Every finding on record at Excell Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/15/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 01/15/26. Standard level deficiencies were cited. Abbreviations: Pt./Pts. = Patient/Patients HHA = Home Health Aide PT = Physical Therapy SOC = Start of Care RN = Registered Nurse AM = Morning PM = Afternoon SN = Skilled Nursing OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and staff interview, it was determined that in 20 of 133 reports submitted for the last 12 months, the Agency failed to submit the report within 30 days after the assessment was completed resulting in a warning. Findings include: 1. The OASIS Error Summary report for 10/01/24 to 12/19/25 was reviewed on 01/13/26. The report included a warning for the error: 20 of the 133 assessments were submitted late; 15.04 % of the OASIS reports were submitted more than 30 days after the assessment was completed. 2. During staff an interview with the Agency Supervisor, on 01/14/26 at 2:30 PM, the above findings were confirmed.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy and staff interviews, for 6 of 7 (Pts. #1, 2, 3, 4, 5 and 7) clinical record reviews, the Agency failed to ensure that services were provided in accordance with accepted standards of practice. Findings include: 1. The following documents, “Lippincott Manual”, and journals from the National Library of Medicine of the National Institute of Health, “Vital Signs Assessment” and “Nursing Fundamentals” were reviewed on 01/15/26 and included documentation: "Normal Ranges: Temperature Range: 97.9 F to 99.5 F (Fahrenheit) Heart Rate/Pulse: 60 to 100 bpm (beats per minute) Respiratory Rate: 12 to 20 (cycles per minute) Systolic Blood Pressure: 120 to 140 (millimeters of Mercury/mmHg) Diastolic Blood Pressure: 80 to 90 (mmHg) Oxygen: 94 to 98 %" 2. The following clinical records were reviewed 01/13/26: Pt. #1 - SOC 12/30/25. Pt. #2 – SOC 10/08/25. Pt. #3 – SOC 12/01/25. Pt. #4 - SOC 08/01/25. Pt. #5 – SOC 09/09/25. Pt. #7 – SOC 06/06/25. The above-mentioned clinical records included a POC that required the following: “Orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range: Heart Rate: greater than 100 bpm, less than 60 bpm Temperature: greater than 102 F, less than 70 F Respiratory Rate: greater than 30, less than 15/minute Pain Level: greater than 10/10 Oxygen saturation: less than 80 % Systolic Blood Pressure: greater than 200 mmHg, less than 60 mmHg Diastolic Blood Pressure: greater than 100 mmHg, less than 50 mmHg 3. The Agency policy “Skilled Nursing Scope of Services” was reviewed and required, “3. Skilled nursing services will be carried out in accordance with accepted standards of practice of professional associations as well as any regulatory bodies impacting presently or in the future on the practice of skilled nursing…” 4. During an interview conducted with the Agency Supervisor on 01/14/25 from 2:00 PM and 3:00 PM, it was confirmed that the vital signs parameters are to be based on accepted standards of practice and Agency policy. During the same interview, the above findings were confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy and staff interview, for 3 of 7 (Pts. #4, 5, 6) clinical records reviewed, the Agency failed to ensure the clinical record was complete. Findings include: 1. Pt. # 4 was admitted for home health services on 08/01/25 with a diagnosis of Type 2 diabetes mellitus. The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 11/20/25, 12/19/25, 12/26/25 and 01/02/26 have not been incorporated in the clinical record. 2. Pt. #5 was admitted for home health services on 09/09/25 with a diagnosis of Type 2 diabetes mellitus with other circulatory complication. The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 12/26/25 and 12/31/25 have not been incorporated in the clinical record. 3. Pt. #6 was admitted for home health services on 05/12/25 with a diagnosis of Type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, affecting both eyes (bilateral). The clinical record was reviewed on 01/13/26. As of the date of clinical record review, the nursing visit notes for the following dates 11/26/25, 12/10/25 and 01/02/26 have not been incorporated in the clinical record. 4. The Agency policy titled “Clinical Documentation” was reviewed on 01/15/26 and required, “8. Required documentation for each service provided must be completed on the day of service is rendered and filed in the clinical record within seven (7) days… When a client is discharged from care, clinical record shall be completed…within 14 days.” 5. During an interview conducted with the Agency Supervisor on 01/14/26 at 2:00 PM, the above findings were confirmed.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation and interviews during a home visit, clinical record review and staff interview, for 6 of 7 (Pts. #1, 4, 5, 6, 2 and 3) clinical records reviewed, the Agency failed to ensure the clinical record included all interventions, services and patient responses. 5. Pt. #2 was admitted for home health services on 10/08/25 with the diagnosis of Bilateral primary osteoarthritis of knee. The clinical record was reviewed on 01/13/26. The record included the following SN visits: 12/10/25, 12/17/25, 12/26/25, and 12/31/25, completed by the RN for the certification period of 12/07/25 to 02/04/26 that lacked the visit narratives. 6. Pt. #3 was admitted for home health services on 12/01/25 with the diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. The clinical record was reviewed on 01/13/26. The record included the following SN visits: 12/03/25, 12/05/25, 12/10/25, 12/17/25, 12/29/25, and 01/07/26, completed by the RN for the certification period of 12/01/25 to 01/29/26 that lacked the visit narratives. 7. During staff interview with the Agency Supervisor on 01/14/26 at 2:00 PM, and 3:00 PM, the Agency Supervisor confirmed the above findings. Findings include: 1. Pt. #1 was admitted for home health services on 12/30/25 with the diagnosis of Type 2 Diabetes Mellitus with diabetic neuropathy. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 01/02/26 and 01/07/26 which lacked documentation of any Pt. education/interventions implemented during the visit. 2. Pt. #4 was admitted for home health services on 08/01/25 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training notes dated 12/05/25 and 12/12/25 which lacked documentation of any Pt. education/interventions implemented during the visit. 3. Pt. #5 was admitted for home health services on 09/09/25 with the diagnosis of Type 2 Diabetes Mellitus with other circulatory complications. The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 12/10/25 and 12/17/25 which lacked documentation of any Pt. education/interventions implemented during visit. 4. Pt. #6 was admitted for home health services on 05/012/25 with the diagnosis of Type 2 Diabetes Mellitus with mild non-proliferative diabetic retinopathy without macular edema, affecting both eyes (bilateral). The clinical record was reviewed on 01/13/26. The record included the SN Teaching/Training Visit notes dated 11/13/25 and 01/02/26 which lacked documentation of any Pt. education/interventions implemented during the visit.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, for 1 of 2(Pts. #7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. 1. Pt. #7 was admitted for home health services on 06/06/25 with the diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. The clinical record was reviewed on 01/13/26. The record included the discharge summary completed by the SN dated 12/01/25. The record lacked documentation that a copy of the summary was sent to the Physician. 2. During staff interview with the Agency Supervisor on 01/14/26 at 2:00 PM, and 3:00 PM, the Agency Supervisor confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: POC = Plan of care SOC = Start of care AM = morning PM = afternoon SN = Skilled Nurse RN = Registered Nurse # = number

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 2 of 4 (Pts. #4 and 1) clinical records reviewed. 2. Pt. # 1 SOC 6/4/22. Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 10/17/22 at 11:45 AM. The record included a "Patient Profile," which listed the referral date of 5/9/22. The SOC Comprehensive SN assessment was completed 6/4/22. The Start of Care was conducted 26 days after the referral date. As of 10/20/22, the record lacked documentation the Agency started service within the required time frame. 3. During an interview with the RN (Owner) and Agency Supervisor on 10/19/22 at 10:30 AM and 11:30 AM, the RN confirmed the Agency failed to conduct the initial assessment visit within 48 hours of the referral date, and/or ensure a referral was received to initiate service. Findings include: 1. Pt. #4. SOC 5/3/22. Principal Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/18/22 at 12:30 PM. The record contained the form titled, "Patient Profile" which included the referral date of 4/23/22. The record also contained the form titled, "Face to Face Encounter” forms which included documentation of a physician visit dated 4/23/22 and required SN visits. This form was faxed from the physician's office to the Agency on 4/27/22. The Initial comprehensive assessment was conducted by the RN on 5/3/22, which was 10 days after the physician encounter. The record lacked documentation of a physician order SOC date. The record lacked documentation the Agency started care/services within 48 hours of the referral date.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to assess and document patients' Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. This was found in 2 of 4 (Pts. #3 and 4) clinical records reviewed. Findings include: 1. Pt. #3. SOC 5/9/22. Principal Diagnosis: Type 2 Diabetes with Diabetic Autonomic Poly Neuropathy. The clinical record was reviewed on 10/18/22 at 11:30 AM. The record contained a form “Vaccine Verification” dated 5/9/22. The "Vaccine Verification" form and the SOC comprehensive assessment document lacked information on influenza and pneumonia status of Pt. #3. 2. Pt. #4. SOC 5/3/22. Principal Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/18/22 at 12:30 PM. The record contained a form “Vaccine Verification” dated 5/3/23. The "Vaccine Verification" form and the SOC comprehensive assessment document lacked information on influenza status of Pt. #4. 3. The Agency Policy “Influenza Vaccines” which was reviewed on 10/19/22 at 11:30 AM, required: (Agency) will annually administer or arrange for administration of a vaccination against influenza to each client/Pt. in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, unless the vaccination is medically contraindicated, or the Pt. has refused the vaccine… (Agency) home health staff will document the following in the individual Pt. record: Date of offer or referral, Date of Administration, Pt. response or outcome, Pt. contraindication if indicated, Pt. refusal, Any follow up activities…a standard check-off form recording Pt. specific information, including the assessment for the need off vaccination, date of offer, or referral, Pt. response, administration, contraindication or refusal and any follow-up activities.” 4. The Agency Policy “Standing orders for Administering Pneumococcal Vaccines to Adults” which was reviewed on 10/19/22 at 10:00 AM required: “Policy: …to assess the need for vaccination and to vaccinate adults who meet…criteria…Document each patient’s vaccine administration information and follow up in the following places: Medical record: Document the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine…if vaccine was not administered, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, Pt. refusal).” 5. During the entrance interview with the Owner/RN and Agency Supervisor on 10/17/22 at 10:45 AM, it was stated that the influenza and pneumonia vaccination status are assessed during the SOC and is documented on the form titled "Vaccine Verification" and also on the SOC comprehensive assessment. During an interview with the Owner/RN and Agency Supervisor on 10/19/22 at 10:30 AM, the above findings were confirmed.

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: A. Based on clinical records review and staff interview it was determined the Agency failed to ensure that staff provided services indicated in the plan of care. This was found in 3 of 4 clinical records reviewed (Pt. #2, 3, and 4). 2. Pt. #3. SOC: 5/9/22. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Autonomic Polyneuropathy. The clinical record was reviewed on 10/18/22 at 11:30 AM. The record included a POC for the certification period of 5/9/22 to 7/7/22 which required to provide skilled services: SN 1 time for 9 weeks. The record lacked an SN visit for the week of 6/27/22 to 7/3/22 and lacked documentation of why the SN visit was missed. 3. Pt. #4. SOC: 5/3/22. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 10/18/22 at 12:30 PM. The record included a POC for the certification period of 7/2/22 to 8/30/22 which required to provide skilled services: SN 1 time for 9 weeks, and, also included a physician order to discharge Pt. from home health services on 7/27/22. The record lacked SN visits for the weeks of 7/4/22 to 7/10/22, 7/11/22 to 7/17/22 and 7/18/22 to 7/24/22 and lacked documentation of why the SN visits were missed. 4. The Agency Policy “Missed Visit Policy and Procedure” which was reviewed on 10/19/22 at 1:00 PM required: “It is the policy of the (Agency) that in the event of missed visit, the primary care physician must immediately be notified by the nurse and indicate the reason for missed visit. Procedure: 1. Complete documentation of the missed visit that include the reason for the missed visit. 2. Primary care physician must be notified by the visiting nurse immediately. 3. Obtain signed telephone order of the missed visit from the primary care physician. 4. File the completed documentation of the missed visit as well as the signed telephone order from the primary care physician on the Pt. medical record.” 5. During an interview with the Owner/RN and Agency Supervisor on 10/19/22 at 10:30 AM and 11:30 AM, the above findings were confirmed. Findings include: 1. Pt. # 2 SOC 5/3/22. Diagnosis: Poly-osteoarthritis. The clinical record was reviewed on 10/17/22 at 10:45 AM. The record included a POC for certification period 5/3/22 to 7/1/22 that required (PT) Physical Therapy visit frequency of 1 time a week for 8 weeks. The record lacked documentation Physical Therapy services were provided for this certification period. No modification orders were found in the record for this certification period, or documentation as to why therapy services were missed. The record also included a POC for re-certification period 7/2/22 to 8/30/22 that required (SN) Skilled Nursing visit frequency of 1 time a week for 9 weeks. The record lacked documentation SN services were provided the weeks of 7/4/22 to 7/10/22 and 7/11 to 7/17/22. The record lacked documentation SN services were provided these dates. No modification orders were found in the record for this certification period, or as to why the nursing services were missed. Pt. was discharged on 7/27/22.