Advent Health Care Services 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 a review of the Home Health Agency (HHA) Error Summary Report for the period 06/01/2024 through 06/01/2025 and staff interview, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This is evident for two (2) clinical records documented in the HHA Error Summary by Agency Report. Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: 1. The HHA Error Summary by Agency Report for the period 06/01/2024 through 06/01/2025 documents: “Error # -3330 Record Submitted Late: The submission date is more than 30 days after M0090 (Start of Care) on this new record… # of Assessments with error two (2). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 06/11/25 at 3:30 PM, the Administrator/Director of Patient Services and the Quality Assurance Assistant were interviewed and did not provide an explanation for the survey findings.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, clinical record reviews, and staff interviews, the agency failed to follow accepted standards of infection control practices. This was evident for one (1) of two (2) observational home visits. (Patient: #1). Failure to follow accepted standards of infection control practices, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 (Home Visit) with a Start of Care date of 04/01/2025 with diagnoses of: Bilateral Primary Osteoarthritis of knee, Age related Osteoporosis, Essential Hypertension, Hyperlipidemia, long term use of Aspirin, long term use of oral hypoglycemic drugs as documented on the Home Health Certification and Plan of Care for the Certification Period from 5/30/2025 to 7/29/2025. The agency’s Policy:5-03 Storage, Cleaning, Disinfection of Equipment, Item #8 documents: “Reusable medical supply items must be cleaned immediately after each use and stored in a designated clean area to maintain their cleanliness and prevent spread of infectious disease “. On 06/09/2025 at 4:35 PM, a home visit was conducted with the Registered Nurse and the following were observed: Bag Technique: The equipment for monitoring the patient’s blood pressure, temperature and oxygen level were removed from the bag. After completion of the assessment, the equipment was returned to the bag without being sanitized. The Registered Nurse was observed not following the agency’s policy and procedure for use of equipment in the home to prevent the transmission of infection. On 06/11/2025 at 2:20 PM, the Administrator/Director of Patient Services and the Quality Assurance Assistant were interviewed and did not provide an explanation for the survey findings.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on clinical record reviews and staff interview, the agency failed to ensure all patients received written notice and were informed of their rights and responsibilities. This was evident for one (1) of eight (8) clinical records reviewed. (Patient: #8). Failure to ensure all patients received written notice and are informed of their rights and responsibilities, has the potential for negative patient outcomes. The Findings Are: 1. Patient #8 (Home Visit) has a Start of Care date of 05/14/2025 with the diagnoses Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene, Essential Hypertension, Long Term (Current) Use of Insulin documented in the Home Health Certification and Plan of Care for the Certification Period 05/14/2025 to 07/12/2025. The “Patient Consent/Acknowledgement Agreement” signed and dated 05/14/2025 by the patient documents: “I hereby give consent to and authorize Advent Health Care Services, LLC, a special needs agency caring for the PWDD (People with Developmental Disabilities) population to render needed health care and support service under the orders of my physician.” The “Non PWDD Home Care Agreement” signed and dated 05/14/2025 by the patient documents the patient was informed of the following: “The New York State Department of Health is requiring Advent Health Care to inform you that it is a Certified Home Health Agency (CHHA) targeted to primarily service the needs of the People with Developmental Disabilities population in the community. We are required to let you know that you have the right to choose another home care provider in the community who can also meet your needs. If you choose to be transferred to another agency, Advent Health Care will be happy to assist you with transferring to the agency of your choice.” The agency’s New York State Department of Health Department of Health “Certificate of Authorization” Effective Date 12/20/2023 does not include authorization for the agency to provide services to the People with Developmental Disabilities population. During the entrance conference interview on 06/09/2025, 12:30 PM, the Administrator/Director of Patient Services stated: “no,” the agency is not a special needs CHHA (Certified Home Health Agency). The clinical record lacks documented evidence of the patient consenting to and being informed of the correct authorized operation of the agency, a general population CHHA. The “Patient Consent/Acknowledgement Agreement” and “Statement of Services and Insurance Coverage” signed and dated 05/14/2025 by the patient document the following: “Yellow: Patient Copy.” During an observational home visit with the skilled nurse on 06/10/2025 at 3:40 PM, the surveyor reviewed the admission folder provided to the patient at the start of care. There is no documented evidence of the patient receiving the Yellow Patient Copy. The Skilled Nurse was interviewed and stated the agency “mails” a copy to the patient. The patient was interviewed and stated, “I did not get it yet” in the mail. There is no documented evidence of the patient receiving a hard copy of the signed written notice/acknowledgment of the patient’s rights and responsibilities, including consent authorizing agency to provide services and the financial liability. On 06/11/2025 at 2:20 PM, the Administrator/Director of Patient Services and the Quality Assurance Assistant were interviewed and did not provide an explanation for the survey findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, clinical record reviews, and staff interviews, the agency failed to establish an individualized plan of care that include all the required information. This was evident for one (1) of eight (8) clinical records reviewed. (Patient: #8). Failure to ensure individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #8 (Home Visit) has a Start of Care date of 05/14/2025 with the diagnoses Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene, Essential Hypertension, Long Term (Current) Use of Insulin documented in the Home Health Certification and Plan of Care for the Certification Period 05/14/2025 to 07/12/2025. The Physician’s Face-to-Face Encounter dated 05/05/2025 documents: patient has a “CGM (Continuous Glucose Monitoring)” device. The Start of Care comprehensive assessment dated 05/14/2025 documents: “Patient able to check BSL (blood sugar level) daily.” The Home Health Certification and Plan of Care for the Certification Period 05/14/2025 to 07/12/2025 documents: “Skilled nurse to evaluate and develop plan of care;” “Skilled Nurse to obtain vitals upon each visit;” “to report vital signs falling outside the following established parameters: “FBS (Fasting Blood Sugar) 250;” and “Patient does administration of insulin, blood glucose testing;” The Skilled Nurse Visit Report document the Registered Nurse obtaining the patient’s Fasting Blood Sugar results 05/14/2025 -137, 05/21/2025 - 121, and 05/28/2025-122. The Skilled Nurse Visit Report lacks documented evidence of how the Registered Nurse obtained the Fasting Blood Sugar results. During an observational home visit with the Skilled Nurse on 06/10/2025 at 3:40 PM, the Skilled Nurse reviewed blood glucose monitoring with the patient. The Skilled Nurse stated the patient has a continuous glucose monitoring (CGM)device and “checks the app” on the cellphone for the blood glucose level. The patient showed the Skilled Nurse and the surveyor the current blood glucose reading during the visit. The Home Health Certification and Plan of Care lacks documented evidence of the method the patient uses to monitor blood glucose levels (e.g. a glucose meter with fingerstick test strips or a Continuous Glucose Monitoring (CGM) device and the frequency to monitor blood glucose level. On 06/11/2025 at 2:20 PM, the Administrator/Director of Patient Services and the Quality Assurance Assistant were interviewed and did not provide an explanation for the survey findings.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to obtain an order and update the Plan of Care (POC) to reflect the patient’s current status. This was evident for one (1) of two (2) observational home visits. (Patient: #6). Failure to obtain an order and update the Plan of Care (POC) to reflect the patient’s current status, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #6 has a Start of Care (SOC) date of 04/18/2025 with the following diagnoses “Bilateral Primary Osteoarthritis of Knee, Mononeuropathies of Right Lower Limb” documented in the Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025. The Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025 documents: Nutritional Requirements: Cardiac Diet, Low Cholesterol. The Visit Note Report documents: 04/18/2025 Endocrine Assessment: WNL (within normal limit). 04/30/2025 Fasting Blood Sugar 114; Diabetes (new diagnosis) 05/14/2025 Fasting blood Sugar 118. 05/28/2025 Fasting blood Sugar 127; Diabetes; Education provided in 1800cal (calorie) diet restrictions. The clinical record lacks documented evidence of the verbal orders for fingerstick monitoring, parameters for blood sugar, and 1800 calories diet from the physician. On 06/11/2025 at 2:20 PM, the Administrator/Director of Patient Services and the Quality Assurance Assistant were interviewed and did not provide an explanation for the survey findings.”