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Amazing Grace Systems Homehealth

(915) 587-4968921 Las Aves Pl, El Paso, TX 79912
CMS Certification Number 747183 · Proprietary · Medicare-certified since 08/25/2009
8deficiencies since 2018
0serious
3inspections
n/aCMS quality stars
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. What the labels mean

Inspection 2025-05-21

· Recertification · 2 deficiencies · CMS source report (PDF)
Moderate Encoding And Transmitting Oasis

The Agency failed to encode and electronically transmit each completed OASIS assessment to the iQIES system, within 30 days of completing the assessment of the patient for 3 of 10 (Patient #4, Patient #5, and Patient #10) of the patient records reviewed.

Source: CMS Form 2567, inspection 2025-05-21, tag G0372 · view on CMS
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Minor All Orders Recorded In Plan Of Care

The agency failed to ensure that clients receiving skilled treatment under the direction of a practitioner had formal plans of care that contained all required elements for 5 of 7 active clients (Patients #2, #4, #5, #9, and #10) whose records were reviewed, in that: 1. Patients #2, #4, #5, #9, and…

Source: CMS Form 2567, inspection 2025-05-21, tag G0576 · view on CMS
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Inspection 2022-05-12

· Recertification · 1 deficiencies · CMS source report (PDF)
Minor Preparing Clinical Notes

The agency failed to ensure that documentation of services provided was accurate and timely for 1 of 7 patients (Patient #1) for which the clinical record was reviewed.

Source: CMS Form 2567, inspection 2022-05-12, tag G0716 · view on CMS
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Inspection 2019-08-01

· Recertification · 5 deficiencies · CMS source report (PDF)
Moderate Program Activities

The agency failed adopt and enforce a policy to ensure that the Quality Assessment Performance Improvement (QAPI) committee met at least bi-annually.

Source: CMS Form 2567, inspection 2019-08-01, tag G0646 · view on CMS
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Moderate Infection Prevention

The agency failed to ensure compliance with the Communicable Disease Prevention and Control Act, Health and Safety Code, Chapter 85, Subchapter I, concerning the prevention of transmission of Human Immunodeficiency Virus and Hepatitis B virus for 2 of 6 employees (Identifiers C and F) for which…

Source: CMS Form 2567, inspection 2019-08-01, tag G0682 · view on CMS
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Minor Preparing Clinical Notes

The Administrator failed to ensure that documentation of services provided is accurate and timely for 4 of 8 patients (Patients #1, #3, #5 and #6) for which records were reviewed.

Source: CMS Form 2567, inspection 2019-08-01, tag G0716 · view on CMS
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Minor Onsite Supervisory Visit Every 14 Days

The agency administrator failed to ensure a registered nurse (RN) conducted an on-site supervisory visit to the client's home at least every 14 days for 2 of 3 patients (Patients #4 and #6) for which home health aide services were ordered.

Source: CMS Form 2567, inspection 2019-08-01, tag G0808 · view on CMS
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Minor Discharge And Transfer Summaries

The agency failed to ensure the patient's record contained a discharge summary that is sent to the physician for 2 of 2 discharged patients (Patients #7 and #8) for which records were reviewed.

Source: CMS Form 2567, inspection 2019-08-01, tag G1022 · view on CMS
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