Every finding on record at Gentiva Certified Healthcare Corp

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: X2024-947 Dates Onsite: 11/18/24 - 11/20/24 This survey was conducted by: Surveyor #3 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below.

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 record review and interview, the agency failed to transmit patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 1,182 of 3,868 records transmitted between 08/01/23 and 07/31/24. Failure to transmit patient data timely could result in inaccurate data and cause delays for patients to receive full benefits. Findings included: 1. As part of the pre-survey preparation, the Surveyor reviewed the "HHA Error Summary by Agency" report from 08/01/23 and 07/31/24 generated from the iqies.cms.gov website. The review showed that the agency had 1,182 of 3,868 patient assessments (M090) that were not submitted in a timely manner. This resulted in a 30.6% late submission error rate. 2. On 11/19/24 at 1:30 PM, the Surveyor interviewed the Branch Director (Staff #301) regarding the error rate for M090. Staff #301 stated that the late submission error rate has been a focus of the agency's QAPI program. Staff #301 stated that during the timeframe between 08/01/23 to 07/31/24 the agency had 2 Clinical Managers on extended leaves of absence which created a backlog. The agency hired new Clinical Managers and Staff #301 runs a daily OASIS report to track timely submission and communicates daily with the Clinical Managers to ensure that all OASIS visits are submitted timely. Staff #301 also reported that the current error rate is 24.72%.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patient’s discharge summary to the patient’s attending physician within 5 business days of the patient’s discharge for 2 of 5 discharge records reviewed (Patient #313 and Patient #314). Failure to provide the discharge summary to the patient’s attending physician disrupts continuity of care and coordination of patient’s ongoing care needs. Findings included: 1. Document review of the agency's policy titled, "03-25 Discharge or Transfer Policy and Job Aide," reviewed 09/2024, showed that discharge documents completed by the agency will be sent within the CMS mandated timeframes and company policy and procedure. The physician or allowed practitioner will receive their patient's discharge summary within five business days following the patient's discharge from the agency. 2. Record review of 2 of 5 discharged patients showed the following: a. Patient #313 was admitted to home health services on 06/20/23 and discharged on 08/14/23. The record showed that the discharge summary was sent to the patient’s attending physician on 10/10/23. The record showed no evidence that the discharge summary was sent within 5 business days. b. Patient #314 was admitted to home health services on 06/02/23 and discharged on 09/25/23. The record showed no evidence that the discharge summary was sent to the attending physician. 3. On 11/19/24 at 1:45 PM, the Surveyor interviewed the Branch Director (Staff #301) about the lack of documentation of discharge summaries being sent to the patients' physicians in the 5 days after agency discharge. Staff #301 acknowledged that the agency's policy is to send the discharge summary within 5 days of discharge. Staff #301 acknowledged that Patient #313's discharge summary was sent more than 5 days after discharge and stated that they were unable to provide documentation that the discharge summary for Patient #314 was sent to the physician.