Every finding on record at Colorado Home Health LLC

A recertification survey was completed on 6/3/26. One deficiency was cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct a risk assessment, utilizing an all-hazards approach, of the potential emergency situations the home health agency could encounter. Findings include: 1. The home health agency’s emergency preparedness (EP) plan was reviewed on 6/3/26. a) The agency failed to conduct a risk assessment of hazards or potential emergency situations. Review of the EP plan did not reveal an agency-specific risk assessment of hazards or potential emergency situations. 2. During an interview on 6/3/26 at 12:15 p.m., the agency administrator stated she was not certain the agency had conducted an emergency preparedness risk assessment and stated she would look for a document she thought might be the agency’s risk assessment for emergency situations. On 6/3/26 at 1:50 p.m., the administrator provided a list of emergencies and natural disasters with definitions and instructions for what to do if the emergencies on the list occurred. However, the list of emergencies and natural disasters did not include an agency- or community-specific assessment regarding which of the listed emergencies or natural disasters the home health agency might be vulnerable to or encounter.

A recertification survey was completed on 7/19/23. One deficiency was cited.

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 interview, review of the Outcome and Assessment Information Set (OASIS) submission validation report data, and Certification and Survey Provider Enhanced Reporting (CASPER), the agency failed to encode and submit OASIS data within 30 days of the completion of the comprehensive assessment. Findings include: 1. On 7/14/23, the Risk Adjusted Potentially Avoidable Event Report, Potentially Avoidable Event report: Patient listening, and Agency Patient Related-Characteristics Report for the time period 5/2022 to 4/2023 were run. The reports revealed "There are no results for this report criteria." 2. On 7/17/23, a review of Patient #5's medical record revealed the patient was over the age of 18 and received services via the Medicaid Long term Care waiver. Review of the OASIS comprehensive assessments report revealed the following; -On 9/29/22 the directory of nursing (DON) completed an OASIS nurse recertification on Patient #5. -On 11/23/22 the DON completed an OASIS nurse recertification on Patient #5. -On 1/25/23 the DON completed an OASIS nurse certification on Patient #5. -On 3/16/23 the DON completed an OASIS nurse certification on Patient #5. -On 5/18/23 the DON completed an OASIS nurse certification on Patient #5. 3. During an interview on 7/18/23 at 9:06 a.m., the administrator and the DON stated they did not know about submitting the OASIS reports after they were completed. The DON stated the agency's EMR system may automatically submit the OASIS report once they were completed by the registered nurse (RN). During a follow up interview on 7/18/23 at 9:26 a.m., the administrator stated the OASIS certifications did not get automatically submitted by the agency's EMR system. The administrator confirmed the agency had not submitted the OASIS comprehensive assessment within 30 days after completion. 4. On 7/19/23, a OASIS activity report was performed on the agency for the submission period from 7/1/22 to 7/19/23. The report came back with the following results, "There are no results for the report criteria."