Every finding on record at All- Ages Home Health Care LLC

Purpose: Recertification Survey Entrance Date: 3/4/2026 Census: Home Health - 97 patients No deficiencies cited.

Purpose: Recertification Survey Entrance Date: 3/4/2026 Census: Home Health - 97 patients

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 encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) to the CMS (Centers for Medicare and Medicaid Services), with respect to the information required to be transmitted, within 30 days of completing the assessment of the beneficiary for 29 (13.67%) of the 212 completed assessments sent to the CMS system between 7/1/2025 to 9/30/2025. The failure resulted in CMS being unable evaluate the quality of care patients received from the agency and the patient outcomes. Review of the OASIS Agency Final Validation report for the agency on 3/4/2026 in the Internet Quality Improvement and Evaluation System, a web-based portal used to collect, validate, and analyze healthcare data for Medicare/Medicaid providers, revealed that the agency received 29 -3300 warnings between 7/1/2025 to 9/30/2025. The OASIS Agency Final Validation report defined the -3300 warning as "Record submitted late: The submission date is more than 30 days after the M0090..." Review of the Outcome and Assessment Information Set OASIS-E1 Manual, effective 1/1/2025, Chapter 3, read in part; "...The M0090- Date Assessment Completed: is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed..." During an interview on 3/6/2026 at 11:13 AM with the Administrator and the Alternate Administrator/Supervising Nurse, the surveyor discussed the OASIS transmissions, that completed assessments were not being transmitted to CMS within 30 days of assessment completion date. The surveyor asked what the process for submitting completed assessments to the CMS system was. The Alternate Administrator/Supervising Nurse informed the surveyor that the Nurse had 48 hours to turn the completed assessment in to the agency; the completed assessment goes to the Alternate Administrator/Supervising Nurse to review for errors so that the submission would not be rejected; the agency had 30 days to export from the date of completed assessment. The surveyor asked why were completed assessments being transmitted greater than 30 days after the assessments were completed. The Alternate Administrator/Supervising Nurse informed the surveyor that the agency does pre-claim review for billing. The Alternate Administrator/Supervising Nurse stated, "Our problem was getting the medical records from the doctors. We have to wait for documents from the physician or hospital, and have it for export." The Alternate Administrator/ Supervising Nurse informed the surveyor that the agency "gets on it immediately, we call the physician's office. We start the process right away." The Administrator and Alternate Administrator/Supervising Nurse did not dispute the finding. Review of the agency's policy titled "IM.10 OASIS Collecting, Encoding and Transmitting" dated 6/30/2025 read in part; "Purpose To ensure the OASIS is collected, encoded and transmitted according to regulation. Policy A. Time points for completing OASIS include...C. Start of care...D. Resumption of Care...following an inpatient stay of at least 24 hours for reasons other than diagnostic testing; E. Follow-Up collected at Recertification and Other Follow-Up (significant change in condition); F. Transfer collected at Transfer to Inpatient Facility, with or without Discharge from Home Health Agency; G. Discharge collected at discharge from home health agency other than Death at Home or Transfer to Inpatient Facility; H. Death at Home...Procedure...C. Encoding and transmitting OASIS data. 1. The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary...3. OASIS must be transmitted for all patients receiving skilled services, regardless of payer source.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to update and revise the comprehensive assessment including the Outcome and Assessment Information Set, as frequently as the patient condition warrants, but no less often then the last 5 days of every 60 days, beginning with the start of care date, where the client did not elect to transfer, did not have a significant change in condition, and did not discharge and return to the same agency during the 60-day episode for 1 (#6) of 5 active client records reviewed, . The failure placed Patient #2 at risk of receiving ineffective care or interruptions in care. Patient #6 Record review of Patient #6's clinical record revealed a 60-day Plan of Care dated 11/27/2025 to 1/25/2026. The Plan of Care indicated that Patient #6 started on the agency's services on 10/3/2024. The Plan of Care listed Acute and Chronic Respiratory Failure with Hypoxia (sudden and chronic- developed over time, inability of the lungs to get oxygen into the blood), End-Stage Renal Disease (irreversible failure of the kidneys to filter waste or fluids), and Dependence on Renal Dialysis (reliance on machinery to filter waste and excess fluid from the blood) as diagnoses. A review of Patient #6's clinical record indicated that a recertification comprehensive reassessment was scheduled to Registered Nurse E on 1/21/2026 and was not done. The review of Patient #6's clinical record revealed that no registered nurse updated or revised the comprehensive assessment from 1/21/2026 to 1/25/2026, the last 5 days of the 60-day period. During an interview on 3/6/2026 at 11:13 AM with the Administrator and the Alternate Administrator/Supervising Nurse the surveyor discussed that the comprehensive reassessment was not updated or revised. The surveyor asked who would be responsible to update and revise the comprehensive reassessment. The Administrator informed the surveyor that a nurse would be assigned to do the comprehensive reassessment. The electronic medical record indicated that the comprehensive reassessment was scheduled to Registered Nurse E. The surveyor asked why the comprehensive assessment was not updated or revised. The Alternate Administrator/Supervising Nurse stated, "I feel sure that (Registered Nurse E) saw the patient." The Administrator and Alternate Administrator/Supervising Nurse did not know why the comprehensive reassessment was not done. The surveyor asked whether Registered Nurse E had been contacted regarding the comprehensive reassessment. The Alternate Administrator/Supervising Nurse informed the surveyor that Registered Nurse E was contacted last week. Registered Nurse E was not available to be interviewed due to being admitted to a facility. Review of the agency's policy titled "PE.4 Patient Reassessment/Recertification/Post Hospital Assessment," dated 12/20/2022, read in part; "Purpose To establish criteria and time line for reassessment of the patient and revision of the plan of care based on this assessment...Policy...B. The Recertification/Follow-up Comprehensive Assessment, which includes the OASIS (Outcome and Assessment Information Set) data set, will be updated and revised during the last five (5) days of the episode (day 56-60)..." Review of the agency's policy titled "IM.9 Timeliness (sic)," dated 6/30/2025, read in part; "Purpose To establish timeframes for completion and incorporation of paperwork and OASIS (Outcome and Assessment Information Set) into the clinical record...Policy A. Agency will ensure timely provision of care and services to meet the patient's needs in compliance with all federal and state laws and regulations and standards of practice...Procedure A. All Agency staff, physician/allowed practitioner and their office/clinic staff as appropriate, will be oriented to the following parameters...8. Recertification's (sic)/comprehensive reassessments will be completed within 5 days window of the end of episode (day 56-60)..."

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: Based on record review and interview, the agency failed to include in the individualized Plans of Care, all medications and treatments, and safety measures to protect against injury, in that oxygen (gas that gives the ability to break down food to get the energy needed to survive) was not included in the Plan of Care and safety measures for a arteriovenous fistula/graft (surgically created permanent connection of an artery and vein) was not included in the Plan of Care for 1 (Patient #6) of 2 records reviewed where the patient had a diagnosis of End Stage Renal Disease (irreversible failure of the kidneys to filter waste or fluids). The failure placed Patient #6 at risk that the fistula wound become unusable or infected, and medication would not be administered resulting in the inability to manage Patient #6's symptoms. Patient #6: Record review of Patient #6's clinical record revealed Plans of Care dated 11/27/2025 to 1/25/2026 and 1/26/2026 to 3/26/2026. The Plans of Care listed Acute and Chronic Respiratory Failure with Hypoxia (sudden and chronic- developed over time, inability of the lungs to get oxygen into the blood), End-Stage Renal Disease (irreversible failure of the kidneys to filter waste or fluids), and Dependence on Renal Dialysis (reliance on machinery to filter waste and excess fluid from the blood) as diagnoses. Registered Nurse C conducted a resumption of care comprehensive assessment on 1/13/2026. Registered Nurse C documented that Patient #6 had a arteriovenous graft/fistula (used for dialysis) on the left arm. Registered Nurse documented that Patient #6 was dependent on oxygen and used oxygen at 3 liters per minute by nasal cannula (flexible tube with two prongs placed in the nostrils to deliver supplemental oxygen). The Plans of Care dated 11/27/2025 to 1/25/2026 and 1/26/2026 to 3/26/2026 did not include that Patient #6 required oxygen at 3 liters per minute. The Plans of Care did not contain safety measures for the arteriovenous fistula/graft in Patient #6's left arm. The National Kidney Foundation listed the following safety measures to keep an arteriovenous fistula/graft working: Feel for a vibration called a pulse or thrill at the arteriovenous graft/fistula site. Do not use a blood pressure cuff on the arm with the arteriovenous graft/fistula. Do not draw blood from the arm with the arteriovenous graft/fistula. https://www.kidney.org/kidney-topics/hemodialysis-access#:~:text=Keep%20catheter%20dressing%20clean%20and,dry.&text=Make%20sure%20the%20area%20of,team%20at%20each%20dialysis%20session.&text=Keep%20an%20emergency%20dressing%20kit,change%20your%20dressing%20between%20treatments. During an interview on 3/6/2026 at 11:13 AM with the Administrator and Alternate Administrator/Supervising Nurse, the surveyor discussed that a review of the Plans of Care for Patient #6 did not include that Patient #6 required Oxygen and did not include safety measures to protect the arteriovenous fistula/graft. The surveyor asked who was responsible for ensuring the Plans of Care included oxygen and safety measure for the arteriovenous graft/fistula. The Alternate Administrator/Supervising Nurse stated, "I am." The surveyor asked why oxygen and safety measures for the arteriovenous graft/fistula weren't included in the Plans of Care. The Alternate Administrator/Supervising Nurse informed the surveyor that the Alternate Administrator/Supervising Nurse thought that the fistula/grafts were part of protocol. The surveyor requested the protocol (the agency did not provide a protocol before exit). The surveyor asked how it could affect patients when medications and safety measures weren't included in the Plans of Care. The Alternate Administrator/Supervising Nurse stated, "It could mess up the fistula, make it unusable, or could cause infection; and if medications were not on the plan of care, it could cause confusion, wrong dosage, or not being able to manage problems." Review of the agency's policy titled "TX.6 Plan of Care" dated 12/29/2022 read in part; "Purpose To develop an individualized Plan of Care which specified the care and services necessary to meet the patient specific needs and according to state and federal regulations. Definition Allowed practitioner is a Nurse Practitioner, Physician Assistant, or a Clinical Nurse Specialist. Policy A. Each patient will receive an individualized written plan of care, including any revisions or additions...Procedure...C. The individualized Plan of Care will specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment, including identification of the responsible disciple(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. The POC (Plan of Care) will contain the following elements...10. All medications and treatments; 11. Safety measures to protect against injury..."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the services ordered by the physician or allowed practitioner as indicated in the plan of care, in that the nursing staff failed to provide the ordered wound care for 1 (Patient #2) of 2 patient records reviewed where the patient had a wound. The failure placed Patient #2 at risk of the wound getting worse or becoming infected. Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 9/19/2025 to 11/17/2025. The Plan of Care indicated that Patient #2 started on the agency's services on 6/2/2023. The Plan of Care listed Pressure Ulcer of Sacral (lower back) Region, Stage II as the primary diagnosis. The Plan of Care contained an order for Patient #2 to receive skilled nurse visits 3 times each week. The Plan of Care contained an order to clean the sacral wound with normal saline (sterile solution of salt and water used to clean wounds) or wound cleanser, pat dry with gauze, apply Medihoney (dressing used to treat wounds, reduce infection, manage odor), cover with alginate (used to manage moderate-to-heavy drainage from wounds) and foam dressing (dressing used to manage moderate to heavy draining wounds) three times a week. Patient #2's clinical record contained an order dated 9/22/2025 to clean Patient #2' sacral wound with normal saline or wound cleanser, pat dry with gauze, cover with Medihoney and foam dressing three times a week. The agency received a physician order on 10/2/2026 from Physician X. Physician X ordered the following wound care; Clean the wound with Anasept (antiseptic wound cleaner) and pat dry with gauze; Apply skin prep (liquid used to intact skin to protect against adhesives) to peri-wound skin; Covered with Hydrofera Blue (antibacterial dressing used in advanced wound care to manage bacteria levels, promote healing environment, and absorb drainage) then Adaptic dressing (non-stick dressing saturated with a topical lubricant to treat wounds); cover with silicone foam (sterile wound dressing used on moderate to heavily draining wounds) and secure with tape as needed. Licensed Vocational Nurse D conducted skilled nurse visits on 10/3/2025, 10/6/2025, 10/8/2025, 10/10/2025, 10/12/2025, and 10/13/2025. Licensed Vocation Nurse D documented that Licensed Vocational Nurse D cleaned Patient #2's wound with normal saline, applied Medihoney, covered with a border dressing and secured with tape at each of the visits. Patient #2 did not receive the wound care as ordered in the Plan of Care. During an interview on 3/6/2026 at 11:13 AM with the Administrator and the Alternate Administrator/Supervising Nurse, the surveyor discussed the wound care provided to Patient #2. The surveyor discussed that Hydrofera Blue and skin prep were ordered on 10/2/2025 but that the nursing staff did not provide wound care that included Hydrofera Blue and skin prep. The surveyor asked if Hydrofera blue and skin prep were used. The Alternate Administrator/Supervising Nurse stated, "I don't have an answer to it." The surveyor asked who was responsible for ensuring that the wound care was followed During an interview on 3/6/2026 at 12:05 PM with Licensed Vocational Nurse D, the surveyor asked if Licensed Vocational Nurse D used Hydrofera Blue when providing wound care for Patient #2 after 10/2/2025. Licensed Vocational Nurse D stated, "I don't remember." Review of the agency's policy titled "TX.6 Plan of Care," dated 12/29/2022, read in part; "Purpose To develop an individualized Plan of Care which specified the care and services necessary to meet the patient specific needs and according to state and federal regulations. Policy...Procedure...E. Modification to the plan of care are indicated by: reassessments, patient condition/needs, changes in orders, and/or achievement of identified goals...Q. The patient will receive all services outlined in the POC (Plan of Care)..."