Every finding on record at Lhcg Ccxxviii, LLC

A Recertification survey was conducted at Three Rivers Home Health Services, Inc. on December 2, 2024, and concluded on December 4, 2024. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A Recertification survey was conducted at Three Rivers Home Health Services, Inc. on December 2, 2024, and concluded on December 4, 2024. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 73. The following deficiencies were cited.

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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by Agency Report, review of policy “OASIS Data Capture, Transmission, Verification, Display and Reports,” and staff interview, it was determined that the agency failed to electronically transmit Outcome and Assessment Information Set (OASIS) data to CMS system within 30 days of completing the assessment. Findings include: Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports,” number 7.002, revised 3/1/2021, revealed the following: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 11/13/2024, revealed the agency failed to transmit OASIS data to CMS within 30 days. On 12/04/2024 at approximately 10:00 am, an interview with the Executive Director (ED) revealed the Office Manager submits OASIS data. The ED failed to provide documentation of OASIS submissions for the agency.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record reviews, and staff interviews, and agency policy “Plan of Care (POC), it was determined the agency failed to include interventions with a diagnosis of acute kidney failure (when your kidneys suddenly stop working) for one patient (P) (P#8) of 11 sampled patients. Findings include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24, reveals the following: Procedure: 2. The POC includes: i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. Review of the plan of care (POC) for P#8 (certification period (start of care) of 7/24/2023 to 9/21/2023) revealed P#8 was admitted to the Home Health agency on 7/24/2023, with a diagnosis of acute kidney failure. The agency failed to address interventions on the POC to monitor fluids retentions, weight, or calf measurement. During an interview on phone with Registered Nurse (RN) AA on 12/3/2024 at 2:55 p.m., RN AA confirmed that the agency failed to address intervention on diagnosis of acute kidney failure on P#8, POC, because her focus was to treat P#8 with urinary tract infection. On 12/3/2024 at 3:19 p.m. an interview conducted with the Area Executive Director (AED), who acknowledged that RN AA failed to include intervention for the diagnosis of acute kidney failure for P#8.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review, staff interview, and agency policy “Physician Orders,” it was determined that the agency failed to have physician sign patient plan of care (POC), and verbal orders for five Patients (P) (P#4, P#8, P#9, P#10, P#11) of 11 sampled patients. The findings include: Review of policy titled “Physician Orders,” revised 10/01/23, reveals the plan of care, telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation of 30 days. 1. Review of clinical record of P#4, certification period dated 7/25/2024 to 9/22/2024, revealed that P#4 was admitted to the home health agency on 7/25/2024. The physician signed the POC on 11/13/2024. 2. Review of clinical record of patient P#8, certification period dated 7/24/2023 to 9/21/2023, revealed that P#8 was admitted to the home health agency on 7/24/2023. The physician signed the POC on 10/6/2023. 3. Review of clinical record of patient P#9, certification period dated 9/11/2024 to 11/9/2024, revealed that P#9 was admitted to the home health agency on 9/11/2024. The physician failed to sign the POC and verbal orders. 4. Review of clinical record of patient P#10, certification period dated 9/25/2024 to 11/23/2024, revealed that P#10 was admitted to the home health agency on 9/18/2024. The physician failed to sign the verbal order. 5. Review of clinical record of patient P#11, certification period dated 8/14/2024 to 10/12/2024, and 10/13/2024 to 12/11/2024, revealed that P#11 was admitted to the home health agency on 8/14/2024. The physician failed to sign the POCs. On 12/3/2024 at 2:58 p.m., an interview was conducted with the Executive Director (ED), who acknowledged that the physician failed to sign POCs’ and verbal orders, and was also late to sign P#4, and P#8 POC’s. The ED additionally revealed that it was a struggle for one of their physicians to sign patients’ plan of care in a timely manner, but the company is working to solve the problem.