Every finding on record at Ambassador Health at Home, Inc.

Ambassador Health at Home, Inc. is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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, policy and procedure review, and staff interview, the agency failed to electronically transmit each completed Outcome Assessment Information Set (OASIS, a patient specific standardized assessment, used in Medicare home health care, to plan care, determine reimbursement, and measure quality) to the Center for Medicare and Medicaid Services (CMS) system, within 30 days of completing the OASIS assessment and failed to follow their policy and procedure to ensure the OASIS submissions are timely. Findings are: A. Review of the Home Health Agency Error Summary by Agency Report, from Internet Quality Improvement and Evaluation System (iQIES, a cloud base application used by CMS to evaluate the quality of care for the Medicare and Medicaid beneficiaries, and help manage patient and provider information), for 1/1/23 through 12/31/23, revealed: 1. 60 out of 957 OASIS assessments data were submitted to the State Agency or the CMS OASIS contractor more than 30 days after completing the OASIS assessment. B. Review of the agency’s policy and procedure titled Reporting of OASIS Information, 6.2.2, no date indicated, revealed: 1. The agency must transmit, to the State Agency or CMS OASIS contractor, the OASIS data for each patient requiring an OASIS data collection within 30 days of the OASIS completion. 2. The agency will periodically conduct past OASIS submission audits to ensure submission of the OASIS remains timely. 3. If the OASIS submissions are considered late, the Administrator or the Clinical Services Manager, will complete ongoing education to the clinicians responsible for the completion of the OASIS and will conduct chart audits to ensure future submissions are timely. C. During an interview on 6/13/24 at 2:40 PM, the Administrator confirmed the agency failed to follow their policy and procedure for OASIS submission and the agency does have periodic OASIS submissions which exceeds 30 days or more after the OASIS completion.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include on the revised/updated plan of care, the patient’s progress towards the measurable outcomes and goals identified by the home health agency and the patient, for 5 of 5 patients (Patient 4, 5, 6, 7 and 8) who had a revised/updated plan of care. The total sample size was 10. The census was 72. Findings are: A. Review of the agency’s policy and procedure titled Care Planning Process, 9.9.1, no date indicated, revealed: 1. Review and revision of the patient’s plan of care will be ongoing with each home visit and will be based on assessments to determine current needs, problems, interventions, and goals. 2. The plan of care will be updated between certification and recertification to document modifications as well as reflect new problems, interventions, goals, and goal evaluation/goal resolution. 3. The policy does not include revision/updating of the patient’s progress towards the measurable outcomes and goals identified by the home health agency and the patient. B. Review of the agency’s policy and procedure titled Plan of Care – CMS #485 and Physicians Orders, no date indicated, revealed: 1. The Plan of Care includes patient-specific interventions and education as well as measurable outcomes and goals identified by the agency and the patient. 2. A revised Plan of Care must contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the agency and the patient. C. Review of clinical records revealed: 1. Patient 4’s Home Health Certification and Plan of Care (POC), for the certification periods of 2/26/24 through 4/25/24 and 4/26/24 through 6/24/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 2. Patient 5’s Home Health Certification and Plan of Care (POC), for the certification period of 2/21/24 through 4/20/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 3. Patient 6’s Home Health Certification and Plan of Care (POC), for the certification period of 4/8/24 through 6/6/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 4. Patient 7’s Home Health Certification and Plan of Care (POC), for the certification periods of 3/3/24 through 5/1/24 and 5/2/24 through 6/30/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 5. Patient 8’s Home Health Certification and Plan of Care (POC), for the certification periods of 10/18/23 through 12/16/23 and 12/17/23 through 2/14/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. D. During an interview on 6/13/24 at 11:00 AM, the Corporate Nurse confirmed the progress towards the measurable outcomes and goals as identified by the home health agency and the patient were not included on the POC for Patients 4, 5, 6, 7, and 8.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure home health aide (HHA) supervision was conducted at least every 14 days for 2 of 4 patients (Patients 4 and 6) who received HHA services. The total sample size was 10. The census was 72. Findings are: A. Review of the agency’s policy and procedure titled Home Health Aide Supervision, no date indicated, revealed all HHA supervisory visits will be made at least every 14 days by a registered nurse (RN) with or without the aide present. B. Review of Patient 4’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for certification periods of 2/26/24 through 4/25/24 and 4/26/24 through 6/24/24, included orders for HHA services 2 times weekly. 2. HHA supervisory visits were not conducted at least every 14 days between 4/14/24 and 5/3/24. C. Review of Patient 6’s clinical record revealed: 1. The POC for certification periods of 4/8/24 through 6/6/24 included orders for HHA services 1 time weekly. 2. HHA supervisory visits were not conducted at least every 14 days between 5/1/24 through 6/5/24. D. During an interview on 6/13/24 at 10:30 AM, the Corporate Nurse confirmed the agency failed to follow their policy and procedure for conducting HHA supervisory visits at least every 14 days for Patients 4 and 6.

Ambassador Health At Home, Inc is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include the progress towards the patient and agency identified measureable goals and outcomes on the plan of care for 5 of 5 patients who had a revised/updated plan of care (Patient 1, 2, 4, 5, and 6). The total sample size was 7. The census was 49. Findings are: A. Review of the agency policy and procedure titled, Care Planning Process, no date indicated, revealed the policy did not include the requirement to include the progress towards the patient and agency identified measureable goals and outcomes on the revised/updated plan of care. B. Review of Patient-1's updated/revised Home Health Certification and Plan of Care (POC) for the certification period of 6/27/21 through 8/25/21 did not include the progress towards the patient and agency identified measureable goals and outcomes. C. Review of Patient-2's updated/revised POC for the certification period of 7/9/21 through 9/6/21 did not include the progress towards the patient and agency identified measureable goals and outcomes. D. Review of Patient-4's updated/revised POC for the certification period of 4/28/21 through 6/26/21 and 6/27/21 through 8/25/21 did not include the progress towards the patient and agency identified measureable goals and outcomes. E. Review of Patient-5's updated/revised POC for the certification period of 5/8/21 through 7/6/21 and 7/7/21 through 9/4/21 did not include the progress towards the patient and agency identified measureable goals and outcomes. F. Review of Patient-6's updated/revised POC for the certification period of 4/29/21 through 6/27/21 did not include the progress towards the patient and agency identified measureable goals and outcomes. G. During an interview on 7/19/21 at 2:00 PM, the Administrator confirmed the revised/updated POC for Patient-1, 2, 4, 5, and 6 did not include the progress towards the patient and agency identified measureable goals and outcomes.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to follow its policy and procedure to ensure 1 of 2 Home Health Aides (HHA- J) received 12 hours of in-service training annually. The agency employs 2 HHA's. Findings are: A. Review of the agency policy and procedure titled, Inservice Education, no date indicated, revealed the agency HHA was to attend 12 hours of in-service each calendar year. B. Review of HHA-J's personnel file revealed there was no in-service trainings completed for the year of 2019. C. During an interview on 7/19/21 at 1:15 PM, the Corporate Director of Human Resources confirmed HHA-J did not complete 12 hours of in-services in 2019 per the agency policy.