Every finding on record at Everest Healthcare Solutions

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 11/20/24. The Agency was in compliance with the Condition 42 CFR 484.102, Establishment of the Emergency Program, for this survey. CFR = Code of Federal Regulations

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 11/20/24. Standard-level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon % = Percent # = Number OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and staff interviews, it was determined that in 1 of 4 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Finding include: 1. The Error Summary Report for 1/24 to 11/24 was reviewed on 11/20/24. The report included error # -3330 for 1 of 4 late submissions, which was 25.00% of the OASIS reports submitted late, more than 30 days after the assessment was completed. 2. During an interview with the Administrator and Agency Supervisor on 11/20/24 at 2:00 PM, the administrative team confirmed that the error occurred.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission booklet and folder, clinical record review, and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies, this has the ability to affect all patients served. Findings include: 1. The Agency’s admission booklet and folder were reviewed on 11/18/24 and lacked documentation of the Agency's transfer and discharge policies. 2. The following clinical records were reviewed from 11/18/24 to 11/20/24: Pt. #1. SOC 4/23/24. Pt. #2. SOC 7/27/23. The records lacked documentation the Agency provided Pts./patient's representative information regarding the Agency's transfer and discharge policies. 3. During an interview with the Administrator and Agency Supervisor on 11/20/24 at 11:00 AM, the administrative team confirmed that the error occurred.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: mg = Milligram POC = Plan of Care Pt./Pts. = Patient/Patients SN = Skilled Nurse SOC = Start of Care

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: A. Based on the onsite observations, entrance interview, review of the admission packet, clinical record reviews, home visit observations, job description reviews and staff interview, it was determined the Agency's Administrator, who was responsible for the day to day operations, failed to ensure the logo of an expired accrediting organization was removed from their admission documents. This has the potential to affect all Patients being served by the Agency. Findings include: 1. On 09/28/21 at 10:00 AM, during the survey entrance interview, the Administrator (Employee #1) stated that the Agency was not accredited with any other organization. 2. On 09/28/21 at 10:45 AM, the Agency’s admission packet was reviewed and included two documents titled “Disaster Prep/DNR/Coordination of Care” and “Consent & Verification of Receipt of Information” that included the logo of an expired accrediting organization. Copies of the signed consents with the organization-logos (expired accreditation was in December 2012) were included in the clinical records. The consent forms with the expired organization- logos were included for: Patients #1- SOC 05/28/21 also observed on home visit (09/28/21-4 PM) Patients #4 - SOC 06/04/21 Patients #5 -SOC 06/05/21 3. The job description for the Administrator titled “Administrator/Director of Nursing” was reviewed on 09/29/21 at 2:00 PM. The job description required "... RESPONSIBILITIES OF POSITION: Complies with all applicable laws and regulations...". 4. The findings related to the lack of maintaining current day to day operations were confirmed during the interview with the Administrator and Agency Supervisor, on 09/29/21 at 2:00 PM.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on clinical record review, home visit observation / interview and staff interview, it was determined that the Agency failed to ensure medications and intervention listed in the clinical records were up to date / accurate and responses to those interventions and services were documented. This was found in 3 of 7 (Pts. #2,5 and 7) records reviewed. 2. Pt. #5 SOC 06/05/21 Diagnoses: Polyneuropathy Unspecified and Essential Hypertension. The clinical record was reviewed on 09/28/21 at 3:00 PM. The SN communication note dated 06/05/21, lacked the documentation for not providing the Occupational Therapy services, in the “Order Description” dated 06/05/21. 3. Pt. #7 SOC 05/21/21 Diagnoses: Anxiety and Type 2 Diabetes Mellitus. The clinical record was reviewed on 09/28/21 at 2:00 PM. The SN visit notes lacked documentation of the blood glucose for 06/03/21, 06/12/21 and 06/17/21. 4. The findings that the Agency failed to ensure the records included all interventions and medication, were confirmed during the interviews with Administrator and Agency Supervisor, on 09/29/21 between 2:00 PM and 3:00 PM. Findings include: 1. Pt. # 2 SOC 08/24/2018 Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/29/2021 at 1:00 PM. The clinical record contained a POC for certification period 08/08/2021 to 10/06/2021. The POC contained, Medications - Amlodipine 10 mg tablet once a day. A home visit was conducted on 09/30/2021 at 12:00PM with Agency Supervisor. During the home visit it was observed that patient home medications include Amlodipine 5 mg tables daily. During a patient caregiver interview, the patient caregiver stated that "pt has been taking Amlodipine 5mg for some time, could not remember how long". The clinical record was reviewed again on 09/30/2021 at 2:00 PM. The clinical record lacked modification physician orders for the Amlodipine dose.