Every finding on record at Family Health Care Services

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. The survey conducted from 06/21/2022 to 06/24/2022 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. The survey conducted from 06/21/2022 to 06/24/2022 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484 Subparts A through C with the following standard-level deficiencies listed below.

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 include patient infection surveillance data in the quality assurance and performance improvement (QAPI) program. The failure to analyze and review patient infection data had the potential to miss identification of trends and opportunities to implement measures to reduce infections for the current 930 patients. Findings include: Review of the HHA policy titled, "Infection Prevention and Control Program Updated," dated 10/04/2021, revealed, "The agency must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases which is an integral part of the agency's quality assessment and performance improvement (QAPI) program." Review of the HHA policy titled, "Quality Assurance Performance Improvement," dated 08/25/2020, revealed, "The primary goals of the Agency's QAPI program are to continually and systematically plan, design, measure, assess, and improve performance of Agency wide key functions and processes related to patient care, treatment, and services … Assessment of the performance of the following patient care and Agency functions are included: … Infection Prevention and Control." Review of an agency untitled document revealed a graph with data elements for the months of January through June showed the number of patients hospitalized each month with a diagnosis related to an infection. During an interview on 06/24/2022 at 9:00 AM, the Administrator confirmed that during a patient home visit assessment the clinician would complete a document in the electronic medical record (EMR) if the patient identified that the physician ordered a new antibiotic for an infection. The document in the EMR would identify the type and location of the infection, when signs and symptoms first started, the name of the antibiotic, and the organism if known. The Administrator confirmed the information entered by the clinician when a new infection was identified was not tracked, analyzed, or included in QAPI and the only data included in the agency's infection surveillance was derived from the "Strategic Healthcare Programs (SHP)" report generated from the "Outcome and Assessment Information Set (OASIS)" completed when a patient was admitted to the hospital and an infection was identified as the cause.

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 930 current patients receiving home health care from the agency. Findings include: Review of an agency untitled document revealed a graph with data elements for the months of January through June showed the number of patients hospitalized each month with a diagnosis related to an infection. During an interview on 06/24/2022 at 9:00 AM, the Administrator confirmed the HHA infection surveillance data was derived from the "Strategic Healthcare Programs (SHP)" report generated from the "Outcome and Assessment Information Set (OASIS)" completed when a patient was admitted to the hospital. The Administrator confirmed that, although staff completed a form in the electronic medical record (EMR) whenever it was confirmed that a patient was recently identified as having an infection or was started on an antibiotic for an infection, the information was not tracked, trended, or investigated by the HHA. Review of the agency policy titled, "Infection Prevention and Control Program Updated," dated 10/04/2021, revealed "The agency must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases which is an integral part of the agency's quality assessment and performance improvement (QAPI) program."