Every finding on record at Divine Home Health Agency LLC

An Emergency Preparedness survey was initiated on 10/29/2024 at 10:00 AM. Census: L&C- 1 LHH- 12 No deficiencies were cited.

A Recertification survey was initiated on 10/29/2024 at 10:00 AM. Census: L&C- 1 LHH- 12 Acronyms: OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services DON- Director of Nurses QAPI- Quality Assurance Performance Improvement PIP- Performance Improvement Project RN- Registered Nurse IQIES- Internet Quality Improvement and Evaluation System EHR- Electronic Health Records POC- Plan of Care SOC- Start of Care SN- Skilled Nurse LVN- Licensed Vocational Nurse Mg- milligrams

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 record review and interview, the agency failed to transmit completed OASIS assessments (used to collect patient information to measure outcomes and quality improvement) to the CMS system within 30 days of completion for 14 of 26 OASIS assessments transmitted between 09/01/2023-08/31/2024. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. FINDINGS INCLUDE: Review of the CMS OASIS-E (tool used by CMS to collect patient information to measure outcomes and quality improvement) Guidance Manual, updated 1/1/2024, read in part; “Chapter 1: OASIS Guidance Manual Introduction…1.5.5.1 General OASIS Item Conventions…14…M0090- Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed…” On 10/29/2024 during Pre-survey review, the surveyor requested OASIS Provider and Quality Measure reports to be provided as scheduled through IQIES. On 10/30/2024 at 8:30 AM, the surveyor reviewed the agency Activity Reports from IQIES. Review of the "OASIS Error Detail Report" showed that between 09/01/2023-08/31/2024, greater than 50% of the assessments submitted contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment was completed. In an interview with the Administrator/DON and RN Case Manager on 10/31/2024 at 2:45 PM, the surveyor reviewed the findings and discussed the OASIS Assessment late submissions. The surveyor asked who in the agency was responsible for transmitting the OASIS Assessments and what the agency’s process was for transmittal. The RN Case Manager stated he was the person responsible for transmitting the OASIS information to CMS and stated the agency used the EHR software, Identifier C. He stated he submitted (to IQIES) after the nurse’s completed their assessments. The surveyor asked why OASIS assessments were submitted late. The RN Case Manager stated, “there was a problem and delay between July and September (2024). We (agency) had requested permission for the Administrator to be added to the approved list to upload and transmit OASIS, but there was a problem with the email. Also, last year, the lady (nurse) who was doing the assessments was not locking them on time. Those were left unfinished and incomplete. That employee is no longer here.” The surveyor stated the time period reviewed was 09/01/2023-08/31/2024 and asked if the Administrator/DON was now involved in the OASIS transmittal process. The Administrator/DON stated, “going forward, I will be the one to ensure the nurses will lock the form (assessment) and will be assisting (with the transmissions) in the future. Agency policy, revised date 05/02/2024, quoted in part, “Timelines, IM.35, Purpose: To establish timely parameters for all medical record information. Policy: The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations. Procedure: … II. All completed and encoded OASIS data will be transmitted via electronic communication software … it will be transmitted … from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date. …”

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 record reviews and interviews, the agency failed to ensure all patients received home health services as ordered in the individualized POC. In 4 (Patients #1, 6, 8 and 9) of 10 patient records reviewed, the SN failed to assess/monitor the patients’ weights and edema. This failure placed patients at risk of not receiving interventions when needed to prevent complications, and a decline in the patients’ health status. FINDINGS INCLUDE: Patient #1: Review of the active patient record revealed a POC dated 07/19/2024 to 09/16/2024 with a SOC date 07/19/2024. The POC included the diagnoses Malignant neoplasm (cancer) of the left breast and Hypertension. The physician ordered SN visits twice a week for one week and once a week for eight weeks and instructed, “SN to assess/monitor weights and edema every visit. If unable to weigh standing measure abdominal girth, arm or ankle circumference….” SN visit notes dated: 07/24/2024; 07/31/2024; 08/02/2024; 08/07/2024; 08/14/2024; 08/21/2024; 09/02/2024 and 09/09/2024 were completed by the RN Case Manager and did not include monitoring or an assessment of the patient’s weight or abdominal girth, arm or ankle circumference. During a home visit interview with the patient on 10/31/2024 at 11:00 AM, the surveyor observed Patient #1 was ambulatory with difficulty. The surveyor asked about the care and services provided by the agency. The patient stated the nurse (RN Case Manager) visited every week and checked her vital signs and blood pressure. Patient #1 stated she had a stroke “a few years ago.” The surveyor asked if the RN Case Manager weighed her or measured her arm, ankles or abdomen. Patient #1 stated, “no.” In an interview with the Administrator and the RN Case Manager on 10/31/2024 at 2:45 PM, the surveyor reviewed the findings and asked why the RN Case Manager did not assess or monitor the patients’ weight or edema. The RN Case Manager stated, “the patient likes to be weighed when she goes to the doctor’s office, so I didn’t do it at the (SN) visits.” Patient #6: Review of the discharged patient record revealed a POC dated 07/25/2023 to 09/22/2023 with a SOC date 03/27/2023. The POC included the diagnoses: Cellulitis (a bacterial infection affecting deeper layers of the skin and surrounding tissue); Heart Failure (a serious condition that occurs when the heart can’t pump enough blood to meet the body’s needs); Hypertension; Chronic Obstructive Pulmonary Disease (a condition caused by damage to the lungs that leads to inflammation and other problems that makes it hard to breathe) and Diabetes. The physician ordered SN visits once a week for nine weeks and instructed, “SN to assess/monitor weights and edema every visit. If unable to weigh standing measure abdominal girth, arm or ankle circumference…. “ SN visit notes dated: 07/27/2023; 08/04/2023; 08/10/2023; 08/17/2023; 08/24/2023; 08/31/2023; 09/07/2023 and 09/14/2023 were completed by LVN D and did not include monitoring or an assessment of the patient’s weight or abdominal girth, arm or ankle circumference. LVN D was unavailable for interview and no longer employed by the agency. Patient #8: Review of the discharged patient record revealed a POC dated 07/01/2023 to 08/30/2023 with a SOC date 07/01/2023. The POC included the diagnoses: Cardiomegaly (a condition where the heart becomes larger than normal); Diabetes and Hypertension. The physician ordered SN visits once a week for nine weeks and instructed, “SN to assess/monitor weights and edema every visit. If unable to weigh standing measure abdominal girth, arm or ankle circumference…. “ SN visit notes dated: 07/04/2023; 07/06/2023; 07/11/2023; 07/18/2023; 07/25/2023; 08/01/2023; 08/08/2023; 08/15/2023; 08/22/2023 and 08/29/2023 were completed by LVN D and did not include monitoring or an assessment of the patient’s weight or abdominal girth, arm or ankle circumference. Patient #9: Review of the discharged patient record revealed a POC dated 07/27/2023 to 09/24/2023 with a SOC date 03/29/2023. The POC included the diagnoses: Heart Failure; Hypertension and Chronic Obstructive Pulmonary Disease. The physician ordered SN visits once a week for nine weeks and instructed, “SN to assess/monitor weights and edema every visit. If unable to weigh standing measure abdominal girth, arm or ankle circumference…. “ SN visit notes dated: 08/04/2023; 08/10/2023; 08/17/2023; 08/24/2023; 08/31/2023; 09/07/2023 and 09/14/2023 were completed by LVN D and did not include monitoring or an assessment of the patient’s weight or abdominal girth, arm or ankle circumference. In an interview with the Administrator/DON and RN Case Manager on 10/31/2024 at 2:45 PM, the surveyor reviewed the findings and asked if LVN D was currently an agency employee. The RN Case Manager stated LVN D was no longer employed by the agency. The surveyor asked why LVN D did not follow the physician plans of care for Client’s 6, 8 and 9 and assess/monitor the clients’ weights or abdominal, girth, arm or ankle circumference. The RN Case Manager stated, “I’m not sure.” The surveyor asked if there was an agency employee who reviewed the SN visit notes. The Administrator/DON stated, “if it was not documented, it was not done. We just hired someone, RN E will be doing QA (Quality Assurance) reviews for us in the future.” Agency Policy, revised date 05/02/2024, quoted in part, “Plan of Care, PC.35, Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. … Procedure: … V. Each patient/client must receive the home health services that are written in an individualized Plan of Care ….” Agency Policy, dated 05/01/2024, quoted in part, “Orders for Care, PC.30, Purpose: To ensure patient/client care is provided in accordance with a physician and/or non-physician practitioner order … Policy: The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care ….”

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: Based on record review and interview, the agency failed to conduct performance improvement projects annually for the three-year period of review 10/31/2021 to 10/31/2024. This failure placed patients at risk of substandard care when the agency had not evaluated the care and operations and developed plans to improve performance, and or address any issues that were or could have impacted patient care. FINDINGS INCLUDE: The surveyor requested the QAPI program documents during the entrance conference on 10/29/2024 AT 10:00 AM. A review of the QAPI documents provided by the Administrator/DON on 10/31/2024 at 2:40 PM did not reveal any evidence of PIPs. A review of the entire QAPI Plan provided by the Administrator revealed no plan for PIPs for 2021, 2022 and 2023. In an interview with the Administrator/DON on 10/31/2024 at 2:40 PM, the surveyor reviewed the findings of the review of the QAPI documents and asked about the lack of PIPs. The Administrator/DON stated, “I’m not sure, what is the PIP?” The surveyor explained the Performance Improvement Projects were required in part of the QAPI. The Administrator/DON stated, “they weren’t done.” Agency policy, revised date 05/01/2024, quoted in part, “Quality Assessment Performance Improvement Program, QAPI.5, Purpose: To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI Plan…. Procedure: E. Performance Improvement projects, 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects.