Every finding on record at Heavenly Nurses Home Health LLC

Purpose of Visit: To conduct a Re-Certification Survey. Census: Licensed & Certified- 60 Licensed Home Health Services -0 Total Census: 60 The Agency was in compliance with no deficiencies/violations cited

Purpose of Visit: To conduct a Re-Certification Survey. Census: Licensed & Certified- 60 Licensed Home Health Services -0 Total Census: 60 Abbreviations: Adm-Administrator ADLs- Activities of Daily living ADON-Alternate Director of Nurses Alt Adm-Alternated Administrator CMS- Centers for Medicaid and Medicare Services DON-Director of Nurses IQIES- Internet Quality Improvement Evaluation System (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) LVN-Licensed Vocational Nurse OASIS- Outcome and Assessment Information Set (data collected as part of the comprehensive assessment) RN-Registered Nurse SN-Skilled Nurse SQ- Subcutaneous

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 72 of 285 (25.26%) records submitted from 02/18/25 to 08/15/25. The agency did not code and electronically submit 72 patient’s OASIS data to IQIES within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance The Findings Included: Record review of an iQIES Error Summary Report dated 08/01/24 to 08/01/25 indicated the agency failed to code and electronically transmit 147 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During a record review and interview on 08/26/25 at 11:56 a.m., with the Adm/DON and Office Manager the above findings were presented. The Adm/DON stated that the Alt Adm/ADON, RN G and herself do all the admissions and completed the OASIS within 5 days. The Adm/DON stated that the Office Manager submitted the OASIS. The Office Manager acknowledge that she was responsible for the submission of the OASIS. The Office Manager stated, “I have no excuse (for late OASIS submissions). I was sick and in and out of work. I wanted to make sure the information was correct.” The Adm/DON then stated, “it would affect everything. It impacts our payments and patient care.” The Adm/DON also stated that the agency wouldn’t get accurate information like ADLs, pain, etc. from quarterly reports they receive.” Review of the agency's policy manual included a policy titled "Timelines” IM. 35 with a revised date of 07/01/25. The policy revealed, in part: “…III. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identifications number, as applicable. It will be transmitted using electronic communications software that complies with Federal Information Processing Standard (FIPS 140-2, issued May,2021) from the Agency contactor to the CMS collection site within 30 days of the M0090 date.” …

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were documented in the patient's clinical record with signature, date and time order was written for 2 of 5 Active Patients (#1 & # 5) whose records were review in that: 1. LVN B received orders to discontinue Farxiga (helps improve blood sugar control) and increase Tresiba (helps lower blood sugar) from 8 units SQ daily to 10 units SQ daily effective 06/26/25 for Patient #1 and failed to write the order. 2. LVN C received orders to discontinue Acyclovir ointment (used to treat and prevent viral infection) effective 06/02/25 for Patient #5 and failed to write the order. This failure could place the agency's patients at risk of receiving improper care and services that could result in negative health outcomes. 1. Review of Patient #1's electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 06/24/25 to 08/22/25 with a primary diagnosis of “Type 2 diabetes mellitus (condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) with diabetic neuropathy (weakness, pain and numbness that occurs to the hands and feet from nerve damage).” SN frequency of 2 visits a week for 1 week, then 3 visits a week for 8 weeks. Continued review of Patient #1’s electronic record revealed a SN note signed and dated 06/27/25by LVN B that read in part… “patient consulted with his primary care provider Dr. X yesterday. New verbal medication orders were received to discontinue Farxiga and increase Tresiba from 8 units SQ daily to 10 units SQ daily effective 06/26/25.” Review of Patient #1's electronic record revealed the medication profile had been reviewed and was signed on 06/27/25 by the LVN B. Further review of Patient #1’s electronic record failed to contain documented evidence of a written verbal order to discontinue Farxiga and to increase Tresiba from 8 units to 10 units SQ daily. During a record review and interview on 08/27/25 1:53 p.m. with the Adm/DON and LVN B the above findings were presented. The Surveyor asked who was responsible for writing orders to discontinue medications. LVN B stated that she was responsible because she got the order and clarified it. The Surveyor then asked if there was an order to discontinue Farxiga and increase of Tresiba. LVN B stated, “no, not an actual order. I didn’t think we had to write an order for it (changes and discontinuation of medication).” The Surveyor then asked what the consequences could be if the patient continued taking Farxiga and increase does of Tresiba. LVN B stated that the patient’s blood sugar could drop, and he might get a hypoglycemic (low blood sugar causing confusion, shaking, etc. or very low blood sugar causing possible life-threatening conditions) episode leading to hospitalization. 2. Review of Patient #5's electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 05/22/25 to 07/20/25 with a primary diagnosis of “Type 2 diabetes mellitus without complications.” SN frequency of 1 visit a week for 8 weeks. Continued review of Patient #5’s electronic record revealed a SN note signed and dated 06/19/25 by LVN C that read in part… “Upon review of medications patient had Acyclovir discontinued on 06/02/25 when patient had appointment with Dr. Y.” Review of Patient #5's electronic record revealed the medication profile had been reviewed and Acyclovir was discontinued on 06/02/25. Further review of Patient #5’s electronic record failed to contain documented evidence of a written verbal order to discontinue Acyclovir. During a record review and interview on 08/27/25 5:00 p.m. with the Adm/DON the above findings were presented. The Surveyor asked if there was an order to discontinue Acyclovir on 06/19/25. Adm/DON stated, “no, I don’t know why he (LVN C) didn’t write the order. (LVN C is no longer employed at agency). The Adm/DON then stated that the Topical Acyclovir could cause more harm because she a had a biopsy that day (06/02/25).” Review of the agency's policy manual included a policy titled "Orders for Care” PC.30 with a reviewed date of 11/01/20. The policy revealed, in part: “…The Agency will obtain orders and provide care with physician’s and/or non-physician practitioner’s orders. .... Orders may be accepted and put into writing by personnel authorized do so…. I. All orders are kept current and renewed or updates as appropriate when: A. Changes in the patient’s/ client’s condition occurs. B. The ordered care is ineffective. C. Changes in diagnosis, treatment (including procedures and medications) …” …