Every finding on record at Northeast Texas Home Health Agency Ltd

A recertification survey, incident investigations (Intake #’s 480053 & 446505) and follow up (00R411 exit 10/13/21) was conducted on 10/14/24. No deficiencies were cited. Census: 652 Sulphur Springs: Licensed and Certified- 161 Licensed Home Health- 9 Canton: Licensed and Certified- 165 Licensed Home Health- 6 Dallas: Licensed and Certified- 194 Licensed Home Health- 1 Allen: Licensed and Certified- 111 Licensed Home Health- 5

A recertification survey, incident investigations (Intake #’s 480053 & 446505) and follow up (00R411 exit 10/13/21) was conducted on 10/14/24. Census: 652 Sulphur Springs: Licensed and Certified- 161 Licensed Home Health- 9 Canton: Licensed and Certified- 165 Licensed Home Health- 6 Dallas: Licensed and Certified- 194 Licensed Home Health- 1 Allen: Licensed and Certified- 111 Licensed Home Health- 5 Acronyms: OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services IQIES- Internet Quality Improvement and Evaluation System SN- Skilled Nurse POC- plan of care RN- Registered Nurse LVN- Licensed Vocational Nurse SOC- start of care Mg- milligrams QI- quality improvement IT.- Information Technology

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 377 of 7858 assessments submitted (4.8%). The agency did not code and electronically submit patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. Findings included: Review of an IQIES Error Summary Report dated 10/11/23 to 10/11/24 generated by the surveyor during pre-survey on 10/11/24 indicated the agency failed to code and electronically transmit 377 of 7858 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 10/16/24 at 10:46 a.m., Vice President of Clinical Strategy E said she was over OASIS submissions. She said once OASIS were locked, they went to workflow and all OASIS were submitted daily at 5:00 p.m. She said at 8:00 a.m. the next day she could see what issues there were or if they were rejected or had a warning. She said from there a coordination note was generated to the branch directors and rejections took priority. Vice President of Clinical Strategy E said every other day her team went through OASIS to make sure there were not any OASIS that hadn’t been done. She said OASIS were locked by the branch director on the clinical level by whoever was reviewing the POC/485. She said OASIS were submitted in IQIES and had to be done within 30 days. She said OASIS were submitted as soon as they were locked. Vice President of Clinical Strategy E said she was aware that some were late but didn’t know how many. She said the agency did not “have a clean slate”. She said she did not know the reasons for being late and it may need getting clarification from coding. During an interview on 10/16/24 at 11:30 a.m., the RN Alternate Administrator/Supervising Nurse said OASIS were all electronic and once reviewed they were locked and got submitted. She said each branch looked at their own OASIS (agency has 4 offices). She said OASIS had to be locked first then got submitted. She said unlocked OASIS were reviewed and if any were late the agency got warnings. She said after OASIS were locked, they got submitted and Vice President of Clinical Strategy E did submissions for the parent location. The RN Alternate Administrator said the timeframe for submissions was less than 30 days. She said she was aware the agency was late on some submissions. She said reasons for late submissions were if the agency was waiting on coding and documentation from the doctor. During an interview on 10/16/24 at 12:11 p.m., the RN Administrator said she had been in her position for 2 weeks and did not know the process for OASIS submissions. During an interview on 10/16/24 at 1:10 p.m., Director of Regional Operations C (previous RN Administrator) said she didn’t know how many OASIS submissions were late, but she knew some were late. She said the agency received weekly reports on OASIS that were getting close to being late. She said late submissions were because when admitting a patient, the SOC went to coding and if the agency didn’t have all the paperwork and was trying to get more records it delayed coding and locking, then OASIS were sent late. Record review of a Timelines policy dated 05/02/24 indicated “…II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS ­ assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…”

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 interview and record review, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases for 1 of 17 patients reviewed for infection control. (Patient #4) The agency did not include Patient #4 (urinary tract infection) in the Event Reporting System for infections. This failure could cause a decrease in patient health if the infections were not followed up on and could prevent the agency from developing actions to improve or prevent the spread of infections. Findings included: Record review of Patient #4's POC dated 07/13/24 to 09/10/24 indicated a SOC date of 07/13/24 and indicated she was 80 years old with diagnoses including acute kidney failure (a sudden decline in kidney function), essential hypertension (high blood pressure), type 2 diabetes mellitus (body can't produce enough insulin), chronic obstructive pulmonary disease (a chronic lung disease that makes it difficult to breathe), dementia (gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), presence of cardiac pacemaker (device implanted in the chest that regulates heart rate), and history of falling. The POC indicated Patient #4 was ordered skilled nursing visits one time a week for ten weeks. Record review of a Patient Coordination Note for Patient #4 dated 07/23/24 by LVN H indicated patient reported dysuria (a painful or uncomfortable feeling when urinating), nausea and vomiting, and lower back/abdominal pain. Patient had low grade temperature of 99.1 during the visit. Patient #4 said symptoms started on Sunday (07/21/24). SN requested order for urinalysis with culture and sensitivity (lab test that identifies bacteria or fungi in a urine sample and determines which antibiotics are effective against them) to be obtained due to reported signs and symptoms of urinary tract infection. Record review of a Patient Coordination Note for Patient #4 dated 07/25/24 by LVN H indicated SN received verbal order from doctor’s office to obtain urinalysis with culture and sensitivity. Patient #4 collected urine specimen via clean technique during visit. SN delivered urinalysis to lab. Record review of a Patient Coordination Note for Patient #4 dated 07/30/24 by LVN F indicated patient continued to have signs and symptoms of dysuria, urinary tract infection. Patient #4 said she continued to burn some during urination. During SN visit patient received phone call from doctor office. SN spoke to RN Alternate Administrator/Supervising Nurse, patient’s doctor was trying to call patient to pick up antibiotics at pharmacy and to start as soon as possible for urinary tract infection. Record review of a Patient Coordination Note for Patient #4 dated 08/06/24 by LVN F indicated patient had by mouth antibiotics for urinary tract infection in home and would complete medication that day (08/06/24). Record review of Patient #4’s medication report dated 09/10/24 indicated Patient #4 was ordered Ciprofloxacin 500 mg tablet (antibiotic) by mouth two times daily for 7 days for urinary tract infection with a start date of 07/30/24 and end date of 08/06/24. Record review of the agency's Event Report for infections dated 2022 to 2024 (current) did not include Patient #4. During an interview on 10/15/24 at 1:58 p.m., LVN F said Patient #4 had an antibiotic for a urinary tract infection. She said the SN entered infections into the infection control portion in the patient’s record. She said the SN completed the information regarding the infection in the system and submitted it. She said Patient #4’s infection should be on the infection control report. LVN F said if an antibiotic was found in the home for any reason, the SN should put it on the infection control log. LVN F said if Patient #4’s infection was not on the report; she probably forgot. She said it should be on the infection control report since Patient #4 was on an antibiotic. During an interview on 10/15/24 at 2:00 p.m., LVN F said she checked Patient #4’s chart and she was the SN. She said she made the error and should have put the infection in the infection control. LVN F said she verified Patient #4 was not on the infection control report and she should have been. During an interview on 10/16/24 10:20 a.m., RN G said every infection should be documented. He said infections were tracked in the office to make sure there were not trends or an issue. He said infections were documented in the patient’s electronic medical record by the SN. RN G said there were infection control interventions where infections were documented. During an interview on 10/16/24 at 12:15 p.m., the RN Administrator said when an antibiotic was found in the home the SN would fill out an infection control report. She said the branch directors followed up on infections in the patient’s chart. The RN Administrator said all patient infections were documented on the infection control report. She said if infections were not being documented it could cause negative outcomes including a patient could end up in the hospital. She said the agency wanted to capture all infections. She said infection control was audited by the QAPI department. During an interview on 10/16/24 at 1:00 p.m., Director of Regional Operations C (previous RN Administrator) said field staff documented all patient infection control in the patient file. She said once this was done it automatically created a workflow for the nurse in office (branch director) to go in and do a follow up. She said if a patient was on an antibiotic or had an infection the SN would initiate the infection control in the electronic medical record then it automatically went into the QI event report as soon as it was filled out. She said all infections were logged. Director of Regional Operations C said she did not see an infection report on Patient #4. She said the SN did documentation in the patient’s electronic medical record. She said the LVN missed that one and it should be on the report. Director of Regional Operations C said if infections were not documented on the report there would be less follow up and the infection wouldn’t be included in the trends. She said infections could be passed between patients and the follow up nurse wouldn’t know to see if the patient finished the antibiotics or to check on symptoms. Record review of an Infection Control Program policy dated 05/01/24 indicated "… 8. Process For Reporting Patient/Client Infections. a. The Agency will track all infections… c. All reported infections will be documented on the appropriate Agency form for monthly review, analysis, trending, and initiation of performance improvement activities if deemed necessary…”