Excell Home Care

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure QAPI Program activities included efforts that analyzed causes and implemented actions to identify problems, improve care, services and operations for all patients and employees. Findings: A review of QAPI Program records showed no program activities for calendar year 2024 and 2025 that included efforts to analyze causes and implement actions to improve care, services and operations. On 01/29/26 at 1:30 p.m., Staff B stated QAPI program records did not show analysis and interventions of the data.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the review and reporting of ongoing PIP data through the QAPI program for all patients and employees. Findings: A review of QAPI program records showed no PIP data reporting in 1st quarter and 2nd quarter in calendar year 2025. On 01/29/26 at 1:30 p.m., Staff B stated QAPI program records showed no reporting of the PIP data in 1st quarter and 2nd quarter in calendar year 2025.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its infection control program surveillance monitoring and reporting was included in QAPI program activities for all patients and employees. Findings: A review of QAPI and Infection Control records showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar year 2024. On 01/29/26 at 1:30 p.m., Staff B stated infection surveillance reporting was not included in QAPI activities in 2024.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHCOC notice prior to physical therapy discharge from agency services were provided to one (Patient #10) of 17 patients. Findings: Patient #10 A review of the clinical record showed no home health change of care notice prior to the physical therapy discharge from the agency services on 12/23/25 for no insurance authorization. On 01/29/26 at 12:17 p.m., Staff B stated the patient was not provided a notice prior to the physical therapy service discharge.”

“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 record review and interview, the agency failed to ensure individualized patient POC’s included: Medical provider reporting parameters for management of peripheral edema for seven (Patient #3, 4, 5, 13, 14, 15 and #17) of 17 patients. Medical provider reporting parameters for management of blood sugar levels for one (Patient #10) of 17 patients. Medical provider reporting parameters for weight management for two (Patients #13 and #17) of 17 patients. Findings: Patient #3 A review of a POC dated 11/21/25 to 01/19/26 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema. The POC showed no peripheral edema reporting parameters. On 01/29/26 at 11:50 a.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #4 A review of a POC dated 01/08/26 to 03/08/26 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema. The POC showed no peripheral edema reporting parameters. On 01/29/26 at 12:02 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #5 A review of a POC dated 01/17/26 to 03/17/26 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema. The POC showed no peripheral edema reporting parameters. On 01/29/26 at 12:06 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #10 A review of a POC dated 12/04/25 to 02/01/26 showed interventions and goals for SN to assess, manage and instruct on the management of blood sugar levels. The POC showed no blood sugar levels reporting parameters. On 01/29/26 at 12:14 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #13 A review of a POC dated 12/07/25 to 02/04/26 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema and weight. The POC showed no peripheral edema or weight reporting parameters. On 01/29/26 at 12:55 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #14 A review of a POC dated 10/17/25 to 12/15/25 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema. The POC showed no peripheral edema reporting parameters. On 01/29/26 at 1:00 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #15 A review of a POC dated 06/22/25 to 08/20/25 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema. The POC showed no peripheral edema reporting parameters. On 01/29/26 at 1:02 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema. Patient #17 A review of a POC dated 11/28/25 to 01/26/26 showed interventions and goals for SN to assess, manage and instruct on the management of peripheral edema and weight. The POC showed no peripheral edema or weight reporting parameters. On 01/29/26 at 1:16 p.m., Staff B stated the POC did not include reporting parameters for peripheral edema.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for three (Patients #3, 4 and #15) of 17 patients. Findings: Patient #3 A review of the clinical record showed a communication note dated 01/09/26 for the patient to discharge to hospice services. The clinical record showed no discharge assessment, no discharge summary, no patient refusal of discharge and no follow up communication to the medical provider. On 01/29/26 at 11:50 a.m., Staff B stated the nurse should have communicated to the physician the patient did not discharge to hospice services. Patient #4 A review of the POC dated 01/08/26 to 03/08/26 showed orders for SN to assess peripheral edema every visit. SN visit notes dated 01/12/26 and 01/19/26 showed the patient had 2-3+ pitting peripheral edema and showed no medical provider communications or coordination of care notes and no changes in orders. On 01/29/26 at 12:02 p.m., Staff B stated the nurse did not communicate the patient’s pitting edema to the medical provider. Patient #15 A review of the POC dated 06/22/25 to 08/20/25 showed orders for SN to assess, monitor and instruct patient’s weight every visit for management of congestive heart failure and SN to assess, monitor and instruct patient’s blood sugar levels and report blood sugar levels greater than 300 every visit for management of diabetes type II. SN visit notes dated: 11/28/25 showed a weight of 252.2 pounds 11/30/25 showed a BS of 350 12/02/25 showed a weight of 250 pounds 12/03/25 showed a weight of 250 pounds 12/04/25 showed a weight of 251 pounds 12/05/25 showed a weight of 249.4 pounds 12/07/25 showed a weight of 246.8 pounds 12/08/25 showed a BS of 322 and 333 12/11/25 showed a BS of 341 12/12/25 showed a BS of 376 12/03/25 showed a weight of 247 pounds SN visit notes showed no medical provider communications or coordination of care notes and no changes in orders. On 01/29/26 at 1:02 p.m., Staff B stated the nurse did not communicate the patient’s weight or blood sugar levels to the medical provider.”

“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 interview, the agency failed to ensure: SN to notify medical provider for patient reported pain levels greater than the reporting parameters for two (Patients #1 and #2) of 17 patients. SN visit frequencies were conducted as ordered for one (Patients #1) of 17 patients. SN to monitor BS every visit and notify medical provider for patient blood sugar levels outside of the reporting parameters for two (Patients #1 and #2) of 17 patients. ST evaluation was conducted for one (Patient #9) of 17 patients. MSW evaluation was conducted for one (Patient #11) of 17 patients. Findings: Patient #1 A review of the POC dated 12/08/25 to 02/05/26 showed orders for SN frequency of one time a week for two weeks and notify medical provider for patient reported pain levels greater than the reporting parameter of six and monitor BS every visit and notify medical provider for patient blood sugar levels outside of the reporting parameters of greater than 300. A review of the clinical records showed during the week of 12/21/25 to 12/27/25 no SN visit was scheduled (one visit ordered, no visit conducted). SN visit notes dated: 12/08/25 show no BS monitoring and a pain level of 7 12/15/25 show no BS monitoring and a pain level of 7 12/23/25 show no BS monitoring and a pain level of 7 12/29/25 show no BS monitoring and a pain level of 7 12/31/25 show no BS monitoring and a pain level of 7 01/16/26 show no BS monitoring and a pain level of 7 01/22/26 show no BS monitoring and a pain level of 9 The SN visit notes showed no patient/caregiver refusal of BS monitoring, no medical provider notifications, and no change in orders. On 01/29/26 at 11:40 a.m., Staff B stated the nurse did not monitor the patient’s blood sugar and did not notify the physician for pain levels that were greater than six. Patient #2 A review of the POC dated 11/20/25 to 01/18/26 showed orders for SN notify medical provider for patient reported pain levels greater than the reporting parameter of six. SN visit notes dated: 11/25/25 show a pain level of 10 01/15/26 show a pain level of 7 The SN visit notes showed no medical provider notifications, and no change in orders. On 01/29/26 at 11:48 a.m., Staff B stated the nurse did not notify the physician for pain levels that were greater than six. Patient #9 A review of the POC dated 01/09/26 to 03/09/26 showed orders for ST to evaluate one time a week for one week effective 01/20/26. The clinical record showed no ST evaluation was conducted, showed no medical provider notifications and no changes in the order. On 01/29/26 at 12:15 p.m., Staff B stated the patient did not have an ST evaluation. Patient #11 A review of the POC dated 11/17/25 to 01/15/26 showed orders for MSW to evaluate one time a week for one week effective 11/20/25. The clinical record showed no MSW evaluation was conducted, no medical provider notifications and no changes in the order. On 01/29/26 at 12:42 p.m., Staff B stated the patient did not have an MSW evaluation.”

“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 record review and interview, the agency failed to ensure SN visit note documentation was complete for three (Patients #3, 6 and #11) of 17 patients. Findings: Patient #3 A review of a POC dated 11/21/25 to 01/19/26 showed wound care orders to the left lower extremity as: cleanse wound with normal saline and apply Xerofoam dressing three times a week. A review of the clinical record showed no documentation of wound care procedure conducted by the nurse during SN visits dated: 11/24/25 SN visit note showed “wound care per order” 11/26/25 SN visit note showed “wound care per order” 12/10/25 SN visit note showed “wound care per order” 12/12/25 SN visit note showed “wound care per order” 12/15/25 SN visit note showed “wound care per order” 12/22/25 SN visit note showed “wound care per order” 12/24/25 SN visit note showed “wound care per order” 12/26/25 SN visit note showed “wound care per order” 12/29/25 SN visit note showed “wound care per order” 12/31/25 SN visit note showed “wound care per order” On 01/29/26 at 11:50 a.m., Staff B stated the nurse did not document the details of the wound care that was performed during the visits. Patient #6 A review of a POC dated 11/19/25 to 01/17/26 showed wound care orders to the left buttock as: cleanse wound with normal saline, apply calcium alginate and apply Mepilex dressing three times a week. A review of the clinical record showed no documentation of wound care procedure conducted by the nurse during SN visits dated: 12/08/25 SN visit note showed “wound care per order” 12/10/25 SN visit note showed “wound care per order” 12/12/25 SN visit note showed “wound care per order” 12/15/25 SN visit note showed “wound care per order” 12/17/25 SN visit note showed “wound care per order” 12/19/25 SN visit note showed “wound care per order” 12/22/25 SN visit note showed “wound care per order” 12/24/25 SN visit note showed “wound care per order” 12/26/25 SN visit note showed “wound care per order” 12/29/25 SN visit note showed “wound care per order” 12/31/25 SN visit note showed “wound care per order” On 01/29/26 at 12:07 p.m., Staff B stated the nurse did not document the details of the wound care that was performed during the visits. Patient #11 A review of a POC dated 11/17/25 to 01/15/26 showed wound care orders to the left heel as: cleanse wound with normal saline, apply Maxorb and apply ABD dressing two times a week. A review of the clinical record showed no documentation of wound care procedure conducted by the nurse during SN visits dated: 11/25/25 SN visit note showed “wound care per order” 12/03/25 SN visit note showed “wound care per order” 12/08/25 SN visit note showed “wound care per order” 12/10/25 SN visit note showed “wound care per order” 12/12/25 SN visit note showed “wound care per order” 12/15/25 SN visit note showed “wound care per order” 12/19/25 SN visit note showed “wound care per order” 12/22/25 SN visit note showed “wound care per order” 12/26/25 SN visit note showed “wound care per order” On 01/29/26 at 12:42 p.m., Staff B stated the nurse did not document the details of the wound care that was performed during the visits.”

“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 record reviews and interviews, the agency failed to ensure a completed transfer summaries were provided to the receiving service provider for five (Patients #2, 8, 11, 13 and #14) of 17 patients. Findings: Patient #2 A review of the clinical record showed transfer from the agency on 11/25/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the inpatient hospital provider. At 11:40 a.m., Staff A stated the transfer summary was not provided to the hospital. Patient #8 A review of the clinical record showed transfer from the agency on 12/24/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the inpatient hospital provider. At 11:40 a.m., Staff A stated the transfer summary was not provided to the hospital. Patient #11 A review of the clinical record showed transfer from the agency on 12/26/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the inpatient hospital provider. At 12:42 p.m., Staff A stated the transfer summary was not provided to the hospital. Patient #13 A review of the clinical record showed transfer from the agency on 12/18/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the inpatient hospital provider. At 12:55 p.m., Staff A stated the transfer summary was not provided to the hospital. Patient #14 A review of the clinical record showed transfer from the agency on 12/15/25 to inpatient hospital services. The clinical record showed no transfer summary was provided to the inpatient hospital provider. At 1:00 p.m., Staff A stated the transfer summary was not provided to the hospital.”