Every finding on record at Hebron Healthcare Services Inc

A relicensure/recertification survey entrance conference was conducted on 01/27/2023. The census was: LCHHS: 0 LHH: 0 PAS: 25 The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited. Abbreviations: CFR – Code of Federal Regulations LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services PAS – Personal Assistance Services

A relicensure/recertification survey entrance conference was conducted on 01/27/2023. The census was: LCHHS: 0 LHHS: 0 PAS: 25 Abbreviations: Adm – Administrator Alt – Alternate CFR – Code of Federal Regulations CMS – Centers for Medicaid and Medicare DC – Disaster Coordinator DON - Director of Nurses EHR – Electronic Health Record LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services OASIS- Outcome and Assessment Information Set PAS – personal assistance services PM - Post meridiem Sup – Supervisor

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview. the agency failed to ensure the clinical records, it contents and the information contained therein were safeguarded against loss in three of three patient records (Patient 1, 2 and 3), in that the agency used a vendor for EHR system and no longer had access to the EHR or have complete paper patient records. This failure resulted in the surveyor being unable to determine the quality of care and treatment provided to the patients by agency employees. Findings include: CFR 484.110(c)(1)(2) Retention of Records reads: "Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time…" During the entrance conference, Adm/DON/PAS Sup/DC stated the agency used an EHR system when they had skilled patients but no longer had access to the EHR. Adm/DON/PAS Sup/DC stated she printed some records prior to losing access and would contact the former EHR provider to gain surveyor access. On 02/03/2023, the surveyor requested and received paper records for Patient 1, 2 and 3 from Adm/DON/PAS Sup/DC. The surveyor asked if the paper records included everything available for review. Adm/DON/PAS Sup/DC stated if she found any skilled nursing notes, she would bring them to the surveyor. The surveyor did not receive any additional records. Patient 1: Record review of the patient discharge list included a discharge date of 10/17/2020. Record review of the paper record included a plan of care dated 08/20/2020-10/18/2020 with nursing visits ordered once a week for nine weeks and two as needed nursing visits for disease exacerbation. The paper record did not include any nursing visit notes or nursing OASIS assessments (Outcome and Assessment Information Set: a patient-specific, assessment used in Medicare home health to plan care, determine reimbursement, and measure quality). Record review of the 21-page OASIS Final Validation Report (a report that provides detailed information about the status of OASIS assessments submitted to CMS by the agency) obtained by the surveyor from the CMS Internet Quality Improvement and Evaluation System website, revealed the agency submitted two OASIS assessment to CMS as follows: Recertification (a follow-up assessment conducted during the last five days of the prior 60 day recertification period completed to continue services for an additional 60 day episode of care)[pg. 18] completed on 08/18/2020. Discharge from agency [page 21] completed on 10/18/2020. There were no skilled nursing notes for surveyor review. The two OASIS assessments were not available for surveyor review. Patient 2: Record review of the patient discharge list included a discharge date of 08/17/2020. Record review of the paper record included a plan of care dated 06/19/2020-08/17/2020 with nursing visits ordered once a week for nine weeks and two as needed nursing visits for disease exacerbation. The paper record did not include any nursing visit notes or nursing OASIS assessments. Record review of the 21-page OASIS Final Validation Report revealed the agency submitted one OASIS assessment to CMS as follows: Recertification [page 13] completed on 06/18/2020. There were no skilled nursing notes for surveyor review. The OASIS assessment was not available for surveyor review. Patient 3: Record review of the patient discharge list included a discharge date of 06/01/2020. Record review of the paper record included a plan of care dated 04/19/2020-06/17/2020 with nursing visits ordered once a week for nine weeks and two as needed nursing visits for disease exacerbation. The paper record did not include any nursing visit notes or nursing OASIS assessments. Record review of the 21-page OASIS Final Validation Report revealed the agency submitted two OASIS assessments to CMS as follows: Recertification [page 12] completed on 04/18/2020. Discharge from agency [page 16] completed on 06/20/2020. There were no skilled nursing notes for surveyor review. The two OASIS assessments were not available for surveyor review. During an interview with Adm/DON/PAS Sup/DC on 02/08/2023 at 3:00 PM, the surveyor presented the above findings and asked if Patient 1, 2 and 3 received skilled nursing visits as ordered on the plan of cares. Adm/DON/PAS Sup/DC stated, “Yes”. During an interview with the Adm/DON/PAS Sup/DC on 02/03/2023 at 12:34 PM, the surveyor presented the above findings and asked if the agency gained access to the EHR. Adm/DON/PAS Sup/DC stated the EHR provider could not provide agency access to the EHR unless the agency paid fees for two full years, but she had the phone number for the EHR manager and would contact him directly. At 1:20 PM, the Adm/DON/PAS Sup/DC stated the EHR manager blocked her calls. During an interview with Adm/DON/PAS Sup/DC on 02/07/2023 at 1:00 PM, the surveyor asked the status of surveyor access to the EHR. Adm/DON/PAS Sup/DC stated the EHR provider had not responded to her and the surveyor would not have access to the EHR. Agency policy titled, “MEDICAL RECORD FORMS AND FORMAT IM.7” with a revision date of 06/21/2006, read in part, “…PURPOSE To establish standardized medical record forms and format. POLICY Agency will maintain active and inactive medical records in a format that facilitates easy retrieve of data/information…PROCEDURE 2.3 DISCHARGED MEDICAL RECORDS: Medical record contents and all thinned material will be combined into the same orders as an active medical record when a patient is discharged from Agency.” Agency policy titled, “MEDICAL RECORD CONTENT IM.8” with a revision date of 10/01/2011, read in part, “…PURPOSE To ensure each medical record, whether paper, electronic or combination, contains complete information which identifies the patient, describes problems and needs of the patient, justifies patient care, and accurately describes care provided, results, significant event and continuity among disciplines. POLICY Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal and state laws and regulations. The record may be in a paper, electronic or combination format…PROCEDURE 1. Each medical record will contain the following: 1.2 Patient’s needs information, as documented in both initial assessments and ongoing assessments…1.3 Justification of care information…1.4 Documentation of care provided…” Agency policy titled, “MEDICAL RECORD INFORMATION RETENTION AND DESTRUCTION IM.13” with a revision date of 11/01/2011, read in part, “…PURPOSE To ensure medical record information retention…is in accordance with federal and state laws and regulations. POLICY Agency will maintain all…medical records for a minimum of six (6) years after discharge of the patient…”