Every finding on record at Mga Home Health Plus Services Inc

Purpose: Recertification survey Entrance Date: 10/28/2024 Census Licensed and Certified - 20 patients No deficiencies cited.

Purpose: Recertification survey Entrance Date: 10/28/2024 Census Licensed and Certified - 20 patients Abbreviations: OASIS - Outcome Assessment Information Set IQIES - Internet Quality Improvement and Evaluation System CMS - Centers for Medicare and Medicaid Services

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 15 of 131 OASIS assessments transmitted between 10/24/2023 to 10/25/2024. 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 (CMS) OASIS-E (Outcome and Assessment Information Set - tool used by CMS to collect patient information to measure outcomes and quality improvement) Guidance Manual, updated 1/1/2024, 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 10/25/2024 indicated that 15 assessments contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment completion date between 10/24/2023 and 10/25/2024. Review of the agency's "OASIS Agency Final Validation" report taken from the Internet Quality Improvement and Evaluation System on 10/25/2024 indicated that the agency submitted 131 OASIS assessments between 10/24/2023 to 10/25/2024. During an interview on 10/30/2024 at approximately 12:50 p.m. with the Administrator, Supervising Nurse, and the Quality Assurance Reviewer, the surveyor discussed the OASIS Error Detail Report; the report indicated that the agency had 15 OASIS assessments that were transmitted to the CMS system more than 30 days after the OASIS assessments had been completed. The surveyor asked why the OASIS assessments were transmitted late and what the OASIS assessment transmissions process was. The Administrator informed the surveyor that they used (software). The surveyor asked when the agency transmitted the OASIS assessments. The Administrator stated, "As soon as the OASIS comes through the system. The surveyor asked who was responsible for completing the OASIS assessments. The Administrator informed the surveyor that the Supervising Nurse would be responsible for completing the assessments. The surveyor asked what was the time frame that the agency required that OASIS assessment be turned in to the agency. The Supervising Nurse stated, "Within 3 days, 5 days maximum." The surveyor asked what the next step was after the OASIS assessment had been turned into the agency by the clinician. The Supervising Nurse informed the surveyor that the Quality Assurance Reviewer would sometimes review, but not all the time. The Quality Assurance Reviewer informed the surveyor that the OASIS would be sent to be pre-approved to another agency, Review Agency. Review Agency would send the OASIS back. The Quality Assurance Reviewer informed the surveyor that sometimes the Review Agency would send it back because the Review Agency could not see all the pages. The Review Agency would send it back to the agency. The agency would send whatever the Review Agency returned. The Administrator informed the surveyor that the agency used the pre-approved method with CMS and the agency would send everything to Review Agency. The surveyor asked who would receive the OASIS when it came back to the agency from the review agency. The Administrator stated that it would go to Quality Assurance Reviewer and then it would go into the Administrator's "hot Box"(in the software System) when it was ready for the Administrator to transmit. The Administrator stated, "I did not know there were more than a couple that were late." Review of the agency's policy titled "Timelines," labeled IM.35," and last revised on 5/02/2024. 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 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 data 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: Recertification Survey Entrance Date: 10/21/2021 An entrance conference was conducted with the Alt Adm/DON at 12:30 p.m. The Alt Adm/DON was informed that the purpose of the survey was for a 36-month recertification survey. L and C Census: 23 Exit Date: 10/26/2021 An exit conference was conducted at 12:00 p.m. with the Alt Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies 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 Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) L and C- Licensed and Certified EP-Emergency Preparedness

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed: to comply with all applicable Federal, State and local emergency preparedness requirements; to review and update the emergency preparedness (EP) plan at least annually, per agency policy and state regulation, for the calendar years 2018, 2019 and 2020. The failure could place patients at risk of harm in the event of an actual emergency or disaster if the agency's emergency plan was not effective. FINDINGS INCLUDED: During the entrance conference on 10/21/2021 at approximately 12:30 p.m. the surveyor requested all agency EP/documents/reports/binders. Record review of the agency’s EP records did not reveal any reports, reviews or documentation that indicated the agency had conducted an annual review of the agency’s EP plan per agency policy and state regulatory requirements, for the years 2018, 2019 and 2020. In an interview at approximately 11:15 a.m. on 10/20/2021, the surveyor discussed the above findings, with the Alt Adm/DON, of why the agency had not conducted annual evaluations/reviews and updates of the emergency preparedness plan for calendar years 2018, 2019 and 2020. The Alt Adm/DON replied, “We were going to do it this week.” Review of agency policy titled “Emergency Preparedness and Response Plan” revised 070120 read in part: “PURPOSE I. To ensure the Agency complies with all applicable Federal, State and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains and implements emergency preparedness policies and procedures, based on the risk assessment, emergency plan, and communication plan, that will be reviewed and updated at least annually…”

Purpose of Visit: Recertification Survey Entrance Date: 10/21/2021 An entrance conference was conducted with the Alt Adm/DON at 12:30 p.m. The Alt Adm/DON was informed that the purpose of the survey was for a 36-month recertification survey. L and C Census: 23 Exit Date: 10/26/2021 An exit conference was conducted at 12:00 p.m. with the Alt Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies 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 Deficiencies. The agency met conditions of participation. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) RN-Registered Nurse SN-Skilled Nurse L and C- Licensed and Certified POC- Plan of Care SOC- Start of Care HHA's- Home Health Agencies PIP(s)-Performance Improvement Projects QAPI-Quality Assessment Performance Improvement

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 review, observation and interview, in one (Patient # 1) of one record reviewed in which the patient had wound care orders, the agency failed to ensure that the patient received the home health services that were written in an individualized plan of care. The failure caused the patient to not receive care and services as ordered on the POC. The failure could cause a lack of physician oversight and an exacerbation of the wound condition. FINDINGS INCLUDED: Patient Record #1: Review of Patient # 1’s clinical records revealed a POC for the certification period 09/23/2021 to 11/21/2021, signed by the ALT Adm/DON and dated 09/23/2021. The POC had a SOC date of 09/23/2021. The POC was also signed by physician, Identifier 100 on 10/05/2021.The POC included a principal diagnosis of pressure ulcer to left heel, stage 2. The POC also included orders for SN visits three times per week for eight weeks. Further review of the clinical records for Patient # 1 revealed an admit order that included wound care orders dated 09/22/2021 and signed by physician, Identifier 100 and NP, Identifier 101. The orders read in part: “…5. SN to perform wound care 3 days per week and pictures to NP weekly…7. Measure areas of ulceration weekly and submit documentation to NP…” The order was not signed, dated or noted by an agency nurse. The clinical records for Patient # 1 did not include any documentation that indicated the SN, LVN A had taken pictures weekly of the left heel wound and submitted pictures and wound measurements, weekly to NP Identifier 101. During a home visit with Patient # 1 on 10/25/2021 at approximately 12:00 p.m., the surveyor observed LVN A perform wound care. The surveyor observed that LVN A did not measure the wound to Patient # 1’s left heel and did not take a picture. During an interview on 10/26/2021 at approximately 11:14 a.m. the surveyor discussed the above findings with the Alt Adm/DON. The DON replied, [LVN A] is good. I don’t know why he did not do it.” Agency policy titled “Plan of Care PC.8” revised 110120 read in part: “…Each patient/client must receive the home health services that are written in an individualized plan of care…”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. This failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 10/21/2021 at approximately 12:30 p.m. the surveyor requested all agency QAPI/documents/reports/binders. Record review of the agency’s QAPI records did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 10/26/2021 with the Alt Adm/DON, the surveyor discussed why the agency had not conducted PIPs for 2018, 2019 and 2020, in accordance with federal regulatory requirements? The Alt Adm/DON stated that she was not aware of the regulatory requirement to conduct PIP(s). Agency policy titled “PERFORMANCE IMPROVEMENT PROCESS: IMPROVEMENT ACTIVITIES QAPI.5” read in part: “…IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved…”