Every finding on record at Oasis Home Health, LLC

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 05/23/2022 to 05/25/2022 resulted in a finding of the following citation respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Home Health Agencies (HHA) Emergency Preparedness Plan, and interview, the HHA failed to participate or conduct exercises to test the emergency plan at least annually based on their all-hazards risk assessment. The HHA chose to conduct the same facility-based exercise i.e., fire drills two years running that only tested their disaster plan, policies, and staff with a small percentage of office staff and did not relate to potential threats that may affect all the patients or staff. Findings include: A review of the HHA’s, “Emergency Preparedness and Response Plan Disaster/Disaster Drill Evaluation(s),” dated 11/08/2021 and 02/11/2022, showed that internal fire drills were chosen and conducted by the HHA’s administrator two years consecutively and presented as evidence of the HHA’s disaster drills. The fire drill conducted on 11/08/2021 began at 2:00 PM and ended at 2:30 PM. The evaluation of the drill stated, “Description of Disaster/Drill: After having the office staff return to the office as of November 1, 2021, the administrator ran a fire drill. without anyone’s knowledge.” There were six employees in the office who participated in the drill. The “Summary of results of Disaster Drill” stated, “What Should Happen: Everyone should have exited the building and gathered in the parking lot located across Bell Street and call 911, the corporate office, and initiate the phone tree to ensure no one comes to the office.” 911 was not called, the corporate office was not notified, and there was no activation of the phone tree. The agency’s employees or their disaster plan was not tested based on their all-hazards assessment. The evaluation of the 02/11/2022 drill stated, “Description of Disaster/Drill: ln response November's drill the Administrator ran another fire drill on this date.” The fire drill began at 1:00 PM and ended at 1:30 PM. In the “Summary of Results of Disaster/Drill” a description of the drill stated, “A. What Should Happen: Everyone should have exited the building and gathered in the parking lot located across Bell Street and call 911, the corporate office, and initiate the phone tree to ensure no one comes to the office.” 911 was not called, the corporate office was not notified and there was no activation of the phone tree. The agencies employees or their disaster plan was not tested based on their all-hazards assessment. For the fire drill conducted on 11/08/2021, there were six employees that participated. In the 02/11/2022 fire drill, there were seven employees that participated in that drill. According to the HHA’s staff roster, they have over forty employees. Both fire drills represented 15% and 17.5% of their total staff, respectively. The purpose of testing of the facility’s emergency program was to identify gaps in response which could result in adverse events for patients and staff and to adjust plans, policies, and procedures to ensure patient and staff safety was maintained regardless of the type of emergency which occurs. In an interview on 05/25/2022 at 10:35 AM, the Administrator confirmed that the two fire drills describe above were the only two drills conducted to test their disaster plan for the past two years.

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 05/23/2022 to 05/25/2022 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.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the home health agency failed to conduct an initial assessment visit within 48 hours of the referral, or within 48 hours of the patients' return home from an inpatient hospital stay, or on the physician ordered start of care (SOC) date for seven of 12 patients (Patient (P)1, P4, P5, P6, P8, P9, and P10). The failure to complete an initial assessment of the patient's immediate care needs in a timely manner had the potential to impact the health and safety of all patients whose admission is delayed. Findings include: 1) Review of the "Attachments" section of P1's electronic medical record (EMR) revealed a referral date of 11/17/2021. Review of the plan of care (POC) located under the "Orders" tab in the EMR indicated a SOC date of 11/23/2021 and primary diagnosis of an ulceration of the left ankle requiring wound care in addition to chronic kidney disease, heart failure, and chronic pain. Further review of the EMR failed to identify a physician ordered SOC date. The SOC was greater than 48 hours after the referral for home health services. 2) Review of the "Attachments" section of P4's EMR revealed a referral date of 02/17/2022. Review of the POC located under the "Orders" tab in the EMR indicated a SOC date of 02/22/2022 and primary diagnoses of age-related osteoporosis, spinal stenosis, pain in left shoulder, and a history of falling. Further review of the EMR failed to identify a physician ordered SOC date. The SOC was greater than 48 hours after the referral for home health services. 3) Review of the "Attachments" section of P5's EMR revealed hospital discharge paperwork which indicated a discharge date of 04/29/2022 and a referral for home health services dated 05/04/2022. Review of the SOC OASIS (Outcome and Assessment Information Set) assessment located under the "Visits" tab in the EMR indicated the SOC visit occurred on 05/12/2022. Review of physician orders under the "Orders" tab failed to reveal a physician ordered SOC date. During an interview on 05/23/2022 at 3:30 PM, the Clinical Manager (CM)2 confirmed P5's SOC occurred more than 48 hours after the referral. 4) Review of the "Attachment" section of P6's EMR revealed a referral dated 04/21/2022. A "Client Communication" note located under "Coordination Note" tab in the EMR stated, "Spoke with patients' son who is requesting for SOC Friday 4/29 due to family in from out of state… doctor's office notified via email." The EMR did not include a physician ordered specific SOC date. Review of P6's POC located under the "Orders" tab indicated a SOC date of 05/02/2022 which is more than 48 hours after the referral and was not on the date requested by the family and communicated in an email to the doctor’s office. 5) Review of the "Attachment" section of P8's EMR revealed a referral dated 04/05/2022 and a diagnosis of a fracture of the right humerus (arm), anemia, and history of syncope (loss of consciousness) and collapse. Hospital discharge summary indicated a date of 04/06/2022. Review of the POC located under the "Orders" tab indicated a SOC date of 04/16/2022 which was greater than 48 hours after the referral. 6) Review of the "Attachment" section of P9's EMR revealed a referral dated 04/05/2022. Review of the POC located under the "Orders" tab indicated diagnoses which included chronic respiratory failure, unspecified dementia, stage 2 pressure ulcer of the buttock, and history of falling. The POC indicated the SOC was 04/11/2022 which was more than 48 hours after the referral. The EMR did not include a specific physician ordered SOC date. 7) Review of the "Attachment" section of P10's EMR revealed a referral dated 04/15/2022. Review of the POC located under the "Orders" tab indicated diagnosis of "aftercare following joint replacement surgery" and a SOC date of 04/20/2022 which was greater than 48 hours after the referral. The EMR did not include a specific physician ordered SOC date. Review of an agency policy titled, "Admission Criteria and Procedure – Medicare Certified Offices," dated 05/04/2020, revealed, "The initial assessment must be completed either within a. 48 hours of referral, or b. 48 hours of the clients return home, or c. on the physician-ordered start of care date." During an interview on 05/25/2022 at 10:45 AM, the Administrator stated, many of the patients who were referred to us did not have a primary care physician and this caused a delay in the start of care because we have to find a physician who would follow the patient. The Administrator confirmed the findings which included the initial visits which occurred greater than 48 hours after the referral, hospital discharge date, or physician ordered start of care 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 document review, policy review, and interview, the home health agency (HHA) failed to maintain an infection surveillance program which included identification, investigation, and analysis of infections that was an integral part of the HHA's quality assessment and performance improvement (QAPI) program. This failure had the potential to affect the current 121 patients and any future patients receiving home health services from the agency. Findings include: During an interview on 05/24/2022 at 10:30 AM, the Administrator stated the agency did not have documentation of any infections during the first quarter of 2022. Review of documentation titled, "QI (Quality Improvement) event Summary" revealed a list of five patient names with identification of "Type of Event" listed as "Infection" printed from the electronic medical record (EMR) program during the survey with date printed of 05/25/2022. The "event date range" was identified as "01/01/2021 to 12/01/2021." Four of the infections during this date range were identified as urinary tract infections and the fifth did not identify the type of infection. The documentation presented did not include investigation or analysis of the infection data or timely dissemination of this information within the agency. Review of the HHA "QAPI quarterly meeting" dated 01/10/2022 and 03/01/2022 failed to identify any review of infection surveillance, identification, control activities, or investigation. During an interview on 05/25/2022 at 8:30 AM, the Administrator stated that, due to being in the process of moving and a new EMR, the HHA was unable to locate any further documentation of the infection surveillance or quarterly QAPI meetings. Review of an agency policy titled, "Infection Prevention Program," dated 12/02/2021, revealed, "Identification, documentation, evaluation and monitoring of infections on an ongoing basis, as they occur among clients, and as appropriate, among staff … Collected data is monitored on an ongoing basis and analyzed at least quarterly, within each office, and company-wide by the Infection Prevention Director. Office Directors and Clinical Managers are responsible for identifying risks and analyzing trends in occurrences and practice, specific to their office, and implementing action plans, as needed."

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview and review of the agency organizational chart, the home health agency (HHA) failed to ensure that the Administrator reported directly to the governing body. This failure had the potential to affect the direct communication of the agency with the "Board of Managers" overseeing the overall management and operation of the HHA's services, operational plans, and quality assessment and performance improvement program (QAPI). Findings include: During the entrance interview on 05/23/2022 at 9:00 AM, the Administrator reported to a Regional Director who reported to the governing body. The Administrator did not report directly to the governing body. The Administrator stated the governing body was known as the Board of Managers as identified on the agency organizational chart. Review of the organizational chart titled dated 01/21/2022 indicated the Administrator reported to the "Board of Managers."