Every finding on record at Covenant Home Services

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/07/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 02/07/25. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning SN = Skilled Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients 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 review of the HHA Error Summary report and Staff interview, it was determined that in 1586 of 1824 OASIS reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The HHA Error Summary report for 01/01/24 to 12/31/24 (12 months), was reviewed on 02/06/25. The report included a warning for Error # -3330. The Error included 1586 of 1824 (86.95 %) OASIS assessments that were submitted late. 2. During an interview with the Administrator and Clinical Director on 02/06/25 at 11:00 AM, the Administrator stated that the Agency should submit the required Medicare OASIS within the 30-day timeframe of the assessment date. During the same interview, the Administrator confirmed that the required Medicare OASIS submissions for the 12 months mentioned above were submitted late.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record reviews and Staff interview, it was determined that in 6 of 13 (Pts. #7, 9,12,13, 10 and 11) clinical records reviewed, the Agency failed to ensure clinical records were complete. 5. Pt. #10 was admitted to Home Health Services on 06/27/24 with the Diagnosis of Spinal Stenosis. The clinical record was reviewed on 02/05/25. The SN visit notes 08/29, 09/02, and 09/05/24 lacked documentation of vital sign assessment. 6. Pt. #10 was admitted to Home Health Services on 06/27/24 with the Diagnosis of Pressure Ulcer of Sacral Region Stage 3. The clinical record was reviewed on 02/06/25. The SN visit notes dated 01/13, 01/20 and 01/27/24 lacked documentation of vital sign assessment. 7. During interviews with the Administrator and Clinical Director on 02/06/25 at 11:00 AM and 1:30 PM finding of the incomplete clinical records was confirmed. Findings include: 1. Pt. #7 was admitted to Home Health Services on 11/02/24 with the Diagnoses of Disruption of External Operation (Surgical Wound) and Type 2 Diabetes Mellitus with Hypoglycemia without coma. The clinical record was reviewed on 02/05/25. The SN notes dated 01/06/25 and 01/10/25, lacked documentation of blood sugar assessments. 2. Pt. #9 was admitted to Home Health Services on 12/12/24 with the Diagnoses of Age related osteoporosis with Current pathological fracture and Type 2 Diabetes Mellitus with Diabetic Chronic kidney disease. The clinical record was reviewed on 02/05/25. The initial SN assessment dated 12/12/24, lacked documentation of a blood sugar assessment. 3. Pt. #12 was admitted to Home Health Services on 05/22/24 with the Diagnosis of Encounter for change or removal of surgical wound. The clinical record was reviewed on 02/05/25. The following SN notes dated 09/20/24, 09/23/24, 09/25/24, 09/27/24, 09/30/24, 10/02/24, 10/11/24, 10/16/24 and 10/18/24, lacked documentation of vital sign assessments. 4. Pt. # 13 was admitted to Home Health Services on 02/13/24 with the Diagnosis of Type 2 Diabetes Mellitus and Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease. The clinical record was reviewed on 02/06/25. The SN note dated 03/23/24, lacked documentation of a blood pressure assessment.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients POC = Plan of Care SOC = Start of Care Amt. = Amount SN = Skilled Nurse PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist OTA = Occupational Therapist Assistant ST = Speech Therapist AM = Morning PM = Afternoon, Evening x = Times COVID-19 = Coronavirus 2019

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, the Agency's "Patient Bill of Rights," and staff interview, it was determined the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline prior to providing Pt. care and services. This was found in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 11/1/21 at 2:30 PM to 11/3/21 at 1:10 PM: Pt. #1. SOC: 9/29/21. Pt. #2. SOC: 10/16/21. Pt. #3. SOC: 10/20/21. Pt. #4. SOC: 10/22/21. Pt. #5. SOC: 9/6/21. Pt. #6. SOC: 10/22/21. Pt. #7. SOC: 8/7/20. Pt. #8. SOC: 11/9/20. Pt. #9. SOC: 6/15/21. Pt. #10. SOC: 12/3/20. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. The Agency document, “Patient Bill of Rights” was reviewed on 11/1/21 at 2:00 PM, and requires, “As a client of (Agency) you have the right to: 4. Participate in, and be informed about, and consent to refuse care in advance and during treatment with respect to… the frequency of visits…” 3. An interview was conducted with the Administrator, Nursing Manager/Director and Rehab Supervisor on 11/4/21 from 9:30 AM to 10:30 AM. During the interview, the above findings were confirmed.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure Patients were notified of their co-payment/deductible financial responsibility, if any, prior to receiving services. This was found in 3 of 10 records reviewed (Pts. #4, 6, and 9). 2. Pt. #6 SOC: 10/22/21. Principal Diagnosis: Unspecified Fracture of the Left Pubis. The clinical record was reviewed on 11/1/21 at 2:15 PM. The record contained a form “Consent/Financial Responsibility and Acknowledgement of Privacy Practices.” The form was signed and dated by Pt. #6 upon admission, but the sections titled “Co-payment Amt. and Deductible” were left blank. 3. Pt. #9. SOC 6/15/21. Principal Diagnosis: Diverticulitis of Intestine, Part Unspecified, Without Perforation or Abscess Without Bleeding. The clinical record was reviewed on 11/2/21 at 10:55 AM. The record contained a form “Consent/Financial Responsibility and Acknowledgement of Privacy Practices.” The form was signed and dated by Pt. #9 upon admission, but the sections titled “Co-payment Amt. and Deductible” were left blank. 4. The Agency policy “Financial Responsibility and Medicare Written Notices” was reviewed on 11/4/21 at 9:30 AM. The policy requires, “Upon admission, the admitting clinician will inform the patient and /or his/her representative of his/her payment responsibilities for services..." 5. During an interview with the Administrator, Clinical Manager/Director, Rehab Supervisor on 11/4/21 from 9:40 AM to 10:30 AM, the above findings were confirmed. Findings include: 1. Pt. #4. SOC 10-22-21. Primary Diagnosis: Unspecified Atrial Fibrillation. The clinical record was reviewed on 11-2-21 at 9:40 AM. The record contained a POC effective 10-22-21 to 12-20-21, which included the Physician’s order “PT evaluation and treat,” and “OT evaluation and treat.” The record also contained a document titled “Consent/Financial Responsibility and Acknowledgement of Privacy Practices,” signed by the Pt. on 10-22-21. This document lacked the amount (if any) the Pt. would be responsible for co-payment/deductible payment for PT and OT services.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy review, and staff interviews, it was determined the Agency failed to assess patients' Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. This was found in 2 of 10 (Pts. #1 and 9) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/29/21. Principal Diagnosis: Chronic Kidney Disease Stage III. The clinical record was reviewed on 11/2/21 at 1:30 PM. The record lacked documentation of Pt. #1’s Influenza and Pneumonia immunization status. 2. Pt. #9. SOC 6/15/21. Principal Diagnosis: Diverticulitis of Intestine, Part Unspecified, Without Perforation or Abscess Without Bleeding. The clinical record was reviewed on 11/2/21 at 10:55 AM. The record lacked documentation of Pt. #1’s Influenza and Pneumonia immunization status. 3. The Agency Policy “Initial and Comprehensive Assessment” was reviewed on 11/4/21 at 11:00 AM. The policy requires, “During the initial and comprehensive patient assessment, all baseline data to be used…and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: U. Immunizations, when appropriate…” 4. During the entrance interview with the Administrator, Clinical Manager/Director and Rehab Supervisor on 11/1/21 at 10:00 AM, the Rehab Supervisor stated that immunization screening/assessment is conducted upon admission and is documented on the initial comprehensive assessment. 5. During an interview with the Administrator, Clinical Manager/Director and Rehab Supervisor on 11/4/21 from 9:40 AM to 10:30 AM, the above findings were confirmed.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to screen Pts. for signs and symptoms of COVID-19 prior to home visits. This was found in 4 of 10 (Pt. #3, 4, 5, and 10) records reviewed. Findings include: 1. Pt. #3. SOC 10-28-21. Primary Diagnosis: Other Fracture of Shaft of Left Fibula, Sequelae. The clinical record was reviewed on 11-2-21 at 9:15 AM. The record contained documentation the SN provided service on 10-28-21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to this visit. 2. Pt. #4. SOC 10-22-21. Primary Diagnosis: Unspecified Atrial Fibrillation. The clinical record was reviewed on 11-2-21 at 9:40 AM. The record contained documentation the SN provided service on 10-22-21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to this visit. The record also included documentation the PT provided service on 10/26/21. The record lacked documentation the PT screened the Pt. for signs and symptoms of COVID-19 prior to this visit. 3. Pt. #5. SOC 9-16-21. Primary Diagnosis: COVID-19. The clinical record was reviewed on 11-2-21 at 10:00 AM. The record contained documentation the SN provided twice weekly service from 10-5-21 to 10-21-21, as well as on 10-26-21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the PT provided service on 10-5-21 and 10-7-21. The record lacked documentation the PT screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also contained documentation the OT provided service on 9-22-21, 10-4-21, 10-6-21, and 10-14-21. The record lacked documentation the OT screened the Pt. for signs and symptoms of COVID-19 prior to these visits. The record also included documentation the ST provided service on 10-7-21. The record lacked documentation the ST screened the Pt. for signs and symptoms of COVID-19 prior to this visit. 4. Pt. #10. SOC 12-3-20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11-3-21 at 1:10 PM. The record contained documentation the SN provided service on 12-11-21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to this visit. 5. During an interview with the Clinical Manager/Director on 11-2-21 at 11:00 AM, the Clinical Manager/Director stated all staff providing home services should screen the Pt. for signs and symptoms of COVID-19 prior to visits, and document the results of these screenings in the Patient’s medical record. 6. During an interview with the Administrator, Clinical Manager/Director, and the Rehab Supervisor on 11-4-21 at 9:40 AM, the above findings were confirmed.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide services as ordered by the Physician in the POC. This was found in 4 of 10 records reviewed (Pt. #10, 1, 8, and 9). 2. Pt. #1. SOC 9/29/21. Principal Diagnosis: Chronic Kidney Disease Stage III. The clinical record was reviewed on 11/2/21 at 1:30 PM. The clinical record included a POC for the period of 9/29/21 to 11/27/21 requiring, “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration): ST 10/3/21 1x week x 1 week.” The record lacked documentation of an ST visit and physician notification for the missed visit. 3. Pt. #8. SOC 11/9/20. Principal Diagnosis: Hypertensive Heart Disease With Heart Failure. The clinical record was reviewed on 11/3/21 at 10:50 AM. The clinical record included a POC for the period of 11/9/20 to 1/7/21 requiring, “Orders for Discipline and Treatments (Specify Amount /Frequency/ Duration): PT 11/8/20 1x week x 1 week, 11/15/20 2 x week x 3 weeks... ST 11/10/20 2 x week x 1 week, 11/15/20 2 x week x 4 weeks.” The record lacked documentation of physician notification for the missed PT visit on 11/25/20 and for the ST visits on 11/19/20 and 11/23/20. 4. Pt. #9. SOC 6/15/21. Principal Diagnosis: Diverticulitis of Intestine, Part Unspecified, Without Perforation or Abscess Without Bleeding. The clinical record was reviewed on 11/2/21 at 10:55 AM. The clinical record included a POC for the period of 6/15/21 to 8/13/21 requiring, “Orders for Discipline and Treatments (Specify Amount /Frequency/ Duration): ST 6/15/21 1 x week x 1 week, 6/20/21 2 x week x 3 weeks.” The record lacked documentation of physician notification for the missed ST visits on 7/7/21 and 7/23/21. 5. The Agency policy “Missed Visit” was reviewed on 11/3/21 at 4:00 PM. The policy requires, “Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visit will be documented in the clinical record…3. Document in the patient clinical record the following information: c. Reason for the missed visit, e. Physician notification including date, time, physician name, method of notification and the staff reporting the information…” 6. During an interview with the Administrator, Clinical Manager/Director, Rehab Supervisor on 11/4/21 from 9:40 AM to 10:30 AM, the above findings were confirmed. Findings include: 1. Pt. #10. SOC 12-3-20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11-3-21 at 1:10 PM. The record contained the POC effective 12-3-20 to 1-31-21, which contained the Physician’s order dated 12-13-20 “OT 2 x week x 3 weeks.” The record also included a OTA “Missed Visit” note dated 12-24-20 which contained “Pt. requested to cancel scheduled OTA visit today, citing family engagement for holiday…” The record lacked documentation the Physician was notified of this missed visit, or that the OTA subsequently provided a second OT visit for the week of 12-20-21 to 12-26-21.

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: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to send the Physician a completed copy of the Discharge Summary within 5 days. This was found in 2 of 3 (Pts. #9 and 10) closed/discharged clinical records reviewed. Findings include: 2. Pt. #10. SOC 12-3-20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11-3-21 at 1:10 PM. The record included a “Agency Discharge Summary,” which documented the Pt. was discharged from all Agency services effective 12-31-20. This “Agency Discharge Summary” was dated 1-20-21, and faxed to the Physician on 1-20-21, 20 days after the Pt. was discharged. 3. The Agency policy titled “Discharge Summary,” was reviewed on 11-3-21 at 11:30 AM. The policy required: “…The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service…A copy of the discharge summary will be provided to the Patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the Patient after discharge from the organization within five (5) business days of the Patient’s discharge…” 4. During a meeting with the Administrator, Clinical Manager/Director, and the Rehab Supervisor on 11-4-21 at 9:40 AM to 10:30 AM, the above findings were confirmed. 1. Pt. #9. SOC 6/15/21. Principal Diagnosis: Diverticulitis of Intestine, Part Unspecified, Without Perforation or Abscess Without Bleeding. The clinical record was reviewed on 11/2/21 at 10:55 AM and indicated that Pt. #9 was discharged from the Agency on 7/26/21. A copy of the Discharge Summary was sent to the Physician 15 days later, on 8/10/21.