A Hug Away Healthcare Inc.

“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 record review and interview, the agency failed to transmit completed Outcome Assessment Information Set (OASIS - a group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the Center for Medicare and Services Assessments) within 30 days of completing the OASIS assessment from 1/01/2024. This failure prevented the patients’ data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings Include: During pre-survey review of the “HHA Error Summary by Agency,” (ran by surveyor on 07/14/25) for the following reporting periods showed the following: 01/01/24 to 7/04/24 revealed 23 assessments of 71 (32%) were processed with the error warning -3330 with error description that read, “Record Submitted late: The submission date was more than 30 days after M0090 (assessment) on this new record.” 10/06/24 to 12/31/24 revealed 1 of 9 assessments (11%) were processed with error warning -3330. 1/1/25 to 5/1/25 revealed 3 of 9 assessments (33%) were processed with error warning -3330. On 7/18/25 surveyor requested OASIS Validation Reports from CMS for 12-month period from 1/1/24 to 12/1/24 and 6-month 1/1/25 to 7/1/25. Record review of OASIS validation reports for date range 01/18/24 to 06/28/24 revealed 71 assessments were processed with 23 assessments (32%) with error warning -3330. Review of the OASIS Agency Final Validation report revealed submission date of 01/24/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 01/26/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 02/02/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 02/09/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 02/16/24 with 2 assessments submitted and showed both assessments had -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 03/11/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 03/13/24 with 1 assessment submitted and the 1 assessment had the -3330- error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 03/19/24 with 1 assessment submitted and the 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 05/09/24 with 16 assessments submitted and 9 assessments had the -3330- error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 03/13/24 with 1 assessment submitted and the 1 assessment had the -3330- error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 05/13/24 with 1 assessment submitted and the 1 assessment had the -3330- error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 06/28/24 with 10 assessments submitted and 3 assessments had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 08/01/24 with 10 assessments submitted and 6 assessments had the -3330 – error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 09/04/24 with 2 assessments submitted and 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 09/04/24 with 2 assessments submitted and 1 assessment had the -3330 -error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 11/26/24 with 2 assessments submitted and 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 1/27/25 with 3 assessments submitted and 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 04/08/25 with 3 assessments submitted and 1 assessment had the -3330-error warning code. Review of the OASIS Agency Final Validation report revealed submission date of 04/18/25 with 3 assessments submitted and 1 assessment had the -3330 -error warning code. During interview with Adm conducted on 7/17/25 at 1:05 p.m., Adm stated the OASIS data was “submitted by external billing company Contractor A.” When asked about the HHA OASIS process, Adm stated that contractor A was responsible of OASIS submissions. When asked when OASIS submissions are due after SOC, the Adm stated, “I think every month.” When asked about the process to prevent late submissions, the Adm stated, “We had worked together with Contractor A, but I also hired a nurse to keep track of the SOC when nurses submit them late. I hired an internal nurse to help when nurses turn in notes late, I paid the nurses to see the patients and turn in notes on time.” When asked when the OASIS assessments should be submitted, Adm stated, “Should be five days by nurse to get them to CMS in thirty days.” Adm stated, “I hired an in-house nurse, my CM to correct.” When asked how OASIS assessments submitted after 30 days could harm the patients, the administrator reminded in silent. During interview with CM on 7/18/25 at 1:15 p.m., CM stated, “Contractor A submits” when asked HHA OASIS process. CM stated, “I did not know that Contractor A was not on time” when asked why the agency submitted OASIS assessments after 30 days. CM stated, “I don’t know” when asked how OASIS assessments submitted after 30 days could harm the patients. CM stated, “scheduling... contractors submit the clinical notes late at times” During interview with RN A on 7/16/25 at 11:30 a.m. when asked if she was the only fulltime RN. RN A stated “yes, hired two months ago all others are staffing/contractors” Review of HHA and Contractor A signed and dated contract titled, “Medical Billing Proposal” signed by Adm and dated 08/18/2023 did not reveal any OASIS specific references. Review of HHA’s policy titled, “Administrative Policy Manual” Section “Timelines”, no date, last reviewed 07/01/25, read in part, “II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout…it will be transmitted… from the agency or agency contractor to the CMS collection site within 30 days of the M0090 date” “D. Mandatory OASIS date collection and submission includes all SOC and subsequent time point assessments.””

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on interview and record review, the agency failed to have one or more qualified individuals to provide oversight of all patient care services and personnel from April 2025 and until exit of survey on July 18, 2025. The position of Clinical Manager remained vacant from April 2025 and until exit of survey on July 18, 2025. The position included coordinating patient care, assuring that patient needs are continually assessed and assuring the development, implementation, and updates of the plan of care. The agency had an alternate supervising nurse, but she was not available for oversight of all patient care services. This failure could place patients at risk of not being provided the necessary services and could result in a decline in health. Findings included: During an entrance conference on 07/15/25 at 11:17 a.m., the Adm stated the Supervising Nurse/Director of Nursing position was “Vacant and the Clinical Manager was the acting Supervising Nurse, and the Alternate Supervising Nurse was at work at the hospital.” Record review of undated Active Employee roster provided by the Personal Assistant did not show anyone as the Supervising Nurse. The personal Assistant added the name and contact number for the Alt Sup Nurse/Alternate Clinical Manager. No Clinical Manager / Supervising Nurse was available. Review of the CM’s personnel file, revealed a document titled “Job Description Agreement”, dated April 28, 2025, signed and dated by CM and Adm, that read in part, “Position title: Clinical Manager and Quality Assurance Nurse, Effective date: April 28, 2025, Employment Classification: Part time, Scheduled Hours: Monday – Wednesday – office hours, Reports to: Director of Nursing/Administrator I. Position Overview …Part time position working Monday through Wednesday Office Hours…. Clinical Manager will support field and administration...documentation compliance review. II. Key Responsibilities Clinical Management (Monday - Wednesday)” … Review of Alternate Supervising Nurse personnel file document titled “Job Description Alternate Supervising Nurse/Clinical Manager” signed with initials but with no date. The CM/RN stated that signed it on 4/28/25 at hire date. During an interview on 07/17/25 at 1:50 p.m., with the Adm, she told the surveyor that due to the low patient census the agency could not employ a CM full time, so the CM had another full-time job, the Alt Sup Nurse had stepped up, but she also had a full-time job and worked at the agency as needed. Surveyor attempted contact with the CM on 07/17/25 at 12:07 p.m. but CM did not answer or return the phone call. Surveyor requested the agency’s Adm call the CM on 07/17/25 at 12:24 p.m. but the CM did not answer or return the Adm call. Surveyor attempted to contact the Alt Sup Nurse on 07/17/25 at 2:05 p.m., but she did not return the phone call. During an interview on 07/18/25 at 10:50 a.m., with the CM, the surveyor asked CM if she provided oversight of all patient care services and personnel. She told the surveyor that she was not the acting supervising nurse, she worked elsewhere and turned her phone off on Thursdays while at work. She added that the agency interviewed for a Sup. Nurse/DON this week as the Sup. Nurse/DON quit in April, and she started at the agency on April 28, 2025. She also added that she worked at the agency Monday – Wednesday, and her job included QA the notes, make sure the OASIS on time by Contractor A. Surveyor asked CM ,, when did she signed her Job Description, CM, said that it was at her hired date 4/28/2025 During an interview on 07/18/25, at 3:30 p.m. with the Adm the surveyor asked how a vacant Supervising Nurse/Clinical Manager position affected patient care. The Adm stated, “Trick question, I had Supervising Nurses before, and they were wrong . This is vacant just three months ago, we are interviewing internal and external Register nurses for the position. As the administrator I am responsible of making sure the CM /RN, oversees the patients care, that is the reason I hired a CM. I do not have a clinical figure head fulltime. It is noncompliant with the state. The Alt Sup. Nurse/Alt CM was always available except for when state here.” When surveyor asked when the Alt Sup. Nurse/Alt CM was available for clinical oversight and to assure patient needs continually assessed, the Adm stated, “CM listed on employee roster is not the Supervising Nurse/the Director of Nursing. The position is vacant.””

“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 observation, records reviewed and interviews the agency failed to provide services and to schedule the frequency of visit as ordered by the physician as indicated in the plan of care for 1 of 2 (#9) active patients whose clinical records were reviewed: In that, the agency’s Nurses failed to perform daily multiple wound care and teach patient and care giver how to do wound care at every completed visit, and there were no daily HHA visits. This failure could potentially have lead to patient #9 missing multiple skilled nurse visits to be readmitted back to the hospital for possible wound infection. Findings included: Review of patient #9’s Home Healthcare referral orders dated 04/10/2025 with a Requested SOC date of 4/12/2025, principal diagnosis of Unspecified open wound, right lower leg (This refers broken skin on the body. Disciplines requested: Skilled revealed that Nursing, Physical Therapy, Services Requested Wound Care. No wound care orders listed on the referral paperwork from the hospital, the referral reveals the physical assessment for all body systems, including skin, which reveals 6 body sites for skin break downs. Review of patient #9’s plan of care (PoC) for certification periods from 04/15/25 to 6/13/25 and 6/14/25 to 8/12/25 showed that patient was admitted to agency on 4/15/25 with the principal diagnosis of Unspecified open wound, right lower leg (This refers broken skin on the body. Both Plan of Care also revealed under orders and treatment: SN: Daily, PT to eval and Treat, and HHA: Daily. Nurse was to instruct patient/care giver on wound care as follow, right leg wound to clean with normal saline, apply adaptive dressing (non-adhesive) and wrap with kerlix (rolled gauze). SN to assess skin for break down’s (spelling, SN to assess/ evaluate wounds at each dressing change and PRN for Sign/symptoms of infection. Review of patient # 9 records for SN visit frequency reveals the following schedule visits: Certification Period from 4/15/25 to 6/13/25 4/18/25 SN Visit Completed 4/22/25 SN Visit Completed 5/1/25 SN Visit Completed 5/3/25 SN Visit Completed 5/5/25 SN Visit Completed 5/6/25 SN Visit Completed 5/7/25 SN Visit Missed Visit, Reason: Pt has Orthopedic appointment 5/8/25 5/8/25 SN Visit Completed 5/12/25 SN Visit Missed Visit, Reason: RN will follow up with schedule and patient continuous care in the home. 5/14/25 SN Visit Completed 5/16/25 SN Visit Missed Visit, Reason: Pt has appointment with Occupational therapy o this day. 5/22/25 SN Visit Completed 5/23/25 SN Visit Completed 5/30/25 SN Visit Completed 6/2/25 SN Visit Missed Visit, Reason: RN out on sick leave until 6/12/25- did not see this patient. 6/7/25 SN Visit Missed Visit, Reason: Pt was having Physical Therapy 6/8/25 SN Visit Missed Visit, Reason: No answer to phone call 6/12/25 SN Visit Completed Certification Period from 6/14/25 to 8/12/25 6/16/25 SN Visit Completed 6/17/25 SN Visit Completed 6/18/25 SN Visit Completed With supervising visit 6/19/25 SN Visit Completed 6/20/25 SN Visit Completed 6/23/25 SN Visit Completed 6/24/25 SN Visit Completed 6/25/25 SN Visit Completed 6/26/25 SN Visit Completed 6/27/25 SN Visit Missed Visit, Reason: Family/ caregiver able to assist patient 6/30/25 SN Visit Completed 7/01/25 SN Visit Completed 7/03/25 SN Visit Completed 7/04/25 SN Visit Missed Visit, Reason: Family/ caregiver able to assist patient 7/09/25 SN Visit Completed 7/10/25 SN Visit Missed Visit, Reason: Doctor/clinical Appointment, Comments reads as part “pt continuous to have dressing change q PM, Mother insisting on doing herself, Strick orders to leave untouched.] Will follow up with patient for any new orders…” note from LVN 7/10/25 SN Visit Missed Visit, Reason: Cancelation of care. Comment: “patient stated LVN will see him tomorrow” note from RN 7/11/25 SN Visit Completed 7/15/25 SN Visit Completed 7/16/25 SN Visit Missed Visit, Reason: Reads as part: Nurse had family emergency, call the agency to restaff for replacement” Review of a communication note dated 5/16 /2025 from clinical supervisor RN # A reads as part: “Patient notified agency no longer needing HHA, declines services at this time. Mother prefers to assist with ADLs….” During a home visit, interview with patient # 9, on 7/16/25 at 12:30 pm., the patient walking with a cane and right foot wound covered . Patient stated that the agency nurses come to see him once or twice a week to take his vital signs and asked how he felt. Surveyor asked patient #9 who take care of his wounds, he stated myself or my mother when she comes back from work. Surveyors ask patient # 9 if any nurse from the home health agency had ever taught him or a family member how to take care of his wounds, he stated, “No”, I learned in the hospital prior to being discharge. Patient was asked if any nurse from the agency had ever provided wound care for him, he said, no. Did nurse unwrap the wound to assess wounds sites at the SN visit? He stated, “No”, my wounds were always wrapped up whenever they come, but we are heling very well. Surveyor asked about HHA services, assistance with ADLs. He said that there was a nurse that came 1 or 2 times to help him with showering, but that was only at the beginning of hospital discharge. Surveyor asked Patient #9 how often he was receiving physical therapy, he said, daily, accept Sundays. Surveyor asked the patient for the patients home folder, he stated I only saw it once , I don’t know where is it, the nurses never use it. Surveyor unable to review logged visits at home to compare with client’s record. Patient stated,” I really never need skill services, they were just coming to my vital signs, nothing else “ Review of Patient #9’s clinical record revealed all completed nurse notes were conducted by LVN # A and Supervising RN did not show any documentation that LVN D assessed patient #9’s Wounds or provided wound care., Further review revealed The completed nurses notes did no show teaching and instruction for wound care to the patient/caregiver, ability to self-care the wounds. Most nurses read the same Completed Nurse note for 5/1/25 from LVN #A reads as part under the skin section comments “Pt has dressing to skin graft to right lower leg, FM doing wound care every evening”. SN observed wound which has no sign of infection with flesh tissue, beef color” … “perform wound care each evening to right low leg of wet to dry”. Completed nurses note from 6/30/25 reads as part: “Mother perform wound care each evening to right low leg of wet to dry” During interview with Administrator on 11/17/24 at 12:17p.m., the Administrator stated it was agency’s policy to ensure the visit frequency were made. Surveyors ask why the patient was not seen daily per PoC. administrator stated, I am paying this nurse to go out to see the patients and provide care, I don’t know why it was not done. I can call the nurse now to ask her .. Administrator stated that any clinical questions could be answered by acting DON. During an Interview with LVN 7/17/25 at 12: 50 pm ., The surveyor asked LVN # A if she had access to patient # 9 PoC. She said, yes. Surveyor asked her, per PoC how often should the patient be seen by the home health agency’s nurses? she stated, daily, Monday to Friday. Surveyor asked the nurse, since the order for frequency was daily, who was seeing patient during on the weekend. She stated I don’t know; I was just doing the visit on my schedule. Surveyor asked nurse what type of skill services she was she providing to patient # 9 during her home visits. She said, the normal, the normal such vital signs, and psychosocial support and physical therapy. Surveyor asked if she was performing wound care patient # 9, she said no, LVN #A stated she had strict orders not to touch the patient wounds. Surveyor asked from whom she received the orders, LVN# A said, from patient’s FM. Surveyor asked nurse if she informed the agency about the FM request, she said “yes, I called the agency to let them know” Surveyor asked if she was providing wound care teaching to patient #9 or family member, she stated, the patient knew how to do it. During an interview on 07/18/25 at 10:50 a.m., with the CM/RN, the surveyor asked CM if she provided oversight of all patient care services and personnel. She told the surveyor that she was not the acting supervising nurse, she worked elsewhere and turned her phone off on Thursdays while at work. She added that the agency interviewed for a Sup. Nurse/DON this week as the Sup. Nurse/DON quit in April, and she started at the agency on April 28, 2025. She also added that she worked at the agency Monday – Wednesday, and her job included QA the notes, surveyor ask CM if she was aware of patient # 9 were not completed or scheduled for Skill Services and Home health aid as order on PoC. She said that when she was hired on April 28, 2025, patient # 9 was already in service, she noticed the frequency and tried to call the doctor to get clarification on the order from the PoC , but she was not able to get on hold with the doctor. She stated that she did not understand why the admission nurse ] added a daily frequency for patient #9. She stated that the admission nurse was a contracted nurse and not a direct employee by the agency. CM/RN manager stated that she was not sure why the previous DON did not follow up on this PoC, CM manager said that she just helps to get thing rights. Surveyor asked the CM what was the medical necessary for daily Skill services if the visiting nurse was not providing wound care because the patient and patient mother was doing the wound care, she said “I am sure, maybe just to avoid infections. In a continued interview with the CM Surveyor asked about the daily Home Health Aid ordered in PoC, she said “I think he refused the home health aide services. Surveyor asked CM/RN why the patient was rectified on 6/13/2025 with daily nursing skill services and daily home health aide services, CM/RN stated I am sure, why patient # 9 was not scheduled to be seen daily as order? CM/RN stated, I haven be able to get in touch with the patient’s doctor to get clarification. Surveyor asked CM/RN what the agency week treatment is, she said Sunday to Saturday. Surveyor askedto CM if patient # 9 was not Scheduled Sunday to Saturday per PoC, Is there any order for change of frequency? She said, no. Review of agency’ administrative undated policy titled, “Care Planning” reads in part, Policy I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs. II. An RN is responsible for coordinating the Plan of Care when multiple disciplines are involved, or when more than one agency is involved, to decrease the possibility of duplication or conflict and to identify responsibilities. III. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur because of implementing and coordinating the Plan of Care. The individualized Plan of Care will indicate if the patient/client has an advance directive(s) and if so, what type(s) of advance directive(s) exists. If the patient does not have an advance directive, this should also be listed on the individualized Plan of Care. The individualized Plan of Care must also specify the patient/client and caregiver education and training. A. The individualized Plan of Care must include the following: 1. All pertinent diagnoses; 2. The patient’s/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; a. The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care. 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors. 13. Patient/client and caregiver education and training to facilitate timely discharge; 14. Patient/client-specific interventions and education; 15. Measurable outcomes and goals identified by the Agency and the patient/client; 16. Information related to any advance directives; and 17. Any additional items the Agency or physician and/or non-physician practitioner may choose to include. IV. All patient/client care orders, including verbal orders, must be recorded in the Plan of Care. A. The POC may include orders for treatment or services received from physicians other than the responsible physician.”