Every finding on record at Gainesville Community Hospital, Inc

A Recertification/CHOW Survey entrance conference was conducted on 04/22/2021 at approximately 11:10 AM with the Administrator/DON (in person), Employee A. Census L&CHHS: 63 An exit conference was conducted on 04/29/2021 at approximately 12:15 PM with Employee A (in person) and the Alternate Administrator/Alternate DON (in person), Employee B. The agency was found in compliance with the Medicare CoP and no deficiencies were cited. ABBREVIATIONS: CHOW - Change of Ownership CoP - Conditions of Participation DON - Director of Nurses L&CHHS - Licensed and Certified Home Health Services

A Recertification/CHOW Survey entrance conference was conducted on 04/22/2021 at approximately 11:10 AM with the Administrator/DON, Employee A. Census L&CHHS: 63 An exit conference was conducted on 04/29/2021 at approximately 12:15 PM with Employee A and the Alternate Administrator/Alternate DON, Employee B. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a PoC within 10 days of the receipt of the Statement of Deficiencies. The agency was found in compliance with the Medicare CoP. Deficiency cited at standard level. ABBREVIATIONS: BNI - Benefits Improvement and Protection Act CHOW - Change of Ownership CMS - The Centers for Medicare and Medicaid Services CoP - Conditions of Participation DC - Discharge DON - Director of Nurses EMR: Electronic Medical Record L&CHHS - Licensed and Certified Home Health Services NOMNC - Notice of Medicare Non-Coverage OASIS- Outcome and Assessment Information Set PT - Physical Therapist POC - Plan of Care PoC - Plan of Correction QIO - Quality Improvement Organization SN - Skilled Nurse

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 interview, the agency failed to provide a completed written NOMNC no later than two days in advance of terminating on-going care that included the correct QIO phone number in three of three (Patient 1, 2 and 3) patient records reviewed with goals met as reason for DC. This failure prevented Patient 1, 2 and 3 from exercising the right to appeal the DC decision, if desired. FINDINGS INCLUDE: A patient DC list with DC reason was provided to the surveyor by the Administrator/DON, Employee A, on 04/22/2021. The DC list included the DC date of 01/16/2021 for Patient 1, 11/18/2020 for Patient 2 and 02/01/2021 for Patient 3. The DC list included the reason for DC as goals met for Patient 1, 2 and 3. DC'd Patient 1: Record review of the DC record included a POC dated 12/22/2020 to 02/19/2021. The record contained a PT DC visit on 01/16/2021 with the reason for DC as goals met. The record contained a SN DC OASIS visit on 01/22/2021 with the reason for DC as goals met. The record contained a two-page NOMNC form that was signed and dated by Patient 1 on 01/22/2021. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 1/22/2021 ..." The form included the QIO phone number as 844-430-9504 to appeal the DC decision, if the patient chose to do so. Patient 1 was only provided one day notice of DC. DC'd Patient 2: Record review of the DC record included a POC dated 09/20/2020 to 11/18/2020. The record contained a two-page NOMNC form that was signed by Patient 2. Patient 2 did not date the NOMNC. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 11/18/2020 ..." The form included the QIO phone number as 844-430-9504 to appeal the DC decision, if the patient chose to do so. DC'd Patient 3: Record review of the DC record included a POC dated 12/04/2020 to 02/01/2021. The record contained page one of two of the NOMNC form that listed the patient as Patient 3. The form was not signed or dated by Patient 3. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 2/1/21 ..." The form included the QIO phone number as 844-430-9504 to appeal the DC decision, if the patient chose to do so. During an interview with the Administrator/DON and the Alternate Administrator/Alternate DON, Employee B, on 04/29/2021 at approximately 11:00 AM, the surveyor reviewed the DC list that included a DC date of 01/16/2021 for Patient 1, the PT DC visit on 01/16/2021 and the SN DC OASIS visit on 01/22/2021. The surveyor asked when Patient 1 was DC'd from the agency. Employee A reviewed the EMR and stated the DC date for Patient 1 was 01/22/2021. The surveyor asked why DC'd Patient 1, 2 and 3 were given an NOMNC with the wrong phone number for the QIO. Employee A stated the agency did not know the phone number had changed. Agency policy titled, "PATIENT/CLIENT TRANSFER AND DC NOTICES PE.6" with a revision date of 08/01/2020 read in part, " ...PURPOSE To provide guidance on completion of the required transfer and DC notices. Policy... I. Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative ...Notification will be provided in accordance with state and federal regulations ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.