Every finding on record at Excel Home Health Services, Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: ALF- assisted living facility CMS-Centers for Medicare and Medicaid Services mg- milligram OASIS- Outcome and Assessment Information Set PoC- Plan of Care PT- Physical Therapy SOC- Start of Care

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 interviews, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 275 patients according to the agency’s active census on 06/04/2025. Findings: Review of the agency’s policy dated 09/09/2020 titled “Encoding and Reporting Oasis Data” revealed, in part: 3. Procedures: 1. [Provider] will submit individual client assessment data within thirty (30) days of completing the comprehensive assessment. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/06/2025 revealed 41 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/27/2025 revealed 36 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/29/2025 revealed 33 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2DON on 06/09/2025 at 3:05 p.m. S2DON confirmed the above late submissions should have been submitted within 30 days of completion and were not. An interview was conducted with S1ADM on 06/09/2025 at 3:08 p.m. S1ADM confirmed the above records were submitted late. S1ADM stated all OASIS Assessments should be submitted within 30 days of completion and were not.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, record reviews and interviews, the agency failed to maintain an accurate medication profile for 1 (#5) of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy with revision date 12/12/2024 titled, “Medication Reconciliation, Review and Administration” revealed, in part: Procedures The Registered Nurse or Therapist will complete a patient medication report/profile for each patient at the time of admission. The report shall include all prescription and nonprescription drugs, including regularly scheduled medications, over the counter, herbal, nutritional supplements, and those taken as needed. The medication profile will be reviewed and updated as needed by all qualified clinicians (Registered Nurse, Licensed Practical Nurse, Physical Therapist, Occupational Therapist and Speech Therapist) to reflect current medication the patient is taking. Review of Patient #5’s clinical record revealed a Start of Care (SOC) date of 05/20/2025. The patient's primary diagnosis was Acute Embolism and Thrombus Unspecified Deep Veins of Left Lower Extremity. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 05/20/2025 through 07/18/2025 revealed orders, which included: Skilled Nurse 2 times a week for 2 weeks, 1 time a week for 1 week, then 1 time a week every 2 weeks for 6 weeks. Physical Therapy 1 time a week for 1 week, 2 times a week for 2 weeks then 1 time a week for 1 week. Occupational Therapy 1 time a week for 1 week then 2 times a week for 2 weeks. Review of the agency’s current medication profile for Patient #5 dated 06/04/2025 revealed the following, in part: Acetaminophen 500 milligram (mg) 2 tablets=1000 mg by mouth three times daily as needed for mild to moderate pain. Atorvastatin 20mg 2 tablets=40mg by mouth daily. Culturelle 10 Billion Cell 1 capsule by mouth daily. Furosemide 20mg 1 tablet by mouth daily as needed for leg swelling. Melatonin 5mg tablet 1 tablet by mouth daily at bedtime. Olmesartan 20mg tablet 1 tablet by mouth daily as needed for Systolic Blood Pressure (SBP) greater than 130 and Diastolic Blood Pressure (DBP) greater than 90. An observation was made on 06/05/2025 at 12:30 p.m. when a home visit was conducted with Patient #5 and S7OT at a local assisted living facility (ALF). S7OT stated the facility’s medication nurse administered all of Patient #5’s medications. S7OT did not reconcile Patient #5’s current medications during the home visit observed, and confirmed medications should be reconciled every visit. Patient #5 confirmed the ALF medication nurse managed all of his current medications. S7OT then left the facility. A record review and interview were conducted on 06/05/2025 at 1:15 p.m. with Patient #5's ALF nurse. Patient #5's current medication profile list provided by the agency was reviewed and compared with the ALF’s medication list. The ALF nurse confirmed the following: 1. Acetaminophen 500mg tablets. This medication was on the agency’s medication profile and not on the ALF medication list. The ALF nurse stated Patient #5 was not taking this medication. 2. Atorvastatin 20mg 2 tablets. This medication was on the agency’s medication profile. The ALF nurse stated Patient #5 was taking 1 tablet daily. 3. Culturelle 10 Billion Cell capsule daily. This medication was on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Complete Probiotic twice daily. 4. Furosemide 20mg tablet daily. This medication was not on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Furosemide 20mg daily. 5. Melatonin 5mg tablet. This medication was on the agency’s medication profile and not on the ALF medication list. The ALF nurse stated Patient #5 was not taking this medication. 6. Olmesartan 20mg tablet daily. This medication was not on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Olmesartan 20mg daily. An interview was conducted with S2DON on 06/09/2025 at 3:10 p.m. S2DON was notified of the medication discrepancies found during the home visit above. S2DON confirmed Patient #5’s agency medication profile list should have accurately reflected the medications currently prescribed and did not. An interview was conducted with S1ADM on 06/09/2025 at 3:12 p.m. S1ADM was notified of the medication discrepancies found during the home visit above. S1ADM confirmed Patient #5’s agency medication profile list should have accurately reflected the medications currently prescribed and did not.

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 reviews and interviews, the agency failed to have the Plan of Care (PoC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 1 (#13) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy with a revision date of 03/04/2025 titled “Plan of Care and Coordination of Care” revealed in part: The patient’s individualized plan of care will be reviewed and revised by the physician or allowed practitioner who is responsible for the plan of care and the home health agency as frequently as the patient’s condition or needs requires, but no less frequently than once every 60 days, beginning with the start of care date or more frequently. Review of Patient #13's Clinical Record revealed Patient #13's SOC date was 07/27/2023. Review of the PoC for certification period 05/22/2024 through 07/20/2024 revealed the physician did not sign the PoC until 07/30/2024. An interview was conducted with S2DON on 06/09/2025 at 3:12 p.m. The above PoC for Patient #13 was reviewed. S2DON confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #13’s was not. An interview was conducted with S1ADM on 06/09/2025 at 3:14 p.m. The above PoC for Patient #13 was reviewed. S1ADM confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #13’s was not.

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 reviews and interviews, the agency failed to provide skilled professional services according to the patient’s Plan of Care (PoC) for 1 (#14) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy dated 03/04/2025 titled, “Plan of Care and Coordination of Care”, revealed in part: Procedures The plan of care will specify the care/services necessary to meet the patient-specific needs as identified in the comprehensive assessment. The plan of care will identify the responsible discipline(s), the amount, frequency, and duration of the disciplines for the patient. Care/services will be provided by the home health agency in accordance with the accepted standards of practice. Review of Patient #14’s Plan of Care (PoC) for the Certification period dated 02/22/2024 through 04/21/2024 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Further review of the plan of care revealed the following orders, in part: Physical Therapy 2 times a week for 2 weeks then 1 time a week for 1 week effective 02/25/2024. Review of the agency’s visit summary report for Patient #14 revealed Physical Therapy (PT) visits were completed on 02/26/2024, 03/05/2024, 03/07/2024 and 03/13/2024. Further review revealed there was no missed visit documentation available for review for Patient #14’s missed PT visit the week of 02/26/2024. An interview was conducted with S2DON on 06/09/2025 at 3:15 p.m. S2DON verified Patient #14’s visit summary for PT. S2DON confirmed Patient #14 did not receive all ordered PT visits the week of 02/26/2025 per the PoC and should have. An interview was conducted with S1ADM on 06/09/2025 at 3:17 p.m. S1ADM verified Patient #14’s visit summary for PT. S1ADM confirmed Patient #14 did not receive all ordered PT visits the week of 02/26/2024 per the PoC and should have. S1ADM stated the clinicians should have documented a missed visit coordination note when services were not provided per Patient #14’s PoC and did not.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations DON Director of Nursing lbs pounds LPN License Practical Nurse Mcg micrograms mg milligrams RN Registered Nurse SOC Start of Care wk week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations during home visits, staff interviews, and record reviews, the agency failed to ensure the patient's comprehensive assessments included a review of all medications the patients were currently using. The agency failed to ensure therapy and skilled nursing staff reconciled a patient's medications during subsequent home visits for 4 (#1, #2, #4 and #5) of 7 (#1, #2 #3, #4, #5, #6 and #7) sampled patients in which home visits were performed. Review of the agency's policy and procedure titled "Medication Reconciliation" revealed the following, in part; Purpose: To prevent potential medication error and to assure clients are receiving all prescribed and necessary medications. Patient #1 Review of the Clinical Record for Patient #1 revealed a Start of Care date of 06/13/2022 with a principal diagnosis of Protein Calorie Malnutrition. Review of the patient’s Plan of Care for the certification period 08/12/2022 – 10/10/2022 revealed Skilled Nurses' visits were ordered for 2wk1, 1wk3, 1every2wk4, effective 08/14/2022. On 08/17/2022 at 11:00 a.m., a visit was made to Patient #1's home. The most updated Patient’s Medication profile provided by S1DON revealed the following discrepancies when compared to the medications in the home: 1. Aspirin low dose 81mg tablet, delayed release- take 1 tablet daily; on the medication profile and not in the home. 2. Centrum Silver 0.4mg -300mcg- 25mcg tablet- take 1 tablet daily; on the medication profile and not in the home. 3. Colace 100mg capsule- take 1 capsule daily; on the medication profile and not in the home. 4. Estradiol 0.01% vaginal cream insert in vagina 2 times per week; on the medication profile and not in the home. 5. Flomax 0.4mg capsule- take 1 capsule at bedtime; on the medication profile and not in the home. 6. Melatonin 5mg tablet- take 1 tablet at bedtime; on the medication profile and not in the home. 7. Prolia 60mg/ml subcutaneous syringe – inject 1ml every 6 months; on the medication profile and not in the home. 8. Senna Plus 8.6mg-50mg capsule- take 1 capsule every p.m.; on the medication profile and not in the home. During the home visit, Patient #1 reported the medications listed above were discontinued on August 8, 2022. An interview was conducted during the home visit on 08/17/2022 at 11:15 a.m. with S2RN. She said the medication profile was not up to date to reflect the medications Patient #1 was currently taking. She said medication reconciliation should be done on every home health visit. Patient #2 Review of the Clinical Record for Patient #2 revealed a Start of Care date of 08/13/2022 with a principal diagnosis of Fracture Shaft of Right Tibia and Essential Hypertension. Review of the patient’s Plan of Care for the certification period 08/13/2022 – 10/11/2022 revealed Skilled Nurse visits were ordered for 1wk1, 2wk1, and 1wk8. Occupational Therapy visits were ordered for 2wk4 and Physical Therapy visits were ordered for 2wk3, 1wk1. On 08/18/2022 at 2:00 p.m., a visit was made to Patient #2’s home. The most updated Patient’s Medication profile provided by S1DON revealed the following discrepancies when compared to the medications in the home: 1. Hydrocodone 5mg-Acetaminophen 325mg tablet - take 1 tablet every 4 hours; on the medication profile and not in the home. 2. Potassium Chloride 20meq- take every day; patient was taking and not on the medication profile. 3. Aspercreme (Lidocaine) 4% topical patch daily as needed for pain: on the medication profile and not in the home. An interview was conducted on 08/19/2022 at 2:20 pm. with Patient #2’s daughter. She said she managed her mother’s medications. She confirmed her mother was currently taking Potassium Chloride 20meq by mouth daily. She said she was taking Potassium Chloride 20meq daily when she admitted to Home Health Services. She said her mother was not using the Aspercreme patch or taking Hydrocodone 5mg/325mg for pain. She said Patient #2 had not taken anything for pain since admission to Home Health Services. Patient #4 Review of the Clinical Record for Patient #4 revealed a Start of Care date of 02/17/2022 with a principal diagnosis of Encounter for Change or Removal of Nonsurgical wound dressing. Review of the patient’s Plan of Care for the certification period 06/17/2022 – 08/15/2022 revealed Skilled Nurse visits were ordered for 1wk8. On 08/16/2022 at 3:00 p.m., a visit was made to Patient #4’s home. The most updated Patient’s Medication profile provided by S1DON revealed the following discrepancies when compared to the medications in the home. 1. Trazodone 50mg tablet - take 1 tablet at bedtime; on the medication profile and not in the home. During the home visit, Patient #4 said the medication listed above was discontinued 4 weeks ago because her doctor said there was an interaction with her blood pressure medication. An interview was conducted on 08/16/2022 at 3:05 p.m. with S4RN. She reviewed Patient #4’s medications and confirmed the medication profile was not up to date. She said Patient #4’s medications should be reconciled each home health visit. Patient #5 Review of the Clinical Record for Patient #5 revealed a Start of Care date of 05/07/2022 with a principal diagnosis of Hypertensive Chronic Kidney Disease. Review of the patient’s Plan of Care for the certification period 07/06/2022 – 09/03/2022 revealed Skilled Nurse visits were ordered for 1wk8. On 08/19/2022 at 9:30 a.m., a visit was made to Patient #5’s home. The most updated Patient’s Medication profile provided by S1DON revealed the following discrepancies when compared to the medications in the home. 1. Humalog Kwikpen (U-100) Insulin 100 unit/mL subcutaneous 20 units three times daily; on the medication profile and not in the home. During the home visit, Patient #5’s son said Patient #5 no longer took Humalog Kwikpen (U-100) Insulin. An interview was on 08/19/2022 at 9:30 a.m. with S5COTA. S5COTA said the medication list was inaccurate and should be up dated with each home visit. An interview was conducted on 08/19/2022 at 2:15 p.m. with S1DON. She confirmed there were discrepancies between the medication profile and the Patient #1, #2, #4 and #5 had been taking. She said the medication profiles should be reviewed and updated by the clinician upon admission and with each visit in the home.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record reviews, the home health agency failed to ensure the RN provided home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 3(#11, #12 and #16) of 3(#11, #12 and #16) patients reviewed for pressure ulcers. The agency failed to ensure the RN assessed and staged Patient #11, #12 and #16’s pressure wound on a weekly basis. Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Wound care management requires the registered nurse to collaborate with other members of the interdisciplinary team to ensure that the individual's nutritional and psychosocial needs are being met and to provide for preventive and therapeutic measures. The Registered Nurse should consult with the physician and/or CWCN (certified wound care nurse) to assure safe, quality nursing measures that facilitate appropriate skin and wound management. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #11 Review of the clinical record for Patient #11 revealed the patient began receiving services with the provider on 07/14/2022. The patient had diagnoses which included Stage 2 Pressure Ulcer to Sacrum. Review of the current Physician orders for Patient #11 revealed the following: Sacrum: Cleanse with wound cleanser, pat dry with gauze. Apply barrier cream, cover with border foam dressing. Wound care to be performed 3 times per week and as needed if soiled. Review of the weekly scheduled Skilled Nurse visit notes revealed the LPN provided wound care the following weeks: Week of 07/17/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 07/24/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 07/31/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 08/07/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 08/14/2022 - no weekly assessment of the pressure ulcer by the RN. Patient #12 Review of the clinical record for Patient #12 revealed the patient began receiving services with the provider on 07/22/2022. The patient had diagnoses which included Stage 2 Pressure Ulcer to Coccyx and Right Upper Back. Review of the current Physician orders for Patient #12 revealed the following: Right Mid-Back area: Cleanse with Normal Saline, pat dry, cover with bordered foam gauze. Change daily and prn. Coccyx: Cleanse with Normal Saline, pat dry, cover with bordered foam gauze. Change daily and prn. Review of the weekly scheduled Skilled Nurse visit notes revealed the LPN provided wound care the following weeks: Week of 07/24/2022 - no weekly assessment of the pressure ulcers by the RN. Week of 07/31/2022 - no weekly assessment of the pressure ulcers by the RN. Week of 08/07/2022 - no weekly assessment of the pressure ulcers by the RN. Week of 08/14/2022 - no weekly assessment of the pressure ulcers by the RN. Patient #16 Review of the clinical record for Patient #16 revealed the patient began receiving services with the provider on 05/14/2022. The patient had diagnoses which included Stage 2 Pressure Ulcer to Left Buttock. Review of the current Physician orders for Patient #16 revealed the following: Left Buttock: Cleanse with wound cleanser, pat dry with gauze, apply skin prep to periwound. Cover with bordered foam dressing. Wound care to be performed 1 time per week and as needed if soiled. Review of the weekly scheduled Skilled Nurse visit notes revealed the LPN provided wound care the following weeks: Week of 03/20/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 03/27/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 04/03/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 04/10/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 04/17/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 04/24/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 05/01/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 05/15/2022 - no weekly assessment of the pressure ulcer by the RN. Week of 05/22/2022 - no weekly assessment of the pressure ulcer by the RN. An interview was conducted on 08/19/2022 at 2:00 p.m. with S1DON. She verified pressure wounds should be assessed and measured by an RN at least weekly. She confirmed an RN had not assessed or measured Patient #11, #12 and #16’s wounds listed above weekly.

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 ensure the patient's written Plan of Care was followed as evidenced by the following: 1. Home Health Aide visits were not conducted as ordered for 1(#11) of 3(#8, #10 and #11) sampled patient records reviewed with orders for Home Health Aide services. 2. Weights were not obtained as ordered for 1(#11) of 2(#6 and #11) sampled patient records reviewed that had orders for obtaining weights with each home visit. Patient #11 Review of the Clinical Record revealed the patient had a SOC date of 07/14/2022. Patient #11 had diagnoses which included Acute Cystitis without Hematuria, Hypertensive Heart Disease with Heart Failure, Chronic Diastolic (Congestive) Heart Failure, and Stage 2 Pressure Ulcer of Sacrum. A review of the Plan of Care for the certification period of 07/14/2022 – 09/11/2022 revealed Orders and Treatments which included the following, in part; -Home Health Aide visits effective 07/17/2022: 1wk1, 2wk7. -Weights to be obtained daily. Weight gain of 2-3lbs overnight or 5lbs in 1 week to be reported to the physician. If unable to weigh patient, skilled nurse to obtain measurements of ankles at each visit and report increase in measurements to physician. Review of the Home Health Aide Visit Calendar for Patient #11 revealed missed visits for home health aide service on 07/22/2022, 07/28/2022, 08/02/2022, 08/04/2022, 08/09/2022 and 08/11/2022. Review of the Vital Signs Report for Patient #11 revealed a weight was obtained only on admit. Further review revealed no ankle measurements documented on the Vital Sign Report. An interview was conducted on 08/18/2022 at 12:00 p.m. with S1DON. She reviewed Patient #11 Clinical Record and confirmed Home Health Aide services were ordered for 1wk1, and 2wk7 effective 07/17/2022. She confirmed there were no Home Health Aide visits done for this certification period for Patient #11. She said she had problems staffing Home Health Aides. She said she was responsible for ensuring the agency was able to staff a Home Health Aide when ordered by the physician. She reviewed the Plan of Care for Patient #11 and confirmed the physician ordered for weight to be obtained with each visit. She reviewed the Vital Sign documentation and confirmed Patient #11 only had one weight obtained during the certification period. She said the Skilled Nurse should have obtained Patient #11’s weight with each visit.