Every finding on record at Excella Home Health Agency LLC

A Recertification survey was conducted at Encompass health Home Health located at 487 Holyoke St., Suite 1, Ludlow, MA., 01056, on November 21, 2025, November 25, 2025 and November 26, 2025, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Encompass Health Home Health located at 487 Holyoke St., Ludlow, MA., 01056, on November 21, 2025, November 25, 2025 and November 26, 2025, to determine compliance with the 42 CFR Part 484 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 2 patients (#15 and #16), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Transfer or Discharges From Services, undated, indicated the following: *The Agency will deliver the generic notice (a prescribed CMS notice) to the patient (or authorized representative), no less than two days prior to the end of the covered period. 1.Patient #15 was admitted to the agency in July 2025 with a diagnosis of Encounter for Surgical Aftercare Following Surgery on the Circulatory System. Review of the clinical record indicated the patient was discharged from the agency on 8/15/25. The clinical record did not contain any documentation that a NOMNC form had been provided to the patient prior to discharge, as required. 2. Patient #16 was admitted to the agency in in January 2025 with a diagnosis of Infection and Inflammatory Reaction due to an Indwelling Urethral Catheter (a thin, flexible tube that drains urine from the bladder). Review of the clinical record indicated the patient was discharged from the agency on 3/6/25. Review of a Client Coordination Note Report, dated 3/12/25, indicated a NOMNC form was not in the chart, as required. Review of the clinical record did not contain any documentation that a NOMNC form had been provided to the patient prior to discharge. During an interview on 11/26/25 at 11:00 A.M., the Director of Operations said there were no NOMNC forms provided to Patients #15 and #16 prior to discharge, as required.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to ensure infection control guidelines were maintained during the home visit observation of a urinary catheter change procedure for 1 patient (#4), out of a total sample of 7 home visits. Findings include: Review of the agency policy entitled, Indwelling Urinary Catheter (Foley) Insertion, Assigned Male at Birth, Home Care, reviewed 11/17/24, indicated the following: *Sterile technique and equipment are required when inserting an indwelling urinary catheter in the home to help prevent Community Associated Urinary Tract Infection (CAUTI). *Organize the equipment and supplies on a clean surface. Place a fluid impermeable pad between the environment and equipment, if needed. Patient #4 was admitted to the agency in June 2025 with a diagnosis of Encounter For Fitting And Adjustment of Urinary Device. During a home visit observation of a procedure for a urinary catheter change on 11/25/25 at 9:00 A.M., Nurse #1 set up the sterile field on the patient's bed. She disconnected the leg bag from the patient's catheter and placed it on a chair next to her. The chair did not have a fluid permeable pad on it. She then withdrew the fluid from the catheter balloon with a syringe and placed the syringe on the chair. She removed the catheter from the patient and wrapped it in her gloves, removed her gloves, and placed the gloves on the chair. During the procedure, she left the patient and went into the next room twice, once to obtain a new catheter and once to obtain a pair of disposable gloves. She did not have visual observation of the patient when she went into the next room to ensure the sterile field was maintained while she stepped away from the patient. During an interview on 11/25/25 at 9:45 A.M., Nurse #1 said she did not place a barrier pad on the chair prior to the procedure and did not have all her supplies prior to the start of the urinary catheter change procedure to ensure infection control safety measures were followed.

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, policy review and interview, the agency failed to ensure that physician ordered services were provided as indicated in the plan of care, for 5 Patients (#6, #11, #12, #14 and #8), out of a total sample of 17 patients. Findings include: 5. Patient #5 was admitted to the agency in October 2025 with a diagnosis of Multiple Sclerosis (a chronic disease that causes breakdown of the protective covering of nerves of the central nervous system and affects the brain and the spinal cord). Review of the physician ordered Home Health Certification and POC, dated 10/30/25 to 12/28/25, indicated the following: -PT visit: 1 time a week for one week, 2 times a week for 4 weeks, 1 time a week for 4 weeks. Review of the clinical record indicated the PT Aide (PTA) called out sick on 11/11/25 and there was no documentation to indicate the agency made an attempt to reschedule another PTA visit that week to ensure the patient was seen 2 times, as ordered. During an interview on 11/26/25 at 9:20 A.M., the Director of Operations said the agency did not make an attempt to reschedule the missed PTA visit and the POC was not followed, as required. Review of the agency's policy entitled General Branch Procedures, revised 2/12/25, indicated the following: *Physicians must always be notified of visits that are missed as they represent a failure to follow the patient's plan of care. *Clinicians must document the missed visit in a missed visit in a missed visit coordination note which includes contact with the patient prior to the missed visits, attempts to find an alternate caregiver and the reason for the missed visits. 1.Patient #6 was admitted to the agency in November 2025 with a diagnosis of hypertensive heart disease and chronic kidney disease and required home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 11/4/25 through 1/2/26, indicated the following: -Physical Therapy (PT) visit: 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 1 week. Review of the clinical record indicated only 1 PT visit was provided, not 2 as ordered, for the week of 11/16/25. Further review of the record indicated a missed PT note, dated 11/19/25, that indicated the patient was unable to be seen. The note did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. 2. Patient #11 was admitted to the agency in October 2025 with a diagnosis of Type 2 Diabetes (chronic condition where the body either does not use insulin properly, or does not produce enough insulin, leading to high blood sugar) with Diabetic Peripheral Angiopathy (damage in the large blood vessels caused by high blood sugar), and required home care services. Review of the physician ordered Home Health Certification and POC, dated 10/22/25 through 12/20/25, indicated the following: -PT visit: 1 time a week for 1 week, 2 times every 2 weeks for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 4 weeks. Review of a physician order, dated 10/29/25, indicated to remove visits for the week of 10/27/25 per patient request, and effective 10/26/25 PT visit, 2 times every 2 weeks for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 4 weeks. Review of the clinical record indicated no visits were provided the week of 10/27/25 as ordered, however only 1 PT visit was provided the week of, not 2 as ordered, for the week of 11/2/25. Further review of the record indicated a missed PT note, dated 11/9/25, for a missed visit on 11/7/25. The missed visit note did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. Review of the clinical record indicated a PT visit was not provided for the week of 11/9/25. Further review of the record indicated missed PT notes, both dated 11/17/25, for missed visits 11/14/25, and 11/15/25. The missed visit notes did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. 3. Patient #12 was admitted to the agency in November 2025 with a diagnosis of Chronic Obstructive Pulmonary Disease (a group lung diseases that cause airflow limitation and breathing difficulties), and required home care services. Review of the physician ordered Home Health Certification and POC, dated 11/2/25 through 12/31/25, indicated the following: -PT visit: 2 times a week for 6 weeks, and 1 time a week for 2 weeks. -Occupational Therapy (OT) visit: 2 times a week for 3 weeks, and 1 time a week for 2 weeks. Review of the clinical record indicated only 1 PT visit was provided, not 2 as ordered, for the week of 11/9/25. Further review of the record indicated a missed PT note, dated 11/12/25, that indicated the patient was unable to be seen. The note did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. Review of the clinical record indicated only 1 OT visit was provided, not 2 as ordered, for the week of 11/16/25. Further review of the record indicated a missed OT note, dated 11/20/25, for services not provided. The note did not indicate any attempt was made to find an alternative caregiver. 4. Patient #14 was admitted to the agency in January 2025 with a diagnosis of hemiplegia (paralysis on one side of the body) after cerebral infarction (bleeding in the brain), and required home care services. Review of the physician ordered Home Health Certification and POC, dated 3/4/25 through 5/2/25, indicated the following: -Speech Therapy (ST) visit: 1 time a week for 1 week, and 2 times a week for 8 weeks. Review of the clinical record indicated only 1 ST visit was provided, not 2 as ordered, for the week of 4/13/25. Further review of the record indicated a missed speech therapy (ST) note, dated 4/16/25, that indicated the patient was unable to be seen. The note did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. Review of the physician ordered Home Health Certification and Plan of Care, dated 5/3/25 through 7/1/25, indicated the following: -ST visit: 2 times a week for 1 week, and 1 time a week for 3 weeks. Review of the clinical record indicated no ST visit was provided for the week of 5/11/25. Further review of the record indicated a missed ST note, dated 5/13/25, that indicated the patient was unable to be seen. The note did not indicate any attempt was made to find an alternative caregiver or to reschedule the visit. During an interview on 11/26/25 at 10:30 A.M., after reviewing the records for Patients #6, #11, #12 and #14, the Director of Operations said that staff had not made attempts to reschedule their visits or find alternative staff to make the visits, as required.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure clinical documentation was 1.) complete and appropriately authenticated and dated in accordance with currently accepted standards for 3 patients (#2, #11 and #12), and 2.) physician's signatures on plans of care were obtained within 60 days for 2 patients (#4 and #10), out of a total sample of 17 patients. Findings include: 1. Review of the agency Standard Operating Procedure, Discipline-specific Documentation, reviewed 3/11/25, indicated the following: *For visits performed during normal business hours, visits should be completed and synched by 10:00 P.M. on the same day of service delivery. *For visits performed after normal business hours, visits should be completed and synched by 10:00 A.M. the following day. 1a. Patient #2 was admitted to the agency in September 2025 with a diagnosis of Stage 2 Pressure Ulcer of the Sacral Region (a shallow, open wound at the base of the spine that has broken through the top two layers of skin). Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 11/11/25 through 1/9/26 indicated the following: -Skilled Nurse (SN) visit: 2 times a week for 1 week, 3 times a week for 6 weeks, 2 times a week for 2 weeks. -Physical Therapy (PT) visit: 2 times a week for 8 weeks. Review of the clinical record indicated the following: *9/15/25 PT visit, note was completed on 9/17/25. *9/26/25 SN visit, note completed on 9/28/25. *11/6/25 SN visit, note completed on 11/10/25. 1b. Patient #11 was admitted to the agency in October 2025 with a diagnosis of Type 2 Diabetes (chronic condition where the body either does not use insulin properly, or does not produce enough insulin, leading to high blood sugar) with Diabetic Peripheral Angiopathy (damage in the large blood vessels caused by high blood sugar), and required home care services. Review of the physician ordered Home Health Certification and POC, dated 10/22/25 through 12/20/25, indicated the following: -PT visit: 1 time a week for 1 week, 2 times every 2 weeks for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 4 weeks. Review of the clinical record indicated the following: *11/20/25 PT visit, note was signed as completed on 11/23/25. 1c. Patient #12 was admitted to the agency in November 2025 with a diagnosis of Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause airflow limitation and breathing difficulties) and required home care services. Review of the physician ordered Home Health Certification and POC, dated 11/2/25 through 12/31/25, indicated the following: -PT visit: 2 times a week for 6 weeks, and 1 time a week for 2 weeks. Review of the clinical record indicated the following: *11/3/25 PT visit, note was signed as completed on 11/5/25. During an interview on 11/26/25 at 10:30 A.M., the Director of Operations said that staff are required to complete their notes within 24 hours of the visit. She said the documentation noted above was not completed timely, as required. 2. Review of the agency policy entitled, Clinical Record, undated, indicated the following: *The Agency obtains the physician's signature on POCs within 60 days and verbal orders within 30 days from the effective date of the order. 2a. Patient #4 was admitted to the agency in June 2025 with a diagnosis of Encounter for Fitting and Adjustment of Urinary Device. Review of the clinical record indicated a physician ordered Home Health Certification and POC for certification period, dated 8/18/25 through 10/16/25, was signed on 10/19/25, beyond the 60 days requirement. 2b. Patient #10 was admitted to the agency in September 2025 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition where the body either does not use insulin properly or does not produce enough insulin, leading to high blood sugar) with foot ulcer. Review of the clinical record indicated an unsigned and undated physician ordered Home Health Certification and POC for certification period dated 9/22/25 through 11/20/25. During an interview on 11/26/25 at 8:15 A.M., after reviewing the clinical records, the Director of Operations said the Home Health Certification and POC for Patient #4 was signed late by the physician. She further said the Home Health Certification and POC for Patient #10 has not yet been signed by the physician, as required.

A Recertification survey was conducted at Enhabit Home Health on 11/8/22, 11/9/22, 11/10/22 and 11/15/22 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Enhabit Home Health on 11/8/22, 11/9/22, 11/10/22 and 11/15/22 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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 record review and interview, the Agency failed to ensure its staff conformed with the Physician's orders for four Patients (#1, #4, #6 and #15) out of a total sample of 17 Patients. Specifically, for Patients #1, #4 and #15, the Agency failed to ensure its staff provided rehabilitative therapy services as ordered, and for Patient #6, the Agency failed to ensure a nurse administered a medication as ordered. Findings include: 3. For Patient #15, the Agency failed to ensure the staff followed the plan of care relative to a Physical Therapist (PT) visit. Patient #15 was admitted to the Agency in September 2022 with diagnoses including Stage III Pressure Ulcer (an open area that extends into the tissue beneath the skin) to the left buttock and Anorexia (an eating disorder characterized by weight and appetite loss). Review of the Physician's Order for certification period 9/27/22 through 11/25/22 indicated PT visit for one time a week for one week, two times a week for two weeks and one time a week for one week. Review of the clinical record indicated one PT visit was provided for the week of 10/2/22-10/8/22 and not two as ordered. During an interview on 11/15/22 at 1:00 P.M., the Administrator said the plan of care was not followed as only one PT visit occurred during the week of 10/2/22-10/8/22 and not two, as ordered. 5. For Patient #6, the Agency staff failed to administer a monthly injectable medication. Patient #6 was admitted to the Agency in January 2022 with a diagnosis of Progressive Supranuclear Opthalmoplegia (a neurological disease that gradually destroys nerve cells in the brain that control eye movements, breathing and muscle coordination). Review of the certification period 7/11/22 through 9/8/22 indicated a Physician Order for Cyanocobalamin (a form of Vitamin B-12) 1000 micrograms (mg)/milliliter (ml) injection solution. The Skilled Nurse for administration of Vitamin B-12 injection monthly, as ordered. Review of the Agency policy titled, Medications, undated, indicated but not limited to: -Nurses administer medications only as prescribed by the physician for the accepted purpose. Review of the Skilled Nurse visit note, dated 8/18/22, indicated the Vitamin B-12 injection was not administered due to unavailability. Further review of the clinical record did not include documentation that the medication was administered in August 2022. During an interview on 11/15/22 at 1:30 P.M., the Administrator said the plan of care for the administration of Vitamin B-12 injection was not followed in August 2022, as ordered. 1. Patient #1 was admitted to the agency in April 2022 with diagnoses including Diabetes Mellitus (a disease that affects how the body processes blood sugar) and sepsis (infection) due to Escherichia Coli (bacteria). Review of the Physician's order for certification period, 6/2/22 through 7/31/22, indicated the following; Occupational Therapy (OT) once a week for one week, OT twice a week for three weeks and OT once a week for three weeks. Review of the clinical record indicated that for the week of 6/5/22-6/11/22, Patient #1 had received an OT visit on 6/10/22 only, and not twice that week as ordered. During an interview on 11/15/22 at 9:45 A.M., the Administrator said, after reviewing the clinical record and the agency's Missed Visit Report (5/7/22 through 7/9/22), that Patient #1 had not received OT visits twice a week as ordered for the week of 6/5/22-6/11/22. She said the plan of care was not followed as ordered and an OT visit was missed on 6/7/22. 2. Patient #4 was admitted to the agency in February 2022 with diagnoses including urinary tract infection and Alzheimer's disease. Review of the Physician's order for certification period, 4/22/22 through 6/20/22, indicated the following; OT once a week for one week, OT twice a week for two weeks and OT once a week for four weeks. Review of the clinical record incidated that for the week of 6/5/22-6/11/22, Patient #4 had not received any OT visits as ordered. Review of the Physician's order for certification period 6/21/22 through 8/16/22, indicated the following; OT twice a week for two weeks and once a week for four weeks. Additionally, an updated Physician's order, dated 7/24/22, indicated the following; OT once a week for three weeks. Review of the clinical record indicated that for the week of 8/7/22-8/13/22, Patient #4 had not received any OT visits as ordered. During an interrview on 11/15/22 at 9:45 A.M., the Administrator said, after reviewing the agency's Missed Visit Report (5/7/22 through 7/9/22) and the clinical record, that Patient #4 had not received once weekly OT visits as ordered by the Physician for the week of 6/5/22-6/11/22 and 8/7/22-8/13/22.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff notified the Physician when there was a change in the plan of care for two Patient's (#4 and #6) out of a total sample of 17 Patients. Specifically, for Patient #4, the Agency staff failed to notify the Physician of a missed Occupation Therapy visit, and for Patient #6, the Agency staff failed notify the Physician of a missed medication administration. Findings include: 2. For Patient #6, the Agency staff failed to notify the physician of an ordered medication that was not administered. Patient #6 was admitted to the Agency in January 2022 with a diagnosis of Progressive Supranuclear Opthalmoplegia (a neurological disease that gradually destroys nerve cells in the brain that control eye movements, breathing and muscle coordination). Review of the Agency policy titled Medications, undated, indicated but not limited to: - All medication errors, significant adverse drug reactions and potential drug adverse events are reported and documented. Review of the certification period 7/11/22 through 9/8/22 indicated a Physician Order for Cyanocobalamin (a form of Vitamin B-12) 1000 micrograms (mg)/milliliter (ml) injection solution. The Skilled Nurse for administration of Vitamin B-12 injection monthly, as ordered. Review of the Skilled Nurse visit note, dated 8/18/22, indicated the Vitamin B-12 injection was not administered due to unavailability. Further review of the clinical record did not contain any documentation that the physician was notified of the unavailability and missed administration of the injection in August 2022. During an interview on 11/15/22 at 1:30 P.M., the Administrator said the clinical record did not contain any evidence that the Physician had been notified of the August 2022 missed dose of the Vitamin B-12 injection, as required. Review of the agency's General Branch Procedure: Physician Notification Policy, dated 5/23/22, indicated the following: -Physicians must always be notified of visits that are missed as they represent a failure to follow the patient's plan of care. -Clinicians must document the missed visit in a missed visit coordination note which includes: contact with the patient prior to the the missed visits, attempts to find an alternate caregiver and the reason for the missed visit. 1. Patient #4 was admitted to the Agency in February 2022 with diagnoses including urinary tract infection and Alzheimer's disease. Review of the Physician's order for certification period 6/21/22 through 8/16/22, indicated the following; OT twice a week for two weeks and once a week for four weeks. Additionally, an updated Physician's order, dated 7/24/22, indicated the following; OT once a week for three weeks. Review of the clinical record indicated that for the week of 8/7/22-8/13/22, Patient #4 had not received any OT visits as ordered. During an interview on 11/15/22 at 9:45 A.M., the Administrator said, after reviewing the clinical record, that Patient #4 had not received an OT visit for the week of 8/7/22-8/13/22 as ordered and there was no clinical documentation that indicated a missed visit and why it was missed. She also said there was no documentation that indicated the Physician had been notified of the missed OT visit as ordered.