Every finding on record at Amazing Grace Systems Homehealth LLC

A relicensure and recertification survey was conducted on 5/13/2025 at 4:30 p.m. with the Administrator. The census was: El Paso: 10 L&CHHS – 10 LHHS- 0 PAS - 0 NO DEFICENCIES CITED

A relicensure and recertification survey was conducted on 5/13/2025 at 4:30 p.m. with the Administrator. The census was: El Paso: 10 L&CHHS – 10 LHHS- 0 PAS - 0 Abbreviations: RN- Registered Nurse ANE – Abuse, Neglect and Exploitation L&CHHS – Licensed and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Attendant Services FM- family member OASIS – Outcome and Assessment Information Set IQIES - Internet Quality Improvement & Evaluation System OM- Office Manager EMR- Employee Misconduct Registry NAR- Nurse Aide Registry QAPI- Quality Assurance Performance Improvement

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 assessment to the iQIES system, within 30 days of completing the assessment of the patient for 3 of 10 (Patient #4, Patient #5, and Patient #10) of the patient records reviewed. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare not to be reported to CMS in the required time frame. The findings included: The Error Summary Report, retrieved from the iQIES website for the time of 06/01/2024 to 12/31/2024 was reviewed. During review of the HHA Error Summary Report, no data was revealed of no OASIS assessments were completed. Further search revealed no data of a completed OASIS assessment for 1/1/2024 to 12/31/2024. During a record review of the agency’s census revealed 3 Medicare billed patients and 7 Medicare Advantage patients with 3 Medicare billed patients as: Patient #4 with a start of care date of 3/28/25, Patient #5 with a start of care date of 1/21/2024, and Patient #10 with a start of care date of 12/24/2024. Further record review revealed evidence of an OASIS assessment was completed and transmitted to IQIES at the start of care date. A joint interview was conducted with the Alternate Administrator and RN A on 5/13/2025 at 3:00 p.m., RN A stated that the agency was not billing for payment for the 3 Medicare patients due to the agency’s account in IQIES that were used for submission had expired. RN A also stated that the Administrator, who is responsible for the failure, did not use the IQIES account due to technological challenges. The agency currently billed the private Medicare Advantage insurance companies for patients, to which an OASIS was not required for payment. During a record review of the agency’s policy titled, “Initial Patient Comprehensive Assessment”, dated 5/4/2007, revealed, “Each patient will receive a patient specific comprehensive assessment with incorporates OASIS data set for Medicare…patients…the assessment will include…OASIS data…which would include pertinent diagnosis…medical history, etc.…” Further record review of the agency policies revealed no other OASIS policy was found.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that clients receiving skilled treatment under the direction of a practitioner had formal plans of care that contained all required elements for 5 of 7 active clients (Patients #2, #4, #5, #9, and #10) whose records were reviewed, in that: 1. Patients #2, #4, #5, #9, and #10’s Plan of Care and physician orders did not reflect frequency of home visits from any discipline. This failure placed the agency's clients at risk for receiving inadequate service delivery. The findings included: During a record review of the clinical records on 5/14/2025 at 3:00 p.m., revealed the plan of care, labeled, “Home Health Certification and Plan of Care,” for Patients #2, #4, #5, #9, and #10. Further record review revealed as follows: Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #2 has a start of care date of 4/8/2025 with an admitting diagnosis of high blood pressure and depression. No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #4 has a start of care date of 3/28/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #5 has a start of care date of 1/28/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #9 has a start of care date of 4/14/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #10 has a start of care date of 11/12/2025 with an admitting diagnosis of arthritis (inflammation of the joints resulting in decreased mobility) and diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” During a joint interview with RN A, OM, the Alternate Administrator on 5/21/2025 at 12:00 p.m., RN A, OM, the Alternate Administrator were informed of the above findings. The Alternate Administrator acknowledged the discrepancy on the order and stated the frequency of the disciplines of nursing and physical therapy visits were not required by the Medicaid Advantage companies but understood the accuracy of the frequency of visits were important because the plan of care is a physician’s order. Review of the agency’s policy titled, “Plan of Care,” dated 12/29/2012, revealed in part, “C. The Plan of care, which includes the following elements, is developed in consultation with staff, patient, caregiver, physician and other providers involved in the patient’s care and will service as the initial plan of care: …11. Physician orders to include the discipline to render the services/treatments, the services or therapy modalities to be rendered and the frequency and during of the visits to be made…to specific procedures to be performed, including the amount, frequency and duration…” Review of the agency’s policy titled, “Implementing Care and Treatment,” dated 3/27/2010, revealed in part, “Agency staff providing patient care and treatment will be competent to the level of care...and the care provided will be within the frequency parameters established on the care planning document…”

An Entrance Conference was conducted on 05/10/2022 with the Administrator/Supervising Nurse. The Agency representative was informed the purpose of the survey was a Recertification Survey. The Agency census was: L&CHHS - 8 LHHS - 1 PAS - 0 An Exit Conference was conducted on 05/12/2022 with the Administrator/Supervising Nurse, the Alternate Administrator, and the Registered Nurse at 4:30 PM. The preliminary findings were discussed. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms: QAPI – Quality Assessment Performance Improvement

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that documentation of services provided was accurate and timely for 1 of 7 patients (Patient #1) for which the clinical record was reviewed. This failure has the potential to place agency patients at risk of negative outcomes by preventing agency staff from knowing what services have or have not been provided. Findings included: Review of the clinical record for Patient #1 revealed a start of care date of 07/10/2020 for a primary diagnosis of Idiopathic normal pressure hydrocephalus and a secondary diagnosis of Unspecified dementia without behavioral disturbance. Review of the plan of care for the time period of 01/01/2022 to 03/01/2022 revealed Orders for Discipline and Treatments: Skilled Nursing (SN): 1w9 (Once a week for 9 weeks). Further review of the clinical record for Patient #1 for the certification period of 01/01/2022 to 03/01/2022 revealed the record did not contain documentation Skilled Nurse visits were completed during the weeks of 01/02/2022 to 01/08/2022, 01/09/2022 to 01/15/2022, 01/16/2022 to 01/22/2022, 01/23/2022 to 01/29/2022, 01/30/2022 to 02/05/2022, 02/06/2022 to 02/12/2022 and 02/13/2022 to 02/19/2022. An interview was conducted with the Registered Nurse on 05/12/2022 at 2:45 PM. The skilled nursing visit notes for the time-period of 01/01/2022 to 03/01/2022 were requested for review. The Registered Nurse stated that the Licensed Vocational Nurse had issues with turning in documentation on time. The Registered Nurse stated that the Agency had discussed this in the Agency’s QAPI committee meeting. The Registered Nurse stated that she was in communication with the Licensed Vocational Nurse regarding completing the skilled nursing visit notes and would provide them to this Surveyor once completed. Review of documentation of QAPI Committee Meeting minutes, dated 07/01/2021 read in part, “Administrator and Supervising Nurse have contacted Licensed Vocational Nurse in one-on-one basis as stated in ACTION/GOAL regarding late submission of notes. Employee notified which notes are missing, Employee has been referred back to home health policy as to timely manner of submission of notes and sign in sheets. Next actions have been discussed with employee.” On 05/12/2022 at 4:20 PM, the findings were discussed with the Administrator/Supervising Nurse regarding lack of documentation of skilled nursing visit notes for Patient #1. The Administrator/Supervising Nurse acknowledged the findings. No additional information was provided. The Agency was given two days to submit the clinical notes. On 05/13/2022 at 8:29 PM, documentation of skilled nursing visit notes, dated 01/07/2022, 01/12/2022, 01/21/2022, 01/28/2022, 02/02/2022, 02/10/2022, 02/17/2022, 02/24/2022 were received via fax transmittal from the Agency. Review of the agency's policy and procedure manual revealed a policy entitled "RESPONSIBILITIES OF THE ADMINISTRATOR, LD.6, Revised date: 070212", which read in part "An Administrator will be responsible but not limited to the following: 3. Ensure that the documentation of services is provided accurately and timely."