Amazing Care Home Health Services, LLC

“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 review of agency policy, clinical records (CRs), and interview with the Director of Nursing and Administrator, it was determined the agency failed to ensure clinical staff was documenting clinical notes/ provide care as required on the plan of care for one (1) of four (4) clinical records reviewed. (CR#1). Findings included: A review of agency policy was completed on 7/3/25 at approximately 8:30 AM. Policy titled, “Submission of Weekly Clinical Paperwork 4.10” stated, “To ensure timely payroll processing and compliance with documentation standards, all employees and contractors must follow the guidelines below: The pay week begins Saturday and ends Friday. All clinical paperwork and invoice must be submitted weekly at the end of the shift, or Sunday by the end of day…nurses are required to be familiar with the Pennsylvania Nurse Practice Act to ensure compliance with professional standards…” Policy titled, “Development of Care Plan” stated, “To ensure that a patient’s needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient situation as needed, a care plan is essential… Steps to be taken in developing the care plan include… Establishment of a schedule for the provision of services which lists the description and frequency of each health care service, the required treatment and procedure, as well as the medication and diet regimen to be provided…” Review of CRs on 6/27/25, 7/1/24 and 7/3/25 at approximately 10:00AM, which revealed: CR #1: Start of Care: 10/2/24. Home Health Certification and Plan of Care for certification period 3/31/25-5/29/25 stated skilled nursing eight (8) hours per day for seven (7) days a week for nine (9) weeks. A review of HHA Exchange showed the skilled nurse (PF#4) completed “clock-in” and “clock-out” for each visits as required during the certification period reviewed, but did not submit documentation of the skilled nursing visit showing tasks/assessments completed as required on the following dates: 3/31/25, 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/19/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 5/5/25, 5/26/25, 5/8/25 and 5/9/25. Interview with Director of Nursing on 7/10/25 at approximately 1:00 p.m. confirmed above findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with the Director of Nursing, the agency failed to document clinical notes in accordance with its policy for one (1) of four (4) CRs reviewed, (CR #1). Findings include: A review of agency policy was completed on 7/3/25 at approximately 8:30 AM. Policy titled, “Submission of Weekly Clinical Paperwork 4.10” stated, “To ensure timely payroll processing and compliance with documentation standards, all employees and contractors must follow the guidelines below: The pay week begins Saturday and ends Friday. All clinical paperwork and invoice must be submitted weekly at the end of the shift, or Sunday by the end of day…nurses are required to be familiar with the Pennsylvania Nurse Practice Act to ensure compliance with professional standards…” A review of CRs was conducted on 6/27/25, 7/1/24 and 7/3/25 at approximately 10:00AM which revealed the following: CR #1: Start of Care: 10/2/24. Home Health Certification and Plan of Care for certification period 3/31/25-5/29/25 stated skilled nursing eight (8) hours per day for seven (7) days a week for nine (9) weeks. A review of HHA Exchange showed the skilled nurse (PF#4) completed “clock-in” and “clock-out” for each visits as required during the certification period reviewed, but did not submit documentation of the skilled nursing visit showing tasks/assessments completed as required on the following dates: 3/31/25, 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/19/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 5/5/25, 5/26/25, 5/8/25 and 5/9/25. An interview with the Director of Nursing on 7/10/25, at approximately 1:00 PM confirmed the above findings.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the director of nursing, the agency failed to assure that clinical notes were present for one (1) of four (4) CR’s reviewed. (CR#1). Findings include: A review of agency policy was completed on 7/3/25 at approximately 8:30 AM. Policy titled, “Submission of Weekly Clinical Paperwork 4.10” stated, “To ensure timely payroll processing and compliance with documentation standards, all employees and contractors must follow the guidelines below: The pay week begins Saturday and ends Friday. All clinical paperwork and invoice must be submitted weekly at the end of the shift, or Sunday by the end of day…nurses are required to be familiar with the Pennsylvania Nurse Practice Act to ensure compliance with professional standards…” A review of CR’s was conducted on 6/27/25, 7/1/24 and 7/3/25 at approximately 10:00AM which revealed the following: CR #1: Start of Care: 10/2/24. Home Health Certification and Plan of Care for certification period 3/31/25-5/29/25 stated skilled nursing eight (8) hours per day for seven (7) days a week for nine (9) weeks. A review of HHA Exchange showed the skilled nurse (PF#4) completed “clock-in” and “clock-out” for each visits as required during the certification period reviewed, but did not submit documentation of the skilled nursing visit showing tasks/assessments completed as required on the following dates: 3/31/25, 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/19/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 5/5/25, 5/26/25, 5/8/25 and 5/9/25. An interview conducted with the director of nursing on 7/10/25 at 1:00 PM confirmed the above findings.”