Every finding on record at County of Flathead

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies, effective 11/15/17, a recertification EP survey was performed on 5/12/21. A COVID-19 Emergency Preparedness abbreviated survey was conducted on 5/12/21 by the Montana Department of Public Health and Human Services. The facility was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6).

A Recertification survey was completed on 5/12/21. Standard level citations were cited for this survey. A COVID-19 Focused Infection Control (FIC) survey was conducted by the Montana Department of Public Health and Human Services on 5/12/21. The facility was found to be in compliance with 42 CFR §484.70 infection control regulations and has implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. An Emergency Preparedness (EP) survey which included a review of 42 CFR §483.73; E-0024 (b)(6), was completed on 5/12/21. The agency was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6). Facility Census: 49 Glossary: CMS Medicare and Medicaid Services EHR Electronic Health Record HHA Home Health Agency OASIS Outcome and Assessment Information Set OT Occupation Therapy PT Physical Therapy SN Skilled Nursing SOC Start of Care UTI Urinary Tract Infection

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to accurately encode a discharge OASIS assessment for a UTI for 1 (#3); and failed to accurately encode a start of care OASIS assessment for pressure ulcers for 1 (#1) of 10 sampled patients. Findings include: A review of the agency's policy and procedure titled, Comprehensive Assessment, showed, "Each patient will receive a patient specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes... 15. [Agency] will ensure timely and accuracy [sic] of the OASIS data. a. The Clinical Manager/[Agency] Administrator and/or designee will consult with the qualified clinician who conducted and completed the comprehensive assessment for purposes of collaboration, clarification or to complete missing OASIS data items. 1. Patient #3 had a SOC date of 4/17/20, with a primary diagnosis of acute respiratory failure. A review of patient #3's SN OASIS discharge assessment completed on 6/2/20 (M0090), showed, (M1600), the patient had been treated for a UTI in the past 14-days. A review of patient #3's EHR, failed to show the patient had been treated for a UTI during the service period of 4/17/20 through 6/2/20. During an interview on 5/12/21 at 9:00 a.m., staff member B stated it was the expectation the discharge OASIS accurately reflect the status of the patient at the time of discharge, and accurately reflect the services provided during the patient's service period. Staff member B said the OASIS were reviewed by two staff members before being submitted to assess for accuracy. During an interview on 5/12/21 at 4:00 p.m., staff member A stated they had reviewed patient #3's records and determined the patient was not treated for a UTI during that service period. 2. Patient #1 had a SOC date of 7/10/20, with a primary diagnosis of urosepsis. A review of patient #1's SOC Skin Assessment, dated 7/14/20, showed, one Unstageable Pressure Ulcer on his buttocks, present at SOC. Patient #1's SOC OASIS assessment completed on 7/14/20 (M0090), showed "no" for (M1306), does the patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher, or designated as Unstageable. During an interview on 5/12/21 at 8:00 a.m., staff member A stated the staff member completing the SOC assessment and OASIS was not sure how to code the pressure ulcer, so they inquired with the primary care physician, who had recommended the wound be Staged as Unstageable. She said unfortunately, although the skin assessment was accurate the coding on the SOC OASIS did not reflect the patient's status.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the timely completion of the initial assessment visit for 1 (# 5) of 10 sampled patients. Findings include: A review of the agency's policy and procedure titled, Referral Process, showed, "7. The initial visit will be made within 48 hours after the referral is received unless a more immediate need is identified or by physician order." Patient #5 had a SOC date of 4/26/21, with a primary diagnosis of clostridium difficile. Review of patient #5's Physician Orders dated 4/19/21, showed a referral for PT and OT. Review of patient #5's Intake Note, dated 4/22/21, showed a referral was received for PT/OT/ST for evaluation and treatment, with PT Admit. Review of patient #5's SOC OASIS showed, SOC (M0030) on 4/26/21, and a referral date (M0104) on 4/22/21. A review of patient #5's EHR did not show the patient's initial assessment was made within 48 hours of the referral. Further review did not show the patient's initial assessment was completed remotely or record review completed within 48-hours of the referral as outlined by CMS Emergency Declaration Blanket Waiver for Home Health Agencies. During an interview on 5/12/21 at 12:30 p.m., staff member B stated it was the expectation for the ordered clinician to initiate an initial SOC assessment within 48 hours of receiving the referral, or on the patient ordered SOC date.