Every finding on record at Ccc Home Health LLC

Purpose of visit: Recertification survey Entrance conference date: 11/25/2024 Total Census: 18 Parent: Mesquite: Licensed and Certified:13 Branch: Fort Worth Licensed and Certified:5 No deficiencies were cited.

Purpose of visit: Recertification survey Entrance conference date: 11/25/2024 Total Census: 18 Parent: Mesquite: Licensed and Certified:13 Branch: Fort Worth Licensed and Certified:5 Abbreviations: SN – Skilled Nurse Adm – Administrator DON – Director of Nursing POC - Plan of Care SOC - Start of Care RN – Registered Nurse QAPI- Quality Assurance Performance Improvement TULIP - Texas Unified Licensure Information Portal OT - Occupational Therapy PT - Physical Therapy EHR – Electronic Health Record NOMNC - Notice of Medicare Non-Coverage OASIS - Outcome and Assessment Information Set EVP - Executive Vice President

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide written notice in advance the intent of terminating on-going care in two (Patient #6, and 7) of two inactive patient records reviewed. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patient from having the ability to exercise their rights to appeal a discharge decision for reconsideration. Findings include: An inactive patients list of last 12 months was provided for the parent and the branch agency with the dates and the reason for discharge by the Adm on 11/25/24. The inactive patient list of parent agency included: Patient #6 SOC date 05/13/2024 and discharged on 07/10/2024 with the discharged reason “Goals Met”. The inactive patient list of branch agency included: Patient #7 SOC date 06/21/2024 and discharged on 10/18/2024 with the discharged reason “Goals Met”. Review of Patient #6’s EHR included a discharge OASIS that was digitally signed by DON on 07/10/2024. Patient #6's clinical record did not show that the patient or patient representative received a written NOMNC notice of intent to discharge no later than two days in advance of terminating on-going care on or before 07/08/2024. Review of Patient #7’s EHR included a discharge OASIS that was digitally signed by RN A on 10/18/2024. Patient #7's clinical record did not show that the patient or patient representative received a written NOMNC notice of intent to discharge no later than two days in advance of terminating on-going care on or before 10/16/2024. During an interview with the Adm/DON on 11/27/2024 at approximately 12:35 PM, the surveyor discussed the above findings of why the agency had not provided a written NOMNC notice of the intent to discharge no later than two days in advance of terminating on-going care for Patients #6, and 7. The Adm /DON did not dispute the survey findings and said, "I didn't know about a two-day notice." Regulation: July 1, 2005, the new Medicare regulations (Benefits Improvement and Protection Act) BNI gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the Quality improvement Organization (QIO) should be included in this notice (XXX-XXX-9504). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. According to 42 Code of Federal Regulations: § 405.1200 Notifying beneficiaries of provider service terminations. (b) Advance written notice of service terminations. Before any termination of services, the provider of the service must deliver valid written notice to the beneficiary of the provider's decision to terminate services. The provider must use a standardized notice, as specified by CMS, in accordance with the following procedures: Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the beneficiary's services are expected to be fewer than 2 days in duration, the provider must notify the beneficiary at the time of admission to the provider. If, in a non-residential setting, the span of time between services exceeds 2 days, the notice must be given no later than the next to last time services are furnished. Review of agency policy titled” Discharge Criteria and Planning, 9.30.1” revised February 2024, read in part, “Purpose: To establish guidelines for discharge of patients from the agency. Any changes …. the patient after discharge from the agency. Procedure: 2. The patient is informed of discharge plan …. plan to avoid. 6. The patient’s continuing …. at discharge. “

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide the patient with written information outlining a visit schedule including frequency of visits by home health agency staff in two (Patient #1 and 2) of two patients home folders reviewed while home visit was conducted. This failure prevented patients from being informed of agency staff visits on a consistent schedule which could result in missed visits and a reduction in care. Findings include: Patient #1: Review of the clinical record contained a POC with a SOC date of 10/11/2024 and a certification period of 10/11/2024 – 12/09/2024. The POC included a Mental/Cognitive Status as “Oriented X 3, Forgetful, Depressed” and the principal diagnosis of “Other specified diseases of upper respiratory tract, Other symptoms and signs involving the musculoskeletal system, Mild cognitive impairment of uncertain or unknown etiology and Unspecified fall.” The POC contained physician orders for: 1. Skilled nurse (SN) to visit two time every week for four weeks and one time every week for four weeks. 2. Occupational Therapy to assess functional status. OT to assess rehabilitation potential and determine need for ADL training, safety precautions, pain management, strengthening/conditioning exercise. Initial OT evaluation recommended OT to visit two times every week for eight weeks. 3. Physical Therapy to assess functional status. PT to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/ coordination, and transfers. Initial PT evaluation recommended PT to visit two times every week for six weeks. Home Visit: On 11/26/2024 at approximately 10 AM, a home visit was conducted with Patient #1. The patient's home folder was reviewed. The surveyor asked if any paperwork had been removed from the patient's home folder. Patient #1 indicated that he did not remove any paper from the folder. When the agency staff visits, they write in it. The surveyor asked if the agency had provided a written schedule showing when they were going to visit. Patient #1 said everything they gave is in the folder. Patient said, “two therapists come Tuesday and Thursdays.” Patient #1 did not receive a written visit schedule from the agency with the frequency of SN, OT, and PT visits. Patient #2: Review of the clinical record contained a POC with a SOC date of 10/19/2024 and a certification period of 10/19/2024 – 12/17/2024. The POC included a Mental/Cognitive Status as “Oriented X 3, Forgetful” and the principal diagnosis of “Hypertensive heart disease with heart failure, Unspecified dementia (loss of memory, and other thinking abilities interfere with daily life), Age related physical disability, and Chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues).” The POC contained physician orders for: 1. SN to visit two time every week for eight weeks. 2. Physical Therapy to assess functional status. PT to assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/ coordination, and transfers. Initial PT evaluation recommended PT to visit two times every week for eight weeks. 3. Occupational Therapy to assess functional status. OT to assess rehabilitation potential and determine need for ADL training, safety precautions, pain management, strengthening/conditioning exercise. Initial OT evaluation recommended OT to visit two times every week for eight weeks. Home Visit: On 11/26/2024 at approximately 10 AM, a home visit was conducted with Patient #2. The patient's home folder was reviewed. The surveyor asked if any paperwork had been removed from the patient's home folder. Patient #2 indicated that indicated that nothing had been removed, everything they gave is in the folder. Patient was not aware who come to visit her, she said “I think a nurse and doctor come to visit. “ Patient #2 did not receive a written visit schedule from the agency with the frequency of SN, OT, and PT visits. An interview was conducted with the Adm/DON on 11/25/2024 at approximately 12:30 p.m. during the entrance conference. The Adm/ DON said she was responsible for ensuring the POC was followed. During an interview with the Adm/DON on 11/27/2024 at approximately 12:20 PM, the surveyor asked why the SN/OT/PT visit schedules were not provided to Patient #1 and 2. The Adm /DON did not dispute the survey findings, stated she was not aware that visit schedules should be provided to the patients. Record review of agency policy titled, Coordination of Patient Care 9.13.1”, revised February 2024, read in part, Purpose: To ensure that quality services ……. eligibility for care. Procedure: 9. Agency will coordinate …. outlining: Visit schedule, … patient’s most current plan of care.”

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 failed to include a discharge summary in 1 (Patient #6) of 2 discharged patient’s record reviewed. This failure prevented continuity of care in the event a summary of the patient’s clinical care, during home health/ hospital admission period, was requested. Findings include: An inactive patients list of last 12 months was provided for the parent and the branch agency with the dates and the reason for discharge by the Adm on 11/25/24. The list indicated that Patient #6 was discharged on 07/10/2024 with the discharged reason “Goals Met”. Review of Patient #6’s electronic clinical record included a discharged from agency OASIS (an assessment), that was digitally signed by DON on 07/10/2024, revealed a discharge date 07/10/2024. The review of entire electronic clinical record did not include documentation of an agency discharge summary. An interview was conducted with the DON/Adm on 11/27/2024 at approximately 12:25 PM. The surveyor asked why the agency failed to complete a discharge summary for Patient #6. The DON/Adm said that they always wrote a discharge summary, she did not know why it was not done. The surveyor asked was the discharge summary sent to the patient’s physician. The Adm/DON did not respond to the question. The DON/Adm did not dispute the findings and did not provide any additional evidence. Review of agency policy titled” Discharge Summary 9.31.1” revised February 2024, read in part, “Policy: A Discharge Summary will be … the agency. Purpose: To record a summary …. through discharge. Procedure: 1. A Discharge Summary form will be completed …... 2. A Discharge Summary will be sent within 5 business …. and services to the patient. 3. The original Discharge Summary form …. medical record.