Guidance Home Health Services 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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the Center for Medicaid and Medicare system for all Medicare patients within 30 days of completing the OASIS assessment of the patient for 25% (27 of 108) of assessments transmitted during 12/31/2024-12/31/2025. This failure prevented the agency’s patient data from being made available to the Center for Medicaid and Medicare within 30 days of the OASIS completion date for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 03/31/2026: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) for the period of 12/31/2024-12/31/2025. The report included 27 of 108 OASIS assessments (25%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted by Surveyor 1 with the Chief Medical Officer on 04/01/2026 at 10:30 AM. The Chief Medical Officer stated he was responsible for submitting the assessments to the Center for Medicaid and Medicare. During an interview with the Chief Medical Officer on 04/07/2026 at 1:38 PM, the surveyor asked why 27 of 108 OASIS assessments (25%) were submitted more than 30 days of the completion date. The Chief Medical Officer stated he did not know why they were submitted late because they were usually submitted right away. The Chief Medical Officer stated the Adm/DON was responsible for submitting the assessments to the Center for Medicaid and Medicare Services. Surveyor 1 asked who was responsible for submitting the OASIS assessments. The Chief Medical Officer stated the Adm/DON. During an interview with the Chief Medical Officer and Surveyor 1 on 04/07/2026 at 2:40 PM, the Chief Medical Officer stated: The agency wanted to make the Chief Medical Officer the security official in the HARP system HARP (allows users to modify profiles, change passwords, revise challenge questions, and update authentication devices) so he could submit the assessments. The Chief Medical Officer completed the online change in the HARP application in December 2025 but there were some issues and the login was suspended for 12 days since he used the wrong password. The Chief Medical Officer called HARP a few times and they discovered he was already in the HARP system for his other business [private doctor office practice]. The Chief Medical Officer’s HARP password was finally fixed yesterday [04/06/2026] to change him to the security official but the process took almost 2 months. The Adm/DON couldn’t submit assessments during that period because she didn’t have the username and password because he had the information, but when he tried to make the change in the security official, it was delayed since January 12, 2026. During an interview with the Adm/DON and Surveyor 2 on 04/08/2026 at 1:36 PM, the Adm/DON stated OASIS assessments were submitted past 30 days in 2025 but she could not give a reason for them being late. Agency policy titled, “Timelines IM.35” with a last reviewed date of 05/02/2024 read in part, “… OASIS data… will be transmitted via electronic communication software… to the Center for Medicaid and Medicare collection site within thirty 30 days of the M0090 [completion] date…””

“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: Based on record review and interview, the agency failed to provide the completed written Notice of Medicare Non-Coverage notice at least two days in advance of terminating on-going care in one of three patient discharged records reviewed (Patient 3). The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patient from exercising their right to appeal the discharge decision if they chose to appeal. Findings included: An agency patient discharge roster was received on 04/02/2026 at 1:07 PM from the Chief Medical Officer. The discharge roster included Patient 3 was discharged on 05/23/2025 with goals met. Patient 3: Record review of the medical record included a plan of care dated 04/21/2025 to 06/19/2025 with a start of care date of 04/21/2025. The physician ordered the nurse to visit the patient twice a week for nine weeks. The plan of care included a diagnosis of surgical aftercare. The record included two visit notes signed and dated by the Adm/DON on 05/16/2025 and 05/19/2025. The two visit notes included a section titled, “Discharge Planning” with two unchecked boxes that read, “Patient Received Discharge Notices per Agency Policy and Procedures, Due to Plan to DC” and “Legal Representative Received Discharge Notices per Agency Policy and Procedures.” The two visit notes did not include the patient was provided the completed written Notice of Medicare Non-Coverage notice (a Medicare form utilized by health care providers to notify patients of their intent to discontinue services that may no longer be covered by Medicare). The record included a discharge OASIS assessment (a standardized data set that measures quality and outcomes of home health patients) completed by the Adm/DON on 05/23/2025. The discharge OASIS included the discharge reason was goals met. The record included a form titled, “Coordination of Care/Communication Note” signed by the patient on 05/23/2025. The form included Patient 3’s reason for discharge was goals met. The record did not include a discharge order. The record did not include a completed written Notice of Medicare Non-Coverage notice at least two days in advance of discharge. During an interview with the Adm/DON on 04/08/2026 at 2:20 PM, Surveyor 1 asked why a completed written Notice of Medicare Non-Coverage notice was not given and signed by the patient at least two days in advance of discharge. The Adm/DON stated at the start of care visit, the patient said he only wanted home health care for one month. The Adm/DON stated if the patient knew he was going to be discharged after one month, she thought she did not have to give discharge notices. Surveyor 1 asked if the patient goals were met. The Adm/DON stated, “Yes.” Agency policy, “Patient/Client Transfer and Discharge Notices PE.30” last reviewed 05/01/2024 read in part “Policy… Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client or the patient’s/client’s parent, family, spouse, significant other, or legal representative… The Agency will deliver the Notice of Medicare Non-Coverage… to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily… Procedure… I. Notice of Medicare Non-Coverage… A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client, or representative (if any), when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client, or representative (if any) when providing notice of discharge. C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received… H. An Agency representative will assure the patient/client, or representative, understands that the purpose and contents of the notice is to notify the patient/client that: 1. End of covered care is imminent 2. The patient/client, or representative, may appeal the termination decision I. The Agency will have the patient/client, or representative, complete and sign the NOMNC. The patient/client, or representative, should sign and date two copies, keeping one and returning the other to the Agency…””

“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: This is a repeated violation cited at G574 on 03/27/2023. Based on record review and interview, the agency failed to ensure the plan of cares included safety measures to protect against injury; 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; patient-specific interventions; and medical power of attorney information (legal document appointing someone to make healthcare decisions on a person’s behalf if they become unable to do so) related to any advanced directives (outlines preferences for medical treatment and appoints someone to make healthcare decisions if someone becomes unable to do so) in eight of eight records reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8) in that: a. In eight of eight records reviewed (Patient 1, 2, 3, 4, 5, 6, 7, and 8), the plan of cares did not include 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. b. In six of eight records reviewed (Patient 1, 2, 4, 5, 6, and 8), the plan of cares did not include medical power of attorney information related to any advanced directives. c. In one of one record reviewed (Patient 1), the plan of care did not include orders for the nurse to assess the amputation stump (partial or total loss of limb) for skin breakdown. d. In one of one record reviewed (Patient 2), the plan of care did not include who was to monitor the blood sugar for the diabetic patient (high blood sugars). e. In one of one record reviewed (Patient 3), the plan of care did not include orders for the nurse to assess the surgical incision site for signs and symptoms of infection and complications. f. In one of one record reviewed (Patient 4), the plan of care did not include the location of the dialysis shunt (surgically created connection between an artery and vein in the arm of patients who need to undergo dialysis, a process in which blood is removed from the body, cleansed and then returned to the body); instructions for the nurse to assess the shunt for a bruit (a rumbling sound that you can hear) and a thrill (a rumbling sensation that you can feel); to assess the shunt site for signs and symptoms of infection, the dialysis center where the client received dialysis treatments, the client’s kidney doctor, and safety measures for the access site to ensure no blood pressures were taken from the arm where the shunt was located. These failures placed patients in jeopardy of harm from agency staff who could not address the patient’s risk factors and types of services needed for appropriate care and placed them at risk of a declining health status and complications. The failure resulted in Patient 4’s blood pressure being taken on the left arm where the dialysis shunt was located. Findings included: According to According to John Hopkins University, dated 2006, blood pressure should not be measured on the arm with a dialysis shunt and the other arm should be used instead. Resource: https://www.kidney.org/sites/default/files/11-50-0216_va.pdf During an interview with the Adm/DON on 04/01/2026 at noon, the Adm/DON stated she was responsible for ensuring the plan of cares included all required elements. Patient 1: Record review of the medical record included a plan of care dated 12/23/2025 to 02/20/2026 with a start of care date of 10/24/2025 that was signed and dated by RN on 12/22/2025. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of respiratory failure with low oxygen levels and amputation stump/artificial left leg. The plan of care did not include 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; patient-specific interventions; medical power of attorney information related to any advanced directives; and orders for the nurse to assess the amputation stump for skin breakdown. During an interview with the Adm/DON on 04/08/2026 at 1:58 PM, Surveyor 1 asked why the plan of care did not include orders for the nurse to assess the amputation stump for skin breakdown. The Adm/DON stated it was surprising that the information was not included on the plan of care and she must have missed adding it. Patient 2: Record review of the medical record included a plan of care dated 02/10/2026 to 04/09/2026 with a start of care date of 08/21/2024 that was signed and dated by RN on 02/10/2026. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of lung disease and diabetes. The plan of care included fasting (before eating) blood sugar parameters of less than 70 and more than 180 and random blood sugar parameters of less than 70 and more than 200 to report to the physician. The plan of care did not include 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; medical power of attorney information related to any advanced directives; and who was to monitor the blood sugar levels. During an interview with RN on 04/08/2026 at 11:00 AM, Surveyor 1 asked why the plan of care did not include who was to monitor the blood sugar. RN stated the patient was checking his blood sugar and it was also monitored by the doctor’s office. RN stated the home health nurses were checking the blood sugar if the patient asked the nurse to check it or if the patient had signs and symptoms of diabetic issues. During an interview with the Adm/DON on 04/08/2026 at 2:15 PM, Surveyor 1 asked why the plan of care did not include who was to monitor the blood sugar. The Adm/DON stated it was an oversight. Patient 3: Record review of the medical record included a plan of care dated 04/21/2025 to 06/19/2025 with a start of care date of 04/21/2025 that was signed and dated by RN on 04/21/2025. The physician ordered the nurse to visit the patient twice a week for nine weeks. The plan of care included a diagnosis of surgical aftercare. The plan of care read in part, “… He has a large 8-pound mass in between his legs in the left side of the groin (area between the stomach area and the upper leg), that complex mass… has been completely removed and the margins of the mass is negative for cancer… patient has a very long wound… the wound edges are a little bit reddish…” The plan of care did not include 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; medical power of attorney information related to any advanced directives; and orders for the nurse to assess the incision site for signs and symptoms of infection and complications. During an interview with RN on 04/08/2026 at 11:08 AM, Surveyor 1 asked why the plan of care did not include orders for the nurse to assess the incision site for signs and symptoms of infection and complications. RN stated she checked the incision site and would have reported to the doctor if it had signs and symptoms of infection. RN stated she was sorry it was not included on the plan of care and it was an oversight. During an interview with the Adm/DON on 04/08/2026 at 2:17 PM, Surveyor 1 asked why the plan of care did not include orders for the nurse to assess the incision site for signs and symptoms of infection and complications. The Adm/DON stated it was an oversight and the agency had been auditing plan of cares when needed, but they should be audited every three months. The Adm/DON stated the nurses needed to be educated. Patient 4: Record review of the medical record included a plan of care dated 02/10/2026 to 04/09/2026 with a start of care date of 02/10/2026 that was signed and dated by the Adm/DON on 02/10/2026. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of End Stage Kidney Disease (kidneys no longer work) and dependence on dialysis. The record included a nursing recertification visit signed and dated by the Adm/DON on 02/10/2026 that included Patient 4’s blood pressure was taken on the left side; the same side the dialysis shunt was located. The plan of care did not include 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 and medical power of attorney information related to any advanced directives. The plan of care did not include the location of the dialysis shunt; instructions for the nurse to assess the shunt for a bruit and a thrill; to assess the shunt site for signs and symptoms of infection, the dialysis center where the client received dialysis treatments, the client’s kidney doctor, and safety measures for the access site to ensure no blood pressures were taken from the arm where the shunt was located. During an interview with the Adm/DON on 04/08/2026 at 2:22 PM, Surveyor 1 asked why the plan of care did not include the location of the dialysis shunt; instructions for the nurse to assess the shunt for a bruit and a thrill; to assess the shunt site for signs and symptoms of infection, the dialysis center where the client received dialysis treatments, the client’s kidney doctor, and safety measures for the access site to ensure no blood pressures were taken from the arm where the shunt was located. The Adm/DON stated the information should have been included and she was not sure how it was missed. Surveyor 1 asked why the patient’s blood pressure was taken on the left arm, which was the same side the dialysis shunt was located on the 02/10/2026 nursing visit. The Adm/DON stated it was an oversight. Patient 5: Record review of the medical record included a plan of care dated 12/14/2025 to 02/11/2026 with a start of care date of 08/16/2025 that was signed and dated by the Adm/DON on 12/13/2025. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of lung disease and knee pain. The plan of care did not include 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 and medical power of attorney information related to any advanced directives. Patient 6: Record review of the medical record included a plan of care dated 11/16/2025 to 01/14/2026 with a start of care date of 09/17/2025 that was signed and dated by RN on 11/12/2025. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of heart and kidney disease. The plan of care did not include 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 and medical power of attorney information related to any advanced directives. Patient 7: Record review of the medical record included a plan of care dated 10/11/2025 to 12/09/2025 with a start of care date of 08/17/2024 that was signed and dated by the Adm/DON on 10/10/2025. The physician ordered the nurse to visit the patient twice a week for nine weeks. The plan of care included a diagnosis of paralysis (loss of muscle movement) of all 4 limbs and memory loss. The plan of care did not include 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 and medical power of attorney information related to any advanced directives. Patient 8: Record review of the medical record included a plan of care dated 01/30/2026 to 03/27/2026 with a start of care date of 01/30/2026 that was signed and dated by RN on 01/30/2026. The physician ordered the nurse to visit the patient once a week for nine weeks. The plan of care included a diagnosis of surgical aftercare. The plan of care did not include 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 and medical power of attorney information related to any advanced directives. During an interview with the Adm/DON on 04/08/2026 at 1:50 PM, Surveyor 1 asked why the plan of care for Patients 1, 2, 3, 4, 5, 6, 7, and 8 did not include 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. The Adm/DON stated she did not realize the information needed to be included on the plan of care. Surveyor 1 asked why the plan of cares for Patients 1, 2, 4, 5, 6, and 8 did not include advanced directive information. The Adm/DON stated the information should have been included but it was overlooked. Surveyor 1 asked why agency policies were not followed. The Adm/DON stated the survey had been a learning experience and she realized she could improve and make sure the plan of cares included all of the information. During an interview with the Adm/DON on 04/08/2026 at 2:28 PM, Surveyor 1 asked why agency policies were not followed for all eight patients to include the required information on the plan of cares. The Adm/DON stated it was an oversight and those were areas for her to improve. Agency policy titled, “Plan of Care PC.35” with a last reviewed date of 05/02/2024 read in part, “… The individualized Plan of Care must include the following… All medications and treatments… Safety measures to protect against injury… 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… Patient/client-specific interventions… Information related to any advance directives…””