Every finding on record at Midas Healthcare Services Inc

A recertification survey was initiated on 5/2/2023. The census was: LCHH-0 LHH-0 PAS -0 Total agency census: 0 The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies. Definitions: LHH-Licensed Home Health LCHH-Licensed & Certified Home Health PAS-Personal Assistant Services

A recertification survey was initiated on 5/2/2023. The census was: LCHH-0 LHH-0 PAS-0 Total agency census: 0 Abbreviations OASIS-outcome and assessment information set iQies-internet quality and evaluation system CMS-Centers for Medicare and Medicaid Services LHH-Licensed Home Health LCHH-Licensed & Certified Home Health PAS-Personal Assistant 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 electronically submit ea[HC(1] ch completed OASIS assessment to the CMS system every 30 days in 1 (Patient #1) of 1 discharged chart reviewed, in that there was no evidence of OASIS start of care or discharge assessments submitted to CMS for Partient #1 Failure of the agency to transmit OASIS assessment within 30 days of completing the assessment, impedes the collection of data for the comparison of the agency’s patient outcomes with those of other agencies nationwide. Findings include: On 5/4/2023 at 11:00 a.m. the surveyor requested the agency final validation reports for OASIS submissions from the Office Manager. On 5/4/2023 at 12:15 p.m. the Office Manager informed the surveyor the agency did not have any final validation reports. On 5/4/2023 at 12:45 p.m. an interview with the Administrator was conducted. The surveyor asked the Administrator why the agency failed to submit the start of care and discharge OASIS assessments to CMS for Patient #1 within 30 days. The Administrator explained that the agency did not have a security official approved to submit OASIS in iQies. The Administrator explained that the agency had requested approval for the Administrative Assistant to be the security official and that it had been approved and the Administrative Assistant was submitting the OASIS at this time. Surveyor requested the final validation report be provided to the surveyor as soon as it was available. Patient #1 chart review revealed a plan of care dated 12/5/2022 through 2/2/2023 with a start of care of 12/5/2022. The chart contained a discharge OASIS dated 12/30/23 signed and dated by the Alternate Administrator/Alternate Supervising Nurse. On 5/5/2023 at 12:48 p.m., the surveyor received an email with an attached final validation report for Patient #1’s start of care OASIS submission. There was no documented evidence that Patient #1’s discharge OASIS was submitted. Agency policy: Timelines IM.10 revised 12/01/14 read in part…”POLICY Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulation….PROCEDURE…1.11 Completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic standards. It will be transmitted to CMS OASIS contractor within 30 days of the M0090 date,,, …”

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 and interview, the agency failed to ensure the patients' plan of care was complete and included all the required elements including 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 for 1 (Patient # 1) of 1 record reviewed. These failures placed patients at risk of a decline in their health status and subsequent emergency room visits and hospital re-admissions. Findings include: Patient #1-review of Patient #1 revealed a plan of care dated 12/5/2022 through 2/2/2023 with a start of care of 12/5/2022. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 12/5/2022 with diagnosis of chronic diastolic (congestive) heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). The plan of care did not include the patient risk factors for emergency department visits or rehospitalizations. An interview was conducted on 5/4/2023 at 12:45 p.m. with the Alternate Administrator/Alternate Supervising Nurse. The surveyor asked Alternate Administrator/Alternate Supervising Nurse why the plan of care did not include the risk factors for emergency department visits and rehospitalizations. The Alternate Administrator/Alternate Supervising Nurse said, “I didn’t know it was supposed to be on the plan of care.”