Every finding on record at National Medical Homecare Inc

Purpose of Visit: Recertification Survey Entrance Conference: 10/05/21 at 9:52 a.m. with the Administrator/Supervising Nurse. Agency Census: Licensed and Certified – 0 Licensed Home Health – 245 Personal Assistance Services – 0 Exit Conference: 10/07/21 at 5:55 p.m. with the Administrator/Supervising Nurse. The preliminary findings were reviewed and discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting an acceptable plan of correction within 10 days of the receipt of the Statement of Deficiencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation was maintained regarding the emergency preparedness training for agency staff for 2019 to 2020. This deficient practice could place the clients at risk of harm if staff were not trained on the procedures in the event of an emergency. The findings included: Review of the Emergency Preparedness binder revealed no documentation regarding emergency preparedness training of agency staff for 2019 to 2020. During a record review and interview on 10/07/21 at 12:00 p.m., the findings above were reviewed and discussed with the Administrator. The Administrator stated that agency staff had been trained on emergency preparedness, but they could not find the documentation. Review of the agency's policy titled "Emergency Preparedness and Response Plan," revised 08/01/11 revealed in part, "…Agency staff (employees and contractors) will be oriented and trained regarding their responsibilities in the agency’s Emergency Preparedness and Response Plan upon hire and annually thereafter...”

Purpose of Visit: Recertification Survey Entrance Conference: 10/05/21 at 9:52 a.m. with the Administrator/Supervising Nurse. Agency Census: Licensed and Certified - 0 Licensed Home Health - 245 Personal Assistance Services - 0 Exit Conference: 10/07/21 at 5:55 p.m. with the Administrator. The preliminary findings were reviewed and discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting an acceptable plan of correction within 10 days of the receipt of the Statement of Deficiencies.

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 that provides L and C home health services must comply with applicable requirements of 42 United States Code Chapter 7, Subchapter XVII and the regulations in 42 CFR Part 484 for two of eight active patients (Patient #3 & #8) whose records were reviewed in that, the agency did not submit OASIS information to CMS according to federal regulation from 2018 to 2021. This deficient practice places patients at risk of receiving inadequate care and services when the OASIS information is not submitted to CMS. The findings included: 1. During the entrance conference on 10/05/21 at 9:52 a.m., the Administrator stated that all agency patients were pediatric patients. 2. Review of Patient #3's clinical record revealed a SOC on 12/18/15 for a POC certification period from 9/17/21 through 12/09/21 with a diagnosis of Dependence on respirator (ventilator). Further review revealed a DOB of 04/28/95 (26 y.o.) with Medicaid as his payor source. Further review of the patient’s clinical record revealed no documented evidence that OASIS data was sent to CMS from 2018 to 2021. Review of Patient #3’s POC for the certification period 09/17/21 to 12/09/21 revealed he was receiving 80 hours of private duty nursing services on a weekly basis. 3. Review of Patient #8’s clinical record revealed a SOC on 09/10/15 for a POC certification period from 09/02/21 to 11/24/21 with a diagnosis of Metabolic Disorder with a g-tube. Further review revealed a DOB of 04/01/94 (27 y.o.) with Medicaid as his payor source and no documented evidence that OASIS data was sent to CMS from 2018 to 2021. Review of Patient #8’s POC for the certification period 09/02/21 to 11/24/21 revealed he was receiving 56 hours of private duty nursing on a weekly basis 4. During an interview on 10/07/21 at 3:16 p.m. with the Administrator, the above findings were reviewed and discussed. The Administrator stated the agency has not submitted OASIS data to CMS for Patient #3 and #8 since 2018 because both patients were in the “aged out program” and had been classified as LHH not L and C patients. 5. Review of the CMS SOM Appendix B federal regulation §484.45(a) Standard: Encoding and transmitting OASIS data Interpretive Guidelines, revealed in part, “…An HHA must transmit a completed OASIS to the CMS system for all Medicare patients, Medicaid patients, and patients utilizing any federally Funded health plan options that are part of the Medicare program (e.g., Medicare Advantage (MA) plans). An HHA must also transmit an OASIS assessment for all Medicaid patients receiving services under a waiver program receiving services subject to the Medicare Conditions of Participation as determined by the State. Exceptions to the transmittal requirements are patients: • Under age 18; • Receiving maternity services; • Receiving housekeeping or chore services only; • Receiving only personal care services; and • Patients for whom Medicare or Medicaid insurance is not billed…”