Every finding on record at Advisacare Solutions of Nevada, Inc

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 05/27/25-05/29/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 05/27/25-05/29/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CRF 484 Subparts A through C with the following standard-level deficiencies listed below.

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 Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all 53 patients receiving services from the HHA who require evaluation and care. Findings include: Review of the undated agency's policy titled, OASIS Completion & Data Processing, documented "Once OASIS assessment is completed it should be reviewed and encoded into the computer as soon as possible. All OASIS assessments must be transmitted to the CMS [Centers of Medicare and Medicaid] system no later than 30 days after completion of the assessment…" The agency's OASIS submission data since May 2021 was reviewed for timely transmission to IQIES. The data revealed late transmissions over the state’s threshold of 10.0% per quarter. This resulted in an error code of -3330 (late submission). During an interview on 05/29/25 at 10:55 AM, the Director of Clinical Services (DCS) confirmed there were issues with staffing. The DCS also furnished an undated e-mail from the Administrator that read, "OASIS transmissions were late related to late processing of OASIS items -Late RN [Registered Nurse] submissions for review -Late RN returning for corrections completed -Late during COVID due to lack of staff to complete state submissions -Previous Administrator/ Clinical manager not completing follow through with staff -Per Diem staff that are not as dedicated as full time staff would be."

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure care was initiated timely after referral to the agency for one of seven sampled patients (Patient (P) 5) reviewed during the survey. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Referral and Acceptance of Patients Policy, indicated "A nurse or appropriate staff member will evaluate patients within 24 – 48 hours of referral or discharge from a facility unless otherwise ordered by the physician." Review of P5's medical record revealed the patient was referred to the agency on 03/27/25 for Physical Therapy services after partial knee replacement surgery. The record revealed services were not initiated by the agency until 04/04/25 when P5 was seen by an agency nurse for evaluation and initiation of ordered care. There was nothing found in the record to indicate a rationale for the delay in P5’s initiation of care. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P5 was not seen by agency staff to initiate services until seven days after her referral to the agency for services. The DCS was not able to explain why there was a seven-day delay in initiation of care for P5 and stated patients were expected to be seen for the initiation of services within 24-48 hours after referral to the Agency.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of seven sampled patients (Patient (P) 6) reviewed for medication reconciliation. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Medication Management Policy, indicated "The medication profile will be updated when there are any medication changes." Observation during a homecare visit performed by Certified Nursing Assistant (CNA) 1 on 05/28/25 at 8:00 AM, revealed that P6's Medication List, did not accurately reflect the medications being administered to the patient in home. Medications indicated in P6's EMR physician’s orders included carbidopa-levodopa (a medication used to control symptoms of Parkinson’s disease) 25-250 milligrams (MG) three times daily, clopidogrel (a blood thinning medication) 75 MG daily, and quetiapine (an antipsychotic medication) 25 MG every night. The carbidopa-levodopa, clopidogrel, and quetiapine were not located in R6’s home during the medication review. During an interview on 0528/25 at 8:25 AM, P6 stated was no longer taking the carbidopa-levodopa, clopidogrel, or quetiapine. P6 stated had stopped taking those medications a while ago. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P6 was receiving ordered weekly skilled nursing visits and indicated medications were expected to be reconciled by the nurse at every visit. The DCS stated the expectation was that the medications being administered to residents in their homes should match the agency's medication order set.

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 interview, record review, and policy review, the home health agency (HHA) failed to ensure home health services were provided as ordered for two of seven sampled patients (Patient (P) 3 and P6). This deficient practice had the potential to cause patient care needs not be met and could affect all patients cared for by the agency. 2. Review of P6's electronic medical record revealed the patient’s CMS 485 (Home Health Certification and Plan of Care), dated 04/30/25 and initiated after the patient’s hospitalization, revealed an order for MSW (Medical Social Worker): Veteran needs MSW assist for more ADL Activities of Daily Living) help. Nothing could be located in P6’s record to indicate the patient had been seen by MSW or a visit by the MSW had been scheduled related to this order. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P6 had not been seen by a Medical Social Worker related to the 04/30/25 return from hospital order. The DCS stated patients referred to MSW were expected to be seen timely to ensure appropriate services were being provided. Findings include: Review of the agency's undated policy titled, Professional and Ancillary Services, indicated "…Occupational Therapy: The Agency shall provide occupational therapy by qualified occupational therapist or occupational assistant under the supervision of an occupational therapist in accordance with the physician’s written orders…The Agency shall provide social services by a qualified social worker…" 1.Review of P3’s Home Health Certification and Plan of Care, revealed a start of care (SOC) date of 04/10/25 with diagnoses including acute and chronic respiratory failure with hypoxia. Review of P3’s physician orders, dated 04/28/25, revealed, "OT [Occupational Therapist] Evaluation…" Review of the Skilled Nurse (SN) visit notes, revealed no evaluation performed by OT. During an interview on 05/29/25 at 9:20 AM, the Director of Clinical Services (DCS) was asked about the OT evaluation. The DCS stated if it was ordered there should have been an authorization request. "I don’t think it has come in yet." During an interview on 05/29/25 at 9:35 AM, the Intake Coordinator (IC) was asked if there was an authorization for the OT request. The IC stated once a request for an evaluation was made, then an authorization was requested. The IC was asked to look and see if there was authorization for OT. The IC brought in an authorization form that included an authorization being approved for OT on 04/08/25.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure physician’s orders/plan of care were reviewed and signed timely by the Patient’s physician for five of seven sampled patients (Patients (P) 6, P1, P2, P3, and P4) reviewed during the survey. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Medical Supervision Policy documented, "The attending physician will provide complete and accurate information about the patient and shall sign and date in the timeframe designated by the Agency, a written plan of treatment and subsequent change orders." Review of P6's electronic medical record revealed the patient’s CMS (Centers for Medicare and Medicaid Services) 485 (Home Health Certification and Plan of Care) was most recently initiated for continuation of home health services for the 60-day period of 04/14/25 through 06/12/25. The document indicated P6 was to receive skilled nursing and physical therapy services throughout the certification period. Review of the record revealed P6 was receiving services according to the patient's plan of care (CMS 485), however there was no evidence to show the document had been reviewed and signed by the patient’s physician to validate the patient’s need for services and establish orders for the patient to receive the services. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed the CMS 485 form had not yet been signed by P6’s physician. The DCS confirmed CMS 485 was expected to be signed by each patient’s physician within 30 days of the initiation or continuation of services for each 60-day certification period. The DCS stated physicians were often difficult to reach to ensure review and implementation of valid and current orders for patient services. 2. Review of P1’s Home Health Certification and Plan of Care revealed a start of care (SOC) date of 06/22/24. The form was digitally signed by the nurse on 07/02/24. The form was not signed by the physician until 08/18/24, which was 47 days later. 3. Review of P2’s Home Health Certification and Plan of Care revealed a SOC of 08/10/24. The form was digitally signed by the nurse on 07/02/24. The form was not signed by the physician until 10/15/24, which was 64 days later. 4. Review of P3’s Home Health Certification and Plan of Care revealed a SOC of 04/10/25. The form was digitally signed by the nurse on 04/10/25. The form was not signed by the physician, which was 49 days later at the time of the survey. 5. Review of P4’s Home Health Certification and Plan of Care revealed a SOC date of 01/26/25, and a recertification period of 03/27/25- 05/25/25. The form was digitally signed by the nurse on 03/26/25. The form was not signed by the physician until 05/12/25, which was 47 days later. During an interview on 05/29/25 at 10:56 AM, the Director of Clinical Services (DCS) stated, "The form should be signed and returned within 30 days. Technically they are the orders we are to follow."

A Medicare Recertification Survey which included a review of the emergency preparedness program was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/11/2021 to 05/13/2021 resulted in a finding of a standard level deficiency citation respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness (EP) Program and interview, the Home Health Agency (HHA) failed to update the contact information for emergency officials at least every two years. This failure had the potential to impact the HHA's ability to respond effectively to the needs of patients in the event of a natural or man-made disaster. Findings include: Review of a document located in the HHA's EP binder titled "Sheriff Search and Rescue Contact List" dated 07/26/2012 identified the name of the contact person, email address, and phone number for the sheriff department in five locations in Nevada. Review of a document located in the HHA's EP binder titled "2018 Emergency Manager's List" dated 02/20/2018 identified the contact information for state, county, and tribal emergency managers at various locations throughout the state of Nevada. Review of the Governing Body meeting minutes dated 02/25/2021 revealed, "The Board hereby approves these contact lists and mechanism for updating them, and they will be reviewed every 2 years." During an interview on 05/13/2021 at 1:15 PM, the Administrator confirmed the information for state, county, local, and tribal emergency contacts had not been reviewed or updated in the past two years.

A Medicare Recertification Survey and Focused Infection Control Survey were conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/11/2021 to 05/13/2021 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to complete an initial assessment visit within 48 hours of the referral for one of 14 patients (Patient (P)1). This failure had the potential to delay the immediate care and support needs of the patient. Findings include: Review of the admission Outcome and Assessment Item Set (OASIS) located in the "Nursing" section of the electronic medical record (EMR) revealed P1's diagnoses included asthma, chronic respiratory failure, Takotsubo syndrome (a sudden and acute form of heart failure) and type 2 diabetes. The OASIS revealed P1 was referred to the HHA on Friday 07/24/2020 from a Skilled Nursing Facility (SNF) and was discharged from that SNF on that same day. Documentation in the OASIS indicated the physician did not order a specific Start of Care (SOC) date. The initial assessment date and the SOC date was identified as Tuesday 07/28/2020. There was no documentation in the EMR to indicate why the initial assessment occurred more than 48 hours after the referral. Review of the policy and procedure manual provided by the HHA failed to identify a policy specifically related to the time frame for the completion of the initial assessment following a referral. During an interview on 05/12/2021 at 10:40 AM, the Acting Administrator stated the initial assessment was to be completed within 48 hours after the referral or within 48 hours after the discharge from the SNF, or on the date identified by the referring or primary care practitioner.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on policy review, record review and interview the Home Health Agency (HHA) failed to ensure an update of the comprehensive assessment was completed upon resumption of care following an inpatient hospital stay for one of 14 patients (Patient (P)5). Findings include: Review of documentation in the electronic medical record (EMR) for P5 revealed an "OASIS (Outcome Assessment Information Set)-D1 Transfer" located in the "PT" (Physical Therapy) section identified P5 was readmitted to the hospital on 03/11/2021 due to a respiratory infection. Hospital discharge records located in the "PT" section indicated P5 was discharged from the hospital on 04/05/2021 with physician orders for home health services to resume. Review of the "Nursing" section in the EMR revealed an "OASIS-D1 Resumption of Care" visit was scheduled for 04/07/2021 but "Status" indicated it was "Not Started." An "OASIS-D1 Resumption of Care" was not located in any section of the EMR following P5's return home from the hospital stay. Visit notes located in the "PT" section and "OT" (Occupational Therapy) section indicate visits had been completed by these disciplines since P5 returned home from the hospital. Review of an undated policy titled, "Outcome-Based Quality Improvement" revealed "Case Manager will collect accurate and complete OASIS data at the following time points ... Resumption of Care (ROC) ...OASIS data will be submitted to the office within 24 hours." During an interview on 05/12/2021 at 10:40 AM, the Acting Administrator confirmed that an "OASIS-D1 Resumption of Care" had not been completed when P5 returned home from the hospital. The Acting Administrator stated, "Since we have not been able to find a Clinical Manager for this office there has not been anyone checking to see if these things have been done." The Acting Administrator stated the HHA nurses all work on a per diem (by the day or as needed) basis and the HHA did not have anyone in the position of case manager at this time.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, document review, and interview, the Home Health Agency (HHA) failed to ensure that a current medication schedule, written in plain language, was provided to the patient and/or caregiver for 4 of 14 patients (Patient (P)1, P3, P10, P14). This failure had the potential to increase the risk of medication errors which could result in serious harm to the patient. Findings include: 1. Review of the "OASIS-D (Outcome Assessment Information Set) Start of Care" (SOC) assessment located in the "Nursing" section of the electronic medical record (EMR) for P1 revealed P1 was admitted on 07/28/2020. Diagnoses included asthma, chronic respiratory failure, Takotsubo syndrome (a sudden and acute for of heart failure), and type 2 diabetes. Review of the "Medication Profile" located in the "Misc." (miscellaneous) section of the EMR revealed the medications were documented in medical terms, not in plain language that a patient or caregiver could easily understand. The list of medications included: "glimepiride 4 mg [milligrams]-po [by mouth] HS [at bedtime], carvedilol 25 mg-po Bid [twice daily], Humalog 5/5-sq [subcutaneous injection] daily, q [every]-var 80 mcg [microgram]-2 puffs daily, and Toujeo 24 units Sq HS." 2. Review of the SOC assessment located in the "Nursing" section of the EMR for P3 revealed P3 was admitted on 01/12/2021 following a hospital stay. Hospital diagnoses included COVID-19, pneumonia, and acute respiratory failure. Review of the "Medication Profile" located in the "Misc." section of the EMR revealed the medications were documented in medical terms, not in plain language that a patient or caregiver could easily understand. The list included: "O2 [oxygen] 3LPM [liters per minute] NC [nasal cannula] cont. (continuous), Benzonatate 200 mg T? po QD [every day], and Metoprolol 25 mg T? BID." 3. Review of the SOC assessment located in the "Nursing" section of the EMR for P14 revealed P14 was admitted on 01/22/2021. Diagnoses included: malignant neoplasm of the aryepiglottic fold (located at the entrance of the larynx) and dysphagia (difficulty swallowing). Review of the "Medication Profile" located in the "Misc." section of the EMR revealed the medications were documented in medical terms, not in plain language that a patient or caregiver could easily understand. The list included: "omeprazole 20 mg T? PO BID GERD (gastroesophageal reflux disease), atenolol 50 mg T? QD, and losartan 100 mg T? QD HTN (hypertension)." 4. The HHA patient information folder provided to P10 was reviewed during a home visit observation with the Occupational Therapist (OT) on 05/13/2021 at 10:00 AM. A blank multi-carbon form titled "Medication Profile" was in the folder. P10 stated the form had been in the folder since the nurse had completed the initial admission assessment visit. P10 had not received a medication list from the HHA. During an interview on 05/12/2021 at 10:40 AM, the Acting Administrator stated the nurse was supposed to complete the multi-carbon form titled "Medication Profile" and leave a copy with the patient. The other copy was supposed to be returned to the office and uploaded to the "Misc." section of the EMR. The Acting Administrator stated the medication list should be written in terms the patient and caregiver could understand and include the dose, route, frequency, and purpose of the medication. The HHA was unable to produce a policy that addressed the completion of the "Medication Profile."

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to include tracking, trending, and analysis of adverse events as a component of its quality assurance and performance improvement (QAPI) program. This had the potential to impact the safety and health of all patients receiving care from the agency. Findings include: The HHA was unable to provide evidence that any QAPI meetings occurred to review tracking, trending, and analysis of adverse event data including falls, emergent care, and infections. During an interview on 5/13/21 at 8:10 AM, the Acting Administrator confirmed the HHA had not completed trending or analysis of adverse events and reviewed the data as a component of QAPI.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, document review, and interview, the Home Health Agency (HHA) failed to ensure staff: 1. followed Standard Precautions during one of one patient (P)9 wound care observation, 2. completed COVID-19 screening of patients per record review and during one of two patient observations (P10), and 3. completed self-screening for COVID-19 and provided documentation to the office daily, This failure had the potential to increase the risk of infection and disease transmission for all patients and staff. Findings include: 1. An observation of Registered Nurse (RN)1 at the home of P9 on 05/12/2021 from 6:00 PM to 6:50 PM revealed the following: a. After checking P9's blood pressure (BP) and pulse using an oximeter (a small device that clips on the finger that measures oxygen saturation levels and pulse) RN1 put on gloves without doing hand hygiene and proceeded to remove the wound dressing covering P9's left foot revealing a small wound. b. While still wearing the same gloves RN1 opened a 4x4 inch gauze and proceeded to cleanse the wound. c. RN1 placed a new dressing on the wound and secured it in place. d. RN1 picked up the old dressing and gauze used to clean the wound in a gloved hand and removed the gloves securing the old dressing inside the glove, then placed the soiled gloves on the counter in the patient's kitchen. e. RN1 wore the same pair of gloves throughout the procedure and did not complete hand hygiene after removing the gloves. f. RN1 then picked up the BP equipment and placed it in a plastic container and, without cleaning the equipment, placed it in an open canvas bag. g. RN1 did not complete hand hygiene prior to leaving P9's home. During an interview on 05/13/2021 at 8:10 AM, the above observations were relayed to the Acting Administrator who stated, competency observations had not been completed with any staff due to COVID-19. The Acting Administrator stated RN1 should have removed the gloves after removing the old dressing and hand hygiene should be completed before putting on gloves, after removing gloves, and before leaving the patient's home. Review of an undated policy titled "Standard Precautions for all Healthcare Workers" signed by RN1 on 12/17/2020 revealed " Hands must be washed: Before and after contact with each client. After contact with potentially infectious material. Before putting on and after removing PPE (personal protective equipment), including gloves." 2. During a home visit observation on 05/13/2021 from 10:00 AM to 11:10 AM, the Occupational Therapist (OT) did not ask P10 any of the COVID-19 screening questions. The OT did take the patients temperature as a part of checking vital signs. During an interview at 11:10 AM shortly after exiting the home the OT stated, "I have the form right here," and held up the COVID-19 screening form. The OT stated, "I didn't observe any cough or other indications of COVID." During review of 14 of 14 patient medical records, no forms, documentation in visit notes, or "Misc." section of the electronic medical record (EMR) were found to indicate that staff completed screening for signs and symptoms of COVID-19 while doing visits to patient's homes. During an interview on 05/13/2021 at 8:10 AM, the Acting Administrator stated staff were supposed to document the patient's response to the COVID-19 screening questions in the visit notes. During an interview on 05/13/2021 at 1:15 PM, the Acting Administrator confirmed the COVID-19 screening was not present in the medical record for each patient. 3. During an interview on 05/13/2021 at 8:10 AM, the Acting Administrator stated staff were supposed to email their responses to the COVID-19 screening questions and check their temperature each morning they worked and email that to the office. Surveyor chose 12 dates for six different staff and requested documentation of the submitted surveillance sheets. During an interview on 05/13/2021 at 1:15 PM, the Acting Administrator confirmed provided documentation for nine of the 12 requested staff self-screening sheets and stated that most of the documents were just emailed to the office that day, but that staff had been tracking at home and had not sent them in. The Acting Administrator stated HHA is following CDC guidance and to follow the direction on responding to COVID-19 pandemic that is provided by the State of Nevada.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to maintain an infection control program that included ongoing surveillance, investigation, and analysis of data or include infection control information in its quality assurance performance improvement (QAPI) program. This failure had the potential to miss opportunities to prevent infections or transmission of communicable disease by not identifying potential causative factors. Findings include: Review of a binder containing the "Patient Infection Prevention and Control Surveillance" log provided by the Office Manager on 05/11/2021 revealed documentation of patient infections stopped being recorded on 05/24/2019. Review of the "Employee Infection Control Log" revealed no documentation since June 2019. During an interview on 05/12/2021 at 8:00 AM with the Acting Administrator, a request was made to produce any additional infection control surveillance data. The Acting Administrator provided additional "Patient Infection Prevention and Control Surveillance Logs" on 05/13/2021 at 8:10 AM. During an interview at this time, the Acting Administrator confirmed the documentation had been compiled on 05/12/2021, the previous day, based on information gathered from the electronic medical record (EMR) system. The Acting Administrator confirmed that no active ongoing tracking, trending, or analysis of infection data had occurred. The Acting Administrator was unable to produce QAPI meeting minutes identifying the date meetings were held, who was present, or what data was reviewed related to ongoing infection control surveillance. During an interview on 05/13/2021 at 1:15 PM, the Acting Administrator stated that due to COVID-19 the HHA had not completed any observation of staff competency related to Standard Precautions and practices to prevent the spread of infection. The agency had not reviewed or analyzed data to identify trends or potential areas for performance improvement. Review of the Governing Body meeting minutes dated 02/25/2021 revealed, "The QAPI Committee will collect data in the following areas ...Infection Control and Surveillance ...data will be collected in each area and reviewed quarterly." Review of an undated policy titled, "Infection Control Program" revealed, "The Agency will maintain and implement an Infection Control Program ... maintain a surveillance system to track the occurrences and transmission of infections related to the care/services provided with reporting of data quarterly ... the risk for and trends of infections are used to study ways to improve both prevention and control activities and reduce the risk and occurrence of infections."

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation and interview, the Home Health Agency (HHA) failed to ensure that a qualified individual was pre-designated by the Governing Body and the Administrator to assume the responsibilities and obligations of the Administrator when the Administrator was not available. This had the potential to impact the HHA's ability to respond promptly to patient's needs or concerns and ensure that care was being provided as ordered by the physician and based on the patient assessment. Findings include: Upon arrival at the HHA on 05/11/2021 at 8:25 AM the surveyor observed one person in the office. The person present was the Office Manager (OM). The Office Manager stated the Administrator lived in Michigan, the office did not have a Clinical Manager, and no one was designated to act on behalf of the Administrator. The OM had contacted the Administrator, and the Administrator would be flying from Michigan today and arrive later in the evening. No other staff were observed to be in the office throughout the remainder of the day. During an interview on 05/12/2021 at 8:00 AM, the Corporate Compliance Officer (CCO) for the parent company in Michigan was the Acting Administrator appointed by the Governing Body while the HHA continues to pursue hiring for the position. The Acting Administrator stated the previous Administrator and Clinical Manager had resigned early last summer and, "I have been covering the office as best I can." The Acting Administrator confirmed that no one had been appointed by the acting administrator or the governing body to assume the responsibilities of the administrator when the acting administrator was not available.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview, the Home Health Agency (HHA) failed to have a qualified Administrator (or pre-designated person) appointed by the Governing Body available during operating hours. This had the potential to affect all day-to-day operations of the agency and the 13 patients who are currently receiving home health services. Findings include: Upon arrival to the HHA on 05/11/2021 at 8:25 AM, the Office Manager stated the Corporate Compliance Officer, who lives in Michigan, was the Acting Administrator and that no one was designated to act on behalf of the Administrator. The Office Manager contacted the Acting Administrator and reported that the acting administrator was making arrangements and would be flying from Michigan for the survey. The Acting Administrator was not available while flying from Michigan to the HHA. During an interview on 05/12/2021 at 8:00 AM, the Acting Administrator had been conducting interviews for an administrator and clinical manager since both resigned last summer. The Acting Administrator stated, "Because of COVID I have not been able to come here as much as I would have liked. There are times when I'm not available, but I try to be as much as possible. Hopefully, I will get someone hired soon."

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 document review and interview, the Home Health Agency failed to ensure that the required assessments, clinical notes, and plans of care were present in the medical record for two of 14 patients (Patient (P)5, P12, and P14). This had the potential to place patients at risk due to lack of communication with the physician, potential for missed visits, and lack of assessment following an inpatient hospital stay. Findings include: 1. Review of the electronic medical record (EMR) for P12 identified the current certification period as 04/12/2021 to 06/10/2021 on the grey bar which identifies the current episode of care. Review of the "Orders" section of the EMR revealed that a current plan of care (POC) has not been completed. The "Target Date" for completion of the POC was identified as 04/12/2021 and "Status" was identified as "Not Started." During an interview on 05/13/2021 at 8:10 AM, the Acting Administrator confirmed a POC had not been completed for the current certification period. The Acting Administrator completes the POC and did not know how the one for P12 was missed. 3. Review of the initial "OASIS-D1 (Outcome Assessment Information Set) Start of Care" for P14 indicated a start of care (SOC) date of 01/22/2021 and diagnoses that included malignant neoplasm (cancer) of the aryepiglottic fold (located at the entrance of the larynx) and dysphagia (difficulty swallowing). Skilled nursing (SN) was initially scheduled 3 times a week to assist with gastrostomy tube (g-tube, a tube inserted into the stomach to provide nutrition) feedings. A "Physician Order" was noted on 03/05/2021 to increase SN to five times per week for the g-tube feedings. Review of the "Nursing" section of the EMR for P14 revealed a SN visit was scheduled for an "OASIS-D1 Recertification" (recert) on 03/22/2021. The status of the SN recert visit was identified as "Not Started" and a recert OASIS was not located in the EMR for P14. The EMR for P14 revealed the current certification period was identified as 03/23/2021 to 05/21/2021 on the grey bar across the top of the page. A total of 22 SN visits were documented as having been completed Monday through Fridays from 03/23/2021 to 04/21/2021. In addition, SN visits were scheduled from 04/22/2021 to 05/11/2021 but were identified in the EMR as "Not Started." Review of the "Orders" section of the EMR revealed there was no POC for the certification period 03/23/2021 to 05/21/2021. There was no discharge summary or discharge OASIS assessment in the EMR for P14. There was no documentation in the "Comm" [sic] section or "Misc." section of the EMR to explain the above findings. During an interview on 05/13/2021 at 8:10 AM, the Acting Administrator did not know what happened in this case and was not aware if this patient was current or was discharged. Review of an undated policy titled, "Outcome-Based Quality Improvement" revealed, "Case Manager will collect accurate and complete OASIS data at the following time points ... Resumption of Care (ROC) ...OASIS data will be submitted to the office within 24 hours."

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure a discharge summary was sent to the primary care practitioner for two of 14 patients (Patient (P)3 and P14). In addition, the HHA failed to ensure the discharge summary addressed all the required elements for one of 14 patients (P4). This had the potential to impact continuity of care for all patients receiving services from the HHA whose primary care practitioner did not receive a completed discharge summary. Findings include: Review of the "Outcome and Assessment Information Set" (OASIS) located in the "Nursing" section of the electronic medical record (EMR) for P3 revealed a start of care (SOC) date of 01/12/2021. Review of the OASIS Discharge in the EMR completed by Physical Therapist (PT)3 revealed a discharge date of 03/08/2021. The EMR did not include a discharge summary or any documentation to indicate a discharge summary was completed and sent to the primary care practitioner. Review of the OASIS located in the "Nursing" section of the EMR for P14 revealed a SOC date of 01/22/2021. Review of the "Skilled Nursing Visit" documentation in the "Nursing" section for the certification period of 03/23/2021 to 05/21/2021 revealed P14 had been seen five days a week for gastrostomy tube (a tube inserted into the stomach for providing nutrition) feedings. The last "Skilled Nursing Visit" was completed on 04/21/2021. The EMR did not include a discharge order, discharge OASIS, or evidence that a discharge summary was completed and sent to the primary care practitioner. Review of the discharge summary located in the "Nursing" section of the EMR dated 09/01/2020 for P4 revealed the document was incomplete when sent to the primary care practitioner. Missing information included a reason there were unmet goals listed or a reason for the discharge. In addition, the sections of the document titled "Living arrangements at discharge," "Resources Ongoing," "Care Summary," and "Coordination Plan" were left blank. Review of a policy titled, "Submission of Patient Documentation Guidelines" dated 01/21, revealed, "Upon discharging a patient from service, the agency Discharge Summary must be submitted along with the comprehensive discharge assessment with applicable OASIS items the next scheduled workday, not to exceed forty-eight hours." During an interview on 05/12/2021 at 10:40 AM, the Administrator confirmed the discharge summary for P4 had been sent to the primary care practitioner but was not complete. The Administrator confirmed that the EMR did not contain a discharge summary for P3 and P14.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview the Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for all patients receiving care from the HHA. Findings include: During an interview on 05/12/2021 at 8:00 AM, the Administrator stated the agency used a web-based electronic medical record (EMR) program and staff accessed the program using their personal computers. Surveyor received a log-in and password to access the patient records in the web-based EMR. During review of patient information, the surveyor identified that the patient assessments, plan of care, visit notes, and personal information including address, date of birth, social security number, and insurance information could be saved to the computer desktop which allowed access when not logged into the EMR. During an interview on 05/13/2021 at 1:15 PM, the Administrator stated the agency provided training on confidentiality of patient information, on hire, for all staff. The Administrator confirmed the agency would not be able to monitor the electronic devices owned by staff and used to access the EMR. The Administrator stated, "We are looking into purchasing small portable laptop computers." The Administrator confirmed there was not a policy that specifically addressed the agency responsibility to maintain the electronic devices used to access the web based EMR or to monitor the electronic devices to ensure the safety and confidentiality of patient information.