Every finding on record at Cdp, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: OASIS- Outcome and Assessment Information Set

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 interviews, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) as evidenced by failing to ensure the agency successfully completed and transmitted OASIS data within 30 days of completion of the assessment of the beneficiary. Findings: Review of the agency’s undated policy on 04/04/2024 titled “Data Entry/Transmission of OASIS Information”, revealed, in part: Policy: The OASIS information sent electronically to the State will match the data in the clinical record. Procedure: 7. The Director of Nursing must designate two (2) employees that possess knowledge how to electronically transmit OASIS data to the State within 30 days of the assessment date of the beneficiary. 8. The OASIS information must be transmitted with accurate, complete, encoded and locked OASIS data for each patient to the State Agency. Review of the agency's OASIS Agency Final Validation Report with a submission date of 01/12/2024 revealed 1 out of 22 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 01/17/2024 revealed 1 out of 5 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 01/26/2024 revealed 1 out of 40 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/07/2024 revealed 2 out of 26 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/20/2024 revealed 1 out of 1 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/26/2024 revealed 1 out of 21 records with Error code-3330 were submitted more than 30 days after the date of completion on the record, which was late. On 04/04/2024 at 12:50 p.m., an interview was conducted with S2MB and the aforementioned Final Validation Reports were reviewed. S2MB stated she was responsible for submitting all OASIS assessments, and reviewed the Final Validation Reports after each OASIS submission. S2MB confirmed the assessments, dated from 01/12/2024-02/26/2024 with Error code-3330 had submissions greater than 30 days from the completion date and were late. On 04/04/2024 at 12:55 p.m., an interview was conducted with S1ADM and the aforementioned Final Validation Reports were reviewed. S1ADM confirmed the assessments, dated from 01/12/2024-02/26/2024 with Error code-3330 had submissions greater than 30 days from the completion date and were late. On 04/04/2024 at 3:45 p.m., an interview was conducted with S3OWN. S3OWN confirmed all OASIS data transmitted to the State agency should be within 30 days of the completion date. S3OWN confirmed the assessments, dated from 01/12/2024-02/26/2024 with Error code-3330 had submissions greater than 30 days from the completion date and were late.

Recertification Survey Abbreviations: AC before meals BID twice a day mg milligrams p.o. by mouth Q every SN Skilled Nurse SOC Start of Care SS sliding scale TID three times a day

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using and/or did not reflect medications the patients were no longer using, for 1 (Patient #2) of 7 (Patients #1-#7) sampled patients reviewed who received home visits. Findings: Patient #2 Review of the clinical record revealed a SOC date of 03/31/2021. The patient's primary diagnosis was Type 2 Diabetes Mellitus with Foot Ulcer. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 03/31/2021 to 05/29/2021 revealed Orders for Discipline and Treatment which included SN 1W1, 2W8. On 04/20/2021 at 3:00 p.m., a home visit was conducted in the home of Patient #2 with S3RN. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medications with discrepancies noted: 1. Gabapentin 300 mg 1 capsule p.o. every night. Review of the patient's medications revealed a bottle of Gabapentin 800 mg tablets with a prescription fill date of 03/29/2021; instructions stated 800 mg p.o. TID. The patient's wife verified Patient #2 took this medication 3 times a day since at least the date the medication was filled. She verified she was very familiar with the patient's medications and assisted him with taking his medications. 2. Roxicodone 5 mg p.o. Q 4 hours as needed with start date of 03/30/2021. The patient's wife stated Patient #2 no longer had any of this medication in the home. She stated he only had about a week's supply and had finished it a couple of weeks ago. 3. Novolog Subcutaneous 100 unit/1 ml 1 unit ml subcutaneous injection TID AC meals. A bottle of Novolog insulin was observed in the home with a prescription fill date of 03/29/2021; instructions stated SS every AM as directed. Patient #2's wife stated she gives the patient a sliding scale dose of the insulin only in the morning before breakfast, if needed, after she checks his blood sugar. 4. Clonidine 0.1 mg 1 tablet p.o. BID. A bottle of Clonidine 0.1 mg with a prescription fill date of 03/29/2021 was observed in the home; instructions stated 0.1 mg at night. The patient's wife verified Patient #2 only takes the medication one time a day at night. 5. Hydralazine 100 mg 1 tablet p.o. BID. A bottle of Hydralazine 100 mg with a prescription fill date of 08/24/2020 was observed in the home; instructions stated 100 mg TID. The patient's wife stated the bottle the pills were in was an old bottle, but the patient has taken the medication three times a day for several months. 6. A bottle of Lasix 40 mg was observed in the home with a prescription fill date of 03/29/2021; instructions stated 40 mg p.o. BID. The patient's wife stated the patient had been taking the medication twice a day but recently had it reduced to once a day. This medication was not listed on the patient's current medication profile list provided by the agency. A review of SN visit documentation revealed SN visits were conducted with Patient #2 on the following dates during the current Certification Period of 03/31/2021 to present: 03/31/2021, 04/07/2021, 04/09/2021, 04/14/2021, and 04/16/2021. On 04/20/2021 at 3:00 p.m., an interview was conducted with S3RN during the home visit. She verified the patient was currently receiving SN visits twice a week. On 04/23/2021 at 11:40 a.m., an interview was conducted with S1DON. She was notified of the medication discrepancies found during the home visit for Patient #2. She verified the medication profiles were not up to date. S1DON verified nurses should reconcile medications during each SN visit and update the medication profile accordingly.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the total plan of care was signed and dated by the patient's physician in a timely manner for 2 (Patients #13, #14) of 17 (Patients #1-#17) sampled patient records reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #13 Review of the clinical record for Patient #13 revealed a start of care date of 11/27/2020. Review of the plan of care for the certification period 11/27/2020 to 01/22/2021 for the patient revealed a principal diagnosis of Acute Pyelonephritis. Further review of the plan of care for this certification period revealed it was signed by the physician on 01/05/2021, which was not within 30 days of the start of care orders. Patient #14 Review of the clinical record for Patient #14 revealed a start of care date of 05/17/2020. Review of the plan of care for the certification period 01/12/2021 to 02/12/2021 for the patient revealed a principal diagnosis of Hypertensive Heart Disease with Heart Failure. Further review of the plan of care for this certification period revealed it was signed by the physician on 03/30/2021, which was not within 30 days of the start of the certification period orders. On 04/23/2021 at 11:50 a.m., an interview was conducted with S1DON. After reviewing the Plan of Care for Patient #13, S1DON verified the orders were not signed for the patient within the required time frame of 30 days. On 04/23/2021 at 2:43 p.m., an interview was conducted with S2OWNER. After reviewing the Plan of Care for Patient #14, S2OWNER verified the orders were not signed for the patient within the required time frame of 30 days.