Every finding on record at Nevada Health Care Group, LLC

A Medicare Recertification/Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority. The survey conducted from 04/29/26 to 05/01/26 resulted in a finding of no citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Medicare Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Health Authority. The survey conducted from 04/29/26 to 05/01/26 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

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, policy review, and interview, the agency failed to ensure the timely submission of Outcome and Assessment Information Set (OASIS) data to the internet Quality and Improvement and Evaluation System (iQIES). The deficient practice resulted in non-compliance with the federal regulations related to encoding and transmitting OASIS data within 30 days after completion. Findings include: FOR QA Purpose .

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/04/2022 to 05/06/2022 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/04/2022 to 05/06/2022 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the home health agency's (HHA) quality assurance performance improvement (QAPI) program failed to investigate and analyze adverse event indicators. Failure to analyze patient adverse event data had the potential to impact patient health outcomes, safety, and quality of care for the 134 current home health patients and any future patients. Findings include: Review of the HHA QAPI document titled, "Plan of Action for Performance Improvement Project" dated 02/23/2022 showed patient adverse event data generated from the electronic medical record system, listed in alphabetical order by patient last name, included identification of infection type, infection location, and antibiotic. Also, included in the QAPI information was a list in alphabetical order by last name which included emergent care, re-hospitalization, and patient fall data. The infection data and other patient adverse event data did not identify trends or an analysis of the information. The QAPI documentation did not include an analysis that summarized the data or showed measurable indicators that would enable the HHA to assess processes of care, potential patient safety concerns, or identify trends that may contribute to patient adverse events. Review of the HHA policy titled, "Infection Control Surveillance System: Prioritized Risks Defined," dated September 2021, revealed, "At least quarterly, the Director of Clinical Services and infection control and QAPI Committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form … Problems and/or undesirable trends in infections will be identified, including potential significant agency acquired and/or community acquired infections. If such problems or un-desirable trends are identified, the infection control and QAPI Committees will identify any common factors that could have led to the transmission of the infection(s)." During an interview on 05/06/2022 at 10:20 AM, Clinical Manager (CM2) stated the HHA did not have any additional QAPI documentation and confirmed the information provided did not include documentation of trends or analysis of the adverse event data that was capable of showing measurable improvement in indicators.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on document review, policy review, and interview, the home health agency (HHA) failed to identify, investigate, and analyze patient infection data generated from the electronic medical record system. The failure to analyze infection surveillance data had the potential to affect all current 134 patients and place them at risk for infection. Findings include: Review of patient infections for the first quarter of 2022 provided by the HHA revealed a list prioritized by patient last name, which identified by "Infection Type," and antibiotic ordered. "Infection Type" included respiratory, wound infections, UTI (urinary tract), skin infections, or "other infections." Review of a HHA policy titled, "Infection Control Surveillance System: Prioritized Risks Defined," dated September 2021, revealed, " The Agency will implement an infection control surveillance system for patients and staff. The definition of infections is based on the most common infections prevalent to Agency's services that are high volume, frequent infectious complications and have a high potential for prevention by staff and/or have an increased risk for negative patient outcomes … Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form … Problems and/or undesirable trends in infections will be identified, including potential significant Agency acquired and/or community acquired infections." Review of a HHA policy titled, "Infection Control Plan," dated September 2021, revealed the policy "Establishes a surveillance program for infections acquired in home health care … The Agency will perform a risk analysis to identify risks for the transmission and acquisition of infectious agents based on: Geographic location and community served. Results of analysis of infection and control data. Care provided … The agency will assign responsibility for infection control program management … The individual coordinates all activities and assures ongoing surveillance, data, collection, aggregation, analysis and monitoring of the effectiveness of the program." During an interview on 05/06/2022 at 10:20 AM, Clinical Manager (CM2) stated there was no other documentation available that identified investigation and analysis of infection data. CM2 identified the infection list was generated from the electronic medical record system based on information entered by the nurse during a patient visit if the primary care physician ordered a new antibiotic. CM2 was not aware of a specific staff person assigned to coordinate infection control surveillance, investigation, and analysis.