Every finding on record at Eh Home Health of the West, LLC

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 06/28/2022 to 06/30/2022 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 06/28/2022 to 06/30/2022 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the home health agency (HHA) failed to complete an assessment of the patient within 48 hours of the referral, within 48 hours of discharge from an inpatient setting, or on the physician ordered start of care (SOC) date for 6 of 17 patients (Patient (P)2, P7, P12, P13, P14, and P17). The failure to complete the initial assessment timely had the potential to affect the patient's health and safety due to the lack of identification and implementation of interventions for the patient's immediate care needs. Findings include: Review of an agency policy titled, "Admission Process and Patient Assessment," dated 03/01/2021, revealed, "The initial admission evaluation/assessment will be performed in the patient's home by the appropriate licensed professional within 48 hours of the referral or patient's return from an inpatient stay or on the physician's ordered start of care date." Review of the "Attachments" section of the electronic medical record (EMR) for P2 with the Branch Director on 06/29/2022 at 8:25 AM, showed a referral dated 04/30/2022. Review of the "Visit" section of the EMR showed a start of care (SOC) visit on 05/04/2022. The Branch Director stated the delay in the SOC was due to waiting for insurance verification. Review of the "Attachments" section of the EMR for P7 showed a referral dated 05/27/2022 requesting skilled nursing (SN) for ostomy care. Review of the "Coordination Note" section showed a hospital discharge date of 05/28/2022. Review of the "Visit" section of the EMR showed a SOC visit occurred on 05/31/2022 greater than 48 hours after the patient's discharge from the hospital. Review of the "Orders" section of the EMR failed to reveal a physician order to delay the SOC until 05/31/2022. Review of the "Attachment" section of the EMR for P12 showed a referral dated 04/15/2022 requesting SN for wound care and identified the patient was at home. Review of the "Visit" section of the EMR showed a SOC visit on 04/20/2022 which was five days after the referral. Review of the "Orders" section of the EMR failed to reveal a physician order to delay the SOC until 04/20/2022. Review of the "Attachment" section of the EMR for P13 showed an initial referral from the hospital dated 05/26/2022 for SN for wound care and a second referral dated 05/27/2022 sent upon discharge from the hospital. A review of the "Coordination Note" section of the EMR revealed a phone call 05/29/2022 with the patient and stated the patient requested the SOC visit to be delayed until Monday 05/30/2022. Review of the "Visit" section of the EMR revealed a SOC visit on 05/30/2022 which was greater than 48 hours from the hospital discharge date. Review of the "Orders" section of the EMR failed to reveal a physician order to delay the SOC until 05/30/2022. Review of the "Attachment" section of the EMR for P14 showed a referral dated 02/06/2022 and indicated the patient was discharged from the hospital on that day. Review of the "Visit" section of the EMR revealed a SOC visit on 02/10/2022 which was four days after the referral. Review of the "Orders" section of the EMR failed to reveal a physician order to delay the SOC until 02/10/2022. Review of the "Coordination Notes" dated 06/19/2022 for P17 revealed the referral was received on 06/19/2022 and that the patient was going to be discharged from the hospital on 06/19/2022 with a fracture of the right leg. Review of the "Visit" Section of the EMR revealed a SOC visit on 06/22/2022 which was greater than 48 hours from the referral. Review of the "Orders" section of the EMR failed to reveal a physician order to delay the SOC until 06/22/2022. During an interview on 06/30/2022 at 8:45 AM, the Regional Vice President of Operations stated the agency considered the referral date to be the date the "referral packet" was completed which would include insurance verification and visit approval, if required, instead of the date the original referral was received by the agency. The Regional Vice President of Operations confirmed this practice could delay the SOC beyond 48 hours from the referral that was originally received.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure a nurse reviewed the list of patient medications for potential adverse effects including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, or noncompliance with drug therapy for 2 of 2 patients (Patient (P)10 and P17) whose start of care (SOC) was completed by a rehabilitation therapist. The failure to have a nurse review the list of patient medications identified at the SOC visit had the potential to affect the health and safety of all patients admitted for home care by a rehabilitation therapist. Findings include: Review of P10's electronic medical record (EMR) revealed a "Client Medication Report" located in the "Medications" section which included the list of patient medications, the dose, frequency, purpose, and the following statement "By signing below you acknowledge that you have reviewed the medication(s) for potential clinically significant medication issues, including drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance" signed by the physical therapist who completed the SOC assessment. Review of P17's electronic medical record (EMR) revealed a "Client Medication Report" located in the "Medications" section which included the list of patient medications, the dose, frequency, purpose, and the following statement "By signing below you acknowledge that you have reviewed the medication(s) for potential clinically significant medication issues, including drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance" signed by the physical therapist who completed the SOC assessment. Review of an agency policy titled, "Admission Process & Patient Assessment," dated 03/01/2021, revealed it failed to identify that an agency nurse must review the list of patient medications identified at the SOC for potential adverse effects. The policy stated, "During the initial evaluation/assessment, the admitting professional … assesses any medications the patient may be taking to identify possible ineffective drug therapy, significant side effects, duplicated drug therapy, drug allergies, and non-compliance with drug therapy." On 06/30/2022 at 12:00 PM, the Branch Director confirmed the EMR did not include a nurse's signature to indicate the nurse had reviewed the list of medications identified when a rehabilitation therapist completed the SOC assessment.

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 document review, policy review, and interview, the home health agency (HHA) failed to investigate, analyze, and trend infection control surveillance data in its quality assurance and performance improvement (QAPI) program. The failure to analyze patient infection data had the potential to miss identification of opportunities to implement measures to reduce infection for all patients receiving home care services. Findings include: Review of the agency policy titled, "QAPI (Home Health)," dated 05/06/2022, showed, "The purpose of a quality assurance performance improvement program is to continuously monitor, analyze and implement an ongoing Agency-wide, data driven work plan that improves patient care outcomes and patient safety through the identification and resolution of problems." Review of the agency policy titled, "Infection Prevention & Control Plan," dated 05/23/2022, showed, "Administrators and Branch Directors will track and trend infection rates and compliance with infection control practices within the agency on a quarterly basis to reduce the risk for acquiring and spreading infection. These trends will be analyzed by the QAPI committee for recommendations and to develop action plans for improvement." Review of an agency document titled, "Quality Assessment & Performance Improvement (QAPI) Meeting Agenda and Governing Body Report," dated "QTR [quarter] 1 04/20/2022," showed a line graph with the number of patient infections each month occurring between 05/2021 and 04/2022. The document did not include identification of infection trends or an analysis of the surveillance data. During an interview on 06/30/2022 at 8:45 AM, the Regional Vice President of Operations stated the agency did not have a specific person who tracked patient and staff infections on an ongoing basis and there was no additional information besides what was in the QAPI report to show infection tracking, trending, or analysis of the data. The Regional Vice President of Operations identified the number of infections comes from an infection form in the electronic medical record completed by staff when they identified during a visit that the patient was started on an antibiotic.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the home health agency (HHA) failed to maintain an infection control surveillance program that included tracking, trending, identification, and analysis of patient infections. The failure to track, investigate, and identify factors which may contribute to patient infections has the potential to increase the emergent care and re-hospitalization for all 245 current patients receiving home health care from the agency. Findings include: Review of the agency policy titled, "Infection Prevention & Control Plan," dated 05/23/2022, showed, "Administrators and Branch Directors will track and trend infection rates and compliance with infection control practices within the agency on a quarterly basis to reduce the risk for acquiring and spreading infection. These trends will be analyzed by the QAPI committee for recommendations and to develop action plans for improvement." Review of an agency document titled, "Quality Assessment & Performance Improvement (QAPI) Meeting Agenda and Governing Body Report," dated "QTR [quarter] 1 04/20/2022," presented by the Regional Vice President of Operations as the only documentation of infection tracking showed a line graph with the number of patient infections each month occurring between 05/2021 and 04/2022. The document did not include identification of infection trends or an analysis of the surveillance data. During an interview on 06/30/2022 at 8:45 AM, the Regional Vice President of Operations stated the agency did not have a specific person who tracked patient and staff infections on an ongoing basis and there was no additional information besides what was in the QAPI report to show infection tracking, trending, or analysis of the data. The Regional Vice President of Operations identified the number of infections comes from an infection form in the electronic medical record completed by staff when they identified during a visit that the patient was started on an antibiotic.