Every finding on record at Genesis Health at Home LLC

A Relicensure Survey was conducted on 01/20/2026. The census was 35 (L&CHHS), 0 (LHHS), 0 (PAS). The agency is in compliance with no deficiencies cited.

A Recertification Survey was conducted on 01/20/2026. The census was 35 (L&CHHS), 0 (LHHS), 0 (PAS) Abbreviations: L&CHHS- Licensed and Certified Home Health Services LHHS- Licensed Home Health Services PAS- Personal Assistance Services AA- Alternate Administrator RN- Registered Nurse SN- Skilled Nurse Pt- patient PRN- as needed EMR- electronic medical record

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 record review and interviews, the agency failed to ensure clinical records included documentation of clinical notes for 1 of 7 patients (Patient #4) for which records were reviewed. The clinical record for Patient #4 did not include documentation of skilled nurse visits scheduled on 12/04/2025, 12/12/2025, 12/16/2025, 12/19/2025, 01/06/2026, 01/13/2026 and 01/15/2026. Failure to ensure patient records were completely and accurately documented, organized and readily accessible, caused valuable patient information to not be available to all staff members who provided care to Patient #4. This places patients at risk of receiving inadequate care and services. Findings Included: Review of the clinical record for Patient #4 revealed a start of care date of 06/02/2025 with a diagnosis of noncancerous cells. Review of the plan of care for the time period 11/29/2025-01/17/2026 revealed orders: SN: SN effective 11/200(29)/25 2W8 (2 times per week for 8 weeks), 1W1 (1 time per week for 1 week), 3 PRN wound care complications. Review of the clinical record revealed skilled nurse visit notes were not documented for scheduled visits on 12/04/2025, 12/12/2025, 12/16/2025, 12/19/2025, 01/06/2026, 01/13/2026 and 01/15/2026. An interview was conducted on 01/20/2026 at 2:20 PM with the Administrator. The clinical record for Patient #4 was reviewed and the Administrator confirmed AA did not document her visits on the dates identified. Surveyor asked what the agency’s policy was for putting notes into the patient record. The Administrator stated within 48 hours. Surveyor asked who responsible to review the clinical records to ensure documentation was completed on time. Administrator stated he and the office manager check weekly and send an email to AA to remind her to get her notes in the system. Administrator stated he emailed AA and she stated, “She’s working on it.” An interview was conducted on 01/21/2026 at 11:00 AM with AA regarding the SN visit notes for Pt #4. AA stated she had been sick with a respiratory illness but was not contagious so she completed the visits. AA stated she fell behind in her charting but completed the documentation yesterday in the EMR. Surveyor asked how she could recall the information collected during the visits. AA stated she had everything written down in a notebook then charts in the EMR after she completed the visits. Review of the agency’s Policy and Procedure Manual revealed a policy titled: IM.9 Timeliness, JCC 06/24/21 L&C/A, which read, “Clinical progress notes are written the day service is rendered. If the agency does not have electronic records, the clinical or progress note is submitted to the agency within 24 hours.”