Every finding on record at Amazing Grace Home Health Agency Inc

A recertification survey was initiated on 9/24/24 with the Administrator, Program Coordinator, PAS Supervisor and the Quality Assurance Manager Agency Census: LCHH-1 LHH-0 PAS-129 Agency total Census: 130 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification survey was initiated on 9/24/24 with the Administrator, Program Coordinator, PAS Supervisor and the Quality Assurance Manager Agency Census: LCHH-1 LHH-0 PAS-129 Agency total Census: 130 Abbreviations: LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistance Services OASIS-Outcome and Assessment Information Set CMS-Centers for Medicare & Medicaid Service HHA-Home Health Agency

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 transmit completed OASIS assessments to the CMS system within 30 days of completing the OASIS assessment of the beneficiary (patient) for 20% of the assessments transmitted during the period of 10/1/23 to 9/24/24. Failure of the agency to transmit OASIS data within the required time frame 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 include: On 9/24/24 at approximately 2:00 pm, the surveyor reviewed the agency OASIS HHA Error Summary by Agency report from 10/1/23 through 9/24/24. The error summary report read in part…”Error -3330, record submitted late: The submission date is more than 30 days after M0090. # (number) of assessments processed, 25.”… 5, 20% submitted over 30 days after the M0090 date. An interview was conducted on 9/24/24 at 2:40 pm with the Program Coordinator. The surveyor reviewed the HHA Error Summary by Agency that indicated 20% of the OASIS were submitted late, over 30 days from the M0090 date. The Program Coordinator said, “I just forgot to submit them.” An interview was conducted on 9/27/24 at 11:45 am with the Administrator/Supervising Nurse. The surveyor asked the Administrator/Supervising Nurse who was responsible for submitting the OASIS. The Administrator/Supervising Nurse said, “the Program Coordinator.” The Surveyor reviewed agency policy IM.35 Timelines with the Administrator/Supervising Nurse. The Surveyor explained the agency policy stated the agency was to submit the OASIS no later than 30 days after the M0090 date. Surveyor reviewed that the agency had 5 of 25 OASIS since 10/1/23 submitted over 30 days from the M0090 date, making 20% late. The Administrator/Supervising Nurse said, “I don’t know why they were late.” Agency policy, “Timelines IM.35” revised 8/1/20 read in part…”Policy The agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations…Procedure…II. 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 identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”…

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients' plan of care was complete and included all the required elements including a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors for 7 (Patients’ # 1, 2, 3, 4, 5, 6 and 7) of 7 records reviewed. These failures placed patients at risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions. Findings include: Patient #1-review of Patient #1 revealed a plan of care dated 7/24/24 through 9/21/24 with a start of care of 12/2/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 7/19/24 with primary diagnosis of non-pressure chronic ulcer (a long lasting open sore not caused by prolonged pressure or friction). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #2-review of Patient #2 revealed a plan of care dated 5/1/24 through 6/29/24 with a start of care of 5/1/24. The plan of care was electronically signed by the Administrator/Supervising Nurse on 5/1/24 with primary diagnosis of type 2 diabetes mellitus (your body doesn’t make enough insulin or doesn’t use insulin well). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #3-review of Patient #3 revealed a plan of care dated 4/28/24 through 6/26/24 with a start of care of 2/28/24. The plan of care was electronically signed by the Administrator/Supervising Nurse on 4/26/24 with primary diagnosis of essential (primary) hypertension (high blood pressure that doesn’t have a known cause). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #4-review of Patient #4 revealed a plan of care dated 4/11/23 through 6/9/23 with a start of care of 10/13/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 4/10/23 with primary diagnosis of unilateral primary osteoarthritis, left hip (a degenerative joint disease, in which the tissues in the joint break down over time). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #5-review of Patient #5 revealed a plan of care dated 1/16/23 through 3/16/23 with a start of care of 1/16/23. The plan of care was electronically signed by the Administrator/Supervising Nurse on 1/16/23 with primary diagnosis of type 2 diabetes mellitus (your body doesn’t make enough insulin or doesn’t use insulin well). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #6-review of Patient #6 revealed a plan of care dated 1/9/22 through 3/9/22 with a start of care of 7/13/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 1/8/23 with primary diagnosis of essential (primary) hypertension (high blood pressure that doesn’t have a known cause). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. Patient #7-review of Patient #7 revealed a plan of care dated 6/4/22 through 8/2/22 with a start of care of 6/4/22. The plan of care was electronically signed by the Administrator/Supervising Nurse on 6/4/22 with primary diagnosis of acute cerebrovascular insufficiency (a condition that affects the blood flow to your brain). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. An interview was conducted with the Administrator/Supervising Nurse on 9/27/24 at 11:45 am. The surveyor reviewed agency policy PC.35 Plan of care that stated the plan of care must include the patient risk factors for emergency department visits and rehospitalizations. The surveyor reviewed that the 7 L&C/Medicare plans of care failed to include the patient risk factors for emergency department visits and rehospitalizations. The Administrator/Supervising Nurse said, “It’s the software.” The surveyor asked the Administrator/Supervising Nurse who was responsible for the content of the plans of care. The Administrator/Supervising Nurse said, “I am.” Agency policy PC.35 Plan of Care last reviewed on 3/17/23 read in part…” Procedure III. A. The individualized plan of care must include the following, 12. A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.”…