A-1 Phoenix Healthcare, LLC

“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: This is a continuing deficiency cited at G 0658 during survey dated 03/31/2023. Based on record review and interview, the agency failed to conduct and document annual PIP(s) for three of three years reviewed (2023, 2024, and 2025) that reflected the scope, complexity, and past performance of the agency’s services and operations. The failure placed the agency’s patients’ physical health and safety at risk; if the agency did not identify poor health and safety outcomes in service provision to the agency’s patients and did not develop and conduct improvement projects to prevent and improve health and safety outcomes. Findings Include: During the entrance conference with Admin B/DON on 03/31/2026 at 09:25 a.m., the surveyor requested all agency QAPI documents/reports/manuals. QAPI binders for 2023, 2024, 2025, and 2026 were provided. Record review of the QAPI binders showed that the documentation contained QAPI quarterly reports for January through June and July through December for 2023, 2024 and 2025. The surveyor also reviewed the agency’s undated Governing Body manual (where the agency files agency meeting minutes and other administrative records). Record review of the QAPI binders, quarterly QAPI reports, and Governing Body manual did not contain any reports, reviews, or documentation that indicated the agency had conducted and documented any annual quality or performance improvement projects undertaken (completed or in progress), the reasons for conducting those projects, and the measurable progress achieved on those projects , for the years 2023, 2024, and 2025. During an interview on 04/08/2026 at 9:35 a.m. with Admin B/DON, the surveyor asked who was responsible for the agency’s QAPI program and performance improvement projects. The Admin B/DON stated that she was responsible. The Surveyor reviewed the findings and asked why the agency had not conducted PIP(s) for the years 2023, 2024, and 2025, and completed the required documentation (according to agency policy). The Admin B/DON stated that the agency did not have performance improvement projects in place for 2023, 2024, or 2025. Review of agency policy titled “Quality Assessment Performance Improvement Program” last reviewed 05/01/24 read in part: “…Procedure…III. The QAPI Plan will be developed based on: A. Program scope: 1. Show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient/client safety, and quality of care. 2. Measure, analyze, and track quality indicators, including adverse patient/client events, and other aspects of performance that enable the Agency to assess processes of care, Agency services, and operations…E. Performance Improvement Projects [:] 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: This is a continuing deficiency cited at G 0442 during survey dated 03/31/2023. Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in four (Patients 6, 7, 8, and 9) of four inactive patient records reviewed who required a written notice in that: The agency failed to provide the patients with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”or any written notice to Patient #6, Patient #7, Patient #8, and Patient #9 of the agency’s intent to discharge/terminate ongoing care. The failure placed the patient’s health and safety at risk and could result in physical or emotional harm due to lack of consistency or continuing care in the patient’s post discharge needs. The failure caused the client to not have written advance notice to appeal the discharge decision. Findings include: Inactive Clinical Record # 6: Record review of the clinical record for Patient # 6 revealed a POC for the certification period of 10/06/2025 to 12/04/2025. Review of the POC revealed a start of care date of 10/06/2025 with a primary diagnosis of Hypertensive heart & chronic kidney disease with heart failure and end stage renal failure (a serious health condition where the heart and kidney function is severely impaired and need intensive medical management). Review of the POC revealed that Alt Admin B/RN B signed and dated the POC on 10/06/2025. Continued review of the POC revealed that it contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the clinical record revealed a communication note dated and signed by (Agency office Staff A). Review of the communication note read in part: “…Discharged from home health services on 11/21/2025. The reason for discharge: Change in insurance to [Health Maintenance Organization]…insurance…” Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 11/21/2025. The record did not include a written NOMNC. Inactive Clinical Record # 7: Record review of the clinical record for Patient # 7 revealed a POC for the certification period of 11/26/2025 to 01/24/2026. Review of the POC revealed a start of care date of 11/26/2025 with a primary diagnosis of pressure ulcer of right heel (a wound caused by prolonged pressure or friction to the skin over the heel). Review of the POC revealed that Alt Admin B/RN B signed and dated the POC on 11/26/2025. Continued review of the POC revealed that it contained an order for skilled nursing visits two times per week for nine weeks. Continued review of the clinical record revealed a communication note dated and signed by (Agency Office Staff A). Review of the communication note read in part: “…Discharged from home health services on [12/31/2025]. The reason for discharge: Change in insurance to [Health Maintenance Organization]…insurance…” Further review of Patient # 7’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 12/31/2025. The record did not include a written NOMNC. Inactive Clinical Record # 8: Record review of the clinical record for Patient # 8 revealed a POC for the certification period of 02/13/2025 to 04/13/2056. Review of the POC revealed a start of care date of 02/13/2025 with a primary diagnosis streptococcal sepsis (a life-threatening condition caused by an extreme bacterial infection in the body). Review of the POC revealed that RN D signed and dated the POC on 02/13/2025. Continued review of the POC revealed that it contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the clinical record revealed a Notice of Medicare Non-Coverage form. Review of the NOMNC form did not include an end date of services. The form included Patient # 8’s signature and date of 03/13/2025. Further review of the form revealed an area titled, “How to Ask For an Immediate Appeal.” The record provided an area to print the name, address, and phone number for QIO (Quality Improvement Organization) that serviced the area where the patient resided. Further review revealed that the area listed a telephone number that was not a working number. Continued review of the record revealed the name, address, and telephone number of QIO that was not current (QIO ).Further review of Patient # 8’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 03/13/2025. The record did not include a written NOMNC with current or correct name and contact information for the QIO. Inactive Clinical Record # 9: Record review of the clinical record for Patient # 9 revealed a POC for the certification period of 07/19/2025 to 09/16/2025. Review of the POC revealed a start of care date of 07/19/2025 with a primary diagnosis of benign neoplasm of cerebral meninges (a non-cancerous slow growing tumor that develops from the membranes of the spinal cord and brain). Review of the POC revealed that Alt Admin B/RN B signed and dated the POC on 07/19/2025. Continued review of the POC revealed that it contained an order for skilled nursing visits one time per week for nine weeks. Continued review of the clinical record revealed a communication dated and signed by (Agency Office Staff B) on 08/22/2025. Review of the communication note read in part: “…Discharged from home health services on (08/22/2025. The reason for discharge: Goals Met…” Further review of Patient # 9’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 08/22/2025. The record did not include a written NOMNC. During an interview on 04/08/2026 at 9:57 a.m. with Admin B/DON the surveyor asked who was responsible for ensuring that the agency provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6, 7, 8, and 9. The Admin B/DON stated that she and the RN on the case were responsible. The surveyor asked what the agency process was for discharging patients. Admin B/DON stated to make sure that the discharge nurse explained the notice and gave written notice to the patients. The surveyor reviewed the findings and asked why the notices were not provided to the patients and provided with the correct and current information. Admin B/DON stated that a lot of the nurses did not understand the reason the notice was given and believed that it was just a part of admission paperwork. Review of agency policy titled, “Patient/Client Transfer and Discharge Notices” last reviewed 01/01/26 read in part: “ Purpose [:] To provide guidance on completion of the required discharge notices…Policy… III. The Agency will deliver the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end… IV. The Agency will deliver a Detailed Explanation of Non-Coverage…to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client requests an expedited review by the QIO of the decision that coverage for items and/or services should end…Procedure [:] I. Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) A. Agency staff will deliver a completed and valid NOMNC to the patient/client, or representative (if any): 1. when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. 2. At least two (2) calendar days before Medicare covered services end... B. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received…””

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure patients’ right to be advised of the name, address, and telephone number of a federally funded entity that serviced the area where the patient resided, in three (Patients # 1, 2 and 3) of three patients who received home visits in that: The agency failed to advise the patients of the Quality Improvement Organization (QIO’s) name, address, and telephone number that serviced the area where the patient resided. The failure placed the patients’ physical health and safety at risk if they were unable to access the QIO to appeal a premature discharge. The failure could place the patients at risk of not having time to access needed resources (medical equipment or outpatient services) that were available for them in their service area. Findings included: Review of agency’s record titled, “Notice of Medicare Non-Coverage” dated 12/31/2011 revealed an area titled, “How to Ask For an Immediate Appeal.” The record provided an area to print the name, address, and phone number for QIO (Quality Improvement Organization) that serviced the area where the patients resided. Further review revealed that the area listed a telephone number that was not a working number. Continued review of the record revealed the name, address, and telephone number of QIO that was not current (QIO A). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization that serviced the area where the patients resided was not listed. Review of agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 revealed an area titled, “Quality Improvement Organization.” The record provided an area to print the name, address, and phone number for QIO that serviced the area where the patient resided. Further review of the record revealed that the name, address, and local telephone number listed were not for the current QIO (QIO C). Continued review of the record revealed that the name and address listed was for the former QIO (QIO B). Further review revealed that the agency did not list the current name, address, or local telephone number of the Quality Improvement Organization that serviced the area where the patient resided. Patient # 1 Review of the clinical record for Patient # 1 revealed a POC for the certification period of 03/03/2026 to 05/01/2026. Review of the POC revealed a start of care date of 09/04/2025 and a primary diagnosis of type 2 diabetes with diabetic peripheral angiopathy with gangrene (a condition where chronic high blood sugar (diabetes) damages blood vessels in the legs and feet (angiopathy) and cause tissue death (gangrene). The Alt Admin/RN B signed and dated the POC on 03/03/2026. The POC contained orders for SN visits two times per week for one week and three times per week for eight weeks. During a home visit with Patient #1 and Family Member #1, record review, and interview on 04/03/2026 at 10:30 a.m., the surveyor reviewed the agency home folder, which included patient rights records, that the agency provided to the patient at admission. Review of the records revealed that it included the following: the agency’s records titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with an area titled, “Quality Improvement Organization;” and “Notice of Medicare Non-Coverage” dated 12/31/2011 with an area titled, “How to Ask For an Immediate Appeal.” Review of the records revealed the same information listed when the records were reviewed at the agency. The surveyor asked Patient # 1 and (Family Member # 1) if the agency staff had advised [Patient # 1] of the name and contact information for how to appeal a discharge if Patient # 1 did not agree with the discharge decision. Patient # 1’s requested that Family Member # 1 answer the question. Family Member # 1 stated that the agency did not advise [Patient # 1] the name and contact information for the current QIO. Patient # 2 Review of the clinical record for Patient # 2 revealed a POC for the certification period of 02/12/2026 to 04/12/2026. Review of the POC revealed a start of care date of 10/15/2025 and a primary diagnosis of Hypertensive heart & chronic kidney disease with heart failure and end stage renal failure (a serious health condition where the heart and kidney function is severely impaired and need intensive medical management). RN C signed and dated the POC on 02/12/2026. The POC contained orders for SN visits two times per week for eight weeks. During a home visit with Patient #2, record review, and interview on 04/03/2026 at 08:30 a.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the records revealed that it included the following: the agency’s records titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with an area titled, “Quality Improvement Organization;” and “Notice of Medicare Non-Coverage” dated 12/31/2011 with an area titled, “How to Ask For an Immediate Appeal.” Review of the records revealed the same information listed when the records were reviewed at the agency. The surveyor asked Patient # 2 if the agency staff had advised [Patient # 2] of the name and contact information for how to appeal a discharge if Patient # 2 did not agree with the discharge decision. Patient # 2 stated that the agency did not advise [Patient # 2] the name and contact information for the current QIO. Patient # 3 Review of the clinical record for Patient # 3 revealed a POC for the certification period of 02/21/2026 to 04/21/2026. Review of the POC revealed a start of care date of 12/3/2025 and a primary diagnosis of essential primary hypertension (high blood pressure without a specific single medical cause). Continued review of the POC revealed that Patient # 3 had a history of cerebral infarction (a stroke, where blood flow was interrupted to the brain and caused brain tissue death). RN A signed and dated the POC on 02/21/2026. The POC contained orders for SN visits one time per week for eight weeks. During a home visit with Patient #3 and Family Member #2, record review, and interview on 04/03/2026 at 12:00 p.m., the surveyor reviewed the agency folder, which included patient rights records, that the agency provided to the patient at admission. Review of the records revealed that it included the following: the agency’s records titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with an area titled, “Quality Improvement Organization;” and “Notice of Medicare Non-Coverage” dated 12/31/2011 with an area titled, “How to Ask For an Immediate Appeal.” Review of the records revealed the same information listed when the records were reviewed at the agency. The surveyor asked Patient # 3 and Family Member # 2 if the agency staff had advised [Patient # 3] of the name and contact information for how to appeal a discharge if Patient # 3 did not agree with the discharge decision. Patient # 3 could not speak due to history of stroke (happened when blood flow was interrupted to part of the brain and caused brain cells to die). Family Member# 2 stated that the agency did not advise [Patient # 3] on the name and contact information for the current QIO. During an interview on 04/08/2026 at 9:44 a.m. with Admin B/DON, the surveyor asked who was responsible for ensuring that the patient rights information for federally funded entities (Quality Improvement Organization name and contact information) was correct. Admin B/DON stated that she was responsible. The surveyor reviewed the findings and asked why Patient #1, Patient #2, and Patient #3 were not advised of the correct name, address, and telephone number of the correct QIO that served the area where the patients resided. Admin B/DON stated that when the agency changed consultants the information was not updated. Admin B/DON also stated that she was not aware of the change in the QIO. Review of agency policy titled “Patient/Client Rights and Responsibilities” last reviewed 05/01/24 read in part: “Purpose [:] To ensure all patients/clients their representatives (if any) and agency staff acknowledge, observe, and implement the patient’s/client’s rights and responsibilities…Procedure [:] I. Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct, and patient/client responsibilities on an ongoing basis…VI. The patient/client has the right to…K. Be advised of the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that service the area where the patient/client resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization...” Review of Center for Medicare Advocacy website on 03/10/2026 at, https://medicareadvocacy.org/medicare-quality-improvement-organization-changes-name/, revealed the following: Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) help Medicare beneficiaries with their concerns about quality of care, and in filing an appeal if coverage is ending too soon. As of July 1, 2024, the BFCC-QIO formerly known as [QIO B] is officially [QIO C]. In December of 2022, CNSI, “a leading provider of innovative healthcare technology solutions,” and [QIO B], “a leading provider of technology-enabled care management, quality oversight and clinical assessment services” merged. The [QIO C] brand was born in 2023, and notices with the new brand’s logo have been received by Medicare beneficiaries. [QIO C] assures beneficiaries there have been no changes to the services it provides. [QIO C]’s service areas include the following CMS Regions…Region 6…[Texas]…” Review of QIO C’s website, https://acentraqio.com/ on 04/16/2026 revealed the name, address, and contact information for Texas.”