Every finding on record at Legacy Visiting Health Services

AMENDED 02/24/25 EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 0213/25, Legacy Visiting Health Services is in compliance with the provisions of 42 CFR Part 484.102 Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey The following deficiencies are based on the Partial Extended Recertification Survey completed on 02/13/25. Legacy Visiting Health Services, 368482, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C Home Health Agency.

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 record review, policy review, and staff interview, the agency failed to ensure each completed Outcome and Assessment Information Set (OASIS) assessment was encoded and electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) system within 30 days of completion. This could potentially affect all patients at this agency. The census was 54. Review of the OASIS transmission reports for 01/2025 revealed the Late Submission Warning 3330, submission more than 30 days from completion, was found on four out of 14 submissions in 01/2025. Review of the undated agency policy titled “Data Entry/Transmission of OASIS Information” revealed OASIS information collected at start of care, resumption of care, discharge and transfer to an inpatient facility will be encoded, edited and locked into the computer system within seven calendar days from the date the assessment is completed. Interview on 02/10/25 at 12:58 PM Staff A and B both confirmed these submissions were more than 30 days after completion.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview ,the agency failed to ensure the Centers for Medicare & Medicaid Services (CMS) Outcome and Assessment Information Set (OASIS) Privacy Notice was given to the patients on admission. This could potentially affect all patients at this agency. The census was 54. Review of the medical record for Patient #4 revealed the “New Skilled Admission Packet Attestation Statement” stated by signing below Patient #4 acknowledges receipt of a copy of all information initialed above. Additionally, Patient #4 acknowledges this information has been verbally reviewed. Above revealed Patient #4 initialed receiving a copy of the OASIS Privacy Act Statement. Review of an admission packet did not contain the CMS OASIS Privacy Notice. Review of the agency policy titled “Patient Privacy Rights,” revised 05/14/2012, revealed patients must be informed of their rights under the Privacy Act of 1974 and receive written and oral instructions as related to the following “Rights”: • The right to be informed OASIS information will be collected and the purpose of collection; • The right. to have the information kept confidential and secure; • The right to be informed OASIS information will not be disclosed except for legitimate purposes allowed by the Federal Privacy Act; • The right to refuse to answer questions; and • The right to see, review, and request changes on their assessment. Prior to initiating the Start of Care OASIS assessment, the patient must be informed in writing and orally of their "Privacy Rights". Interview on 02/10/25 at 11:57 AM, Staff B confirmed they do not have the CMS OASIS Privacy Notice and were not aware of this form. Staff B confirmed they do not give the patients the OASIS Privacy Act Statement. Interview on 02/12/24 at 8:25 AM, Staff A stated they were not aware of the CMS OASIS Privacy Notice and are not using it. Staff A stated the OASIS information would be explained verbally at the start of care but was not documented.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure the Quality Improvement Program measured, analyzed, and tracked quality indicators, that enable the agency to assess processes of care and services. This could potentially affect all patients at this agency. The census was 54. Review of the agency policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised 05/14/2012, revealed the Agency will establish and maintain an ongoing Quality Assessment and Performance Improvement Program comprised of a system of measures that captures significant outcomes essential to optimal care, and are used in the care planning and coordination of services. Measures to be used included an analysis of services furnished to patients and use the evaluation process to correct identified problems. Review of the Infection Control log for 2024 Quarter One revealed six out of 14 infections were urinary tract infections (UTI). All 14 infections were on antibiotics. Review of Quarter Two revealed four out of 13 infections were UTIs. All 13 infections were treated with an antibiotic. Review of Quarter Three revealed four out of 20 infections were UTIs. All 20 infections were treated with an antibiotic. Review of Quarter Four revealed two out of 10 infections were UTIs. All 10 infections were treated with an antibiotic. Review of the Quality Improvement binder for 2024 did not reveal any infection control action plans for the UTIs, nor monitoring or tracking of infection control. There was no other data collected, tracked or monitored. Interview on 02/13/25 at 2:10 PM Staff A and Staff B confirmed they did not analyze or track the UTI infections. Staff B stated they analyzed the infections but did not document them. Staff A and Staff B both confirmed there was no other data collected, analyzed, monitored or tracked.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview the agency failed to ensure the home health aide (HHA) followed the HHA Care Plan developed by the registered nurse (RN). This affected one (Patient #4) out of one patient reviewed with an HHA. The census was 54. Review of the medical record for Patient #4 and the HHA care plan last updated by the RN on 01/02/25 revealed the HHA was to do peri care to Patient #4 twice a day and apply lotion with daily bath. Review of the monthly log from 01/05/25 to 01/19/25 of the HHA services provided to Patient #4 did not reveal peri care had been done twice a day. There was no documented evidence lotion had been applied daily. Review of the agency policy titled “Home Health Aide (HHA),” revised 07/02/2012, revealed the agency Clinical Director or RN Case Manager are responsible for assigning and overseeing the HHA visits. Interview on 02/12/25 at 1:48 PM Staff A confirmed peri care was not done twice a day on Patient #4 and verified there was no documented evidence lotion had been applied daily as ordered.