Every finding on record at M & L Medical Services Inc

Purpose: Recertification survey Entrance Date: 9/19/2024 Census: Licensed and Certified - 13 patients The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification survey Entrance Date: 9/19/2024 Census: Licensed and Certified - 13 patients

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 and interview, the agency failed to transmit completed OASIS assessments (Outcome and Assessment Information Set - used to collect patient information to measure outcomes and quality improvement) within 30 days of completing the OASIS assessments to the Centers for Medicare & Medicaid Services (CMS) system for 19 of 36 OASIS assessments transmitted between 6/1/2023 to 5/31/2024. The failure made the agency's data unavailable to the Centers for Medicare & Medicaid Services to evaluate the agency's provision of patient care. Review of the Centers for Medicare and Medicaid Services OASIS-E Guidance Manual (updated January 1, 2024) read in part; “Chapter 1: OASIS Guidance Manual Introduction…1.5.5.1 General OASIS Item Conventions…14…M0090- Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed…” Review of the "OASIS Error Detail Report" taken from the Internet Quality Improvement and Evaluation System (IQIES) on 9/18/2024 indicated that 19 assessments contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment completion date (M0090) between 6/1/2023 and 5/31/2024. Record review for Patient 1: Review of the OASIS Agency Final Validation report taken from IQIES revealed submission identification number 63234636, submitted on 5/14/2024 with three records submitted. Record 1 (Patient 1) indicated that the M0090 date was 4/11/2024. Record 1 listed the following error: "Message Number/Severity: - 3330 Warning, Message: Record submitted late: The submission date is more than 30 days after M0090 on this new record." Record review for Patient 7: Review of the OASIS Agency Final Validation report taken from IQIES revealed submission identification number 63140645, submitted on 4/24/2024, with three records submitted. Record 3 (Patient 7) indicated that the M0090 date was 3/13/2024. Record 3 listed the following error: "Message Number/Severity: -3330 Warning, Message: Record submitted late: The submission date is more than 30 days after M00090 on this new record." During an interview on 9/24/2024 at approximately 1:00 p.m. with the Administrator and Supervising Nurse, the surveyor discussed the OASIS Error Detail Report. The surveyor discussed that the report indicated that the agency had 19 OASIS assessments that were transmitted to the CMS system more than 30 days after the assessments had been completed. The surveyor asked why the OASIS assessment transmissions were late. The Administrator informed the surveyor that it was like "pulling teeth" to get the nurses to turn in the OASIS. The Supervising Nurse stated, "We call them and send them emails" about turning in the OASIS assessments. The surveyor asked what the agency’s process regarding OASIS assessments was. The Supervising Nurse informed the surveyor that the registered nurses have 48 hours to complete the OASIS assessment and give the assessment to the agency. After the OASIS assessment was turned in to the agency, quality assessment would approve it, and the nurse would sign it. The Administrator would then export the OASIS assessment. The surveyor asked who was responsible to track the OASIS to be turned in. The Supervising Nurse informed the surveyor that Employee D, (works in the office) would tract the OASIS. The surveyor asked what Employee D would do when it was noted that the OASIS assessments were not turned in within the agency's timeframe. The Supervising Nurse stated that Employee D would call the nurse and text them. The Supervising Nurse would also call and text the nurses. The Supervising Nurse stated that the skilled nurses, "Know to turn it in." The nurses would tell the agency that they would get them turned in. Employee D was on leave at the time of the survey. Review of the agency's policy titled "Timelines," labeled IM.7, and dated 8/1/2020. The policy read in part; "Purpose To establish timely parameters for all medical record information. Policy The Agency will ensure timely provision of care and services to meet the patient's/client's needs in compliance with all federal and state laws and regulations...Procedure...II. All completed and encoded OASIS data which accurately reflects the patient's/client's status at the time of the assessment, will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS date set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within thirty (30) days of the M0090 date..."

Purpose of Visit: Re-certification Survey. Entrance Date: 07/27/2021 An entrance conference was conducted with the Adm and DON at 11:05 a.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 18 Exit Date: 07/30/2021 An exit conference was conducted at 4:53 p.m. with the Adm and DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviation List: L & C- Licensed and Certified Adm-Administrator DON-Director of Nursing/Supervising Nurse

Purpose of Visit: Re-certification Survey. Entrance Date: 07/27/2021 An entrance conference was conducted with the Adm and DON at 11:05 a.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 18 Exit Date: 07/30/2021 An exit conference was conducted at 4:53 p.m. with the Adm and DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional information. Additional information was not provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified Adm-Administrator DON-Director of Nursing/Supervising Nurse ADON-Assistant Director of Nurses (Alternate Supervising Nurse Registered Nurse (RN) Licensed Vocational Nurse (LVN) Physical Therapist (PT) NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care HHA's- Home Health Agencies

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 five of five (Patients #5 through 10) inactive patient records reviewed. The agency failed to provide the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 6: Record review 07/29/2021. Record review of the electronic clinical record for Patient # 6 revealed a POC for the certification period of 04/30/2021 to 06/28/2021 with a SOC date of 04/30/2021. The POC was dated and signed by PT on 05/14/2021. Patient # 6's clinical 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, 06/25/2021. The record did not include a written NOMNC. Review of the agency's discharge patient list revealed that Patient # 6's was discharged on 06/25/2021. Clinical Record # 7: Record review 07/29/2021. Record review of the electronic clinical record for Patient # 7 revealed a POC for the certification period of 03/21/2021 to 05/19/2021 with a SOC date of 01/20/2021. The POC was dated and signed by RN # 5 on 03/16/2021. Patient # 7's clinical 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, 05/19/2021. The record did not include a written NOMNC. Review of the agency's discharge patient list revealed that Patient # 7's was discharged on 05/19/2021. Clinical Record # 8: Record review 07/29/2021. Record review of the electronic clinical record for Patient # 8 revealed a POC for the certification period of 08/26/2020 to 10/24/2020 with a SOC date of 08/26/2020. The POC was dated and signed by RN # 6 on 08/26/2021. Patient # 8's clinical 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, 09/24/2020. The record did not include a written NOMNC. Review of the agency's discharge patient list revealed that Patient # 8's was discharged on 09/24/2020. Clinical Record # 9: Record review 07/29/2021. Record review of the electronic clinical record for Patient # 9 revealed a POC for the certification period of 05/29/2021 to 07/27/2021 with a SOC date of 05/29/2021. The POC was dated and signed by RN # 4 on 05/29/2021. Patient # 9's clinical 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, 07/27/2021. The record did not include a written NOMNC. Review of the agency's discharge patient list revealed that Patient # 9's was discharged on 07/27/2021. Clinical Record # 10: Record review 07/29/2021. Record review of the electronic clinical record for Patient # 10 revealed a POC for the certification period of 04/02/2021 to 05/31/2021 with a SOC date of 12/03/2020. The POC was dated and signed by RN # 7 on 03/31/2021. Patient # 10's clinical 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, 05/27/2021. The record did not include a written NOMNC. Review of the agency's discharge patient list revealed that Patient # 10's was discharged on 05/27/2021. In an interview on 07/30/2021 at approximately 4:40 p.m. with the Adm and DON, the surveyor discussed the above findings of 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 through 10. The DON stated that the contract nurses did not upload it. Review of agency policy titled "PATIENT/CLIENT RIGHTS AND RESPONSIBILITIES RIGHTS OF THE ELDERLY RI.2" REVISED 011318 READ IN PART: " ...PROCEDURE ...VI. The patient/Client has the right to: I. Receive proper written notice ... in advance of the Agency reducing or terminating on-going care ... "

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's individualized plan of care was reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date in four (Patients # 1, 2, 4 and 5) of five active patient records reviewed. The failure could cause harm to agency patients due to lack of physician oversight if there were changes in the patient's condition or the need for additional care and services. FINDINGS INCLUDED: Review of the clinical record for Patient # 1 revealed a SOC date of 01/15/2021. Review of POC(s) for the certification period: 03/16/2021 to 05/14/2021 dated and signed by RN # 2 on 03/11/2021 and 05/15/2021 to 07/13/2021 dated and signed by RN # 3 on 05/12/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 62 days between the order dates of 03/11/2021 and 05/12/2021. Review of POC(s) for the certification period: 05/15/2021 to 07/13/2021 dated and signed by RN # 3 on 05/12/2021 and 07/14/2021 to 09/11/2021 dated and signed By RN # 3 on 07/13/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 62 days between the order dates of 05/12/2021 and 07/13/2021. Review of the clinical record for Patient # 2 revealed a SOC date of 01/15/2021. Review of POC(s) for the certification period: 03/16/2021 to 05/14/2021 dated and signed by RN # 2 on 03/11/2021 and 05/15/2021 to 07/13/2021 dated and signed by RN # 3 on 05/12/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 62 days between the order dates of 03/11/2021 and 05/12/2021. Review of POC(s) for the certification period: 05/15/2021 to 07/13/2021 dated and signed by RN # 3 on 05/12/2021 and 07/14/2021 to 09/11/2021 dated and signed the DON on 07/12/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 61 days between the order dates of 05/12/2021 and 07/12/2021. Review of the clinical record for Patient # 4 revealed a SOC date of 06/14/2019. Review of POC(s) for the certification period: 10/06/2020 to 12/04/2020 dated and signed by RN # 1 on 10/01/2020 and 12/05/2020 to 02/02/2021 dated and signed by RN # 1 on 12/02/2020 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 62 days between the order dates of 10/01/2020 to 12/02/2020. Review of POC(s) for the certification period: 12/05/2020 to 02/02/2021 dated and signed by RN # 1 on 12/02/2020 and 02/03/2021 to 04/03/2021 dated and signed by RN # 1 on 02/01/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 61 days between the order dates of 12/02/2020 to 02/01/2021. Review of POC(s) for the certification period: 04/04/2021 to 06/02/2021 dated and signed by RN # 1 on 03/31/2021 and 06/03/2021 to 08/01/2021 dated and signed by RN # 1 on 05/31/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 61 days between the order dates of 03/31/2021 to 05/31/2021. Review of the clinical record for Patient # 5 revealed a SOC date of 08/13/2019. Review of POC(s) for the certification period: 10/06/2020 to 12/04/2020 dated and signed by the Alt DON on 10/02/2020 and 12/05/2020 to 02/02/2021 dated and signed by RN # 4 on 12/02/2020 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 61 days between the order dates of 10/02/2020 to 12/02/2020. Review of POC(s) for the certification period: 12/05/2020 to 02/02/2021 dated and signed by RN # 4 on 12/02/2020 and 02/03/2021 to 04/03/2021 dated and signed by RN # 3 on 02/01/2021 revealed that the POC(s) were not reviewed by a physician within the 60-day requirement. There were 61 days between the order dates of 12/02/2020 to 02/01/2021. An interview was conducted on 07/30/2021 with the Adm and DON at approximately 4:28 p.m., the Surveyor discussed the above findings of the Patient # 1, 2, 4 and 5's individualized POC(s) not being reviewed by their physicians. The DON replied, "That's the contract staff." Review of the agency policy titled "PLAN OF CARE PC.8" revised on 110120 read in part: " ...PROCEDURE ...VI. The individualized plan of care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health plan of care and the Agency as frequently as the patient's/client's condition or needs require, but no less frequently than once every sixty (60) days, beginning with the start of care date..."