Immaculate Home Health Care Services LLC

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: This CONDITION is not met as evidenced by: Based on medical record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure clinical nursing notes were completed and/or accurately documented (G716). In addition, the HHA failed to ensure missed nursing visits and low pulse oximetry readings were communicated to the physician (G718).”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on medical record review, staff interview, and review of policy, the agency failed to ensue clinical notes were completed timely and accurately. This affected two (Patient #1 and Patient #3) of three patient medical records reviewed. The census was 31. Findings include: 1.Review on 07/31/25 of Patient (Pt) #1’s plan of care and physician’s orders for the certification periods of 09/29/24 through 11/28/24 and 11/29/24 through 01/27/24 revealed the patient had a diagnosis of dementia and was to receive skilled nursing visits twice a day in the morning and evening for medication administration. Review on 07/31/25 of Pt #1’s skilled nursing notes from 11/01/24 through 12/04/24 revealed the skilled nurse, Staff A, did not complete a note for the evening visit on 12/01/24. Review of the signature logs revealed there was no patient signature for the evening visit on 12/01/24 and 12/03/24. In place of the patient’s signature, “missed visit,” was documented. However, there was a skilled nurse visit note for the evening visit on 12/03/24 despite the signature log noting a missed visit and there was no patient signature. There was no physician notification of missed visits. In addition, the signature logs from 11/01/24 through 12/04/24 revealed the nurse was in the home from 9:00 AM-9:45 AM. For the evening visits the signature log said the nurse was in the home from 7:00 PM through 7:15 PM except for the week of 11/03/24 through 11/09/24 when the nurse documented 4:00 PM through 4:45 PM. Review of the skilled nursing notes from 11/01/24 through 12/03/24 revealed the nurse documented he was there from 8:15 AM through 9:00 AM and 4:15 PM through 5:00 PM, except on 12/03/24 when the nurse documented 5:00 PM through 5:45 PM. In addition, review of the skilled nursing notes revealed the nurse copied and pasted the same visit narrative from 11/11/24 through 11/18/24. 2. Review on 07/31/24 of Pt #3’s physician ordered plan of care revealed for the certification period of 05/19/25 through 07/17/25 revealing the patient was to receive 21 skilled nursing visits each week for nine weeks. The nurse, Staff A, was to visit the patient three times a day. Review of the skilled nursing notes revealed there were no skilled nursing visit notes completed from 07/05/25 through 07/16/25. Review of Pt #3’s nurse visit signature logs from 07/05/25 through 07/17/25 revealed signatures from the nurse, Staff A, and the patient for visits three times a day. Interview on 07/31/25 at 3:43 PM with the Director of Clinical Services revealed she was unsure why Pt #1’s signature log times were different from the times documented by Staff A on skilled nursing visit notes. She stated the visit note time and signature log time should match. In addition, she verified the signature log for the 12/03/24 evening nurse visit noted “missed visit” with no patient signature however, there was a completed skilled nursing visit note for the date and time. She stated she was unsure how there was a visit note and no patient signature evidencing the visit was completed. She verified Staff A was using the same visit note for several days at a time for Pt #1. In addition, the Director of Clinical Services verified Pt #3’s nursing visit notes were not completed from 07/05/25 through 07/16/25 despite the signature logs being completed for the time period. She stated she was unaware Pt #3’s notes were not completed and stated staff should have notes from the previous week turned in by the Monday of the following week. She stated the agency uses the signature logs to bill for the visits. She verified Staff A was the nurse for Pt #1 and Pt #3.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure the physician was notified of missed visits and low pulse oximetry readings. This affected one (Patient #1) of three medical records reviewed. The census was 31. Findings include: Review on 07/31/25 of Patient (Pt) #1’s plan of care and physician’s orders for the certification periods of 09/29/24 through 11/28/24 and 11/29/24 through 01/27/24 revealed the patient had a diagnosis of dementia and was to receive skilled nursing visits twice a day in the morning and evening for medication administration. The physician orders instructed the nurse to notify the physician of abnormal vital signs to include pulse oximetry readings below 88% room air. Review on 07/31/25 of Pt #1’s skilled nursing notes from 11/01/24 through 12/04/24 revealed the skilled nurse, Staff A, did not complete a note for the evening visit on 12/01/24. Review of the signature logs revealed there was no patient signature for the evening visit on 12/01/24 and 12/03/24. In place of the patient’s signature “missed visit” was written, however there was a skilled nurse visit note for the evening visit on 12/03/24 despite the signature log saying missed visit. There was no physician notification. Further review of the skilled nursing notes revealed for the morning visit on 11/18/24 the nurse documented a pulse oximetry of 82% on room air. On 11/19/24 for the evening visit, the nurse documented a pulse oximetry of 85% on room air and on 11/27/24 for the evening visit the nurse documented 86% on room air. There was no physician notification of the low pulse oximetry readings as directed in the plan of care/physician orders. Interview on 07/31/25 at 1:00 PM with the Director of Clinical Services revealed Staff A is a licensed practical nurse who was educated on the missed visit policy on 02/06/25. When asked why Staff A was educated, she stated they educated everyone on the missed visit policy. She stated Staff A had not received any disciplinary action. On 07/31/25 at 3:43 PM the Director of Clinical Services verified the signature log for the 12/03/24 evening nurse visit noted “missed visit” with no patient signature however, there was a completed skilled nursing visit note for the date and time. She verified there were no physician notification notes for missed visits from 11/01/24 through 12/03/24 even though there was no nursing note or patient signature for 12/01/24. She verified that the physician had not been notified of the low pulse oximetry readings. The Director of Clinical Services stated when a visit is missed the physician is to be notified and the patient is to be notified to ensure their back-up person can provide the care. Review of the agency policy titled “Coordination of Patient Care” revealed the agency must assure communication with all physicians involved in the plan of care and coordinate care delivery to meet the patient’s needs. The Director of Clinical Services provides oversight of all patient care services to include ensuring the implementation and update of the individualized plan of care.”