Every finding on record at Maxicare Homehealth Inc

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/30/23 to 06/01/23 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/30/23 to 06/01/23 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure two patients (Patient (P)2 and P6) from a total of seven medical records reviewed were not seen for an initial assessment within 48 hours of referral, or within 48 hours hospital discharge, or on the practitioner's ordered start of care date. The failure to complete an initial assessment to determine if the patient has any immediate care needs could affect the health and safety of all patients not evaluated within 48 hours. Findings include: 1. Review of P2's referral, which was accepted by the agency, located in the Electronic Medical Record (EMR) in the "Documents" section showed a referral dated 02/23/23 for skilled nursing and physical therapy to monitor blood pressure due to medication increase, teach use of inhalers, blood glucose checks, medication compliance, back strengthening, and range of motion (ROM). Review of P2's initial visit which included a comprehensive assessment showed that it occurred on 03/02/23 which is more than 48 hours after the referral. 2. Review of P6's referral, which was accepted by the agency, located in the EMR in the "Documents" section showed a referral dated 03/13/23 for physical therapy, occupational therapy, skilled nursing, and aide services following an inpatient hospital stay with a discharge date of 03/14/23. Review of P6's initial visit which included a comprehensive assessment showed that it occurred on 03/21/23 which is more than 48 hours after P6's discharge from the hospital. During an interview on 06/01/23 at 1:30 PM, the Administrator confirmed that P2 and P6 were admitted more than 48 hours after the initial referral or discharge from an inpatient stay. The Administrator stated the delay was due to the patient's not having a primary care provider at the time of the referral to sign ongoing home health orders and the agency needed to find a practitioner willing to sign orders prior to the start of care. The Administrator was aware of the requirement that an initial visit must be completed within 48 hours of the referral or discharge from an inpatient stay, or on a physician ordered start of care date. Review of an agency policy titled, "Acceptance of Patients," dated 01/16/23, showed, "Patients will be accepted for care and services in accordance with the following … The patient is under a physician's care, and the physician is willing to a provide face-to-face and the required written orders for care and/or services."

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, policy review, and interview, the agency failed to ensure five of seven patients (Patient (P)1, P3, P4, P6 and P7) reviewed had a plan of care (POC) that included all required items. The failure to include relevant patient care orders on the individualized POC had the potential to affect the patient's health and safety. Findings include: 1. Review of P1's POC for the certification period 11/18/22 to 01/16/23 located in the section of the electronic medical record (EMR) labeled "Plan of Care" revealed the section for "DME [durable medical equipment] and Supplies" was blank. 2. Review of P3's POC for the certification period 04/02/23 to 05/31/23 located in the section of the EMR labeled "Plan of Care" revealed the section for "DME and Supplies" and the section for "Nutritional Req [Requirements]" were blank. In addition, the section to check "Prognosis" was not completed. 3. Review of P4's POC for the certification period 05/29/23 to 07/27/23 located in the section of the EMR labeled "Plan of Care" revealed the section for "DME and Supplies" and the section for "Nutritional Req" were blank. 4. Review of P6's POC for the certification period 03/21/23 to 05/19/23 located in the section of the EMR labeled "Plan of Care" revealed the section for "DME and Supplies" and the section for "Nutritional Req" were blank. 5. Review of P7's POC for the certification period 05/18/23 to 07/16/23 located in the section of the EMR labeled "Plan of Care" revealed the section for "DME and Supplies" was blank. Review of the agency policy titled "Care Planning-Home Health," dated 01/16/23, revealed, "The Plano of Care shall include at least the following … Prognosis … Required supplies … … Nutritional requirements … other items as appropriate." During an interview on 06/01/23 at 1:30 PM, the Administrator confirmed the POC for P1, P3, P4, P6, and P7 were missing the required elements that were identified on the POC. The Administrator stated it was the agency expectation that all sections of the POC document were completed to include DME, supplies, and dietary orders.

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 record review, policy review, and interview, the agency failed to ensure that physician or other practitioner orders were followed as indicated in the Plan of Care (POC) for four of seven patients (Patient (P)1, P2, P3, and P6) when staff did not document patients' blood sugar, medication teaching, diabetic foot checks, or the weight of a patient taking diuretic. The failure to implement medical orders had the potential to affect the health and safety of the patients. Findings include: 1. Review of P1's POC located in the "Plan of Care" section in the electronic medical record (EMR) showed P1's primary diagnosis was type 2 diabetes and revealed the following orders "SN [skilled nurse] to teach … Medication … possible side effects/adverse reactions and proper administration …blood sugar checks … insulin preparation/administration observing aseptic technique, proper skin and foot care … SN to perform … BS [blood sugar] check every visit, if not yet done by PT/PCG [patient/patient caregiver], observing aseptic technique, proper handling and disposal of sharps … foot care check every SN visit … blood sugar of [more than] 300.00 mg/dl [milligrams per deciliter] Notify MD [medical doctor]." Review of the seven visit notes located in the "Visit Note" section of the EMR revealed that on four of seven skilled nursing (SN) visits blood sugar was not documented. In the "Medications" section of all seven visit notes there was no documentation of patient teaching or observation of insulin administration. In the "Skin" section of all seven visit notes there was no documentation that foot care was completed. 2. Review of P2's POC located in the "Plan of Care" section in the EMR showed P2's primary diagnosis was type 2 diabetes and revealed the following orders "SN to teach …. Medication … possible side effects/adverse reactions and proper administration …blood sugar checks … SN to perform … BS [blood sugar] check every visit, if not yet done by PT/PCG, observing aseptic technique, proper handling and disposal of sharps … foot care every SN visit … blood sugar of 300.00 mg/dl Notify MD." Review of a physician order located in the "Orders" section of the EMR showed an order to stop Metformin (diabetes) due to high creatinine and add Clonidine 0.1 milligram (mg) twice per day to control high blood pressure. Review of all five visit notes failed to show documentation of P2's blood sugar levels, medication teaching, or diabetic foot care. 3. Review of P3's POC located in the "Plan of Care" section in the EMR showed a start of care date (SOC) of 04/02/23 and primary diagnosis was type 2 diabetes. The POC revealed an order to notify the MD if blood sugar " 300.00 mg/dl." Review of all visit notes failed to show documentation of any patient blood sugars. 4. Review of P6's POC located in the "Plan of Care" section in the EMR showed a Start of Care (SOC) date of 03/21/23 and primary diagnosis of type 2 diabetes. The POC revealed the following orders "SN to teach … Medication … possible side effects/adverse reactions and proper administration … blood sugar checks … SN to perform … BS [blood sugar] check every visit, if not yet done by PT/PCG, observing aseptic technique, proper handling and disposal of sharps … foot care check every SN visit … blood sugar of 300.00 mg/dl Notify MD … weight gain of more than 5 [five] pounds in 1 [one] week." Review of the "Medications" section located in the POC revealed P6 is prescribed Furosemide [diuretic] 20 milligram daily. Review of all visit notes failed to show documentation of P6's blood sugar readings, medication teaching, diabetic foot checks, or weight. Review of the agency policy titled, "Care Planning – Home Health," dated 01/16/23, revealed, "All clinical services shall be implemented in accordance with a Plan of Care established by a physician's written orders." During an interview on 06/01/23 at 1:30 PM, the Administrator confirmed the details of the missing documentation and stated that it was the agency expectation that staff comply with implementation of the physician or other practitioner's orders as documented in the POC.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR) system. This failure had the potential to result in unauthorized access to patient information for all patients receiving home health care from the agency. Findings include: During an interview on 05/31/23 at 10:10 AM, the Administrator stated agency staff used their personally owned computers or other devices capable of accessing the web based EMR to complete patient documentation during or after completing home visits. During review of seven patient medical records located in "Note-e-fied" (web based EMR program) showed that the password to access the program could be saved and patient information including care plans, visit notes, Outcome and Assessment Information Set (OASIS) data, and other medical and personal information could be saved and accessed without logging into the program. During an interview on 06/01/23 at 1:30 PM, the Administrator confirmed that the agency cannot monitor, manage, or maintain the staff's personal electronic devices. The Administrator also confirmed the agency would not know if an employee saved patient information to their computer or if the employees device was lost or stolen. No policy was presented that addressed the agency's responsibility to ensure that the devices used to access the EMR could be monitored and maintained by the agency.