Every finding on record at Dallas Horizon Home Health Agency LLC

A relicensure/recertification survey entrance conference was conducted on 12/14/2022. The census was: LCHHS: 0 LHH: 0 PAS: 18 The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted on 12/14/2022. The census was: LCHHS: 0 LHH: 0 PAS: 18 Abbreviations: Adm – Administrator Alt – Alternate AM - Ante meridiem Att - attendant CFR – Code of Federal Regulations CHC -Criminal History Check CMS – Centers for Medicaid and Medicare DADS - Department of Aging and Disability DON - Director of Nurses DNR – Do Not Resuscitate EMR – Employee Misconduct Registry hha – Home Health Aide HHSC - Health and Human Services Commission LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services LVN -Licensed Vocational Nurse NAR – Nurse Aide Registry OASIS- Outcome and Assessment Information Set PAS – personal assistance services pg. – page PIP - Performance Improvement Project PM - Post meridiem PoC _ Plan of Correction PT - Physical Therapist QAPI – Quality Assessment Performance Improvement RN – Registered Nurse SN - Skilled Nurse Sup – Supervisor

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: This is a repeat deficiency cited at G0658 on survey dated 12/11/2019. Based on record review and interview, the agency failed to conduct and document PIP’s for three of three calendar years 2019, 2020 and 2021 and failed to have at least one PIP in development or on-going for calendar year 2022 that reflected the scope, complexity and past performance of the agency's services and operations and the measurable progress achieved on the projects. This failure could prevent the agency from identifying weaknesses and making needed improvements in patient care. Findings Include: Record review of the agency's QAPI binder did not include any reports, reviews or documentation that indicated the agency had conducted a PIP for calendar year 2019, 2020 and 2021 or had a PIP in development or on-going for calendar year 2022. During an interview with the Adm/PAS Sup on 12/22/2022 at 4:36 PM, the surveyor presented the above findings of what the agency's PIP had been in 2019, 2020 and 2021 and for the current year, 2022. The Adm/PAS Sup stated the agency did not have a PIP for those years due to ignorance on his part. The Adm/PAS Sup stated it was something he needed to make corrections on. The surveyor stated at the 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm/PAS Sup stated it wasn’t corrected because he had so much going on with his personal life. Agency policy titled, “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT” with a revision date of 1ST Quarter, 2012, read in part, “POLICY: As we strive for excellence in the provision of care, the organization is committed to the development and implementation of a performance improvement program….PURPOSE: To systematically evaluate the quality of care rendered to individuals, families, and the community, in order to improve the quality of care provided, and to assure proper utilization of services…PROCEDURE: IX. The QAPI Committee should complete individual Performance Improvement Projects on areas for improvement…” Agency policy titled, “REGULATORY AGENCY COMPLIANCE” with a revision date of 3rd Quarter, 2011, read in part, “POLICY: This Agency will adhere to all Medicare and state regulations…The licensee (Owner) is ultimately responsible for compliance with the regulations…”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Add/PAS Sup failed to carry out, organize and direct the agency's ongoing functions in that: 1. The Adm/PAS Sup failed to include in each personnel record with direct patient contact a signed statement about compliance with agency policies in nine of nine personnel records reviewed (Adm/PAS Sup, DON, RN, LVN, hha, Att A, B, D and Att C/LVN). 2. The Adm/PAS Sup failed to designate in writing a similarly qualified Alt to serve as DON/Sup Nurse in the absence of the DON/Sup Nurse. 3. The Adm/PAS Sup failed to maintain a written policy that complied with the Advance Directives Act, Texas Health and Safety Code, Chapter 166, that included a clear and precise statement of any procedure the agency is unwilling or unable to provide or withhold in accordance with a patient’s advance directive. 4. The agency failed to ensure the Adm/PAS Sup and Alt Adm completed 12 clock hours of continuing education within each 12 month designation period beginning with the date of designation in two of two records reviewed for continuing education requirements. 5. The Adm/PAS Sup failed to conduct searches of the NAR and EMR before the agency hired unlicensed applicants with face to face contact with patients in three of four attendant records reviewed (Att A, B and D) and before one administrative (Adm/PAS Sup) current record employees' first face to face contact with a patient. 6. The agency failed to ensure the clinical records, it contents and the information contained therein were safeguarded against loss in seven of seven patient records (Patient 3, 4, 5, 6, 7, 8 and 9), in that the agency used a vendor for an electronic clinical record system and did not have access to the electronic patient's records or have complete paper patient records. 7. The agency failed to conduct and document PIP’s for three of three calendar years 2019, 2020 and 2021 and failed to have at least one PIP in development or on-going for calendar year 2022 that reflected the scope, complexity and past performance of the agency's services and operations and the measurable progress achieved on the projects. These failures showed lack of overall administrative leadership and agency oversight and could place the agency's patients at risk of abuse, neglect and/or exploitation; at risk of unsafe practices and inadequate care and services from employees who were unaware of agency polices; could violate patient rights to direct end of life decisions; placed the patients at risk of poor outcomes and prevented the surveyor from reviewing complete patient records. Findings Include: 1. Record review and Adm/PAS Sup interview on 12/22/2022 determined the following: Adm/PAS Supervisor was hired on 09/13/2003; DON was hired on 11/14/2008; RN was hired on 06/18/2019; LVN was hired on 07/30/2019; hha was hired on 06/07/2018. Att A was hired as Att on 07/30/2022; Att B was hired as Att on 011/03/2022; Att D was hired as Att on 06/21/2020; Att C/LVN was hired as LVN on 07/30/2019. Record review of the personnel record for Adm/PAS Sup, DON, RN, LVN, hha, Attendant A, B, D and Att C/LVN revealed no evidence of a signed a statement about compliance with agency policies. During an interview with the Adm on 12/22/2022 at 3:50 PM, the surveyor presented the above findings of why the personnel files for Adm/PAS Supervisor, DON, RN, LVN, hha, Attendant A, B, D and Att C/LVN did not include a signed statement about compliance with agency policies. The Adm stated he thought the information was included on an agency form titled, “Orientation Checklist”. The surveyor reviewed the orientation checklist form with the Adm. The form did not include a signed statement about compliance with agency policies. The Adm/PAS Sup stated he didn’t realize the information was not on the orientation form. The surveyor reviewed the above findings and stated at the survey dated 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm stated it was failure on his part as he thought it had been corrected. Agency policy titled, “MAINTENANCE OF PERSONNEL DOCUMENTATION” with a revision date of 3rd Quarter, 2012, read in part, “…PROCEDURE…III. The personnel record for employees…shall include…M. the signed statement about compliance with agency policies…” Agency policy titled, “REGULATORY AGENCY COMPLIANCE” with a revision date of 3rd Quarter, 2011, read in part, “POLICY: This Agency will adhere to all Medicare and state regulations…The licensee (Owner) is ultimately responsible for compliance with the regulations…” 2. Review of the Texas Unified Licensure Information Portal reflected an Alt DON/Sup Nurse was designated. During the entrance conference with the Adm/PAS Sup on 12/14/2022, it was discovered the designated Alt DON/Sup Nurse no longer held the position and the agency currently had no Alt DON/Sup Nurse. During an interview with the Adm/PAS Sup on 12/14/2022 at 1:45 PM, the surveyor presented the above findings and asked when the Alt DON/Sup Nurse position became vacant. The Adm/PAS Sup stated February 2022 and he had not found a replacement. The surveyor asked Adm/PAS Sup if he was aware it was a requirement for the agency to have an Alt DON/Sup Nurse. The Adm/PAS Sup stated he was aware but since the agency had zero skilled patients, it would be financially difficult to hire a replacement. Agency policy titled, “SUPERVISING NURSE” with a revision date of 3rd Quarter 2012, read in part, “POLICY: The Supervising Nurse is responsible for the supervision of clinical services in the Agency…PROCEDURE: I. The Supervising Nurse and Alternate are designated in writing by the Administrative Director…X. An agency must designate in writing a similarly qualified alternate to serve as supervising nurse in the absence of the supervising nurse…” Agency policy titled, “ADMINISTRATIVE FUNCTIONS” with a revision date of 3rd Quarter 2012, read in part, “POLICY: The Administrator must be responsible for implementing and supervising the administrative policies of the Agency and administratively supervising the provision of services…PROCEDURE…X. The Administrator…appoints a supervising nurse. The Administrator also appoints a similarly qualified alternate to serve as supervising nurse in the absence of the supervising nurse…” 3. During the entrance conference with the Adm/PAS Sup, the surveyor provided a list of documents needed for review by the surveyor. The list requested the agency policy and procedure manual. The Adm/PAS Sup provided the surveyor with three policy and procedure manuals labeled I, II and III. During an interview on 12/16/2022 at 12:30 PM with the Adm/PAS Sup, the surveyor asked which manual the agency used. The Adm/PAS Sup stated, “manual III.” Record review of manual III did not include an Advance Directive policy. The surveyor requested the Adm/PAS Sup locate the agency Advance Directive policy. The Adm/PAS Sup presented the policy to the surveyor from policy Manual I. The policy titled, “ADVANCE DIRECTIVE 3.2” without a revision date, read in part, “PURPOSE...To ensure that adult patients/legal guardians are informed of patient rights under state law to make and direct decisions concerning medical care; including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives such as a "Living Will', "Medical Power of Attorney", "Out-Of-Hospital DNR", or "Declaration of Mental Health Statement". To guide Agency staff in implementing the provisions of the Patient Self-Determination Act...POLICY...Agency recognizes an adult patient's/legal guardian's right under state law to make decisions regarding medical care...However, if at any time Agency staff is unable to honor an advance directive elected by the patient, the patient will be notified and will be transferred to another appropriate agency/organization...” The policy did not define what circumstances or reasons why agency staff would be unable to honor an advance directive. The policy did not include a clear and precise statement of any procedure the agency staff were unwilling or unable to provide or withhold in accordance with an Advance Directive. During an interview with the Adm/PAS Sup on 12/21/2022 at 4:48 PM, the surveyor presented the above findings and asked why the advance directive policy did not define what circumstances or the reason why agency staff would be unable to honor an advance directive and a clear and precise statement of any procedure the agency staff were unwilling or unable to provide or withhold in accordance with an advance directive. The Adm/PAS Sup stated it was an old advance directive policy and agency policies had not been overhauled like they should have been. The surveyor reviewed the above findings and stated at the survey dated 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm/PAS Sup stated it was failure on his part. Advance Directives Act, Texas Health and Safety Code, Chapter 166. Subchapter A, Section 166.004(3)(b) A health care provider shall maintain written policies regarding the implementation of advance directives. The policies must include a clear and precise statement of any procedure the health care provider is unwilling or unable to provide or withhold in accordance with an advance directive. 4. Record Review of the personnel record for Adm/PAS Sup and Alt Adm: The records included a signed job description for the Adm/PAS Sup and Alt Adm dated 09/13/2003. The designation periods under review were determined to be: 09/13/2019-09/14/2020 (Period 1), 09/13/2020-09/14/2021 (Period 2), 09/13/2021-09/14/2022 (Period 3). The record for Adm/PAS Sup and Alt Adm included zero continuing education hours for designation Period 1, 2 and 3. During an interview with the Adm/PAS Sup on 12/21/2022 at 3:00 PM, the surveyor presented the above findings and asked if the Adm/PAS Sup or the Alt Adm completed any Adm continuing education hours for designation period 1, 2 or 3. The Adm/PAS Sup stated, “No”. The surveyor asked why no continuing education hours were completed. The Adm/PAS Sup stated he just didn’t complete any and neither did the Alt Adm. The surveyor reviewed the above findings and stated at the survey dated 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm stated he just did not complete them due to so much going on with his personal life. Agency policy titled, “ADMINISTRATIVE FUNCTIONS” with a revision date of 3rd Quarter 2012, read in part, “POLICY: The Administrator must be responsible for implementing and supervising the administrative policies of the Agency and administratively supervising the provision of services…PROCEDURE…IV. An Administrator is responsible for implementing and supervising the administrative policies of the Agency and administratively supervising the provisions to agency client s on a day-to-day basis. An Administrator must: A. manage the daily operations of the agency; B. organize and direct the agency’s ongoing function; C. administratively supervise the provision of quality care to agency clients; D. supervise to ensure implementation of agency policy and procedures…” 5. According to: https://www.hhs.texas.gov/business/licensing-credentialing-regulation/long-term-care-credentialing/employee-misconduct-registry-emr, the one method available to perform the required NAR/EMR searches is by using the HHSC Employability Status Search at https://emr.dads.state.tx.us/DadsEMRWeb/ and entering the first and last name or the social security number of the person. Record review and Adm/PAS Sup interview on 12/22/2022 determined the following: Adm/PAS Supervisor was hired on 09/13/2003; Att A was hired on 07/30/2022; Att B was hired on 011/03/2022; Att D was hired on 06/21/2020. Adm/PAS Sup: During an interview with the Adm/PAS Sup on 12/21/2022 at 3:00 PM, the surveyor presented the above findings and asked who the PAS Sup was. The Adm/PAS Sup stated he was since the agency added PAS to their license in 2019. The surveyor asked if he had face to face contact with agency patients. The Adm/PAS Sup stated he started seeing non-skilled patients in 2020. Record review of the personnel record did not include evidence NAR/EMR searches were conducted prior to face to face contact with patients. The surveyor reviewed the above findings and asked if a NAR/EMR check was done prior to face to face contact with agency patients. The Adm/PAS Sup stated, “No, I didn’t do any”. Att A: Record review of the personnel record revealed no evidence a NAR/EMR search was conducted prior to hire. During an interview with the Adm/PAS Sup on 12/16/2022 at 2:40 PM, the surveyor presented the above findings and asked why the personnel record did not include a NAR/EMR search prior to hire. The Adm/PAS Sup stated the search was conducted over the phone and he did not have a printout reflecting the search result. Att B: Record review of the personnel record included a NAR/EMR search conducted on 12/15/2022. The personnel record revealed no evidence a NAR/EMR search was conducted prior to hire. During an interview with the Adm/PAS Sup on 12/22/2022 at 4:10 PM, the surveyor presented the above findings and asked why the personnel record did not include a NAR/EMR search prior to hire. The Adm/PAS Sup stated the search was conducted over the phone and he did not have a printout reflecting the search result. Att D: Record review of the personnel record included a NAR/EMR search conducted on 12/15/2022. The personnel record revealed no evidence a NAR/EMR search was conducted prior to hire. During an interview with the Adm/PAS Sup on 12/22/2022 at 4:13 PM, the surveyor presented the above findings and asked why the personnel record did not include a NAR/EMR search prior to hire. The Adm/PAS Sup stated he knew he did a NAR/EMR check at hire so if it was not included in the personnel file, he would have to look for it. The surveyor stated additional NAR/EMR checks would be accepted if received via email by 5:00 PM on 12/23/2022. The surveyor received an email from Adm/PAS Sup on 12/23/2022 at 1:20 PM that included a NAR/EMR search conducted on 02/01/2022, after Att D was employed. The surveyor reviewed the above finding and stated at the survey dated 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm stated he thought the phone call to check NAR/EMR was sufficient but he now knew it was not. Agency policy titled "Employability and Use of Unlicensed Persons" with a revision date of 3rd Quarter 2011, read in part, "POLICY: The Agency will not…employ/use an unlicensed person listed as unemployable on the Nurse Aide Registry or Employee Misconduct Registry…PROCEDURE: II ...Before hiring an unlicensed applicant ...the Agency must search the Nurse Aide Registry (NAR) and the Employee Misconduct Registry (EMR) using the DADS website to determine if the applicant ...is listed in either registry as unemployable ... III. Agency may not offer employment or allow face-to-face contact with a client until…the registry is completed ..." 6. CFR 484.110(c)(1)(2) Retention of Records reads: "Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time…" During the entrance conference, the Adm/PAS Sup stated the agency had used an electronic clinical record system when they had active, skilled patients but no longer had access to the electronic records and did not have paper records for any of the patients. The Adm/PAS Sup stated the agency’s last active skilled patient was discharged in January 2021 and the agency had been locked out of the electronic records. The surveyor stated access to the electronic records would be required for surveyor review. An email received by the Adm/PAS Sup on 12/20/2022 at 8:14 AM read in part, “…Unfortunately, [electronic record vendor] refused to grant me access into the portal…I have 7-10 patient files [paper records] within this period. However, I'm not sure if this will be be(sic) sufficient for what you need...” On 12/20/2022, the Adm/PAS Sup brought paper records for skilled patients and stated they were the only records available for surveyor review. Discharged Patient 3: Record review of the Patient discharge list included a discharge date of 04/01/2020. Record review of the paper record included a plan of care dated 12/12/2019-02/09/2020 with an unreadable frequency of nursing visits. The record included seven nursing visit notes from 12/12/2019-01/07/2020. Nursing visit notes after 01/07/2020 were not available for review. Record review of the 69-page OASIS (a patient-specific, assessment used in Medicare home health to plan care, determine reimbursement, and measure quality) Final Validation Report (a report that provides detailed information about the status of OASIS assessments submitted to CMS by the agency) obtained by the surveyor from the CMS Internet Quality Improvement and Evaluation System, revealed the agency successfully submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED: Patient transferred to an inpatient facility (pg. 14) / 01/10/2020; Resumption of home health care following an inpatient stay (pg. 15) / 01/28/2020; Discharge from home health agency (pg. 15)/ 02/08/2020. The three OASIS assessments were not available for surveyor review. Discharged Patient 4: Record review of the Patient discharge list included a discharge date of 03/28/2020. The time period under review was 12/31/2019-02/28/2020. Record review of the paper record did not include a plan of care. The record included eight nursing visit notes from 12/21/2019-01/23/2020. No documents under review were available between 01/24/2020- 02/28/2020. Record review of the 69-page OASIS Final Validation Report revealed the agency successfully submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED: Recertification (a follow-up assessment conducted during the last five days of the 60 day recertification period completed to continue services for an additional 60 day episode of care)(pg. 19) / 12/30/2019 Discharge from home health agency (pg. 63) / 02/28/2020. The two OASIS assessments were not available for surveyor review. Discharged Patient 5: Record review of the Patient discharge list included a discharge date of 02/19/2020. Record review of the paper record did not include any records for the surveyor to review in the discharge episode. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 17) / 02/03/2020 Recertification (pg. 60) / 03/30/2020. The two OASIS assessments were not available for surveyor review. The Final Validation Report did not include a discharge OASIS for the 02/19/2020 agency discharge. Discharged Patient 6: Record review of the Patient discharge list included a discharge date of 04/15/2020. Record review of the paper record did not include any records for the surveyor to review in the discharge episode. Record review of the OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 16) / 01/15/2020 Discharge from home health agency (pg. 55) / 03/15/2020. The two OASIS assessments were not available for surveyor review. Patient 7: Record review of the Patient discharge list included a transfer date of 03/01/2020. Record review of the paper record included a plan of care dated 01/11/2020-03/10/2020 that included orders for the nurse to conduct visits one time a week for nine weeks. The record included three nursing visit notes from 01/15/2020-01/31/2020. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 16) / 01/06/2020 Recertification (pg. 58) / 03/10/2020. The two OASIS assessments were not available for surveyor review. The Final Validation Report did not include a transfer to an inpatient facility OASIS for 03/01/2020. No documents under review were available between 02/01/2020- 03/10/2020. Discharged Patient 8: Record review of the Patient discharge list included a Patient expiration date of 03/01/2020. Record review of the paper record did not include any records for the surveyor to review in the expiration episode. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 18) / 02/03/2020 Recertification (pg. 56) / 04/04/2020 Died at Home (pg. 62) / 05/23/2020. The three OASIS assessments were not available for surveyor review Discharged Patient 9: Record review of the Patient discharge list included a discharger date of 10/28/2020. Record review of the paper record included a plan of care dated 12/17/2019-02/14/2020 that included orders for the nurse to conduct visits one time a week for nine weeks. The record did not include nursing visit notes for the period under review. The record included two supplemental physician orders: (1) 12/18/2019 Hold SN and PT until week of 01/06/2020; (2) 01/10/2020 Discharge per Patient request. No other documents were available for review. Record review of the 11-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / COMPLETED Recertification / 12/16/2019. The OASIS assessment was not available for surveyor review. During an interview with the Adm/PAS Sup on 12/14/2022 at 3:05 PM, the surveyor presented the above findings and asked why the electronic record vendor would not grant agency access to patient records. The Adm/PAS Sup stated the agency broke its contract with the vendor by thinking the contract was month to month but instead the agency was locked into a set period of time with the vendor. The Adm/PAS Sup stated the agency did not owe the vendor money but it would cost $2,500 for the agency to gain access to the records. Agency policy titled, “CLIENT RECORDS” with a revision date of 1st Quarter 2012, read in part, “…POLICY: Agency will establish and maintain client record system to ensure that the care and services are completely and accurately documented, readily accessible and systematically organized to facilitate compilation and retrieval of information. PURPOSE: To ensure that client records are maintained and to clarify and define process of both paper and electronic health record maintenance…PROCEDURE: I. A client record is maintained for each patient and is made available to inspectors as required by law. II. Agency will provide surveyors access to all required records and readily provide…information necessary to assist the surveyor in the review process. III. For electronic medical records the agency may provide the surveyor with a guest log-on and instructions regarding access of the EHR…IV. The client record whether paper or electronic must ensure that the care and services provided to each client are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information. VI. The record shall contain pertinent past and current medical and social data and include …assessments…a written plan of care…physician orders…signed and dated clinical progress notes…X. The EHR includes all services provided…The EHR is…safeguarded against loss, destruction and unofficial use, and is maintained according to professional standards of practice…XV. An agency may incorporate and file in the client’s EHR a signed paper record by preserving its electronic duplicate in the EHR; or the agency may maintain the client record as a combination of a signed paper record and EHR…” 7. Record review of the agency's QAPI binder did not include any reports, reviews or documentation that indicated the agency had conducted a PIP for calendar year 2019, 2020 and 2021 or had a PIP in development or on-going for calendar year 2022. During an interview with the Adm on 12/22/2022 at 4:36 PM, the surveyor presented the above findings of what the agency's PIP had been in 2019, 2020 and 2021 and for the current year, 2022. The Adm stated the agency did not have a PIP for those years due to ignorance on his part. The Adm stated it was something he needed to make corrections on. The surveyor stated at the 12/11/2019, the agency was cited for the same violation and submitted a PoC to correct the identified failure. The surveyor asked why the agency had not followed their PoC. The Adm stated it wasn’t corrected because he had so much going on with his personal life. Agency policy titled, “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT” with a revision date of 1ST Quarter, 2012, read in part, “POLICY: As we strive for excellence in the provision of care, the organization is committed to the development and implementation of a performance improvement program….PURPOSE: To systematically evaluate the quality of care rendered to individuals, families, and the community, in order to improve the quality of care provided, and to assure proper utilization of services…PROCEDURE: IX. The QAPI Committee should complete individual Performance Improvement Projects on areas for improvement…” Agency policy titled, “REGULATORY AGENCY COMPLIANCE” with a revision date of 3rd Quarter, 2011, read in part, “POLICY: This Agency will adhere to all Medicare and state regulations…The licensee (Owner) is ultimately responsible for compliance with the regulations…”

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview. the agency failed to ensure the clinical records, it contents and the information contained therein were safeguarded against loss in seven of seven patient records (Patient 3, 4, 5, 6, 7, 8 and 9), in that the agency used a vendor for an electronic clinical record system and did not have access to the electronic patient's records or have complete paper patient records. This failure resulted in the surveyor not being able to determine the quality of care and treatment provided to the patients by agency employees. Findings include: CFR 484.110(c)(1)(2) Retention of Records reads: "Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time…" During the entrance conference, the Adm/PAS Sup stated the agency had used an electronic clinical record system when they had active, skilled patients but no longer had access to the electronic records and did not have paper records for any of the patients. The Adm/PAS Sup stated the agency’s last active skilled patient was discharged in January 2021 and the agency had been locked out of the electronic records. The surveyor stated access to the electronic records would be required for surveyor review. An email received by the Adm/PAS Sup on 12/20/2022 at 8:14 AM read in part, “…Unfortunately, [electronic record vendor] refused to grant me access into the portal…I have 7-10 patient files [paper records] within this period. However, I'm not sure if this will be be(sic) sufficient for what you need...” On 12/20/2022, the Adm/PAS Sup brought paper records for skilled patients and stated they were the only records available for surveyor review. Discharged Patient 3: Record review of the Patient discharge list included a discharge date of 04/01/2020. Record review of the paper record included a plan of care dated 12/12/2019-02/09/2020 with an unreadable frequency of nursing visits. The record included seven nursing visit notes from 12/12/2019-01/07/2020. Nursing visit notes after 01/07/2020 were not available for review. Record review of the 69-page OASIS (a patient-specific, assessment used in Medicare home health to plan care, determine reimbursement, and measure quality) Final Validation Report (a report that provides detailed information about the status of OASIS assessments submitted to CMS by the agency) obtained by the surveyor from the CMS Internet Quality Improvement and Evaluation System, revealed the agency successfully submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED: Patient transferred to an inpatient facility (pg. 14) / 01/10/2020; Resumption of home health care following an inpatient stay (pg. 15) / 01/28/2020; Discharge from home health agency (pg. 15)/ 02/08/2020. The three OASIS assessments were not available for surveyor review. Discharged Patient 4: Record review of the Patient discharge list included a discharge date of 03/28/2020. The time period under review was 12/31/2019-02/28/2020. Record review of the paper record did not include a plan of care. The record included eight nursing visit notes from 12/21/2019-01/23/2020. No documents under review were available between 01/24/2020- 02/28/2020. Record review of the 69-page OASIS Final Validation Report revealed the agency successfully submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED: Recertification (a follow-up assessment conducted during the last five days of the 60 day recertification period completed to continue services for an additional 60 day episode of care)(pg. 19) / 12/30/2019 Discharge from home health agency (pg. 63) / 02/28/2020. The two OASIS assessments were not available for surveyor review. Discharged Patient 5: Record review of the Patient discharge list included a discharge date of 02/19/2020. Record review of the paper record did not include any records for the surveyor to review in the discharge episode. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 17) / 02/03/2020 Recertification (pg. 60) / 03/30/2020. The two OASIS assessments were not available for surveyor review. The Final Validation Report did not include a discharge OASIS for the 02/19/2020 agency discharge. Discharged Patient 6: Record review of the Patient discharge list included a discharge date of 04/15/2020. Record review of the paper record did not include any records for the surveyor to review in the discharge episode. Record review of the OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 16) / 01/15/2020 Discharge from home health agency (pg. 55) / 03/15/2020. The two OASIS assessments were not available for surveyor review. Patient 7: Record review of the Patient discharge list included a transfer date of 03/01/2020. Record review of the paper record included a plan of care dated 01/11/2020-03/10/2020 that included orders for the nurse to conduct visits one time a week for nine weeks. The record included three nursing visit notes from 01/15/2020-01/31/2020. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 16) / 01/06/2020 Recertification (pg. 58) / 03/10/2020. The two OASIS assessments were not available for surveyor review. The Final Validation Report did not include a transfer to an inpatient facility OASIS for 03/01/2020. No documents under review were available between 02/01/2020- 03/10/2020. Discharged Patient 8: Record review of the Patient discharge list included a Patient expiration date of 03/01/2020. Record review of the paper record did not include any records for the surveyor to review in the expiration episode. Record review of the 69-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / DATE COMPLETED Recertification (pg. 18) / 02/03/2020 Recertification (pg. 56) / 04/04/2020 Died at Home (pg. 62) / 05/23/2020. The three OASIS assessments were not available for surveyor review Discharged Patient 9: Record review of the Patient discharge list included a discharger date of 10/28/2020. Record review of the paper record included a plan of care dated 12/17/2019-02/14/2020 that included orders for the nurse to conduct visits one time a week for nine weeks. The record did not include nursing visit notes for the period under review. The record included two supplemental physician orders: (1) 12/18/2019 Hold SN and PT until week of 01/06/2020; (2) 01/10/2020 Discharge per Patient request. No other documents were available for review. Record review of the 11-page OASIS Final Validation Report revealed the agency submitted OASIS assessments as follows: REASON FOR ASSESSMENT / COMPLETED Recertification / 12/16/2019. The OASIS assessment was not available for surveyor review. During an interview with the Adm/PAS Sup on 12/14/2022 at 3:05 PM, the surveyor presented the above findings and asked why the electronic record vendor would not grant agency access to patient records. The Adm/PAS Sup stated the agency broke its contract with the vendor by thinking the contract was month to month but instead the agency was locked into a set period of time with the vendor. The Adm/PAS Sup stated the agency did not owe the vendor money but it would cost $2,500 for the agency to gain access to the records. Agency policy titled, “CLIENT RECORDS” with a revision date of 1st Quarter 2012, read in part, “…POLICY: Agency will establish and maintain client record system to ensure that the care and services are completely and accurately documented, readily accessible and systematically organized to facilitate compilation and retrieval of information. PURPOSE: To ensure that client records are maintained and to clarify and define process of both paper and electronic health record maintenance…PROCEDURE: I. A client record is maintained for each patient and is made available to inspectors as required by law. II. Agency will provide surveyors access to all required records and readily provide…information necessary to assist the surveyor in the review process. III. For electronic medical records the agency may provide the surveyor with a guest log-on and instructions regarding access of the EHR…IV. The client record whether paper or electronic must ensure that the care and services provided to each client are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information. VI. The record shall contain pertinent past and current medical and social data and include …assessments…a written plan of care…physician orders…signed and dated clinical progress notes…X. The EHR includes all services provided…The EHR is…safeguarded against loss, destruction and unofficial use, and is maintained according to professional standards of practice…XV. An agency may incorporate and file in the client’s EHR a signed paper record by preserving its electronic duplicate in the EHR; or the agency may maintain the client record as a combination of a signed paper record and EHR…”