Every finding on record at A-1 Phoenix Healthcare, LLC

A recertification inspection survey was conducted on 03/31/2026. Licensed and certified home health services census was 135. No deficiencies were cited.

A recertification inspection survey and complaint investigation for complaint IQ2716646 was conducted on 03/31/2026. Licensed and certified home health services census was 135. Abbreviations and Acronyms: Admin-Administrator Alt. Admin-Alternate Administrator DON-Director of Nurses POC- Plan of Care Registered Nurse (RN) SN- Skilled Nursing QIO-Quality Improvement Organization CMS- Centers for Medicare and Medicaid Services CNSI-Classified national Security Information PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement

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.

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…”

A recertification inspection survey was conducted on 03/27/2023. Licensed & Certified Home Health Services census was 13. Abbreviations/Acronyms: Adm-Administrator Alt Adm/Disaster Coord/hha-Alternate Administrator/Disaster Coordinator/home health aide Alt DON-Director of Nursing EP-Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for three of three years reviewed (2020, 2021 and 2022). The failure could place the agency’s patients’ health, safety, and care at risk if the agency was not prepared in emergency or disaster situations. FINDINGS INCLUDED: During the entrance conference on 03/27/2023 at 11:25 a.m. the Alt Adm/Disaster/hha Coord self-identified as the Disaster Coordinator. The surveyor requested all agency EP records. Review of the agency’s EP binders did not reveal that the agency had maintained an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for the years 2020, 2021 and 2022. The EP binders included “Disaster Risk Analysis Facility and Community Based” assessments dated 06/18/2020, 10/20/2020, 02/12/2021, 06/18/2021, 02/11/2022. The risk analysis/assessments did not include the COVID-19 pandemic. The binders did not include an updated risk assessment that included the COVID-19 pandemic for the years 2020, 2021 and 2022. During an interview with the Adm and Alt Adm/Disaster Coord/hha on 03/31/2023 at 1:29 p.m. the surveyor asked the Alt Adm/Disaster Coord/hha what the agency id (their processes) the EP program. The Alt Adm/Disaster Coord/hha replied, “We call our patients and document that we called. We refer them to shelter in place. We ask them if they need to be evacuated and have them call 911 if it is needed. We give the patient information for food banks and disaster shelters and 211 information. We Also call their emergency contacts. The Adm replied, If there is a weather warning we call our patients, like one day before the weather event.” At 1:34 p.m. the surveyor discussed the above findings and asked why the agency did not maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment that included the COVID-19 pandemic for the years 2020, 2021 and 2022. The Alt Adm/Disaster Coord replied, “I did not know about it (the need to update/maintain the risk assessment).” Review of agency policy titled, ““Emergency Preparedness Plan” revised 11/17/2017 read in part: “Policy [:] The Agency must comply with all applicable Federal, State, and local emergency preparedness requirements… The Emergency Preparedness Plan must be reviewed and updated at least annually…Procedure[:] The Agency will maintain its developed disaster plan, disaster procedures and documentation of implementation and response to the plan in a manual titled “Emergency Preparedness Plan.” The…manual will contain…c. A risk Assessment that identified the potential disasters from natural and man-made causes most likely to occur in the agency’s service area with strategies for each potential disaster…”

A recertification inspection survey was conducted on 03/27/2023. Licensed & Certified Home Health Services census was 13. Abbreviations/Acronyms: Adm-Administrator Alt Adm/Disaster Coord/hha-Alternate Administrator/Disaster Coordinator/home health aide Alt DON-Alternate Director of Nursing EHR- Electronic Health Record PT- Physical Therapist RN-Register Nurse LVN-Licensed Vocational Nurse hha-Home Health Aide CNA-Certified Nurse Aide QA Mgr.-Quality Assurance Manager POC- Plan of Care SOC- Start of Care NOMNC-Notice of Medicare Non-Coverage OASIS -outcome and assessment information set CMS- Center for Medicare and Medicaid Services HHA's- Home Health Agencies PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement SN- Skilled Nursing

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 ensure proper written notice was provided, in advance of terminating on-going care in five (Patients # 6, # 7, # 8, # 9, and # 10) of five discharged patient records reviewed. The agency failed to provide Patients # 6 through # 10 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could affect patients’ health and safety and result in harm due to lack of timely discharge planning in the patients post discharge needs. FINDINGS INCLUDED: “HHAs…are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending. The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO. A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered services…” Record review on, 03/28/2023, of the website: H"https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices" https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices Record review of the NOMNC form, labeled "FORM CMS 10123- NOMNC," instructions, read in part: the HHA “…must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily…This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR 422.624(b)(1) and (2)…” Record review on, 03/28/2023, of the website: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf Patient # 6: Record review of the EHR for Patient # 6 revealed a POC with a SOC date of 04/02/2021 and a certification period 01/27/2022 to 03/27/2022. The POC had a primary diagnosis Essential primary hypertension (high blood pressure) and was signed by RN D and dated 01/27/2022. Continued review of Patient # 6’s record revealed a discharge OASIS/Summary that had a discharge date of 03/24/2022. Further review of Patient # 6's record 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, 03/24/2022. The record did not include a completed written NOMNC. Patient # 7: Record review of the EHR for Patient # 7 revealed a POC with a SOC date of 09/22/2021 and a certification period 01/20/2022 to 03/20/2022. The POC had a primary diagnosis Pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) left heel and was signed by RN D and dated 01/20/2022. Continued review of Patient # 7’s record revealed a discharge OASIS/Summary that had a discharge date of 03/18/2022. Further review of Patient # 7's record 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, 03/18/2022. The record did not include a completed written NOMNC. Patient # 8: Record review of the EHR for Patient # 8 revealed a POC with a SOC date of 01/31/2022 and a certification period 01/31/2022 to 03/31/2022. The POC had a primary diagnosis Hemiplegia (paralysis of one side of the body), affecting right dominant side and was signed by RN A and dated 01/31/2022. Continued review of Patient # 8’s record revealed a discharge OASIS/Summary that had a discharge date of 03/29/2022. Further review of Patient # 8's record 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, 03/29/2022. The record did not include a completed written NOMNC. Patient # 9: Record review of the EHR for Patient # 9 revealed a POC with a SOC date of 02/06/2022 and a certification period 02/06/2022 to 04/06/2022. The POC had a primary diagnosis Hemiplegia following cerebral infarction affecting right dominant side and was signed by RN A and dated 02/06/2022. Continued review of Patient # 9’s record revealed a discharge OASIS/Summary that had a discharge date of 04/06/2022. Further review of Patient # 9's record 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, 04/06/2022. The record did not include a completed written NOMNC. Patient # 10: Record review of the EHR for Patient # 10 revealed a POC with a SOC date of 02/18/2022 and a certification period 02/18/2022 to 04/18/2022. The POC had a primary diagnosis Multiple fractures of left side ribs and was signed by RN C and dated 02/18/2022. Continued review of Patient # 10’s record revealed a discharge OASIS/Summary that had a discharge date of 04/16/2022. Further review of Patient # 10's record 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, 04/16/2022. The record did not include a completed written NOMNC. In an interview on 03/31/2023 at 2:45 p.m. with the Adm and Alt DON the surveyor discussed the above findings and asked why the agency had not provided proper 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, # 9, and # 10. The Adm replied, “I’m not aware of that [the regulatory requirement to provide the notice].” Review of agency policy titled “Notices of Non-Coverage for Medicare Beneficiaries…” revised 12/01/2013 read in part: “…POLICY…Notice of Medicare Provider Non-Coverage CMS-10123-NOMNC. The Agency will give a completed copy of CMS-10123, the Generic Notice for Non-Coverage of Medicare Services to its’ Medicare beneficiaries receiving home health services not later than 2 days before termination of services…”

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, observation and interview the agency failed to ensure that the patient’s individualized plan of care had been reviewed and revised by the patient’s physician no less frequently than once every 60 days, in two (Patients # 1 and # 4) of three active patient records reviewed with the current 60-day certification period ending in March 2023. The failure could cause harm to agency patients due to lack of physician oversight if there were changes in the patient's condition or was a need for additional care and services. FINDINGS INCLUDED: Patient # 1: Patient # 1 was listed on the agency’s “active list” patient roster with a current episode period of 03/22/2023 to 05/20/2023. On 03/28/3023 review of the clinical record for Patient # 1 revealed a POC with a SOC date of 11/22/2022. The POC contained a certification period of 01/21/2023 to 03/21/2023 dated and signed by RN A on 01/21/2023. The POC also contained orders for SN visits one time per week for nine weeks and hha visits for two times per week for eight weeks and one time per week for one week. The record did not include a current POC, that had been reviewed and revised by the patient’s primary physician (Identifier 100), before, on or after the end date (03/21/2023) of the current certification period. There had been 67 days since the last individualized POC had been reviewed and revised by Patient # 1’s physician. During a home visit with Patient # 1 on 03/29/2023 at approximately 9:00 a.m., the surveyor observed the Alt/Adm/Disaster Coord/hha take Patient # 1’s vital signs and assist Patient # 1 with a shower. During an interview with the Adm and Alt Adm/Disaster Coord/hha on 03/31/2023 at approximately 2:55 p.m., the Surveyor discussed the above findings and asked why Patient # 1 did not have a current individualized plan of care that had been reviewed and revised by the patient’s physician at least every 60 days. The Adm replied, “The nurse [RN A] did not submit the assessment [OASIS], so the POC did not generate.” Patient # 4: Patient # 4 was listed on the agency’s “active list” with a current episode period of 01/28/2023 to 03/28/2023. On 03/28/3023 review of the clinical record for Patient # 4 revealed a POC with a SOC date of 06/02/2022. The POC contained a certification period of 01/28/2023 to 03/28/2023 dated and signed by RN B on 01/28/2023. The POC also contained orders for SN visits one time per week for nine weeks and hha visits for one time per week for nine weeks. Continued review of Patient # 4’s record on 03/31/2023 revealed the record did not include a current POC, that had been reviewed and revised by the patient’s primary physician (Identifier 200), before, on or after the end date (03/28/2023) of the current certification period. There had been 63 days since the last individualized POC had been reviewed and revised by Patient # 4’s physician. During an interview with the Adm and Alt Adm/Disaster Coord/hha at approximately 3:31 p.m., the Surveyor discussed the above findings and asked why Patient # 4 did not have a current individualized plan of care that had been reviewed and revised by the patient’s physician at least every 60 days. The Adm replied, “The nurse [RN B] has not submitted his recertification OASIS. He hasn’t completed it yet.” Review of the agency policy titled "Plan of Care and Physician’s Orders” revised on 01/13/2018 read in part: " ...Each patient must receive an individualized written plan of care…The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment…Standard: Plan of care …The total Plan of Care shall be reviewed and signed by the attending physician and Agency personnel involved in the patients care…at least once every sixty days…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observations, and interviews, the agency failed to provide written visit schedule in three (Patients # 1, # 2 and # 3) of three patients who received a home visit. The HHA failed to provide the patients and caregiver with a copy of the written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The failure could place the patients at risk of harm due to being uninformed and/or unable to identify the staff scheduled to provide care and services on behalf of the agency. FINDINGS INCLUDED: Review of the agency's sample "Medicare" admission packet revealed that the sample packet contained a form for visit schedules. Clinical Record # 1: On 03/28/3023 review of the clinical record for Patient # 1 revealed a POC with a SOC date of 11/22/2022. The POC contained a certification period of 01/21/2023 to 03/21/2023 dated and signed by RN A on 01/21/2023. The POC also contained orders for SN visits one time per week for nine weeks and hha visits for two times per week for eight weeks and one time per week for one week. The record did not include a current POC. During a home visit conducted on 03/29/2023 at approximately 9:00 a.m., the surveyor observed, and reviewed Patient # 1's home admission folder. The folder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder included a visit calendar that was blank (the visit schedule did not include a schedule of visits with the frequency of visits for SN and hha). The surveyor conducted the home visit with the Alt Adm/Disaster Coord/hha and the surveyor observed the Alt Adm/Disaster Coord/hha assist Patient # 1 with a shower. Clinical Record # 2: On 03/28/3023 review of the clinical record for Patient # 2 revealed a POC with a SOC date of 08/31/2022. The POC contained a certification period of 02/27/2023 to 04/27/2023 dated and signed by RN B on 02/27/2023. The POC also contained orders for SN visits daily. During a home visit conducted on 03/29/2023 at approximately 8:00 a.m., the surveyor observed, and reviewed Patient # 2's home admission folder. The folder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder included a visit calendar that was blank (the visit schedule did not include a schedule of visits with the frequency of visits for SN). The surveyor conducted the home visit with LVN A, and the surveyor observed LVN A provide wound care to Patient # 2. Clinical Record # 3: On 03/28/3023 review of the clinical record for Patient # 3 revealed a POC with a SOC date of 09/08/2022. The POC contained a certification period of 03/07/2023 to 05/05/2023 dated and signed by RN B on 03/07/2023. The POC also contained orders for SN visits one time per week for nine weeks, PT to evaluate and treat, and hha visits for two times per week for nine weeks. During a home visit conducted on 03/30/2023 at approximately 3:00 p.m., the surveyor observed, and reviewed Patient # 3's home admission folder. The folder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder included a visit calendar that was blank (the visit schedule did not include a schedule of visits with the frequency of visits for SN, PT or hha). The surveyor conducted the home visit with PT A and the surveyor observed PT A provide Patient # 3 with physical therapy exercises/treatment. During an interview with the Adm and Alt DON on 03/31/2023 at 2:40 p.m., the surveyor discussed the above findings and asked why the agency had not provided a visit schedule with frequency of visits to Patients # 1, # 2 and # 3. After looking in the admission packet, the Adm replied, “It’s there but it is not filled out.” Review of agency policy titled “Care planning Process” revised 01/13/2018 read in part: “…Procedure…Written information to the patient: The Home Health Agency must provide patient and caregiver with a copy of written instructions outlining: Visit schedule, including visit frequency of visits by Home Health Agency personnel and personnel acting on behalf of the Home Health Agency…”

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, as part of the QAPI program, the agency failed to conduct and document PIP(s) for three of three years reviewed (2020, 2021 and 2022) that reflected the scope, complexity and past performance of the agency's services and operations. The failure could prevent the agency from improving and providing quality care and services to the agency's patients, placing the agency’s patients’ health and safety at risk. FINDINGS INCLUDED: During the entrance conference on 03/27/2023 at 11:25 a.m., the surveyor requested all agency QAPI documents/reports/manuals. QAPI binders for 2020, 2021 and 2022 were provided. Record review of the binders showed that they contained “QAPI Report[s]” for the 1st, 2nd, 3rd and 4th quarters of 2020, 2021 and the 2nd, 3rd and 4th quarters of 2022. The surveyor also reviewed the agency’s business profile binder (binder where the agency files agency meeting minutes and other administrative records). The business profile binder, QAPI binders and quarterly QAPI reports did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2020, 2021 and 2022. The agency failed to document quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects for the years 2020, 2021 and 2022. During an interview on 03/31/2023 at 2:15 p.m. with the Q A Mgr. and the Adm, the surveyor discussed the above findings and asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2020, 2021 and 2022. The Adm stated that she was not aware of the regulatory requirement to conduct performance improvement projects. Review of agency policy titled "Quality Assessment Performance Improvement Plan (QAPI)” revised 01/13/2018 read in part: “…Policy[:] The QAPI Program will consist with the following…4. Performance Improvement Projects…The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to state and federal authorities…Achieved and Sustained Improvement…The Agency’s performance improvement activities must…Focus on high risk, high volume, or problem-prone areas…The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the Agency's services and operations…The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.” Continued review of the agency’s QAPI policy revealed a “Performance Improvement Project” form for the documentation of the PIP(s). The QAPI binders and the business profile binder did not include any completed PIP forms.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a registered nurse or other appropriate skilled professional made an onsite visit to the patient's home no less frequently than every 14 days, in two (Patients # 1 and # 4) of five active patient records reviewed. The failure could place the patients at risk to receive unsafe care and to not receive services as ordered in the plan of care. FINDINGS INCLUDED: Patient # 1: Review of the clinical record for Patient # 1 revealed a POC with a SOC date of 11/22/2022. The POC contained a certification period of 01/21/2023 to 03/21/2023 dated and signed by RN A on 01/21/2023. The POC included a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (A condition which affects the arteries that supply the heart with blood. It is usually caused by a buildup of plaque inside the artery walls. This buildup causes the inside of the arteries to become narrower and slows down the flow of blood. Angina pectoris is chest pain or discomfort that keeps coming back).The POC also contained orders for SN visits one time per week for nine weeks and hha visits for two times per week for eight weeks and one time per week for one week. Review of Patient # 1’s SN hha supervision notes revealed missed visit notes dated 01/31/1023 and 02/14/2023. The missed visits were scheduled hha supervision visits. The record contained one SN visit with hha supervision (for the certification period of 01/21/2023 to 03/21/2023) dated 02/28/2023 and signed by RN, A. Patient # 4 Review of the clinical record for Patient # 4 revealed a POC with a SOC date of 06/02/2022. The POC contained a certification period of 01/28/2023 to 03/28/2023 dated and signed by RN B on 01/28/2023. The POC included a primary diagnosis of Hypertensive chronic kidney disease. The POC also contained orders for SN visits one time per week for nine weeks and hha visits for one time per week for nine weeks. Review of Patient # 4’s SN hha supervision notes revealed two SN visits with hha supervision dated 02/21/2021 and 03/08/2023 and signed by RN, B. The record did not include SN hha supervision visits that were due 02/07/2023 and 03/21/2023. During an interview with the Adm and Alt Adm/Disaster Coord/hha on 03/31/2023 at 2:55 p.m., the surveyor discussed the above findings and asked why the agency did not ensure hha onsite supervisory visits were conducted no less frequently that every 14 days. For Patient # 1 the Alt Adm/Disaster Coord/hha stated that the nurse did not do it. For Patient # 4 the Alt Adm/Disaster Coord/hha stated that “it should have been done on the 7th.” Review of agency policy titled “Home Health Aide Supervision” revised 01/13/2018 read in part: “…All home health aide supervisory visits will be conducted at least every two weeks…Procedure[:] Home Health Aides are closely supervised to ensure their competence in providing care. At least every 2 weeks/14 days the registered nurse…makes an onsite home supervisory visit…Home Health Aide supervision must ensure that aides furnish care in a safe and effective manner…including…following the patient’s plan of care for completion of tasks assigned to a Home Health Aide by the Registered Nurse…”

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have an alternate administrator who met the qualifications required for the position, in one (Alt Adm/Disaster Coord/hha) of one current Alternate Administrator personnel record reviewed. The Alt Adm/Disaster Coord/hha did not meet the federal requirements to hold an undergraduate degree. The failure could cause harm to the agency’s patients if the alternate administrator did not meet qualifications for the supervision and management of the safe delivery of patient care and services. FINDINGS INCLUDED: During the entrance conference on 03/27/2023 at approximately 11:25 a.m., the Alt Adm/Disaster Coord/hha self-identified as the agency’s alternate administrator. Review of the agency’s policy and procedure manual revealed a document dated 02/23/2021 and titled “Appointment of Alternate Administrator.” The document read in part: “…The Agency’s Governing Body herby appoints: [Alt Adm/Disaster Coord/hha] to serve as the Alternate Administrator…effective February 23, 2021…” Review of the agency’s business profile binder revealed “Joint Meeting: Governing Body and Professional Advisory Committee” meeting minutes. The meeting minutes dated 01/05/2021 read in part: The following items were discussed and approved by the [Professional Advisory Committee]…Appointments… Alt Adm/Disaster Coord/hha [as] Alternate Administrator/Disaster Coordinator…” Alt Adm/Disaster Coord/hha: Review of the agency’s office staff, and discipline rosters revealed that the Alt Adm/Disaster Coord/hha’s date of hire was 04/30/2018. Review of the Alt Adm/Disaster Coord/hha personnel record revealed the following: A signed job description for the position of alternate administrator, dated 02/23/2023. The job description included the qualification of “is a licensed physician, a registered nurse, or holds an undergraduate degree.” The record included signed job descriptions for the positions of hha, dated 04/30/2018. The record also included a signed application for the position of alternate administrator, dated 02/23/2021 and hha dated 04/30/2018. The applications included educational history of high school diploma and certification as nurse assistant (hha). The personnel record did not include any records that indicated Alt Adm/Disaster Coord/hha held an undergraduate degree. The record included two reference verification forms for the positions of [CLO-Community Liaison Officer] and hha with duties of “marketing, vital signs and patient care.” During an interview with Adm and Alt Adm/Disaster Coord/hha on 03/31/2023 at 2:10 p.m., the surveyor discussed the above findings and asked the Alt Adm/Disaster Coord/hha to discuss her educational experience (license, degree, or certifications). Alt Adm/Disaster Coord/hha stated that she was a CNA. The surveyor asked why the Alt Adm/Disaster Coord/hha had been appointed to the position without the required undergraduate degree. The Adm stated that the alternate administrator “could have management experience.” Review of agency’s “Alternate Administrator Job Description”, revised 01/13/2018 read in part: “Qualifications…For individuals that began employment with the HHA on or after January 13, 2018, a person who: Is a Licensed Physician, a Registered Nurse, or holds an undergraduate degree; and has experience in health service administration, with at least 1 year in home health care or related health care program…”