Every finding on record at Atrium Home Health Systems, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 10/25/24. No deficiencies cited.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 10/25/24. Standard level deficiencies cited. Abbreviations: OASIS = Outcome and Assessment Information Set POC=Plan of care Pt./ Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse SOC = Start of care

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 the review of the Agency’s Error Summary report and Staff interview, it was determined in137 of 365 reports submitted for the last 12 months, the Agency failed to submit timely OASIS reports. Finding include: 1. The Agency’s Error Summary report for October 2023 thru September 2024, was reviewed on 10/22/24 at 9:30 AM. The report included error # -3330 for 137 of 365 submissions. 37.5% of the OASIS reports were not submitted timely, resulting in a warning. 2. The finding was confirmed, during an interview with the Administrator, on 10/24/24 at 1:00 PM.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 9/23/21. Standard level deficiency cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care POC = Plan of Care E = Employee AM = Morning PM = Evening # = Number % = Percent w = week SN = Skilled Nurse HHA = Home Health Aide PT = Physical Therapist COVID-19 = Coronavirus 2019

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: A. Based on clinical record review, observations made during home visits, Agency policy, and staff interview, it was determined the Agency failed follow its policies to document Pt. COVID-19 screening results prior to home visits, and to ensure non-disposable medical equipment was disinfected after Pt. care use. This was found in 5 of 7 Pts. (Pts. #5, 6, 7, 1, and 2) reviewed for infection control measures. 2. Pt. #1. SOC 9/3/21. Primary Diagnosis: Urinary Tract Infection, Site Not Specified. A home visit was conducted with E #2 on 9/20/21 at 2:05 PM. During the home visit E #2 removed a blood pressure machine (reusable equipment) from the therapy bag and used the equipment on the Pt. E #2 placed the used equipment into a bag and stated: “I put my equipment in a bag after I use it, I spray …(Disinfectant spray) in the bag, I close the bag and leave it sealed until I use it again on the next Pt.” E# 2 failed to comply with the Agency Infection Control policy. 3. Pt. #2. SOC 6/18/21. Diagnoses: Essential (Primary) Hypertension and Autoimmune Thyroiditis. A home visit was conducted with E#1 on 9/21/21 at 2:00 PM. During the home visit, observed E #1 remove a thermometer and blood pressure machine (reusable equipment) from the nursing bag and use the equipment on the Pt. E #1 proceeded to clean the equipment with “…hand and face wipes”, then returned the equipment into the nursing bag. E #1 failed to comply with the Agency Infection Control policy. 4. The Agency’s policy titled, “COVID-19 Home Health Care Setup” was reviewed on 9/22/21 at 11:30 AM. The policy required, “…Patient Screening: When making a home visit, the Agency shall identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home…” 5. The Agency’s policy titled, “Infection Control” was reviewed on 9/22/21 at 1:15 PM. The policy included: “Required Infection Procedures…5. Disinfect equipment..." 6. During an interview with the Director of Nursing on 9/21/21 at 2:45 PM, the Director of Nursing stated after employees use their reusable equipment they are required to clean/disinfect the equipment. The Director of Nursing stated: “This is what we give to the staff to use”, and presented a pack of “75% Alcohol Wipes”. 7. During an interview with the Administrator, Director of Nursing and the Quality Assurance Nurse on 9/22/21 at 11:40 AM; and with the Administrator, Director of Nursing, Quality Assurance Nurse and the Quality Assurance Staff Person (Administrative Staff) on 9/22/21 at 1:35 PM, the Administrative Staff confirmed staff failed to follow Agency policies, regarding the use of disinfecting equipment and COVID-19 screening. Findings include: 1. Pt. #5. SOC 7/14/21. Primary Diagnosis: Hemiplegia following Cerebral Infarction affecting Left Non-Dominant Side. The clinical record was reviewed on 9/20/21 at 2:00 PM. The record contained documentation the PT provided service on 7/29/21 and 9/10/21. The record lacked documentation the PT screened Pt. #5 for signs and symptoms of COVID-19 prior to these visits. 2. Pt. #6. SOC 12/22/20. Primary Diagnosis: COVID-19 Acute Respiratory Disease. The clinical record was reviewed on 9/21/21 at 9:45 AM. The record contained documentation the PT provided service on 12/24/20, 12/29/20, 12/31/20, 1/5/21, 1/7/21, 1/12/21, and 1/14/21. The record lacked documentation the PT screened Pt. #6 for signs and symptoms of COVID-19 prior to these visits. 3. Pt. #7. SOC 8/11/21. Primary Diagnosis: Unspecified Rotator Cuff Tear/Rupture of Left Shoulder, not Trauma. The clinical record was reviewed on 9/21/21 at 1:15 PM. The record contained documentation the SN provided service on 9/14/21. The record laced documentation the SN screed Pt. #7 for signs and symptoms of COVID-19 prior to this visit.

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: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to follow its policy to ensure clinical notes were incorporated into the patient’s medical record within 7 days. This was found in 1 of 2 (Pt. #7) closed records reviewed. Findings include: 1. Pt. #7. SOC 8/11/21. Primary Diagnosis: Unspecified Rotator Cuff Tear/Rupture of Left Shoulder, not Trauma. The clinical record was reviewed on 9/21/21 at 1:15 PM. The record included the POC effective 8/11/21, which included the Physician’s order: “HHA: 1wk1, 2wk8.” The record lacked documentation of the HHA visits provided on 8/23/21, 8/26/21, 8/30/21, 9/2/21, 9/6/21, 9/9/21, and 9/13/21. 2. The Agency policy titled “Clinical Documentation” was reviewed on 9/22/21 at 11:00 AM. The policy required: “...Documentation of services ordered on the Plan of Care will be completed the day service is rendered, and incorporated into the clinical record within seven (7) days after the care has been provided…” 3. During an interview with the Administrator, Director of Nursing, and Quality Assurance Nurse on 9/22/21 at 11:40 AM, the Administrator confirmed the above HHA visits were completed; however, the notes from these visits were not contained in the patient’s medical record.