Every finding on record at American Family Health Services Inc

A recertification and re-licensure survey were conducted on 06/19/2024 at 5:00pm. Census: Licensed and Certified- 43 Licensed Home Health- 0 Personal Assistance Services- 27 Agency found to be in compliance with Federal Emergency preparedness standards and codes.

A recertification and relicensure survey were conducted on 06/19/2024 at 5:00pm. Census: Licensed and Certified- 43 Licensed Home Health- 0 Personal Assistance Services- 27 Acronyms used: CMS – Center for Medicare and Medicaid Services DON – Director of Nursing FIPS – Federal Information Process Standards HHA – Home Health Agency IM – Internal Memorandum IQIES - Internet Quality Improvement and Evaluation System M0090 – Official OASIS assessment form OASIS – Outcome and Assessment Information Set QAPI – Quality Assessment and Performance Improvement

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 completed OASIS assessments to the state agency within 30 days of completing OASIS assessments for 119 of 205 assessments processed from 06/01/2023-06/12/2024. 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: The surveyor reviewed the OASIS Error Detail Report and HHA Error Summary by Agency for the agency in the IQIES portal on 06/12/2024, as part of the Pre-survey preparation for the survey. The report documented 119 patients whose OASIS assessments were submitted more than 30 days after the M0090 (the date of completion of the assessment). The time period of review was 06/01/2023-06/12/2024. In an interview with the Administrator/DON on 06/19/2024 at 3:45 PM, the surveyor asked who in the agency was responsible for transmitting the OASIS assessments. The Administrator/DON stated it was the responsibility of the Administrator/DON to transmit the OASIS assessments. The surveyor asked the Administrator/DON how often he transmitted the OASIS reports. The Administrator/DON stated there was no set schedule, the OASIS report was transmitted as soon as possible. The Administrator/DON stated many times it came down to a choice of tending to the client or transmitting the OASIS reports. The surveyor reviewed the information on the OASIS Error Detail Report and HHA Error Summary by Agency for the time period 06/01/2023-06/12/2024 with the Administrator/DON and asked about the late transmission of the assessments. The Administrator/DON stated he had provided correction proposals within the QAPI of the OASIS late reports as the agency had a problem in the past with time constraints conflicting with the transmissions of OASIS assessments and client treatments. The Administrator/DON stated he was aware the (OASIS) assessments were transmitted late and he knew they were supposed to be transmitted within 30 days of the assessments. Review of agency policy, Administrative Policy Manual, revised date 05/02/2024 by Health Care Consult Link, quoted in part, “TIMELINES, IM.35 Page 2 0f 2… 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."

Purpose of visit: Recertification survey Entrance Date: 06/08/2021 at 10:25 AM with the Administrator/DON, Identifier A and the Office Manager, Identifier B, and Human Resources, Identifier C. Agency Census: 118 Licensed and Certified Home Health - 2 Licensed Home Health - 77 Personal Assistance Services - 39 Exit Date: 06/11/2021 at 2:05 PM with the Administrator/DON, Identifier A and the Office Manager, Identifier B, and Human Resources, Identifier C. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies." The agency was in compliance with 42 CFR Part 484.22, the Conditions of Participation for Emergency Preparedness for Home Health Agencies with no deficiencies cited. Abbreviations: DON- Director of Nurses

Purpose of visit: Recertification survey Entrance Date: 06/08/2021 at 10:25 AM with the Administrator/DON, Identifier A and the Office Manager, Identifier B, and Human Resources, Identifier C. Agency Census: 118 Licensed and Certified Home Health - 2 Licensed Home Health - 77 Personal Assistance Services - 39 Exit Date: 06/11/2021 at 2:05 PM with the Administrator/DON, Identifier A and the Office Manager, Identifier B, and Human Resources, Identifier C. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies." Abbreviations: # - number DON-Director of Nurses POC - Plan of Care POCs - Plans of Care OASIS - Outcome and assessment information set

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 observation, record review, and interview, the agency failed to ensure the patients' plans of care were complete and included all the required elements for 5 (patients 1,2,3,4 and 5) of 7 records reviewed. Two (Patient 1 and 2) of three patients who the surveyor observed during home visits had plans of care that failed to include orders for the nurse to assess the AV shunt used for dialysis for thrill, bruit, and signs and symptoms of infection. Four (Patient 1, 3, 4, and 5) of seven patient records reviewed failed to include 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. These failures placed patients receiving dialysis at risk of losing their dialysis access, and also placed all 5 patients at greater risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions, when the agency's staff failed to provide interventions to address each patient's specific care needs and risk factors. Findings: Record review for patient 1 revealed a POC dated 04/10/21 to 06/08/21 with a start of care date of 04/10/21. The POC listed diagnoses of Thrombosis due to vascular prosthetic devices, implants and grafts, Encounter for change or removal of surgical wound dressing, Essential hypertension, Type 2 diabetes mellitus, Fibromyalgia, End stage renal disease, Gastro-esophageal reflux disease, Iron deficiency anemia, and Mixed hyperlipidemia. The POC listed orders for skilled nursing visit one time for one week, two times per week for eight weeks. A review of the entire POC revealed no orders for the nurse to assess the AV shunt used for dialysis for thrill, bruit, and signs and symptoms of infection and no description of the patient's risks for emergency department visits and hospital re-admissions, and interventions to address the underlying risk factors. The record reveal revealed patient 1 was hospitalized on 04/19/2021 and readmitted to the agency on 05/03/2021. A home visit was conducted by the surveyor on 06/10/21 at 11 AM. The surveyor observed the patient's AV shunt on the patient's left upper arm. The patient confirmed this was the access currently used for dialysis. Record review for patient 2 revealed a POC dated 12/28/20 to 02/25/21 with a start of care date of 03/03/20. The POC listed diagnoses of Non-pressure Chronic Ulcer of other part of right lower leg with fat layer exposed, Encounter for change or removal of nonsurgical wound dressing, Type 2 diabetes mellitus, Essential Hypertension, Other complications of amputation stump, Chronic atrial fibrillation, End stage renal disease, Dependence on renal dialysis, and Presence of artificial left leg. The POC listed orders for skilled nursing visit two times per week for nine weeks. A review of the entire POC revealed no orders for the nurse to assess the AV shunt used for dialysis for thrill, bruit, and signs and symptoms of infection. A home visit was conducted by the surveyor on 06/10/21 at 12 noon. The surveyor observed the patient's AV shunt on the patient's left upper arm. The patient confirmed this was the access currently used for dialysis. Record review for patient 3 revealed a POC dated 5/28/21 to 07/26/21 with a start of care date of 05/28/21. The POC listed diagnoses of Cellulitis of left lower limb, Encounter for change or removal of nonsurgical wound dressing, Lymphedema, Essential Hypertension, Mixed Hyperlipidemia, and Bipolar Disorder. The POC listed orders for skilled nursing visits one time per week for one week and three times per week for eight weeks. A review of the entire POC revealed no description of the patient's risk for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for patient 4 revealed a POC dated 3/03/21 to 05/03/21 with a start of care date of 03/05/21. The POC listed diagnoses of Cutaneous abscess of left foot, Encounter for change or removal of surgical wound dressing, Type 2 diabetes mellitus, Essential Hypertension, and Puncture wound without foreign body, left foot. The POC listed orders for skilled nursing visits one time per week for one week and three times per week for eight weeks. A review of the entire POC revealed no description of the patient's risk for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. Record review for patient 5 revealed a POC dated 11/03/20 to 01/03/21 with a start of care date of 05/09/20. The POC listed diagnoses of Stress fracture, right femur, Essential Hypertension, Type 2 diabetes mellitus, Gastro-esophageal reflux disease, Dependence on supplemental oxygen, muscle weakness, Pain in right shoulder, Other abnormalities of gait and mobility, and Muscle spasm of back. The POC listed orders for skilled nursing one time per week for eight weeks. A review of the entire POC revealed no description of the patient's risk for emergency department visits and hospital re-admission, and interventions to address the underlying risk factors. An interview was conducted with the Administrator / DON, A on 06/11/21 at 12:35 PM. The surveyor shared the results of the clinical record reviews and home visits for patients 1 and 2. The surveyor asked why the POCs did not contain include orders for the nurse to assess the AV shunt used for dialysis for thrill, bruit, and signs and symptoms of infection. The surveyor asked why the POCs for and why the POCs for patients 1, 3, 4, and 5 failed to include 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. The Administrator stated that the orders flowed from the OASIS to the POC. The Administrator / DON logged onto the electronic medical record and reviewed the oasis and plans of care. At 1:01 PM the Administrator / DON stated: "I am struggling many of these things they should pull over to the POC from the OASIS. I don't know why." A review of the agency policy titled: "Plan of Care PC.8" dated 110120 read in part: "The individual plan of care must include the following: ...Safety measures to protect against injury; 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. ... 14. Patient/client-specific interventions and education ..." According to Davita Dialysis (2011), an AV graft "is an artificial vein that is used for needle placement and blood access during hemodialysis. Hemodialysis filters the blood by removing it from the body and passing it through a filter. Measures should be taken to avoid any restriction of blood flow that could cause clotting in the AV graft. These include avoiding tight clothing, jewelry and blood pressure cuffs that could put pressure in the access area." (retrieved from http://www.davita.com/kidney-disease/preparing-for-dialysis/planning -for-a-vascular-access/arteriovenous-av-fistula-%EF%BF%BD-the-gold-standard-hemodialysis-access/e/5032). According to the National Kidney Foundation (2011), "palpation for thrill (pulse) must be performed daily and after any episode of hypotension, dizziness, or light-headedness. Physical examination, including the assessment of the arteriovenous graft, can be used as a monitoring tool to exclude low flows associated with impending graft failures (retrieved from http://www.kidney.org/atoz/pdf/va.pdf).