Every finding on record at Home Health Plus Inc

A recertification entrance survey was conducted on 07/06/2023 The census was 21 Licensed and Certified patients - 21 Licensed Home Health patients - 0 Personal Assistance Services patients – 0 The agency was in substantial compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health.

A recertification entrance survey was conducted on 07/06/2023 The census was 21 Licensed and Certified patients - 21 Licensed Home Health patients - 0 Personal Assistance Services patients – 0 The agency was found to be out of compliance with the following Conditions of Participation: 484.60 - Care Planning, Coordination and Quality of Care 484.60(a)(2)(i-xvi) - Plan of care must include the following: 484.60(d)(4) - Coordinate care delivery Abbreviations: NOMNC - Notice of Medicare Non-Coverage SN – Skilled Nurse ADM - Administrator DON - Director of Nursing OASIS - Outcome and Assessment Information Set OM – Office Manager POC - Plan of Care SOC - Start of care RN – Registered Nurse ESRD – End Stage Renal Disease HD – Hemodialysis AVF – Atrioventricular Fistula PT – Physical Therapy OT – Occupational Therapy ST - Speech Therapy Mg - Milligram ML – Milliliter

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 home health agency failed to provide written notice of the intent to discharge before the date of discharge to five (Patient #6, 7, 8, 9, and 10) of six discharged patients record reviewed. The failure prevented the patient from having the ability to exercise their rights to appeal a discharge decision for reconsideration. Findings include: A list of discharge patient for the last 12 months was provided to the surveyor by the office manager (OM) on July 6, 2023, at approximately 12:40 PM. The discharge patient list provided the dates and the reason for discharge. Review of Patient #6’s discharge clinical record included a discharge summary dated 02/26/2023 revealed patient was discharged from the agency on 02/26/23 with discharged reason “Goals Met”. The entire clinical record did not include any documentation that indicated a “Notice of Medicare Non-Coverage (NOMNC)” written notification had been provided to the patient at least two days prior to the discharge. Review of Patient #7’s discharge clinical record included a discharged from agency OASIS (an assessment) revealed a discharge date 07/06/22 with discharged outcome “Goals Met”. The entire clinical record did not include any documentation that indicated a NOMNC written notification had been provided to the patient at least two days prior to the discharge. Review of Patient #8’s discharge clinical record included documentation of OASIS-E Discharge revealed a discharge date 01/06/23 with discharged reason “Goals Met”. The entire clinical record did not include any documentation that indicated a NOMNC written notification had been provided to the patient at least two days prior to the discharge. Review of Patient #9’s discharge clinical record included documentation of OASIS-E Discharge revealed a discharge date 03/06/2023 with discharged reason “Goals Met”. The entire clinical record did not include any documentation that indicated a NOMNC written notification had been provided to the patient at least two days prior to the discharge. Review of Patient #10’s discharge clinical record included a discharge summary dated 12/31/2022 revealed a discharge date 12/31/22 with discharged reason “Goals Met”. The entire clinical record did not include any documentation that indicated a NOMNC written notification had been provided to the patient at least two days prior to the discharge. During the interview with the ADM and the DON on 07/12/23 at approximately 11:00 AM, the surveyor asked if the agency provided a written notification to the patients at least two days before the date of discharge. The DON responded that she gives a notice to patients before discharge from the agency. The surveyor presented the findings regarding the discharged Patients #6, 7, 8, 9, and 10. The DON search for NOMNC written notification for the above listed patients then said she did not find the written notice for six above listed discharged patients. Regulation: July 1, 2005, the new Medicare regulations (Benefits Improvement and Protection Act) BNI gave beneficiaries access to the new expedited determination process when their home health agency services are ending. There are two notices required by these regulations. The first is a generic notice (called a Notice of Medicare Provider Non-coverage) that the provider will deliver at least two days prior to when a beneficiary's Medicare coverage of services is ending. The phone number for the Quality Improvement Organization (QIO) should be included in this notice (XXX-XXX-9504). The second is a detailed notice (called a Detailed Explanation of Provider Non-Coverage) that the provider will deliver to the beneficiary and the appropriate QIO only if the beneficiary requests an expedited review by the QIO of the decision that coverage for items and/or services should end. According to 42 Code of Federal Regulations: § 405.1200 Notifying beneficiaries of provider service terminations. (b) Advance written notice of service terminations. Before any termination of services, the provider of the service must deliver valid written notice to the beneficiary of the provider's decision to terminate services. The provider must use a standardized notice, as specified by CMS, in accordance with the following procedures: Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. If the beneficiary's services are expected to be fewer than 2 days in duration, the provider must notify the beneficiary at the time of admission to the provider. If, in a non-residential setting, the span of time between services exceeds 2 days, the notice must be given no later than the next to last time services are furnished. Review of agency policy titled” Patient Discharge, PE.6” of the Administrative Policy Manual Revised date 04/06/10, read in part: “Purpose: To provide patients access to an expedited determination process when their Medicare covered Home Health Agency services are ending. Policy: Agency will provide appropriate discharge planning and notification per regulations. Procedure: B. Patient Discharge - 3. Agency intending to discharge a patient will perform the following: providing written notification …… or legal representative. 10. Agency will keep the following in the patient’s file: a copy of the written notification provided to patient …. or legal representative. C. Agency staff will provide valid notice (involves both delivery and completion) of the …... agrees with the discharge.”

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, observation and interview, the agency failed to coordinate missed skilled evaluation and visits with the patient’s Physician in 2 (Patient # 1, and 2) of 7 active patients and the coordination of service with the dialysis facilities to meet the patient-specific needs in 2 (Patient # 4, and 5) of 2 dialysis dependent patients with the diagnosis of stage 5 chronic kidney disease (kidneys are severely damaged and stopped filtering waste from blood). The failure to include an effective interchange and coordination placed patients at risk of negative patient care outcomes to meet the patient-specific health needs. Refer to G0608 Based on record review and interview, the agency failed to meet the safety measures to protect against injury in 2 (Patient # 4 and 5) of 2 hemodialysis (an artificial machine that removes excess fluids and toxins from the blood because the kidneys no longer work) dependent patients with the diagnosis of stage 5 chronic kidney disease (kidneys are severely damaged and stopped filtering waste from blood). The agency did not include a description of the patient's hemodialysis treatments and care of the dialysis access (blood vessels under the skin that connects the patient to the dialysis machine to clean the blood) on the plan of care. The failure to include all the required elements for safe and effective care on the plan of care placed patients subjected to an increased risk of not receiving necessary medical interventions and protection from injury to meet the client's health needs. Refer to G0574

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 record review and interview, the agency failed to meet the safety measures to protect against injury in 2 (Patient # 4 and 5) of 2 hemodialysis (an artificial machine that removes excess fluids and toxins from the blood because the kidneys no longer work) dependent patients with the diagnosis of stage 5 chronic kidney disease (kidneys are severely damaged and stopped filtering waste from blood). The agency did not include a description of the patient's hemodialysis treatments and care of the dialysis access (blood vessels under the skin that connects the patient to the dialysis machine to clean the blood) on the plan of care. The failure to include all the required elements for safe and effective care on the plan of care placed patients subjected to an increased risk of injury and not receiving necessary medical interventions and protection from injury to meet the client's health needs. Findings include: During the entrance conference on 07/06/2023 at 11:20 AM, the surveyor requested active patient rosters. The OM provided active patient roster with current 21 active patent. Patient #4 has the diagnosis of ESRD (End Stage Renal Disease), and diagnosis were not listed for Patient #5. Patient #4: The clinical record for Patient 4 included a recertification OASIS (assessment) dated 05/29/2023 and signed by RN B. The recertification OASIS documented Patient 4’s past medical history includes (page -2) Chronic Kidney Disease, Renal Failure and Dialysis. Further review of assessment (page 13) RN B documented on 3/3/23 Pt underwent for AVF repair of the left upper arm AV fistula and patient has HD every Tuesday, Thursday, and Saturday. Review of the clinical record contained POCs with a SOC date of 04/07/2022 for the certification periods from 06/01/2023 to 07/30/2023, 04/02/2023 to 05/31/2023, and 02/01/2023 to 04/01/2023. The POCs included the diagnosis of chronic kidney disease with heart failure with stage 5 kidney disease/ESRD, dependent on renal dialysis, Type 2 diabetes with other diabetes kidney complication, …”. The POC was electronically signed by the RN B and signed by the physician MD A. Further review entire POCs of the clinical records with a SOC date of 04/07/2022 did not reveal instructions for the SN to assess patient’s dialysis access dialysis access AV fistula on left upper arm. Patient #5: The clinical record for Patient 5 included a recertification OASIS (assessment) dated 05/04/2023, signed by RN B. The recertification OASIS documented Patient #5’s past medical history includes (page -2) Chronic Kidney Disease, Renal Failure and Dialysis. Further review of assessment (page 13) RN B documented patient has left upper arm AV fistula and patient goes for HD every Monday, Wednesday, and Friday. Review of the clinical record contained POCs with a SOC date of 05/12/2022 for the certification periods from 11/08/2022 to 01/06/2023, 01/07/2023 to 03/07/2023, 03/08/2023 to 05/06/2023, and 05/07/2023 to 07/05/2023. The POCs included the diagnosis of chronic kidney disease with stage 5 kidney disease/ESRD, and dependent on renal dialysis. The POC was electronically signed by the RN B and signed by the physician MD B. Further review of the entire POCs of the clinical records with a SOC date of 05/12/2022 did not reveal instructions for the SN to assess Patient 5’s dialysis access AV fistula on left upper arm. An interview was conducted with the DON on 7/12/23, at approximately 11:30 AM. The surveyor reviewed the findings from the record reviews and asked why the plans of care failed to include the patient’s (Patient # 4 and 5) dialysis access assessments. Patient # 4’s SN visit notes has documentation of accessing dialysis access and Patient # 5’s SN visit notes has no documentation of accessing dialysis access. The DON said the RN’s supposed to do it and she does not know why it wasn’t in the POC. Review of agency policy titled:” Patient Assessment Guidelines, PE.2, revised date 04/09/11” of the Administrative Policy Manual read in part: Purpose: To provide accurate and consistent patient assessments which are appropriate to the diagnosis and condition of the patient, as well as appropriate for the care, treatment and the service needs of the patient. Procedure: A. Agency will assign staff to perfume patient assessment according to each patient’s specific/individualized needs and required level of care.” Review of the Lippincott Procedures – Hemodialysis access care, home care dated 5/5/21 revealed in part “…Inspect the AV access extremity and compare it with the other extremity, noting any obvious differences, assess the AV access extremity for swelling, redness, warmth, drainage from prior needle sites, ecchymosis (black and blue areas), …Auscultate for the presence of a bruit (whooshing sound (blood flow) and palpate (touch) the AV access for a continuous sensation, known as a “thrill” (pulse) (patency)…Document all assessments including…as well as your assessment of the AV access extremity and AV access site. Make sure to document the presence or absence of a bruit and thrill… “

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to coordinate missed skilled evaluation and visits with the patient’s Physician in 2 (Patient # 1, and 2) of 7 active patients and the coordination of service with the dialysis facilities to meet the patient-specific needs in 2 (Patient # 4, and 5) of 2 dialysis dependent patients with the diagnosis of stage 5 chronic kidney disease (kidneys are severely damaged and stopped filtering waste from blood). The failure to include an effective interchange and coordination placed patients at risk of negative patient care outcomes to meet the patient-specific health needs. Findings include: Patient record # 1: Review of the clinical record contained a Plan of Care (POC) with a start of care (SOC) date of 03/10/2023 and a certification period from 05/09/2023 thru 07/07/2023. The POC revealed Patient #1 has the following diagnosis: Intervertebral disc disorders (breakdown of one or more discs) with myelopathy (Myelopathy is an injury to the spinal cord due to severe compression) of lumber region; Cervical disc disorder w radiculopathy (nerve in the neck is compressed); The POC was electronically signed by the RN C on 05/05/2023 and not signed by the MD C. The POC included physician orders for SN visits once a week for nine weeks and PT twice a week for 9 weeks staring the week of 05/09/2023. Further review of the record revealed 1. SN visit was started on 06/15/23 with a missed visit. A complete SN visit was only performed on 06/21/2023 and recertification visit on 07/07/2023. No documentation was noted why SN visits were not performed staring the week of 05/09/2023. 2. PT visits were started on 06/08/2023. There is no documentation of why the PT services were not provided staring the week of 05/09/2023. Further review of Patient 1’s record reveal there was no interchange of coordination of care delivery with the physician of missed visits. Patient record # 2: Review of the clinical record contained a POC with a SOC date of 02/28/2023 and the initial certification period from 02/28/2023 thru 04/28/2023. The POC revealed Patient #2 has the following diagnosis: Epilepsy unspecified not intractable, without status epilepticus (two or more seizures may or may not be associated with loss of consciousness), Cognitive communication deficit (difficulty to initiate and effectively communicate), Generalized muscle weakness, …. Metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), Bipolar disorder (mental health condition), and Anxiety disorder. The POC was electronically signed by the RN A on 02/28/2023 and signed by the MD D. The POC included physician orders for SN visits once a week for nine weeks and PT, OT, and ST eval and treat. The review of the entire record revealed 1. On 03/22/2023 OT evaluation was performed, and OT skilled visits completed only on 04/18/2023 and 04/20/2023. Review of OT evaluation on 03/22/2023, recommendation for the visit frequency was once a week for one week and twice a week for three weeks. There is no documentation of why the OT services was not done as per OT evaluation recommendations. 2. ST evaluation was not performed. There is no documentation of why the ST evaluation and service not provided per physician order. Further review of Patient 2’s record reveal there was no interchange of coordination of care delivery with the physician of the missed OT visits and why ST evaluation was not performed. On 07/10/2023 at approximately 12:10 PM, a home visit was conducted with Patient 2. Patient and family stated patient was hospitalized for continues seizures and intubated (a tube inserted through a person's mouth or nose, down into trachea for ventilation) because he was in coma stage. The patient recovered and discharged from hospital but still had problem with swallowing and speech. Patient said he required ST service but never got it. Patient record #4: The clinical record for Patient 4 included a recertification OASIS (assessment) dated 05/29/2023 and signed by RN B. The recertification OASIS documented Patient 4’s past medical history includes (page -2) Chronic Kidney Disease, Renal Failure and Dialysis. Further review of assessment (page 13) RN B documented on 3/3/23 Pt underwent for AVF repair of the left upper arm AV fistula and patient has HD every Tuesday, Thursday, and Saturday. Review of the clinical record contained POCs with a SOC date of 04/07/2022 for the certification periods from 06/01/2023 to 07/30/2023. The POCs included the diagnosis of stage 5 kidney disease/ESRD, dependent on renal dialysis. The POC was electronically signed by the RN B and not signed by the physician MD A. Further review the entire clinical records with a SOC date of 04/07/2022 did not reveal the coordination of service with the dialysis facilities to meet the patient-specific needs. Patient record #5: The clinical record for Patient 5 included a recertification OASIS (assessment) dated 05/04/2023, signed by RN B. The recertification OASIS documented Patient #5’s past medical history includes (page -2) Chronic Kidney Disease, Renal Failure and Dialysis. Further review of assessment (page 13) RN B documented patient has left upper arm AV fistula and patient goes for HD every Monday, Wednesday, and Friday. Review of the clinical record contained POCs with a SOC date of 05/12/2022 for the certification periods from 03/08/2023 to 05/06/2023. The POCs included the diagnosis of chronic kidney disease with stage 5 kidney disease/ESRD, and dependent on renal dialysis. The POC was electronically signed by the RN B and signed by the physician MD B. Further review the entire clinical records with a SOC date of 05/12/2022 did not reveal the coordination of service with the dialysis facilities to meet the patient-specific needs. During an interview with the ADM and the DON on 7/12/23, at approximately 11:30 AM the surveyor reviewed and discussed the findings of Patient 1’s SN visit and PT visit was not started on the week of 05/09/2023 and Patient 2 is not receiving OT as ordered and ST evaluation was not performed. The DON said they cannot provide service until patient’s insurance authorize the services. The surveyor asked why the agency had not coordinated with Physician. The DON stated she called over the phone, but it is not documented. The surveyor asked why the agency had not coordinated dialysis patients (Patient # 4 and 5) care with the dialysis facilities. The ADM said he is taking responsibility of not doing it. Review of agency policy titled:” Monitoring Patient Care/Coordination Of Care, TX.8 Revised date 03/22/11” of the Administrative Policy Manual read in part:” Policy: Agency will monitor, evaluate and report to the patient’s physician regarding the …. of every sixty days. Agency will collaborate with other organizations providing service …. ensure appropriate coordination of care for the patient. Procedure: A. Effective interchange and reporting, as well as coordination of care …. Proving care. D. When other organizations are involved.…. communication is documented in the medical record. E. Agency staff are expected to contact …... will serve as coordination of care.” Review of agency policy titled:” Patient Assessment Guidelines, PE.2, revised date 04/09/11” of the Administrative Policy Manual read in part: Purpose: To provide accurate and consistent patient assessments ……treatment and the service needs of the patient. Procedure: Q. The scope of other discipline’s assessment …... patient population. T. An assessment performed …... within the timeframe as follows: 1. Nursing – 24-28 hours; 2. Physical Therapy – 5 days; 3. Occupational Therapy – 5 days; Speech Therapy – 5 days; Medical Social Worker – 5 days”.

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 home health agency failed to include an agency completed discharge summary in the patient’s discharged record in 3 (Patient 7, 8 and 9) of 6 discharged patient’s record reviewed. This failure prevented continuity of care in the event a summary of the patient’s clinical care, during home health/ hospital admission period, was requested. Findings include: A list of discharge patient for the last 12 months was provided to the surveyor by the office manager on July 6, 2023, at approximately 12:40 PM. The discharge patient list provided the dates and the reason for discharge. Review of the discharged list: The list indicated that Patient 7 was discharged on 07/06/2022. The list indicated that Patient 8 was discharged on 01/06/2023. The list indicated that Patient 9 was discharged on 02/27/2023. Review of Patient #7’s clinical record included a discharged from agency OASIS (an assessment), revealed a discharge date 07/06/22. The review of entire discharged clinical record revealed that the record did not include documentation of an agency discharge summary. Review of Patient #8’s clinical record included documentation of OASIS-E Discharge revealed a discharge date 01/06/23. The review of entire discharged clinical record revealed that the record did not include documentation of an agency discharge summary. Review of Patient #9’s clinical record included a physician Order dated 03/06/2023 with the order “discharge from home health services with goals met”. The review of entire discharged clinical record revealed that the record did not include documentation of an agency discharge summary. An interview was conducted with the DON on 7/12/23, at approximately 11:10 AM. The surveyor reviewed and discussed the findings regarding the omission of the agency discharge summary, which includes the reason for discharge or transfer, from the discharged patient’s clinical record. The surveyor asked why the discharge summary not included in the patient’s clinical records. The DON said that they always write a discharge summary. The DON search for discharged summary for the above listed patients but could not find the discharge summaries. Review of agency policy titled” Patient Discharge, PE.6” of the Administrative Policy Manual Revised date 04/06/10, read in part: “Purpose: To assess each patient’s discharge planning …. agency. To provide for continuity of care …. Post-discharge care and documentation. Procedure: B Patient Discharge – 8. Medical record documentation for discharge includes, but not limited to: progress towards goal/Discharge Summary. K. A discharge Summary is completed and …. But not limited to: 1 …. 6. Any discharge instructions and referrals provided to the patient. “