Every finding on record at Kay Carrington

Purpose: Recertification with follow-up Entrance Date: 2/22/2022 at 11:12 a.m. with the Administrator/Director of Nursing Census: Licensed and Certified - 10 Exit Date: 3/2/2022 at 1:07 p.m. with the Administrator/Director of Nursing, Assistant General Manager, and the Office Manager. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification with follow-up Entrance Date: 2/22/2022 at 11:12 a.m. with the Administrator/Director of Nursing Census: Licensed and Certified - 10 Exit Date: 3/2/2022 at 1:07 p.m. with the Administrator/Supervising Nurse/Director of Nursing, Assistant General Manager, and the Office Manager. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. The agency was in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies.

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 individualize the Plans of Care to include a description of the patient’s risk for emergency department visits and hospital readmission in 5 (#1, #2, #3, #4, and #5) of 5 active patient records reviewed. The failure placed the patients at risk for emergency room visits and hospitalizations. The agency had a combination of electronic and paper clinical records. Patient #1: Record review of Patient #1’s record revealed a Plan of Care dated 10/19/2021 to 12/17/2021. The Plan of Care indicated that Patient #1 started on the agency’s services on 7/2/2019. The Plan of Care listed Epilepsy, Anxiety, Bipolar, Chronic Pain, and Hypertension as diagnoses. The Plan of Care was signed by the Director of Nursing. The Plan of Care did not include Patient #1’s risks for emergency department visits and rehospitalization. Patient #2: Record review of Patient #2’s record revealed a Plan of Care dated 11/24/2021 to 1/22/2022. The Plan of Care indicated that Patient #2 started on the agency’s services on 7/27/2021. The Plan of Care listed Diabetes Mellitus with other Specified Complication, and Elevated Blood-Pressure Reading without Diagnosis of Hypertension as diagnoses. The Plan of Care was signed by the Director of Nursing. The Plan of Care did not include Patient #2’s risks for emergency department visits and rehospitalizations. Patient #3: Record review of Patient #3’s record revealed a Plan of Care dated 11/21/2021 to 1/19/2022. The Plan of Care indicated that Patient #3 started on the agency’s services on 12/12/2017. The Plan of Care listed Downs Syndrome, Anemia, Heart Murmur, Mild Intellectual Disability, and Hypertension as diagnoses. The Plan of Care was signed by the Director of Nursing. The Plan of Care did not include Patient #3’s risks for emergency department visits and rehospitalizations. Patient #4: Record review of Patient #4’s record revealed a Plan of Care dated 12/6/2021 to 2/3/2022. The Plan of Care indicated that Patient #4 started on the agency’s services on 8/19/2019. The Plan of Care listed Other Abdominal Hernia without Obstruction or Gangrene, Dysphagia, Edema, Hypertension, Schizophrenia, Hypercholesterolemia, Effusion of Unspecified Joint, and Pain in Unspecified Joint as diagnoses. The Plan of Care was signed by the Director of Nursing. The Plan of Care did not include Patient #4’s risks for emergency department visits and rehospitalizations. Patient #5: Record review of Patient #5’s record revealed a Plan of Care dated 12/2/2021 to 1/30/2022. The Plan of Care indicated that Patient #5 started on the agency’s services on 8/12/2008. The Plan of Care listed Atrial Fibrillation, Diabetes Exacerbation, Hypertension Exacerbation, Cervix Hemorrhage, Osteoarthritis Exacerbation, Edema Exacerbation, and Effusion of Joints as diagnoses. The Plan of Care was signed by the Director of Nursing. The Plan of Care did not include Patient #4’s risks for emergency department visits and rehospitalizations. During an interview on 3/1/2022 at approximately 12:21 p.m. with the Administrator/Director of Nursing, the surveyor discussed and asked questions regarding the Plans of Care and that the risks for rehospitalizations and emergency department visits were not included. When asked how this could affect the patients, the Administrator/Director of Nursing responded that: “the risks had been assessed but that the software program had not pulled the risks from the Outcome and Assessment Information Sets to the Plans of Care.”

Purpose of Visit: Complaint Investigation Entrance Date: 02/10/2021 An entrance conference was conducted with the agency administrator (Employee A) at 11:50 a.m. L&CHHS Census: 17 Complaint Investigation Intake number: TX00374844 Exit Date: 02/25/2021 An exit conference was conducted at 3:00 p.m. with Employee A. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was to be faxed to the Arlington office. The agency was informed that if violations were cited, the agency would receive the Statement of violations within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Violations. Additional documentation was received, from the agency, in the Arlington office on 03/01/2021. Abbreviations: Licensed and Certified Home Health Services-L&CHHS Licensed Home Health Services-LHHS Personal Assistance Services-PAS Registered Nurse (RN) Physical Therapist (PT) Licensed Vocational Nurse (LVN) Home Health Aide (hha) NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care HMO- health maintenance organization RT-Right SN- Skilled Nursing CMS- Center for Medicare and Medicaid Services

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 agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 5 and 6) of two inactive patient records reviewed whose payer source changed to a Medicare HMO. The agency failed to provide patients # 5 and 6 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure of the agency to provide proper written notification of the agency's intent to discharge could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and prevented the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 5: Record review of the electronic and hard copy clinical records for Patient # 5 contained a POC with a SOC date of 03/14/2019. The POC had a certification period 03/08/2020 to 05/06/2020 and a principal diagnosis of cholesterol. The POC was signed by supervising nurse, RN A and dated 03/08/2020. The POC contained an order for SN visits one time per week for nine weeks and two as needed visits. Patient # 5's record included a discharge OASIS signed by RN A that showed a date of discharge as 05/01/2020. The record also included a discharge summary that was signed by RN A and dated 05/06/2020. The discharge summary did not list the reason for discharge. A physician telephone order dated 04/30/2020 listed the reason for discharge as, patient signed up with a Medicare HMO. Patient # 5's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 05/01/2020. The records did not include a written NOMNC. Clinical Record # 6: Record review of the electronic and hard copy clinical records for Patient # 6 contained a POC with a SOC date of 09/20/2019. The POC had a certification period 11/13/2020 to 01/11/2020 and a principal diagnosis of right lower leg cellulitis. The POC was signed by supervising nurse, RN A and dated 11/13/2020. The POC contained an order for SN visits one time per week for nine weeks and two as needed visits. Patient # 6's record included a discharge OASIS signed by RN A that showed a date of discharge as 01/01/2021. The record also included a discharge summary that was signed by RN A and dated 02/07/2021. A physician telephone order dated 01/15/2021 listed the reason for discharge as, patient payer source changed to a Medicare HMO. Patient # 6's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 01/01/2020. The records did not include a written NOMNC. Patient # 6's record contained a letter dated 01/15/2021. The letter stated that due to the change in insurance provider the agency was no longer able to service Client # 6's home care needs. In an interview on 02/25/2021 at approximately 2:00 p.m. with the administrator/supervising nurse, RN A, the surveyor discussed the above findings and asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 5 and 6? RN A stated the agency was not aware of the need to give the notice. The agency faxed a NOMNC form for Client # 6 to the Arlington office on 03/01/2021 that was dated 01/15/2021. The NOMNC provided a signature line for the patient or patient representative. The office manager (Employee G) signed on the provided signature line. The form also did not include the current QIO's name and contact information. Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.