Every finding on record at Dj Montgomery Enterprise LLC

Purpose of Visit: 36 month Re-Certification Survey with Follow up to survey dated 06/01/2018. A survey entrance conference was conducted on 05/18/2021 at approximately 11:40 a.m. with the Agency Administrator, Employee A. A pre-survey COVID-19 screening was conducted via telephone with the Administrator per the Texas Health and Human Services protocol. The agency was provided with the HHS handout, "What to expect during your agency survey" and the comment card for survey monkey online survey. Agency L & C Census: 32 Agency LHH Census: 0 Agency PAS Census: 0 An exit conference was conducted on 05/21/2021 at approximately 4:00 p.m. with the Agency Admininstrator, Employee A, Alternate Administrator/Supervising Nurse, Employee B, and Administrative Assistant, Employee D. The survey preliminary findings were discussed, and the agency was afforded the opportunity to provide additional information. The agency was provided with written instructions for submitting a plan of correction within ten (10) days of the receipt of the Statement of Deficiencies. Reminded agency of online survey for comments. The agency is in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviation List: L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care LVN-Licensed Vocational Nurse SN- Skilled Nursing Registered Nurse (RN) CMS- Center for Medicare and Medicaid Services OASIS -outcome and assessment information set QIO-Quality Independent Contractor OMB-Office of Management and Budget

Purpose of Visit: 36 month Re-Certification Survey with Follow up to survey dated 06/01/2018. A survey entrance conference was conducted on 05/18/2021 at approximately 11:40 a.m. with the Agency Administrator, Employee A. A pre-survey COVID-19 screening was conducted via telephone with the Administrator per the Texas Health and Human Services protocol. The agency was provided with the HHS handout, "What to expect during your agency survey" and the comment card for survey monkey online survey. Agency L & C Census: 32 Agency LHH Census: 0 Agency PAS Census: 0 An exit conference was conducted on 05/21/2021 at approximately 4:00 p.m. with the Agency Admininstrator, Employee A, Alternate Administrator/Supervising Nurse, Employee B, and Administrative Assistant, Employee D. The survey preliminary findings were discussed, and the agency was afforded the opportunity to provide additional information. The agency was provided with written instructions for submitting a plan of correction within ten (10) days of the receipt of the Statement of Deficiencies. Reminded agency of online survey for comments. Physicians Choice Health Services was found to be in compliance with Medicare Conditions of Participation. Abbreviation List: L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care LVN-Licensed Vocational Nurse SN- Skilled Nursing Registered Nurse (RN) CMS- Center for Medicare and Medicaid Services OASIS -outcome and assessment information set QIO-Quality Independent Contractor OMB-Office of Management and Budget

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to provide a Notice of Medicare Non-Coverage (NOMNC) written notice at least 2 days in advance of terminating on-going care in 3 (Patient Records #12, #13 & #14) of 3 discharged patient records reviewed in which the patients were discharged from agency services with goals met. The failure to provide written notification could place patients at risk of harm due to inadequate continuity of care and prevented patients from exercising their right to appeal the discharge decision . Findings include: Patient #12: Review of Patient 12's clinical record included an agency form titled "Discharge Summary" dated 01/28/2021. The Agency Discharge Summary stated Patient #12 was discharged from the agency services on 01/28/2021 due to goals met. Patient 12's clinical record did not include a NOMNC form signed by Patient #12 or any evidence the agency had given Patient #12 a NOMNC notice of discharge at least 2 days prior to discharge from the agency services. Patient #13: Review of Patient 13's clinical record included an agency's Agency Discharge Summary dated 06/30/2020. The discharge summary stated Patient #13 was discharged from the agency services on 06/30/2020 due to goals met. Patient 13's clinical record contained a NOMNC incomplete of date services would end or date signed by Patient #13. The record did not include any evidence the agency had given Patient #13 a completed NOMNC notice of discharge at least 2 days prior to discharge from the agency services. Patient #14: Review of Patient 14's clinical record included an agency's Agency Discharge Summary dated 04/17/2021. The discharge summary stated Patient #14 was discharged from the agency services on 04/17/2021 due to goals met. Patient 13's clinical record contained the 2nd page of the NOMNC only. Patient #14 was not provided a complete NOMNC nor informed of the date services would end. The record did not include any evidence the agency had given Patient #14 a complete NOMNC notice of discharge at least 2 days prior to discharge from the agency services. In an interview via phone on 05/20/2021 at approximately 2:00 p.m. with the Administrator, Employee A, the surveyor reviewed the survey findings. The surveyor presented the above findings to the Administrator of why Patient #12, #13 and #14 were not provided with a completed NOMNC at least 2 days prior to discharge. The Administrator said, "They should be, we have went over this (NOMNC) a million times." The Administrator did not dispute the findings Agency policy titled, "PE.6 Patient Discharge/Discharge Planning with a revised date of 04/17/19 read in part ..."Purpose ...To provided patients access to an expedited determination process when their Medicare covered Home Health Agency services are ending. To allow the patients to appeal the Agency's decision to discharge ... Policy ...I. Agency will provide notice to eligible patients of their right to expedited determinations when their period of covered care ends. J. Agency will deliver the generic CMS notice NOMNC to the patient (or authorized representative), no less than two (2) days prior to the day of anticipated discharge, or as soon as the Agency determines coverage will end. K. The NOMNC must remain two pages ....Procedure ...J Termination Notice and Expedited Review 1. Agency staff will provide a valid OMB-approved NOMNC delivery notice (involved both delivery and completion) to the patient when the end of all covered care is foreseen, even if the patient agrees with the discharge. a. No later than two (2) days before the proposed end of covered services ..." Regulation: July 1, 2005, the new Medicare regulations BNI (Benefits Improvement and Protection Act) gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) labeled "FORM CMS (Centers for Medicare and Medicaid Services) 10123- NOMNC" that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The telephone number for the QIO (Quality Improvement Organization) should be included in this notice (844-430-9504). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to individualize the POC to include all required elements in 5 (#2, #5, #8, #9 and #10) of 10 active clinical records reviewed, where the patient had a diagnosis of Heart Failure, the agency failed to include appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician in the POC. This failure placed patients at risk for receiving inadequate care, a decline in status, exacerbation of disease process and at risk of subsequent emergency room visits and/or hospital re-admissions. This failure also meant the patient's needs would not be addressed by the physician . Findings Include: Patient #2 record review: Review of Patient #3's clinical record included a POC with a SOC date of 12/29/2021 for the certification period of 02/21/2020-04/21/2021. The POC was electronically signed by agency RN, Employee H, on 02/20/2021 and included a diagnosis of "Chronic diastolic (congestive) heart failure." The POC contained orders for the SN to visit one time every other week with first visit week of 02/28/2021. Review of the POC failed to include evidence of appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician. Patient #5 record review: Review of Patient #5's clinical record included a POC with a SOC date of 01/18/2019 for the certification period of 03/08/2021-05/06/2021. The POC was electronically signed by agency RN, Employee J, on 03/03/2021 and included a diagnosis of "Hypertensive heart disease with heart failure." The POC contained orders for the SN to visit one time every week for nine weeks. Review of the POC failed to include evidence of appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician. Patient #8 record review: Review of inactive Patient #8's clinical record included a POC with a SOC date of 02/21/2021 for the certification period of 02/02/2021-04/02/2021. The POC was electronically signed by Employee J on 02/02/2021 and included a diagnosis of "Hypertensive heart and Chronic kidney disease with heart failure." The POC contained orders for the SN to visit one week one, zero week one, one week one, zero week one, one week one, zero week one, one week one zero week one, and one week one. Review of the POC failed to include evidence of appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician. Patient #9 record review: Review of inactive Patient #9's clinical record included a POC with a SOC date of 08/07/2019 for the certification period of 01/28/2021-03/28/2021. The POC was electronically signed by Employee J, on 01/23/2021 and included a diagnosis of " Hypertensive heart and Chronic kidney disease with heart failure." The POC contained orders for the SN to visit one time every week for nine weeks. Review of the POC failed to include evidence of appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician. Patient #10 record review: Review of inactive Patient #10's clinical record included a POC with a SOC date of 03/09/2019 for the certification period of 02/26/2021-04/26/2021. The POC was electronically signed by Employee J, on 01/23/2021 and included a diagnosis of " Chronic combined systolic and diastolic heart." The POC contained orders for the SN to visit one time every week for eight weeks beginning 02/28/2021. Review of the POC failed to include evidence of appropriate interventions to assess for fluid retention with abnormal parameters to report to the physician. An interview was conducted via phone with Alternate Administrator/Supervising Nurse, Employee B on 05/20/2021 at 1:43 p.m. Employee B said, "a regular assessment with the clinical pathways for heart failure which encompasses weekly weights, peripheral edema, teaching the patient to weigh daily." The surveyor reviewed findings of no orders on the plan of care/485 to measure for fluid retention on patients # 2, #5, #8, #9, and #10. The surveyor asked why there was no orders to assess for fluid retention. Employee B said, "The clinicians should know to do that (sic)" Employee B did not dispute the findings. Agency policy: TX.6 Plan of Care with revision date of 01/13/18 read in part ..."Purpose ... To develop and individualize plan of care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations ... Procedure ...C. The individualized plan of care will specify care and services necessary to meet the patient specific needs as identified...14. Patient-specific interventions and education ..."