Every finding on record at Community Care Nursing Services of Dc

The State Agency conducted an unannounced Federal Medicare/Medicaid recertification Survey from 08/29/2023 through 09/06/2023 for compliance with Emergency Preparedness requirements for Home Health Agencies. The Home Health Agency's total active census was 15 patients. Based on a review of the Emergency Preparedness Program and an interview with the Home Health Agency's staff, the surveyor found the Home Health Agency in compliance with the requirements for the Emergency Preparedness Program. There were no deficiencies cited.

The State Agency conducted an unannounced Federal Medicare/Medicaid Home Health Agency Recertification Survey from 08/29/2023 through 09/06/2023. The Agency reported the number of unduplicated admissions for skilled services during the most recent 12-month period was five (5) patients. The sample consisted of eight (8) clinical records, 11 personnel records, and three (3) home visits. On the first day of the survey, the Home Health Agency reported the total active census was 15 patients. The following condition-level deficiency was identified: §484.45 Condition of Participation: Reporting OASIS Information In addition, Standard-level deficiencies were cited based on observations, clinic records review, agency policies review, interviews with agency staff and caregivers, and home visits. Glossary ADLs- Activities of Daily Living BID- Two times a day CFR- Code of Federal Regulations CM- Clinical Modification CMS - Centers for Medicare and Medicaid Services DCMR- District of Columbia Municipal Regulations DME - Durable Medical Equipment ER - Emergency Room G-Tube - Gastrotomy Tube HHA- Home Health Aide HHA- Home Health Agency IADLs -Instrumental Activities of Daily Living LPN - Licensed Practical Nurse MAR - Medication Administration Record mg - milligram(s) ml - milliliter(s) OASIS- Outcome and Assessment Information Set Items PCA- Personal Care Aide PRN - As Needed REG- Regulation RN - Registered Nurse SN - Skilled Nurse (ing) SOC - Start of Care WK- week (s) WNL - within normal limits % - Percentage

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on clinical record review and staff interviews, the Home Health Agency failed to electronically report OASIS (Outcome & Assessment Information Set) data collected for all applicable patients, in an electronic format that meets CMS (Centers for Medicaid and Medicare Services) for two (2) of two (2) patients (Patient’s #3 and #6). Findings included: A review of the Home Health Agency’s Start of Care Policies showed the facility failed to provide policies as requested for reporting OASIS information, encoding, and transmitting OASIS data. A review of the Home Health Agency's undated policy titled, "Start of Care (SOC); Assessment, Lock, and Submission Date”, showed the Start of Care will be assessed within five (5) calendar days, …locked within seven (7) days following the information completion date. Submission will be no later than the last day of the month following the month the assessment was locked.” On the first day of the survey, a review of the Home Health Agency's active census showed the following patients: A. Record review of Patient #3's clinical record on 08/31/2023 at approximately 12:30 PM showed a Recertification Comprehensive assessment with OASIS dated 07/29/2023. B. Record review of Patient #6's clinical record on 09/05/2023 at approximately 10:30 AM showed a Recertification Comprehensive assessment with OASIS elements dated 08/17/2023. Patients #3 and #6 were over the age of 18. The Home Health Agency failed to collect and electronically report OASIS comprehensive assessment data to CMS. During the entrance conference, on 08/29/2023 at approximately 10:30 AM, Employees #2 (Director of Clinical Services) and Employee #3 (Quality Assurance Nurse), stated there had been no transmittal of any OASIS Comprehensive Assessments within the last three (3) months when they were asked about Oasis Validation reports. During a face-to-face interview with Employees, #1 (Administrator) #2, (Director of Clinical Services), and #3 (Quality Assurance Nurse) on 09/06/2023 at approximately 3:00 PM acknowledged the findings.

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 observation, interviews with agency staff, review of clinical records, the agency's policy, and medications in patients' homes, the agency's staff failed to conduct accurate medication reviews for one (1) of six (6) current clinical records reviews to include three (3) patients for home visits conducted (Patients # 2). Findings included... A review of the Home Health Agency’s policy titled, "Medication Profile and Reconciliation," dated 6/2023 showed the medication profile is completed in its entirety, including dosage, frequency, and administration routes…the list of current medication is incorporated into the plan of care. The surveyor conducted a home visit with Patient #2 on 08/30/2023, at approximately 12:30 PM in the presence of Employees #3 (Quality Assurance Nurse), and 6, Licensed Practical Nurse (LPN). During the home visit, the surveyor requested permission from the agency and the patient's caregiver to review all the medications the patient was taking, including those prescribed by a physician, medications purchased over the counter, and herbal supplements. The surveyor observed 24 medications in the patient's home, including the following: Polyethylene Glycol 3350, mix and dissolve one (1) capful in eight (8) oz of water and give by gastrostomy tube as needed (PRN) for constipation. The surveyor conducted a review of Patient #2's clinical record on 08/31/2023, at approximately 11:00 AM. The record showed a Plan of Care with a Start of Care date of 05/09/2019 and a Recertification Period from 08/15/2023 to 10/13/2023. The diagnoses listed on the Plan of Care included Huntington’s Disease, Gastrojejunostomy, Tracheostomy, Seizure Disorder, and Ventilator Dependent. For one (1) of the medications (Polyethylene Glycol), the surveyor observed the prescription label as Polyethylene Glycol 3350, mix and dissolve one (1) capful in eight (8) oz of water and via gastrostomy tube as needed (PRN) for constipation in the home. The Plan of Care and the Medication Administration Record (MAR) showed Polyethylene Glycol 3350 (MiraLAX) 17 grams/capful. Give one (1) cap full (17 grams) in 240 milliliters of water daily via gastrotomy tube for bowel regimen. The clinical record lacked documented evidence that the home health agency clinical staff conducted accurate medication reconciliation or notified the physician regarding the discrepancies. During a face-to-face interview with Employee # 2 (Director of Clinical Services), and #3, (Quality Assurance Nurse) on 09/06/2023, at approximately 3:00 PM, they both acknowledged the findings.

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 clinical record review, the Home Health Agency's policy review, and staff interviews, the Home Health Agency failed to submit completed discharge summaries within five (5) business days of discharge to the primary care physicians for two (2) of two (2) closed clinical record reviews. (Patients #7 and 8). Findings included… Record review of the Home Health Agency's undated policy titled, “Criteria for Discharge/Transfer/Referral,” showed a copy of the signed discharge form becomes part of the patient’s record within five (5) days of discharge…a copy of the signed form is sent to the primary physician…documentation in the medical record that the physician was notified. A. The surveyor reviewed Patient #7's closed clinical record on 09/05/2023 at approximately 10:30 AM. The closed clinical record included a Plan of Care with a Start of Care date of 03/09/2020 and a Recertification Period from 02/20/2023 to 04/20/2023. The diagnoses included Liver Disease, Congenial Malabsorption of Digestive System, Intestinal Malabsorption, Gastrojejunostomy, and History of Colostomy (closed). A review of the closed clinical record showed a completed Discharge Summary by employee #2 (Director of Clinical Services) dated 03/13/2023 with a fax cover sheet dated 03/13/2023. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #7's discharge summary to the primary care physician within five (5) business days of discharge. B. The surveyor reviewed Patient #8's closed clinical record on 09/05/2023 at approximately 11:15 AM. The clinical record included a Plan of Care with a Start of Care date of 05/23/2022 and a Recertification Period from 01/18/2023 to 03/18/2023. The diagnoses included Cerebral Palsy, Gastrostomy, and Ventriculoperitoneal (VP) Shunt. A review of the closed clinical record showed a completed discharge summary by employee #2 (Director of Clinical Services) with a fax cover sheet dated 03/07/2023. The closed clinical record review lacked documented evidence that the Home Health Agency staff submitted Patient #8's discharge summary to the primary care physician within five (5) business days of discharge. The Home Health Agency staff failed to submit a completed discharge summary to the primary care physician within a specified time for Patients #7 and 8. The surveyor conducted a face-to-face interview with Employee #2 (Director of Clinical Services) on 09/05/2023 at approximately 1:00 PM. Employee #2 acknowledged she was unable to provide a copy of the fax transmittals submitted to the physician for Patients #7 and 8.