Every finding on record at Humanity Home Health LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/28/24. The Agency was in compliance with the Condition, 42 CFR 484., Establishment of the Emergency Program for this survey.

Recertification survey conducted on 06/28/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning BP = Blood pressure SN = Skilled Nurse SOC = Start of care POC/PsOC = Plan of Care/Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients OT = Occupational Therapist PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and Staff interview, it was determined that in 24 of 128 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 03/23 to 02/24 (12 months), was reviewed on 06/27/24. The report included a warning for Error # -3330. The Error included 24 (18.75 %) assessments that were submitted late. 2. During an interview with the Administrator and Agency Supervisor on 06/27/24 at 11:00 AM, the Agency Supervisor stated that the Agency submits OASIS reports and should be within 30 days after completion date. During the same interview, the Agency Supervisor confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record reviews, observation during home visits and Staff interview, it was determined that in 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure that Pts./Pts. representatives were informed advance of the disciplines to provide care/service and the frequency of visits provided by each discipline. Findings include: 1. The following clinical records were reviewed from 06/26/24 9:00 AM to 06/27/24 2:00 PM: Pt. #1 SOC 05/16/24 Pt. #2 SOC 04/29/24 Pt. #3 SOC 01/25/24 Pt. #4 SOC 05/21/24 Pt. #5 SOC 01/25/24 Pt. #6 SOC 12/04/23 Pt. #7 SOC 04/11/24 During home visits for Pt. #1 on 06/26/24 at 9:00 AM and for Pt. #3 on 06/27/24 at 11:00 AM, the Pt’s admission folder was observed and lacked the discipline(s) to provide service and the proposed frequency for each discipline. 2. During an interview with the Administrator and Agency Supervisor on 06/27/24 at 11:00 AM, the Agency Supervisor confirmed the above findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on a review of closed clinical records and Staff interview, it was determined that in 1 of 2 (Pt. #7) closed clinical records, the Agency failed to ensure the comprehensive assessment was updated at discharge. Findings include: 1. Pt. # 7 was admitted to Home Health Services on 04/11/24 with Diagnosis of: Heart Failure, Unspecified. The clinical record was reviewed on 06/26/24. The Physician order dated 05/30/24 indicated Pt. #7 was discharged from all home health services due to Pt. expired at acute care facility. The record lacked a comprehensive assessment update at discharge. 2. During an interview with the Administrator and Agency Supervisor on 06/27/24 at 11:00 AM, the Agency Supervisor confirmed that the comprehensive assessment was not updated at discharge.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on a review of clinical records review, Agency's policy review and Staff interview it was determined that in 3 of 7 (Pts # 1,4 and 7) clinical records review, Agency staff failed to provide services ordered by the Physician. Findings include: 1. Pt. #1 was admitted to Home Health Services on 05/16/24 with Diagnosis of: Paraplegia. The clinical record was reviewed on 06/25/24. The clinical record contained a POC for certification period 05/16/24 to 07/14/24 that required SN frequency of 1 time a week for 9 weeks. The clinical record lacked an SN visit for the week of 05/19/24 to 05/25/24. There was no modification in Physician orders or a communication indicating why no SN visits were done as ordered in the POC. 2. Pt. #4 was admitted to Home Health Services on 05/21/24 with Diagnosis of: Systemic Lupus Erythematosus, Unspecified. The clinical record was reviewed on 06/27/24. The POC for certification period of 05/21/24 to 07/19/24, required: “…. OT frequency: To evaluate and treat….”. The clinical record contained an initial OT evaluation dated 06/06/24 (16 days from SOC). There was no modification in Physician orders or a communication indicating reason for delay in start of OT services. 3. Pt. # 7 was admitted to Home Health Services on 04/11/24 with Diagnosis of: Heart Failure, Unspecified. The clinical record was reviewed on 06/26/24. The POC for the certification period of 04/11/24 to 06/09/24, required: “….Notify Physician of Systolic BP: Greater Than (>) 160 Less Than ()90 Less Than ( The POC for the same certification period, required: “…. Physical Therapy to assess functional status….” The clinical record contained an initial PT evaluation dated 04/22/24 (12 days from SOC). There was no modification in Physician orders or a communication indicating reason for delay in start of PT services. The POC for the same certification period, required: “…. Occupational Therapy to assess functional status….” The clinical record contained an initial OT evaluation dated 04/20/24 (9 days from SOC). There was no modification in Physician orders or a communication indicating reason for delay in start of PT services. 4. The Agency policies titled: “Physical Therapy” and “Occupational Therapy” indicated: “….The first visit is made within 5 days from the start of care….” 5. During an interview with the Administrator and Agency Supervisor on 06/27/24 at 11:00 AM, the Agency Supervisor confirmed the above findings.

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 a review of clinical records and Staff interview, it was determined that in 2 of 2 (Pts. # 6 and 7) closed clinical records reviewed, the Agency failed to ensure the Physician or health care facility where patient was receiving care, was sent a copy of the Transfer summary and Discharge summary. Findings include: 1. Pt. #6 was admitted to Home Health Services on 12/04/23 with Diagnosis of: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 06/26/24. The Discharge assessment and Discharge summary, indicated Pt. #6 was discharged from the Agency on 05/30/24. The record lacked documentation that the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 04/11/24 with Diagnosis of: Heart Failure, Unspecified. The clinical record was reviewed on 06/26/24. A transfer assessment and transfer summary, indicated Pt. #7 was transferred to inpatient, not discharged from Agency on 05/16/24. The record lacked documentation that the transfer summary was sent to the Physician or health care facility where patient was receiving care. 3. During an interview with the Administrator and Agency Supervisor on 06/27/24 at 11:00 AM, the Agency Supervisor confirmed the above findings.