Every finding on record at Midwest Healthcare Provider, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 08/30/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 08/30/24. Standard level deficiencies cited. Abbreviations: OASIS = Outcome and Assessment Information Set SN = Skilled Nurse Pt / Pts = Patient / Patients SOC = Start of Care

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 a review of the Agency's OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency's past 12 months OASIS submission report was reviewed on 08/28/24. The report contained information that out of the 323 Agency's OASIS assessment reports, 25 (7.74%) were submitted beyond the required time frame of 30 days. 2. During an interview with the Administrator and Agency Supervisor on 08/29/24 at 2:30 PM. The Administrator confirmed the Agency's late OASIS submission.

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 clinical record review and staff interview, it was determined in 2 of 7 (Pts. # 3 and 5) clinical records reviewed, patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #3 was admitted to Home Health Services on 02/16/24 with diagnoses of Type 2 Diabetes Mellitus without complications and Heart Failure, Unspecified. The clinical record was reviewed on 08/29/24. The clinical record contained a recertification POC dated 08/09/24, that required the SN to notify the physician of weight gain/loss greater than 5 lbs. The SN visit notes lacked the weight assessments after 08/07/24 (weeks #1 and #2). 2. Pt. #5 was admitted to Home Health Services on 06/01/23 with diagnoses of Bilateral Primary Osteoarthritis of Knee and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/29/24. The clinical record contained a recertification POC dated 05/26/24, that required the SN to notify the physician of pain greater than 7 and weight gain/loss greater than 5 lbs. The SN did not assess the pain or the weight on 06/14/24 (weeks #3) and 06/21/24 (week #4). 3. The findings were confirmed, during the interview with the Administrator and Agency Supervisor, on 08/29/24 between 11:00 am – 11:30 am.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined in 2 of 7 (Pts. #5 and 7) clinical records reviewed, the clinical records were not accurate or completed as required. Findings include: 1.Pt. #5 was admitted to Home Health Services on 06/01/23 with diagnoses of Bilateral Primary Osteoarthritis of Knee and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/29/24. The clinical record included the SN visit note dated 07/19/24 with a weight of 265 lbs. The SN assess the weight on 07/23/34 as 231 lbs (34 lbs difference). During the interview with the Agency Supervisor, it was stated this weight was not accurate, it was a documentation error. 2. Pt. #7 was admitted to Home Health Services on 06/22/23 with the diagnoses of Bilateral Primary Osteoarthritis of Knee. The complete clinical record was reviewed on 08/28/24. The clinical record included a POC dated 06/22/23 that lacked the signature of the physician. 3. The findings were confirmed, during the interview with the Administrator and Agency Supervisor, on 08/29/24 between 11:00 am – 11:30 am.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 07/30/2021. Midwest Healthcare Providers was in compliance with the requirements for Infection Control for COVID-19. Identification of abbreviations: DON = Director of Nursing HHA = Home Health Aide LPN = Licensed Practical Nurse RN = Registered Nurse SOC = Start of care POC = Plan of care PsOC = Plans of care SN = Skilled Nurse PT = Physical Therapy Pt./Pts. = Patient/patients tid = Three times a day

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview it was determined that the Agency failed to ensure that interdisciplinary assessment / communication is maintained to coordinate patient care. This was found in 2 of 7 clinical records reviewed. (Pts #2 and 7) Findings include: 1. Pt. #7 SOC 03/23/2021 Diagnoses: Heart Failure Unspecified, Chronic Kidney Disease Stage 3 and Weakness. The clinical record was reviewed on 07/28/2021 at 11:00 AM. The clinical record contained a POC beginning 03/23/2021 with orders for SN, PT and Aide services. The clinical record contained a missed visit note completed by the Aide dated 04/01/2021. The note states the reason for missed visit is "patient hospitalized". The clinical record lacked an interdisciplinary communication note between disciplines providing care informing of patient hospitalization. Patient #7 contained a SN visit note dated 04/05/2021 the note lacked documentation indicating that the patient was hospitalized (4 days after Aide note), 2 Pt. #2 SOC 11/07/2020 Primary Diagnosis Essential Hypertension. The clinical record was reviewed on 7/28/2021 at 10:10 AM. The clinical record contained an Aide visit note dated 5/18/2021 that included, "pain to bottom area and itching in the vaginal area ... changes reported to the nurse." Pt. #2 record also contained a note from the patient's MD's office dated 5/27/2021, which documented LPN reported, "patient has blisters on the buttocks area, on both sides ..." The MD note also included, " ...to take Tylenol and have the nurse clean with NS, pat dry, do a foam dressing daily, wound care to see patient and pressure relief measures ... start vit c 500 tid and zinc 1 tab daily, report changes." Additionally, the record contained an Aide visit note dated 5/30/2021 which included, " ...the skin breakdown on her bottom is about the same. The area was cleaned and dried, over the counter ointment was applied ..." The clinical record lacked interdisciplinary communication between (MD, RN, LPN and Aide) on assessment and care of patient integumentary system. 3. During interviews with the Administrator and DON on 7/29/2021 between 10:30 AM and 12:00 PM the above findings were confirmed.

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: 2. Pt. #4. SOC 11/18/2020. Primary Diagnosis: Essential Hypertension. The clinical record was reviewed on 7/27/2021 at 11:30 AM. The record included a POC effective 5/17/2021 which contained the following orders, " ...HHA Frequency 1 wk 9 ..." The record lacked documentation of Aide weekly visits beginning week of 6/06/2021 through week of 7/11/2021. 3. Pt. #6. SOC 1/22/2021. Primary Diagnosis: Epilepsy. The clinical record was reviewed on 7/28/2021 at 9:30 AM. The record included a PT evaluation signed by the physician dated 5/27/2021 that included, "Visit Frequency 1 wk 1, 2 wk 4." The record lacked documentation of any PT visits after the PT evaluation on 05/27/2021. 4. During interviews with the Administrator and DON on 7/29/2021 between 10:30 AM and 12:00 PM the above findings were confirmed. . Based on clinical record review, and staff interview, it was determined the Agency failed to ensure services were provided as ordered by the Physician in the POC. This was found in 3 of 7 clinical records reviewed (Pts. # 7,4, and 6) Findings Include: 1. Pt. #7 SOC 03/23/2021 Diagnoses: Heart Failure Unspecified, Chronic Kidney Disease Stage 3 and Weakness. The clinical record was reviewed on 07/28/2021 at 11:00 AM. The clinical records contained a POC for certification period 03/23/2021 to 05/21/2021 that required "Notify Physician of vital signs parameters out of range...Weight Gain / Loss (lbs/7 days)". The SN visit notes for entire certification period lacked documentation of weight assessment.