Every finding on record at Excela Health Home Care & Hospice

Based on the findings of an unannounced Complaint investigation survey conducted on August 13, 2025, Excela Home Health Care and Hospice, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical record (CR), and staff (EMP) interview, it was determined the agency failed to follow physician orders for one (1) of four (4) CR's reviewed. (CR1) Findings Included: Review of CR1 on August13, 2025 at approximately 11:20am revealed a start of service (S0S) date of 6/26/25. The certification period reviewed was 6/26/25-8/24/25. Plan of care (POC) included intervention: ..."Apply tubi grip size G to bilateral lower legs from distal knees to tips of toes. On first thing on rising, off at bedtime. Elevate legs while at rest. Start Date: 6/26/25." Clinical visit note written by nurse dated 8/1/25, documented "...using ace wraps at this time..." Verbal order for ace wraps not obtained until 8/2/25." Clinical notes dated 7/7/25 and 7/11/25 included documentation that read, "...wound cleansing/dressing change. No documentation of wound care or dressing changes ordered at this time. No documentation included to describe wound care or dressing change. Findings confirmed during exit conference on August 13, 2025, at approximately 3:30pm with Director of Patient Care Services, Director of Quality and Transitional Care, Clinical Manager of Home Health, and Vice President of Post Acute Services and Ambulatory Strategy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of agency policy, clinical record (CR), and staff (EMP) interview, it was determined the agency failed to promptly alert physician of relevant changes in patient condition for one (1) of four (4) CR's reviewed. (CR1) Findings Included: Agency policy titled "Coordination of Services" reviewed on 8/13/25, at approximately 2:00pm revealed: I. Objective, 1. To assure cooperative care planning and continuity of patient care...II. Policy Statement... The agency must also communicate with all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient..." Review of CR1 on August13, 2025 at approximately 11:20am revealed a start of service (S0S) date of 6/26/25. The certification period reviewed was 6/26/25-8/24/25. Initial comprehensive assessment dated 8/26/25, documented, "...Instructed patient and mother no visible wounds on feet and or lower legs. Both requested skilled nurse (SN) look again-SN assessed bilateral feet and lower legs 3 times no open areas noted..." Narrative note at next visit, dated 7/2/25 documentation read, "...several areas of redness with apparent ulceration to bilateral legs. No documentation that physician was notified of the change in patient condition. Findings confirmed during exit conference on August 13, 2025, at approximately 3:30pm with Director of Patient Care Services, Director of Quality and Transitional Care, Clinical Manager of Home Health, and Vice President of Post Acute Services and Ambulatory Strategy.

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on November 4, 2022, Excela Health Home Care and Hospice, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies-Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Recertification and State Re-Licensure survey completed on November 4, 2022, Excela Health Home Care and Hospice, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of policy and procedure, clinical records (CR), and staff (EMP) interview, it was determined the agency failed to ensure clinicians conduct a review of all medications the patient is currently using for one (1) of six (6) observations conducted in the home. (OBS 1/CR 11). Findings included: Review of policy on 11/4/2022 at approximately 3:45pm revealed: “…Medication Administration…III. Guidelines…2. The patient’s medication regimen is determined and reconciled on admission (i.e., utilizing medication reconciliation form/discharge instruction, physician orders, and hm medications and over the counter medications reviewed each visit by the skilled professional and revised as indicated) …” OBS 1 of skilled nurse wound care visit conducted 11/1/2022 at approximately 8:30am: Surveyor compared current medication list to bottles in patient’s home with patient permission. Surveyor noted a bottle of One a Day Vitacraves Women’s Daily Gummy Vitamins with pill bottles. Surveyor inquired with patient if these were currently included in medication regimen. Patient confirmed taking 2 a day for “a long time now.” Daily Vitamins not on patient medication list. Current medication list included Prosource liquid 30cc by mouth daily. Patient reports not taking this for a long time. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of procedure, clinical records (CR), and staff (EMP) interview, it was determined the agency failed to consult the signing physician for orders/modification to a plan of care (POC) that could not be completed for one (1) of seventeen (17) CR reviewed. (CR 4) Findings included: Review of procedure on 11/4/2022 at approximately 3:45pm revealed: “…Coordination of Services…II. Policy Statement…The agency must also communicate with all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient…” “…Physician Orders/Plan of Treatment… II. Guidelines…3. Plan of Care (485): …H. The home health agency will alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered…” Review of CR 4 on 11/4/2022 at 11:05am revealed start of service (SOS) 9/17/2022. Dates reviewed 9/17/2022-11/4/2022. CR revealed documentation of refusal of patient/wife to allow nurse to perform wound care or visualize wounds on 9/17/2022, 9/21/2022, and 9/28/2022. Documentation revealed wife refused nursing visits on 9/20/2022 and 9/22/2022. Documentation of patient refusal to allow nurse to collect ordered urine specimen on 9/28/2022. No evidence of nurse communication with physician regarding missed visits or refusal of treatment which could result in clinical impact on the patient to obtain modifications/order to POC. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

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 review of policy and procedure, observation of home visits (OBS), clinical records (CR), and staff (EMP) interview, it was determined the agency failed to ensure the Plan of Care (POC) contained supplies and equipment required for eight (8) of seventeen (17) CRs reviewed (CR1-3, 6, 10, 11, 13, & 16). Agency also failed to ensure POC included orders for one (1) of seventeen (17) CR reviewed. (CR 5) Findings included: Review of policy on 11/4/2022 at approximately 3:45pm revealed: “…Physician Orders/Plan of Treatment…II. Guidelines…3. Plan of Care (485): …D. The plan of care developed includes: …3. Types of services, supplies and equipment required…” Review of CR 1 on 11/2/2022 at 2:00pm revealed start of service (SOS) 10/20/2022. Dates reviewed 10/20/2022-11/2/2022. Plan of Care (POC) included a diagnosis of Diabetes, diabetic interventions, and insulin to be administered based on blood glucose results. Diabetic supplies not included on POC. Review of C 2 on 11/3/2022 at 9:15am revealed start of service (SOS) 10/27/2022. Dates reviewed 10/27/2022-11/3/2022. POC included orders to wear Ted Hose (compression stockings). Ted Hose not included on POC. Review of C 3 on 11/3/2022 at 10:15am revealed start of service (SOS) 10/5/2022. Dates reviewed 10/5/2022-10/31/2022. POC included Oxygen to be used as needed for shortness of breath. Oxygen supplies not included on POC. Review of C 5 on 11/3/2022 at 10:55am revealed SOS 10/11/2022. Dates reviewed 10/11/2022-11/3/2022. POC revealed primary diagnosis of stage 4 pressure ulcer of the sacral region. POC failed to include orders for wound care to sacral region until resumption of care on 10/29/2022. Review of C 6 on 11/3/2022 at 12:15pm revealed start of service (SOS) 1/22/2022. Dates reviewed 1/22/2022-2/13/2022. POC revealed orders for wound care. Wound supplies not included on POC. Review of C 10 on 11/3/2022 at 9:00am revealed start of service (SOS) 7/7/2022. Dates reviewed 7/7/2022-7/20/2022. POC included orders for Ted Hose and CPM (continuous passive motion) machine. Ted Hose and CPM not included on POC. Review of C 13 on 11/4/2022 at 2:00pm revealed start of service (SOS) 10/27/2022. Dates reviewed 10/27/2022-11/1/2022. POC included orders to wear Ted Hose. Ted Hose not included on POC. Review of C 16 on 11/4/2022 at 2:10pm revealed start of service (SOS) 10/15/2022. Dates reviewed 10/15/2022-11/1/2022. POC revealed orders for IV (intravenous)antibiotics and midline management. IV supplies not included on POC. OBS 1 of skilled nurse wound care visit with CR 11 conducted 11/1/2022 at approximately 8:30am and review of POC at this time revealed patient wears right lower leg prosthesis daily. Prosthesis not included on POC. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of procedure, clinical records (CR), and staff (EMP) interview, it was determined the agency failed to ensure interventions were performed per physician order for one (1) of seventeen (17) CR reviewed. (CR 6) Findings included: Review of procedure on 11/4/2022 at approximately 3:45pm revealed: “…Performance of Lab Tests…II. Policy Statement It is the policy of Excela Health Home Care and Hospice that labs specimens will be collected according to physician orders…” Review of C 6 on 11/3/2022 at 10:15am revealed SOS 1/22/2022. Dates reviewed 1/22/2022-2/13/2022. 1/25/2022 visit contained evidence that nurse attempted to obtain labs x2. No order in CR for labs to be drawn this date. Plan of Care (POC) contained order for blood work (CMP, CBC/diff, platelets, Alpha-fetoprotein, and tumor markers) to be drawn on 1/27/2022. No evidence of visit or lab draw that day. 1/28/2022 visit revealed nurse drew CMP, CBC, platelets, Alpha-fetoprotein, tumor markers, Liver function (Ammonia), LDH, TSH, T4, and FREE T4. No order for labs to be obtained at this visit. Physician order written 1/31/2022 for Ammonia level and Alpha-fetoprotein to be obtained at 1/31/2022 visit. Nurse documentation revealed that CMP, CBC, Liver function, LDL, and TSH were drawn at visit also. No order for additional labs to be obtained 1/31/2022. POC contained order for blood work (Liver function (Ammonia), tumor markers (Alpha-fetoprotein), CMP, CBC/diff, platelets, LDH, and thyroid labs (TSH, T4, and FREE T4) to be drawn on 2/1/2022. No evidence of labs drawn at that visit. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of procedure, clinical records (CR), home visit observation (OBS), and staff (EMP) interview, it was determined the agency failed to ensure clinical procedures carried out per agency protocol to ensure infection control/prevention for one (1) of two (2) OBS of clinical procedures conducted (OBS 6). Findings included: Review of procedure on 11/4/2022 at approximately 3:45pm revealed: “…Midline Procedures…Midline Removal…CONTENTS: …5. Cleanse site with chlorhexidine prep swab or alcohol swab…” OBS 6 (CR 16) of midline removal and agency discharge on 11/1/2022 at 11:00am revealed skilled nurse failed to perform cleansing of midline site with chlorhexidine prep swab or alcohol swab after removing dressing and prior to removing midline catheter. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

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 review of policy and procedure, clinical records (CR), and staff (EMP) interview, it was determined the agency failed to assess and document wounds per agency policy for three (3) of three (3) CR reviewed that included non-surgical wound care. (CR 4, 5, & 6) Findings included: Review of policy on 11/4/2022 at approximately 3:45pm revealed: “…Wound Management…III. Guidelines…2. Complete wound assessment at initial visit, and document in wound addendum at start of care and each subsequent visit of the week. 3. Wound measurements will be obtained weekly by the primary discipline at the first visit of the week. Measurements will be recorded in the wound addendum…” Review of CR 4 on 11/4/2022 at 11:05am revealed start of service (SOS) 9/17/2022. Dates reviewed 9/17/2022-11/4/2022. Referral and initial comprehensive assessment revealed patient had multiple wounds, including wound on scrotum. Wound addendum failed to include measurements/assessment of scrotal wound on 9/28/2022 when wife/patient let nurse observe wound care. Review of C 5 on 11/3/2022 at 10:55am revealed SOS 10/11/2022. Dates reviewed 10/11/2022-11/3/2022. POC revealed primary diagnosis of stage 4 pressure ulcer of the sacral region. No documentation of wound measurement/assessment on 10/11/2022 or 10/17/2022, both being the first visit of each week. Review of C 6 on 11/3/2022 at 10:15am revealed SOS 1/22/2022. Dates reviewed 1/22/2022-2/13/2022. Comprehensive assessment revealed patient had wound on lower left leg. No wound measurements/assessment documented the week of 1/23/2022 or the week of 1/30/2022. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.

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 review of policy and procedure, clinical records (CR), and staff (EMP) interview, it was determined the agency failed to provide all services ordered by the physician as stated in the Plan of Care (POC) for one (1) of ten (10) CR reviewed that included orders for ancillary services. (CR 7) Findings included: Review of policy on 11/4/2022 at approximately 3:45pm revealed: “…Comprehensive Assessment/Reassessment…I. Objective…2. To ensure appropriate and timely services, assessments, and reassessments of patient’s needs and care delivery, and/or referrals to alternative care providers…III. Guidelines…3…a) Physical therapy, occupational therapy, and speech therapy may have up to four (4) business days to complete their evaluation visit…” Review of CR 7 on 11/4/2022 at 9:35am revealed start of service (SOS) 7/8/2022. Dates reviewed 7/8/2022-7/23/2022. Plan of Care (POC) included order for occupational therapy (OT) and speech therapy (ST) evaluations to be conducted the week of 7/10/2022. CR failed to include evidence that either evaluation was conducted or documentation to reflect reason for disciplines failing to assess patient. Exit interview with Vice President, Director of Transitional Care & Quality, and clinical management team on 11/4/2022 at approximately 4:00pm confirmed the above findings.