Every finding on record at Mcm Loving Healthcare, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/19/25. 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 07/19/25. Standard level deficiencies cited. Abbreviations: # = number % = percent x = times Pt./Pts. = Patient/Patients SOC = Start of Care NSS = Normal Saline Solution

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, the Agency failed to submit a timely report, resulting in a warning, for 25 of 223 reports submitted in the last 12 months. Findings include: 1. The Error Summary report for 07/01/24 to 07/01/25 (12 months), was reviewed on 07/18/25. The report included a warning for Error # -3330. The Error included 25 (11.21 %) of 223 assessments that were submitted late. 2. During an interview with the Administrator and Agency Supervisor on 07/18/25 at 2:30 PM, the Administrative team confirmed the above findings.

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 clinical record review, Agency policy review and staff interview, the Agency failed to ensure that wound care treatment was provided for 1 of 7 (Pt. #6) Pts. as ordered by the Physician. Findings include: 1. Pt. #6 was admitted to home health services on 01/20/25 with the diagnosis of Type 2 Diabetes Mellitus, Pressure Ulcer of Right Buttock, Stage 2 and Pressure Ulcer of Left Buttock, Stage 2. The clinical record was reviewed on 07/18/25. The clinical record included Skilled Visit Notes dated 05/24/25 and 05/29/25, documented: “Wound 1….wound location….right buttock…size…0.7 x 0.4 x 0…pressure injury Stage 2…type…pressure ulcer…wound status…open….wound care…Cleanse with NSS, pat dry gently with gauze then apply triple antibiotic then cover with 4x4 gauze and secure with tape…..Wound 2…wound location….left buttock….size…0.7 x 0.5 x 0….pressure injury Stage 2…type…pressure ulcer…wound status…open….wound care…Cleanse with NSS, pat dry gently with gauze then apply triple antibiotic then cover with 4x4 gauze and secure with tape…..”The clinical record lacked documentation that Physician orders were obtained for the use of the above-mentioned wound treatment. 2. The Agency policy “Plan of Care – CMS #485 and Physician Orders”, was reviewed on 07/18/25, and required: “….treatments as administered by staff only as ordered by physician.” 3. During an interview with the Administrator and Agency Supervisor on 07/18/25 at 2:30 PM, the Agency Supervisor confirmed the above findings.

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: Based on clinical record review, Agency policy review and staff interview, the Agency failed to ensure Pts. were assessed for the status of Influenza and Pneumonia vaccination for 5 of 7 (Pts. # 1, 3, 5, 6 and 7) clinical records reviewed. 1. The following clinical records were reviewed on 07/17/25 and 07/18/25: Pt. #1. SOC 06/24/25. Lacked inquiry for Influenza and Pneumonia vaccine. Pt. #3. SOC 04/08/25. Lacked inquiry for Pneumonia vaccine. Pt. #5. SOC 06/20/25. Lacked inquiry for Influenza and Pneumonia vaccine. Pt. #6. SOC 01/20/25. Lacked inquiry for Influenza and Pneumonia vaccine. Pt. #7. SOC 04/14/25. Lacked inquiry for Influenza and Pneumonia vaccine. 2. The Agency Policies were reviewed on 07/18/25 and required: “Influenza Vaccination Policy…. (Agency) shall administer or arrange for administration of an Influenza vaccination….unless the vaccination is medically contraindicated of the patient has refused the vaccine.... 1)For all patients that will be admitted between October 1 to March 31 and existing active patients, the Registered Nurse shall document on the “Flu and Pneumonia Vaccine Questionnaire” regarding the administration or arrangement for administration of an Influenza vaccination to each patient who is 65 years of age or older and who has not received this immunization prior to or upon service initiation, unless the patient refuses the offer for vaccination or the vaccination is medically contraindicated….The nurse case manager shall document the referral or arrangement made, including: a) Date of offer or referral b) The patient’s response (acceptance of refusal) c) Result (administration, contraindication, etc.) d) Outcome.” “Pneumococcal Vaccination Policy….(Agency) shall administer or arrange for administration of a pneumococcal vaccination….unless the patient refuses the offer for vaccination or the vaccination is medically contraindicated.... 1) Upon admission, the Registered Nurse shall complete the “Flu and Pneumonia Vaccine Questionnaire” regarding the administration or arrangement for administration of a pneumococcal vaccination to each patient who is 65 years of age or older and who has not received this immunization prior to or upon service initiation, unless the patient refuses the offer for vaccination or the vaccination is medically contraindicated….The nurse case manager shall document the referral or arrangement made, including: a) Date of offer or referral b)The patient’s response (acceptance or refusal) c) Result (administration, contraindication, etc.) d) Outcome.” 3. During interviews with the Administrator and Agency Supervisor on 07/18/25 between 11:30 AM and 2:30 PM, the Agency Supervisor confirmed the above findings.