Every finding on record at Delmar Gardens of Omaha, LLC

St. Joseph Villa Homecare & Hospice is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include on the patient’s revised/updated plan of care, the patient’s progress toward the measurable outcomes and goals identified by the home health agency and the patient, for 5 of 5 patients (Patient 2, 4, 5, 6, and 8) who had a revised/updated plan of care. The total sample size was 8. The census was 27. Findings are: A. Review of the agency policy and procedure titled Care Planning Process, revised 8/2013, revealed: 1. The written plan of care was to be updated at least every 60 days. 2. The policy failed to require staff to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient on the plan of care. B. Review of the agency policy and procedure titled 3.005 On-going Communication 60-Day Summary/Progress Summary, undated, revealed: 1. A 60-day summary was to be completed during the recertification period. 2. The summary reflects the care provided by all disciplines. 3. The policy failed to require staff to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient on the plan of care. C. Review of clinical records revealed: 1. Patient 2's Home Health Certification and Plan of Care for the certification period of 1/8/25 through 3/8/25 and 3/9/25 through 5/7/25 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient. 2. Patient 4's Home Health Certification and Plan of Care for the certification period of 11/30/24 through 1/28/25 and 1/29/25 through 3/29/25 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient. 3. Patient 5's Home Health Certification and Plan of Care for the certification period of 2/6/25 through 4/6/25 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient. 4. Patient 6's Home Health Certification and Plan of Care for the certification period of 1/28/25 through 3/28/25 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient. 5. Patient 8's Home Health Certification and Plan of Care for the certification period of 11/11/24 through 1/9/25 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient. D. During an interview on 3/25/25 at 3:15 PM, the Administrator confirmed the revised/updated plan of care for Patient 2, 4, 5, 6, and 8 failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the home health agency and the patient.

An unannounced complaint investigation was completed on 3/17/2021. An allegation was verified with related and unrelated deficiencies cited including four (4) condition level deficiencies at G570, G640, G940, and G1008. Agency census was 115.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Deficiencies cited at G572 and G592. Findings are: G572 Based on clinical record review, policy and procedure review, and staff interview, the agency failed to complete an individualized plan of care, identifying patient-specific measurable outcomes and goals, for 6 of 6 patients reviewed (Patient 1, 2, 3, 4, 5, and 6) and the agency failed to notify the patient's physician when Home Health Aide (HHA) services were not provided according to the frequency ordered on the physician approved plan of care for 2 of 6 patients reviewed (Patient 1 and 4). Census was 115. G592 Based on clinical record review, policy and procedure review and staff interview, the agency failed to include information regarding the patient's progress toward measurable outcomes and goals identified by the agency and the patient in the updated plan of care for 6 of 6 patients, (Patient 1, 2, 3, 4, 5, and 6). Census was 115.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, policy and procedure review, and staff interview, the agency failed to complete an individualized plan of care, identifying patient-specific measurable outcomes and goals, for 6 of 6 patients reviewed (Patient 1, 2, 3, 4, 5, and 6) and the agency failed to notify the patient's physician when Home Health Aide (HHA) services were not provided according to the frequency ordered on the physician approved plan of care for 2 of 6 patients reviewed (Patient 1 and 4). Census was 115. Findings are: A. Review of the agency's policy and procedure titled Physician's Plan of Care/Change Orders, no date indicated, revealed the plan of care was to identify specific, individualized, measurable goals and interventions; specific services to be provided including the frequency and duration; dates of problem resolution and dates of ongoing review and revision. The same policy and procedure indicated the agency was to provide care/services consistent to the plan of care. B. Review of Patient 1's Home Health Certification and Plan of Care (Plan of Care) for the certification periods of 9/12/2020 to 11/10/2020, 11/11/2020 to 1/9/2021 and 1/12/21 to 3/12/21 2021 revealed no patient-specific measurable outcomes and/or goals. C. Review of Patient 2's Home Health Certification and Plan of Care for the certification period of 12/27/2020 to 2/24/2021 and 2/25/21 to 4/25/21 did not include patient-specific measurable outcomes and/or goals. D. Review of Patient 3's Home Health Certification and Plans of Care for the certification period of 11/27/2020 to 1/26/2021 and 1/26/2021 to 3/26/2021 did not include patient-specific measurable outcomes and/or goals. E. Review of Patient 4's Home Health Certification and Plans of Care for the certification period of 1/7/2021 to 3/7/2021 and 3/8/2021 to 5/06/2021 did not include patient-specific measurable outcomes and/or goals. F. Review of Patient 5's Home Health Certification and Plans of Care for the certification period of 12/15/2020 to 2/12/2021 and 2/13/2021 to 4/13/2021 did not include patient-specific measurable outcomes and/or goals. G. Review of Patient 6's Home Health Certification and Plans of Care for the certification period of 1/2/2021 to 3/2/2021 and 3/3/2021 to 5/01/2021 did not include patient-specific measurable outcomes and/or goals. H. During interview on 3/11/2021 from 2:00 PM to 3:00 PM, the agency Administrator confirmed the Plans of Care for Patients 1, 2, 3, 4, 5, and 6 did not include patient-specific measurable outcomes and/or goals. I. Review of the agency policy and procedure titled, Missed Visits, dated 5/2019, revealed the agency was to complete a missed visit report when visits of the disciplines were not provided at the frequency ordered by the physician. J. Patient 1's Plan of Care revealed a physician's order for HHA services 7 days per week for 8 weeks. Review of the patient's clinical record revealed no documentation of HHA visits and/or a missed visit report for 9/13, 9/20, 9/27, 10/4, 10/17, 10/18 or 10/24/2020. The same Plan of Care revealed a physician's order for HHA services, 4 times per week for 1 week beginning 11/11/20 and to increase HHA services to 7 times per week on 11/16/2020. Review of Patient 1's clinical record revealed no documentation of HHA visit and/or a missed visit report for 11/15/20, 12/29/20 or 1/2/2021. K. Interview with the agency Administrator and Intake Coordinator, on 3/11/21 from 2:00 PM to 3:00 PM confirmed the HHA visits for Patient 1 were not conducted as ordered and missed visit forms were not completed and submitted to the physician for notification of the missed visits on 9/13, 9/20, 9/27, 10/4, 10/17, 10/18 or 10/24/2020 and 11/15/20, 12/29/20 or 1/2/2021. L. Review of Patient 4's Home Health Certification and Plans of Care for the certification period of 1/7/2021 to 3/7/2021 revealed physician orders for HHA services 1 time per week for 1 week and then 3 times per week for 8 weeks. Review of documentation in Patient 4's clinical record revealed no documentation of a HHA visit and/or a missed visit report for the week of 1/7/2021 through 1/9/2021 as ordered. Documentation in Patient 4's clinical record revealed 2 HHA visits were conducted the week of 1/10/2021 through 1/16/2021. There was no documentation of a 3rd HHA visit and/or a missed visit report for the week of 1/10/2021 to 1/16/2021. M. Interview with the agency Administrator and Intake Coordinator, on 3/11/21 from 2:00 PM to 3:00 PM confirmed there were no HHA visits conducted for Patient 4 as ordered the week of 1/7/2021 to 1/9/2021 and a missed visit form was not completed and submitted to the physician for notification. The Administrator and the Intake Coordinator confirmed a 3rd visit was not conducted the week of 1/10/2021 to 1/16/2021 as ordered by the physician and a missed visit report was not completed.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, policy and procedure review and staff interview, the agency failed to include information regarding the patient's progress toward measurable outcomes and goals identified by the agency and the patient in the updated plan of care for 6 of 6 patients, (Patient 1, 2, 3, 4, 5, and 6). Census was 115. Findings are: A. Review of the agency's policy and procedure titled Physician's Plan of Care/Change Orders, no date indicated, revealed the plan of care was to identify specific, individualized, measurable goals and interventions; specific services to be provided including the frequency and duration; dates of problem resolution and dates of ongoing review and revision. Review of the plan of care, according to the same policy and procedure was to address the patient's response to care and services and the patient's outcome to care/services. B. Review of Patient 1's Home Health Certification and Plan of Care for the certification periods of 9/12/2020 to 11/10/2020, 11/11/2020 to 1/9/2021 and 1/12/21 to 3/12/21 2021 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. C. Review of Patient 2's Home Health Certification and Plan of Care for the certification period of 12/27/2020 to 2/24/2021 and 2/25/21 to 4/25/21 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. D. Review of Patient 3's Home Health Certification and Plans of Care for the certification period of 11/27/2020 to 1/26/2021 and 1/26/2021 to 3/26/2021 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. E. Review of Patient 4's Home Health Certification and Plans of Care for the certification period of 1/7/2021 to 3/7/2021 and 3/8/2021 to 5/06/2021 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. F. Review of Patient 5's Home Health Certification and Plans of Care for the certification period of 12/15/2020 to 2/12/2021 and 2/13/2021 to 4/13/2021 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. G. Review of Patient 6's Home Health Certification and Plans of Care for the certification period of 1/2/2021 to 3/2/2021 and 3/3/2021 to 5/01/2021 revealed there was no documentation of the patient's progress toward patient-specific measurable outcomes and/or goals. H. During interview on 3/11/2021 from 2:00PM to 3:00 PM the agency Administrator confirmed the revised plans of care for Patient 1, 2, 3, 4, 5, and 6 did not include measurable outcomes and goals and/or the progress toward the outcomes and/or goals.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Deficiencies cited at G642 Findings are: G 642 Based on review of the agency's policy and procedure, review of documentation of the Home Health QAPI (Quality Assurance and Performance Improvement) meeting annual agendas dated 2019 and 2020 and staff interview, the agency failed to follow its policy and procedure to improve the performance and processes determined to be directly related to patient outcomes. The agency failed to measure, analyze and track quality indicators to access the agency's processes, identify areas of needed improvement and document or implement interventions to correct deficient practices as identified during survey with an exit date of 5/24/2019.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on review of the agency's policy and procedure, review of documentation of the Home Health QAPI (Quality Assurance and Performance Improvement) meeting annual agendas dated 2019 and 2020 and staff interview, the agency failed to follow its policy and procedure to improve the performance and processes determined to be directly related to patient outcomes. The agency failed to measure, analyze and track quality indicators to access the agency's processes, identify areas of needed improvement and document or implement interventions to correct deficient practices as identified during survey with an exit date of 5/24/2019. Findings are: A. Review of agency policy titled Performance Improvement with a review date of 7/2013, revealed the agency implements a continuous, systematic and coordinated approach to plan, design measure, assess and improve the performance of those functions and processes determined to be most directly related to good patient outcomes. All Quality Management activities are to be documented and tracked. B. Review of the agency Home Health QAPI documentation for 2019, revealed documentation titled Therapy Documentation (no date or agency staff signature), which revealed therapy documentation did not meet the goals of QAPI and ongoing review of therapy documentation was to occur. There was no documentation of ongoing review and/or processes implemented for the improvement of therapy documentation . There was no documentation the deficient practices identified during the recertification survey with an exit date of 5/24/2019 were addressed by the agency QAPI. C. Interview with the agency Administrator on 3/17/2021 at 10:25 AM revealed there was no additional documentation of QAPI processes and/or interventions following the survey with an exit date of 5/24/2019. The Administrator revealed the QAPI material ..."was probably thrown away..." during the process of packing to move the agency to another location. D. Review of the agency Home Health QAPI documentation for 2020 revealed the agency addressed Emergency Care Planning, Fall Prevention and Medication Management. There was no documentation the agency assessed and or implemented interventions to maintain compliance with the deficient practices identified during the survey with an exit date of 5/24/2019 to maintain and ensure ongoing compliance. E. Interview with the Administrator on 3/17/2021 from 11:45 AM to 12:15 PM confirmed there was no documentation of QAPI processes implemented by the agency to prevent recurrence of deficient practices identified during the survey with an exit date of 5/24/2019 and/or interventions implemented by the agency to ensure compliance with state and federal regulations. F. Review of the Plan of Correction submitted by the agency for the survey with an exit date of 5/24/2019, and signed by the agency Administrator on 6/24/2019 revealed the agency was to conduct chart audits to ensure compliance with G 570- Condition level, G 572, G 940- condition level, and G 1022. There was no documentation of chart audits completed by the agency to ensure compliance,as outlined in the Plan of Correction for G 570, G 572, G 940, and/or G 1022.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Deficiencies cited at G 948. Findings are: G948 Based on review of clinical records, the job description for the agency Director of Home Care/Administrator, policies and procedures, and staff interviews, the agency Administrator failed to organize and direct the day-to-day operations of the agency to ensure the agency's continued compliance with state and federal regulations for home health agencies following the 7/2/2019 revisit survey. This is evidenced by deficiencies which were cited during the survey with an exit date of 5/24/2019, and were determined to be corrected during a revisit survey conducted on 7/2/2019, but are being cited again during this onsite complaint investigation. The agency census was 115. This practice had the potential to affect all 115 patients served by the agency.

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 review of clinical records, the job description for the agency Director of Home Care/Administrator, policies and procedures, and staff interviews, the agency Administrator failed to organize and direct the day-to-day operations of the agency to ensure the agency's continued compliance with state and federal regulations for home health agencies following the 7/2/2019 revisit survey. This is evidenced by deficiencies which were cited during the survey with an exit date of 5/24/2019, and were determined to be corrected during a revisit survey conducted on 7/2/2019, but are being cited again during this onsite complaint investigation. The agency census was 115. This practice had the potential to affect all 115 patients served by the agency. Findings are: A. Review of the Director of Home Care job description, no date indicated, revealed the Administrator's responsibilities include: 1. Oversee and be responsible for the provision and coordination of patient services. 2. Organize and direct the agency's ongoing functions. 3. Ensure the agency is in compliance with all state and federal laws and regulations governing the practice of homecare nursing. 4. Assures compliance with all policies and procedures of the agency. 5. Coordinates the ongoing monitoring of medical record documentation to promote compliance with state and federal standards. B. Review of the patient's clinical records, policies and procedures and interviews with the agency staff revealed deficient practice cited at: 1. G570 - Condition level 2. G572 3. G592 4. G640 - Condition level 5. G642 2. G940- Condition level 3. G948 4. G1008- Condition level 4. G1022 C. The Administrator during interview on 3/17/2021 at 12:15 PM confirmed the agency had not ensured the interventions as outlined in the plan of correction for deficiencies cited at G570, G572, G940, G948, and G1002 for the survey with an exit date of 5/24/2019 were ongoing and monitoring was conducted by the agency to ensure compliance with federal regulations. The Administrator confirmed the agency failed to ensure and maintain ongoing compliance with federal regulations.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Deficiencies cited at G1022. Findings are: G 1022 Based on review of clinical records, review of policy and procedure and staff interview the agency failed to complete a transfer summary and send it to the receiving health care facility within 2 days of becoming aware of an unplanned transfer of 1of 2 patients (Patient 4) transferred from the agency. Agency census was 115. This practice had the potential to cause a lack of continuity of care for the patient between facilities when a patient was transferred.

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 review of clinical records, review of policy and procedure and staff interview the agency failed to complete a transfer summary and send it to the receiving health care facility within 2 days of becoming aware of an unplanned transfer of 1of 2 patients (Patient 4) transferred from the agency. Agency census was 115. This practice had the potential to cause a lack of continuity of care for the patient between facilities when a patient was transferred. Findings are: A. Review of the agency policy and procedure titled Transfer Information, no date indicated, revealed all patients transferred from the agency will have a transfer summary completed and filed in the clinical record. The policy did not address the requirement of sending the summary to the receiving health care facility within 2 days. B. Review of Patient 4's clinical record revealed a Confirmation of Physician's Orders form dated 1/21/21, revealed home health care services were to be placed on hold due to the patient being in the hospital. C. There was no documentation in the clinical record of the agency contacting and/or providing a transfer summary to the receiving healthcare facility, following Patient 4's transfer on 1/21/2021. D. Interview with the Administrator and the agency Intake Coordinator on 3/11/2021 at 2:30 PM confirmed a transfer summary was not completed and/or provided to the receiving health care facility following the agency becoming aware of Patient 4's transfer on 1/21/2021.