note for 8/18/25 was completed and signed 9/14/25. -SN visit note for 8/21/25 was completed and signed 9/14/25. -SN visit note for 8/25/25 was completed and signed 9/14/25. -SN visit note for 9/2/25 was completed and signed 9/15/25. -SN visit note for 9/5/25 was completed and signed 9/15/25. -SN visit note for 9/8/25 was completed and signed 9/15/25.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and document review, the Agency failed to ensure a substantiated allegation of abuse (misappropriation: wrongful temporary or permanent use of a patient’s belongings or money without such patient’s consent) was reported to the Department of Public Health for 1 patient (#8), out of a total sample of 8 patients. Review of the agency’s policy titled “Abuse Policy”, undated, indicated the following: -An employee must immediately make a verbal report of suspected patient abuse, neglect, mistreatment, or misappropriation of patient or property to his or her supervisor. Upon receiving such report, said supervisor shall immediately notify the Department of Public Health (DPH) by calling the State Hotline. A form to document report can be obtained by calling the State Hotline. The Supervisor will fill out the report and fax to designated fax line outlined on the form. -Upon receiving a report regarding misappropriation of patient property, with the exception of a controlled substance, supervisor shall within 48 hours complete an internal investigation into the matter to determine whether the item(s) in question may have been misappropriated. If within 48 hours there is reasonable cause to suspect misappropriation said supervisor shall immediately notify the Department of Public Health telephone or fax. Review of an undated incident report indicated that on 1/22/24 Patient #8 informed the agency that he/she had filed a police report for elder abuse. He/she said that Home Health Aide (HHA) #1 used his/her credit card to purchase items online. A report was filed verbally to the elder abuse hotline 1/22/24. Upon investigation the agency found that HHA #1 had been making online purchases for Patient #8 and the credit card information for Patient #8 was saved to the online account of HHA #1. Further investigation indicated that HHA #1 said her daughter had used the credit card of Patient #8 to make personal online purchases in the amount of $524.78. HHA #1 employment was terminated and a written report was sent to the Case Manager. Review of an Executive Office of Elder Affairs - Elder Abuse Mandated Reporter Form, dated 2/1/24 (10 days after being notified, not within 48 hours) failed to include verification that it had been submitted to the Executive Office of Elder Affairs or to the Department of Public Health. Review of the DPH Healthcare Facility Reporting System indicated that there had been no reports submitted to DPH since 4/13/23. During an interview on 12/16/25 at 12:50 P.M., the Administrator said that misappropriation should be reported to DPH.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review, policy review and interview, the home health agency failed to ensure that services and treatments were administered only as ordered by a physician or allowed practitioner for 1 patient (#3), out of a total sample of 8 patients. Findings include: Review of the agency policy titled “Physician’s Orders”, undated, indicated the following: Purpose: -To ensure that all patient care services are authorized, medically necessary, and delivered in accordance with valid physician orders. Policy Statement: -All patient services must be supported by a valid physician order. No care maybe initiated, changed, or continued without proper authorization. Physicians order must include: -Patient name, description of ordered services and frequency, date of the order, physicians’ signature and credentials, duration of services when applicable. Verbal and Telephone Orders: -Verbal or telephone orders may be accepted by licensed staff when permitted by regulation and must be documented immediately and signed by the physician within required timeframes. Patient #3 was admitted to the agency in October 2025 with a diagnosis of acute kidney failure and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 10/30/25 through 12/28/25, indicated the following: -Skilled Nurse Visit (SNVs): 5 times a week for 9 weeks. -Home Health Aide Services: 7 times a week for 9 weeks. Review of the medical record indicated that occupational therapy (OT) evaluation and treatment were provided twice a week for the week of 11/9/25-11/15/25 and 11/16/25-11/22/25. Further review of the medical record failed to indicate and order for OT evaluation and treatment. During an interview on 12/17/25 at 12:15 P.M., the Administrator said that telephone order for OT evaluation and treatment was obtained from the physician but was not documented and transcribed.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the home health agency failed to ensure that the physician ordered plan of care was followed for 1 patient (#4) out of a total of 8 sampled patients. Specifically, the Agency failed to provide a Physical Therapy (PT) assessment/evaluation. Findings include: Patient #4 was admitted to the agency in December 2025 with diagnosis of history of Transient ischemic attack (TIA) and required skilled home care services. Review of the admission service agreement dated 12/3/25 indicated services for skilled nursing, physical therapy evaluation, and occupational therapy (OT) evaluation. Review of the plan of care for certification period of 12/4/25-1/24/25, indicated an order for skilled nursing services, PT and OT assessment/evaluation. Review of the clinical record failed to indicate that a PT Assessment/evaluation was conducted as ordered. During an interview on 12/17/25 at 11:30 A.M., the Administrator reviewed the medical record and said that PT evaluations were not done for Patient #4.”

“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 interview and documentation review, the home health agency failed to ensure a completed discharge summary was sent to the physician within 5 business days of the patient’s discharge from the agency as required for 1 patient (#7), out of a total sample of 8 patients. Findings include: Patient #7 was admitted to the agency in August 2025 with a diagnosis of pre-eclampsia (persistent high blood pressure that develops during pregnancy or the postpartum period) and required skilled home care services. Review of the Plan of Care, dated 8/8/2025 through 10/6/2025, indicated the following: -Skilled Nursing 2 times per week for 9 weeks and 3 Skilled Nursing visits as needed (PRN). Review of the OASIS (a standardized assessment tool used by home health agencies for adult patients receiving Medicare/Medicaid funded care) Discharge Assessment, dated 9/11/25, indicated Patient #7 was discharged from service as all goals were met. Additional review of the clinical record failed to include documentation the discharge assessment was sent to the physician as required. During an interview on 12/17/25 at 11:55 A.M., the Administrator said the Oasis Discharge Assessment should be sent to the physician when a patient is discharged from services. The Administrator was unable to provide supporting documentation to verify the physician was provided with the discharge assessment as required.”