Every finding on record at One Care, Inc

Based on the findings of an onsite unannounced Medicare recertification survey conducted February 1, 2023, and February 2, 2023, and concluded offsite on February 3, 2023, One Care, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of facility policies/procedures, documentation, and interview with the administrator and director of nursing, the facility failed to ensure the emergency preparedness plan included the contact information for agency staff. Findings include: Review of the agency's Emergency Preparedness Plan on 2/2/23 at approximately 12:00 PM. revealed no contact information for the agency staff. During interview on 2/2/23 at approximately 2:30 P.M., the administrator and director of nursing confirmed the above finding.

Based on the findings of an onsite unannounced Medicare recertification survey conducted February 1, 2023, and February 2, 2023, and concluded offsite on February 3, 2023, One Care, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 review of iQies reports, agency policy, clinical records (CR) and interview with the administrator and director of nursing, the agency failed to follow its policy regarding transmitting OASIS (outcome and assessment information set) for seven (7) of seven (7) clinical records reviewed. (CR # 1, 2, 3, 4, 5, 6 & 7). Findings included: Policy review was completed on 2/2/23 at approximately 11:00AM and revealed the following: Policy titled, "Outcome and Assessment Information Set (OASIS)" states, "All OASIS data is encoded and transmitted for each patient within seven (7) days of completing an OASIS Data set. OASIS data must be encoded and transmitted using software from CMS or software that conforms to CMS standard electronic layout. All OASIS data is transmitted no later than the last day of the current month." Review of iQies reports on 2/1/23, at 8:00 A.M. revealed that the agency had not attempted to transmit any OASIS information since November 2020. An interview was conducted with the administrator and the director of nursing on 2/1/23, at approximately 11:10 A.M. When asked if the agency collects and transmits OASIS data, the administrator and the director of nursing stated that they have attempted to submit OASIS reports but do not know how. Review of clinical records on 2/1/23 and 2/2/23 at approximately 10:00 AM. revealed the following: CR #1, start of care 7/14/16, contained physician orders for skilled nursing (SN) five (5) hours per day, seven (7) days per week. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR #2, start of care 12/10/16, contained physician orders for SN two (2) hours weekly. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR #3, start of care 2/28/17, contained physician orders for SN two (2) visits per day, seven (7) days a week. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR #4, start of care 3/10/17, contained physician orders for SN three (3) visits per day, 7 days a week. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR #5, start of care 12/20/16, contained physician orders for SN two (2) visits per day. seven (7) days per week. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR #6, start of care 8/1/18, contained physician orders for SN one (1) visit weekly. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. CR#7, start of care10/9/18. contained physician orders for SN one (1) visit per day, seven (7) days per week. The CR contained no evidence of the transmission of OASIS data on admission or at the time of recertification for any of the subsequent recertification periods. Interview with the administrator and director of nursing on 2/2/23, at approximately 2:30 P.M. confirmed that the agency has not been transmitting OASIS data.

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 upon clinical record review, and an interview with the Director of Nursing, it was determined the agency failed to provide services according to the plan of care for one (1) of seven (7) clinical records reviewed. (CR # 7) and the agency failed to ensure length of service provided was listed on the Plan of Care for seven (7) of seven (7) clinical records reviewed (CR# 1, 2, 3, 4, 5, 6 & 7). Findings include: Policies were reviewed on 2/2/23 at approximately 1:00 PM and revealed the following: Policy titled, "Physician's Plan of Treatment" states, "A physician prepares a plan of treatment, and it is made available to the agency. A physician's plan of treatment must be signed by the physician and in the chart within thirty (30) days after admission to the agency and must include: All diagnoses relevant to the agency's plan of care. The type and frequency of needed. Prognosis, Medications, special diets, activities permitted, specific orders and frequency of visits, IV therapy services, necessary medical supplies and equipment..." Policy titled, "Patient/Client Notification of Charges" states, "In home health care under the CMS guidelines, a missed visit occurs when a scheduled RN, LVN/LPN (licensed practical nurse), HHA (home health aide) ... does not keep an appointment with a patient...The agency must communicate with the patient to ensure that his or her needs are met and there is no jeopardy. Though the physician must be notified, there is no need to get an order. The agency can notify the physician by phone, fax, e-mail or mail. If no rescheduling within the physician prescribed frequency can be accomplished, then a call to the physician to apprize him/her of the missed visit is necessary and, in the case, a new order may be necessary. Documentation will reflect the missed visit and will become part of the clinical record." Clinical records were reviewed on 2/1/23 and 2/2/23 at approximately 11:00 AM and revealed the following: CR#1. Start of Care: 7/14/16. Certification period reviewed: 12/10/22-2/7/23. Skilled Nursing ordered for five (5) hours a day for seven (7) days a week. There was no listed length of service provided on the plan of care. CR#2. Start of Care: 12/10/21.Certification period reviewed: 12/5/22-2/2/23. Skilled Nursing ordered for two (2) hours weekly. There was no listed length of service provided on the plan of care. CR#3. Start of Care: 12/28/17.Certification period reviewed:11/29/22-1/27/23. Skilled Nursing ordered for two (2) visits per day for seven (7) days per week. There was no listed length of service provided on the plan of care. CR#4. Start of Care: 3/10/17. Certification period reviewed: 12/19/22-2/16/23. Skilled Nursing ordered for three (3) visits per day for seven (7) days a week. There was no listed length of service provided on the plan of care. CR #5. Start of Care: 12/20/16. Certification period reviewed: 1/18/23-3/18/23. Skilled Nursing ordered for two (2) visits per day for seven (7) days a week. There was no listed length of service provided on the plan of care. CR#6. Start of Care: 8/1/18. Certification period reviewed: 1/7/23-3/7/23. Skilled Nursing ordered for one (1) visit weekly. There was no listed length of service provided on the plan of care. CR#7. Start of Care: 10/9/18. Patient was discharged on 7/10/22. Certification period reviewed: 5/21/22-7/19/22. Skilled Nursing ordered for one (1) visit per day for 7 days per week. There was no listed length of service provided on the plan of care. During the certification period reviewed 5/21/22-7/19/22 visits were conducted only six (6) time per week instead of the ordered seven (7) times per week. There was no physician notification of the missed visits or any verbal orders updating the plan of care. An interview the Administrator on 2/2/23 at approximately 2:30 PM confirmed the above findings.

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 upon review of agency policy, interview with Administrator and Director of Nursing, agency failed to analyze quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services and operations. Findings included: Review of agency policy on 2/2/23 at approximately 12 p.m. titled, "Evaluation of Findings and Improving Performance" states, "The focus of quality improvement activities is to identify opportunities for improved performance by the agency. The improvement can be accomplished by redesigning a process which will lead to improved processes and performance by the agency or designing a new process...improvement strategy may be implemented system wide or may encompass only a limited are of concern or staff performance. The professional advisory committee, management, and others involved with clients including physicians and staff participate in evaluating the information collected and improving the process and performance of the agency...The information is presented quarterly...at this time identified problems are analyzed. Policy titled, "Assessment of Effectiveness of Actions" states, "Ongoing monitoring and evaluation of each indicator and analysis of logs will be performed to ensure effective resolution..." Review of QAPI documentation on 2/2/23 at approximately10:00AM revealed no documentation to analyze the data collected by the agency as part of the QAPI program. When surveyor asked Administrator and Director of Nursing on 2/2/23 at approximately 1:00 PM if any QAPI data collection was analyzed, Administrator and Director of Nursing replied that nothing was documented. Interview with administrator and director of nursing on 2/2/23 at approximately 2:30 P.M confirmed the above findings.