Every finding on record at Hamilton Co Public Health Chha

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of six patient records (Patient # 3) the physician was notified regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur, has the potential for unmet patient needs and/or negative patient outcomes. Patient # 3 (start of care 02/28/2023) has diagnoses of Aftercare following Surgery for Neoplasm and Malignant Neoplasm of Rectum. The physician's POC for certification period 04/25/2025 through 06/23/2025 contains an order for physical therapy (PT) visits 1 time a week for 9 weeks (1WK9), starting week of 04/25/2025. The record (reviewed 07/07/2025) lacks any documented evidence of physician notification of a missed PT visit the week of 05/25/2025 through 05/31/2025. The finding was confirmed on 07/08/2025 at 12:40 PM with the Director of Patient Services and Clinical Manager/Senior Physical Therapist; no additional evidence was provided.

The following statement of deficiencies represents the results of a re-certification survey of Hamilton County Public Health Certified Home Health Agency conducted August 26 through August 28, 2024. A standard re-certification survey was initiated on August 26, 2024. Deficient practices were identified within Level 1 standards in 484.60 Condition: Care planning, coordination of services and quality of care resulting in a partially extended survey. The survey consisted of a review of seven clinical records including two discharge records, six personnel records for professional and paraprofessional personnel and three observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for the past twelve months, agency's Admission Packet, the Emergency Preparedness Plan and the Complaint Log. The census at the time of the survey was nineteen. Pre-survey activities consisted of a review on August 19, 2024 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 06/2023-05/2024 (The Potentially Avoidable Event Report, The Potentially Avoidable Event Report-Patient Listing, The Agency Patient Related Characteristics Report and The Home Health Agency (HHA) Error summary by Agency Report for the period 01/01/2023-12/31/2023) and the agency's compliance with report submissions for the 2022 statistical report. The agency's Acting Director of Public Health, Director of Patient Services and Medical Records Clerk were interviewed. Findings were reviewed at the exit conference on August 29, 2024. The following deficiencies are identified as a result of the survey: Federal: G0372 and G0574 State: J0424, J1108, J1276, J1412, J1424, J1428, J1440, J1444, J1460 and R0504.

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 Certification and Survey Provider Enhanced Reports (CASPER) review and staff interview the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), 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. Failure to encode and electronically transmit each completed OASIS assessment, 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 has the potential for incorrect and incomplete reporting data. On 08/19/2024 the surveyors reviewed Certification and Survey Provider Enhanced Reports (CASPER) "Home Health Agency Error Summary Report by Agency". The report contains a warning code -3330 "Record Submitted Late": The submission date is more than 30 days after M0090 "Date Assessment Completed" on this new record. The report states 17 (5.78%) out of 294 assessments processed were submitted more than 30 days after M0090. There is no documented evidence the agency submitted required the documents timely for 17 out of 294 assessments, or for 5.78 % of submissions. The finding was confirmed on 08/28/2024 at 12:00 PM with the Acting Director of Public Health, Director of Patient Services and Medical Records Clerk; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a complete physician Plan of Care (POC) was developed to meet the individualized needs of the patient in one of seven patient records reviewed (Patient # 3). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 3 (start of care 06/21/2024) has diagnoses of Posterior Tibial Tendinitis, Left Leg and Obstructive and Reflux Uropathy. The physician's POC for certification period 08/20/2024 through 10/18/2024) contain orders for: - Polyethylene glycol 3350 oral powder for reconstitution, 17 gram once a day oral as needed/(PRN). The order is incomplete as it lacks reconstitution instructions (i.e. the fluid the powder is to be reconstituted in and the amount of fluid to be used) and - Calmoseptine 0.44%-20.6% topical ointment 1 application every 2 hours topical PRN/as needed. The order is incomplete as it lacks the anatomical location to apply the ointment. The findings were confirmed on 08/28/2024 at 9:00 AM with the Acting Director of Public Health, Director of Patient Services and Medical Records Clerk; no additional evidence was provided.