Every finding on record at A - Friendly Home Health Care, LLC

A re-licensure, re-certification survey was conducted on 7/18/2023. The census was Licensed and Certified: 16, Licensed Home Health: 16, Personal Assistance Services: 0. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A re-licensure, re-certification survey was conducted on 7/18/2023. The census was Licensed and Certified: 16, Licensed Home Health: 16, Personal Assistance Services: 0. OASIS: Outcome and Assessment Information Set. CMS: Centers for Medicare and Medicaid Services. IQIES: Internet Quality Improvement and Evaluation System QA: Quality Assurance PT: Physical Therapy EMR: Electronic Medical Record RN: Registered Nurse

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 record review and interview, the agency failed to electronically transmit the completed OASIS assessment for 2 of 2 discharged patient records reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. OASIS is a tool used by CMS to collect patient information. Citing Patient # 6 and Patient #7. This failure prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission for the agency on the IQIES portal on 7/16/2024 as part of the preparation for the survey. On 7/16/2024 the surveyor requested from the agency Administrator the OASIS summary report for the last 12 months. Patient # 6 Review of the OASIS summary report revealed Patient #6's discharge date as 8/5/2023. The report documented the date of the discharge assessment as entered by the agency at OASIS assessment item M0090 was 8/5/2023. The report documented that the submission date of the discharge assessment was 9/15/2023. The report documented the following error message: "Record Submitted Late: The submission date is more than 30 days after M0090 on this new record." Patient # 7 Review of the OASIS summary report revealed Patient #7's discharge date as7/31/2023. The report documented the date of the discharge assessment as entered by the agency at OASIS assessment item M0090 was 7/31/2023. The report documented that the submission date of the discharge assessment was 9/19/2023. The report documented the following error message: "Record Submitted Late: The submission date is more than 30 days after M0090 on this new record." An interview was conducted with the agency's Administrator, Employee A, on 7/16/2024 at approximately 2:00 p.m. The surveyor reviewed the above findings with the Administrator. The surveyor inquired as to what the agency's procedure is for transmitting OASIS information. The Administrator stated, "...With admission it is within 24 hours. Once QA is complete then it's exported. Doesn't take more than 3 or 4 days...The same applies with discharge. The day the discharge is done, it's completed. It goes to QA. It's top priority to get it on time..." Review of the agency's policy titled, " Section 8: Outcome and Assessment Information Set (OASIS)...HCL/Orientation Manual...Page 70 of 103...Last Reviewed: 070524..." read, in part, "...The Agency is required to submit all OASIS assessments to the national database specified by CMS within 30 days of the M0090 date..."

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure that patients were provided with a visit schedule in 1 of 1 home visits conducted. Citing Patient # 2 This failure could prevent the patient and other personnel from being aware of the patient's schedule and could cause scheduling conflicts and missed visits leading to poor patient outcomes Findings: Patient #2 Review of the EMR for Patient #2 revealed a plan of care with a certification period of 6/5/2024 - 8/3/2024. Further review of the plan of care revealed orders for the Skilled nurse to visit 1 time a week for 9 weeks and for PT to re-evaluate and treat the patient. A home visit was conducted with Patient #2 on 7/18/2024. During the visit, the surveyor reviewed Patient #2's admission packet. In the admission packet was a visit schedule. The visit schedule was undated and not filled out. There was no dated or filled out visit schedule anywhere in the patient's immediate surroundings. An interview was conducted with Family Member AA on 7/18/2024 at approximately 11:40 a.m. The surveyor inquired if the agency ever filled out a visit schedule for the patient. Family Member AA stated, "...No. I have never seen this..." The surveyor inquired as to how they knew when any agency personnel are scheduled. Identifier AA stated, "...The nurse calls every Sunday evening and gives us a time window. Physical Therapy texts me the day before..." An interview was conducted with the agency's Director of Nursing on 7/18/2024 at approximately 2:10 p.m. The surveyor inquired as to why the visit schedule was not being filled out. The Director of Nursing stated "...I don't know..." The surveyor inquired of the Director of Nursing whose responsibility it is to fill out the schedules. The Director of Nursing stated "...The admitting RN...We have had in-services on this..." The surveyor asked for documentation that there were in-services done. The Director of Nursing stated "...We do it via TEAMS..." There was no documentation of any in-services done regarding filling out the schedules. Review of the agency's policy titled "Implementing Care and Treatment PC. 40 Page 2 of 3 Last Reviewed: 050224..." read, in part, "...VI. Written information to the patient/client. 1. The visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency..."