Every finding on record at Ndubuisi D Acho

A recertification and complaint survey was initiated with the Alternate Administrator on 11/26/24. Agency Census Licensed and Certified Home Health-1 Licensed Home Health-0 Personal Assistance Services-73 Total census: 74 Intakes: 407423 & 513274 No deficiencies cited

A recertification and complaint survey was initiated with the Alternate Administrator on 11/26/24. Agency Census Licensed and Certified Home Health-1 Licensed Home Health-0 Personal Assistance Services-73 Total census: 74 Intakes: 407423 & 513274 Abbreviations: OASIS-Outcome and Assessment Information Set ERSD-end stage renal disease

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 interviews, the agency failed to ensure the plan of care included all pertinent diagnosis in 1 (Patient # 1) of 1 active Patients record reviewed. The failure placed Patients 1 at risk to not have receiving appropriate care and services. Findings include: Review of Patient #1’s chart revealed a plan of care with a certification period of 11/8/24 through 01/6/25. The plan of care included the primary diagnoses of hypothyroidism (thyroid gland is underactive.), mixed hyperlipidemia (excess of lipids or fat in your blood), unsteadiness on your feet, dependence on wheelchair, and essential primary hypertension (high blood pressure with no clear identifiable cause). The review revealed the plan of care, section labeled “Case Summary” read in part…”Patient goes to dialysis Monday, Wednesday and Friday”… The plan of care did not include a diagnosis for ESRD[HC(1] (end stage renal disease: your kidneys have completely failed and can no longer filter wast from your blood, requiring either dialysis treatments or a kidney transplant to survive). Review of the OASIS comprehensive assessment completed and signed by the Supervising Nurse on 11/8/24 revealed On page 19 of 35 read in part…”Is Patient on Dialysis” with the box for Yes was indicated. The box for Hemodialysis was also indicated. Review of nurses note dated and signed by the Supervising Nurse on 11/21/24 read in part…”Has diagnosis of end stage renal failure.”… An interview was conducted [HC(2] on 12/2/24 at 10:35 am with the Supervising Nurse. The surveyor reviewed chart audit findings for Patient #1, in that, the plan of care did not include the diagnosis of end stage renal disease. The plan of care included in the case summary section that Patient #1 went to dialysis on Monday, Wednesday and Fridays. The OASIS comprehensive assessment signed and dated by the Supervising Nurse on 11/8/24 indicated the patient was on hemodialysis. A nurse note signed and dated by the Supervising Nurse on 11/21/24 indicated Patient #1 had a diagnosis of end stage renal disease. The Supervising Nurse explained that she was told that the diagnosis had to be on the face to face from the physician or she could not include the diagnosis of end stage renal disease on the plan of care. Surveyor explained the comorbid diagnosis affected the care to be provided and was being addressed with interventions of teaching by the Supervising Nurse and must be included in the plan of care with related interventions and goals. The surveyor asked the Supervising Nurse how the diagnosis of end stage renal disease could affect the patient. The Supervising Nurse said, “I don’t know.” Agency policy: PC.8 Plan of Care revised 3/1/19 read in part,… “PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems…PROCEDURE…III… A. The individualized plan of care must include the following: 1. All pertinent diagnoses”…

Purpose of Visit: Recertification Survey A survey entrance conference was conducted on 11/16/2021 at approximately 2:00 p.m. with the Agency Alternate Administrator and the Agency Supervising Nurse. Agency Licensed & Certified Census: 1 Agency Personal Assistance Services Census: 77 An exit conference was conducted on 11/22/2021 at approximately 5:00 p.m. with the Agency Administrator, Employee B, and the Agency Supervising Nurse, Employee C. The survey preliminary findings were discussed, and the agency was afforded the opportunity to provide additional information. The agency was provided with written instructions for submitting a plan of correction within ten (10) days of the receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22 Conditions of Participation for Home Health Agencies.

Purpose of Visit: Recertification Survey A survey entrance conference was conducted on 11/16/2021 at approximately 2:00 p.m. with the Agency Alternate Administrator and the Agency Supervising Nurse. Agency Licensed and Certified Census: 1 Agency Personal Assistance Services Census: 77 Abbreviations: Adm = Administrator Alt Adm = Alternate Administrator CMS = Centers for Medicare and Medicaid Serivces NOMNC = Notice of Medicare Non-Coverage OASIS = Outcome and Assessment Information Set POC - Plan of Care QIO = Quality Improvement Organization Sup Nurse = Supervising Nurse An exit conference was conducted on 11/22/2021 at approximately 5:00 p.m. with the Agency Administrator, Employee B, and the Agency Supervising Nurse, Employee C. The survey preliminary findings were discussed, and the agency was afforded the opportunity to provide additional information. The agency was provided with written instructions for submitting a plan of correction within ten (10) days of the receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care, in four (Patients #1, #6, #7 and #11) of four discharged patient records reviewed in which the reason for discharge was "goals met". The agency failed to provide the completed CMS form titled, "Notice of Medicare Non-Coverage." The failure placed the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. Findings Include: A patient discharge list with reason for discharge was provided to the surveyor by the Sup Nurse on 11/16/2021 at approximately 4:30 p.m. The discharge listed included the discharge date for Patient #1 as 08/28/2020, Patient #6 as 09/30/2020, Patient #7 as 07/29/2021 and Patient #11 as 08/18/2019. The discharge listed included the reason for discharge as goals met for Patients #1, #6, #7 and #11. Patient #1: Record review of the hard copy record for Patient #1 included a POC for the certification period of 07/31/2020 to 09/28/2020. The POC was electronically signed by the Sup. Nurse. The record also contained a discharge OASIS visit that was electronically signed by Employee C on 07/27/2020. The record did not include evidence Patient #1 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 09/28/2020. The record did not include a written NOMNC complete with the contact information of the QIO in which Patient #1 could appeal termination of their skilled home health services. Patient #6: Record review of the hard copy record for Patient #6 included a POC for the certification period of 08/02/2020 to 09/30/2020. The POC was electronically signed by Employee C. on 07/28/2020. The record also contained a discharge OASIS visit that was electronically signed by the Sup Nurse on 09/30/2020. The record did not include evidence Patient #6 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 09/30/2020. The record did not include a written NOMNC complete with the contact information of the QIO in which Patient #6 could appeal termination of their skilled home health services. Patient #7: Record review of the hard copy record for Patient #7 included a POC for the certification period of 05/31/2021 to 07/29/2021. The POC was electronically signed by Sup Nurse on 05/26/2021. The record also contained a discharge OASIS visit that was electronically signed by the Sup Nurse on 07/29/2021. The record did not include evidence Patient #7 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 07/29/2021. The record did not include a written NOMNC complete with the contact information of the QIO in which Patient #7 could appeal termination of their skilled home health services. Patient #11 Record review of the hard copy record for Patient #11 included a POC for the certification period of 06/20/201 to 08/18/2019. The POC was electronically signed by Sup Nurse on 05/26/2021. The record also contained a discharge OASIS visit that was electronically signed by Employee C on 06/17/2019. The record did not include evidence Patient #11 received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 08/18/2019. The record did not include a written NOMNC complete with the contact information of the QIO in which Patient #11 could appeal termination of their skilled home health services. During an interview with the Alt. Adm. and the Sup. Nurse on 11/22-2021 at approximately 11:00 a.m., the surveyor presented the survey findings. The surveyor asked why the agency had not provided written notice of the intent to discharge with the completed NOMNC form no later than two days in advance of terminating on-going care for Patients #1, #6, #7 and #11. The Sup. Nurse did not respond, but later stated “We are supposed to be their advocate.” Agency policy titled, "PATIENT/CLIENT TRANSFER AND DISCHARGE NOTICES PE.6" with a revision date of 12/01/2018 read in part, "... PURPOSE To provide guidance on completion of the required transfer and discharge notices... POLICY I. Prior to ...discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative...Notification will be provided in accordance with state and federal regulations...III. The Agency will deliver the Notice of Medicare Non-Coverage...to the patient/client (or authorized representative), at least two (2) calendar days before Medicare covered services end...PROCEDURE…I…C. The Agency will keep the following in the patient's/client's file: 1. A copy of the written notification provided to the patient/client or their parent, family, spouse, significant other, or legal representative... II. Notice of Medicare Non-Coverage (NOMNC)... A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end...the Agency representative will provide the NOMNC to the patient/client ...C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received ...I. The Agency will have the patient/client (or their representative) complete and sign the NOMNC. The patient/client or representative should sign and date two copies, keep one, and return a copy to the Agency ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.