Every finding on record at P W Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/08/24. The Agency was in compliance with the Condition, 42 CFR 484,22, Establishment of the Emergency Program for this survey.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number % = percent AM = morning SOC = Start of care PsOC = Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients

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 the Error Summary report and staff interview, it was determined that in 2 of 287 reports submitted for a 12-month period, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 05/2023 to 04/2024 (12 months) was reviewed on 08/05/24. The report included a warning for 2 of 287 (0.70 %) assessments with Error # -3330 were submitted late, more than 30 days after completing the assessment. 2. During an interview with the Administrator and the Alternate Administrator on 08/07/24 at 10:45 AM, the Alternate Administrator stated he is responsible for submitting OASIS information, aware of the submission error, and confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./representative in advance of treatment, the service(s) to be provided and frequency of visits in writing. Findings include: 1. The following clinical records were reviewed from 08/05/24 to 08/06/24: Pt. #1. SOC 04/30/24. Pt. #2. SOC 07/03/24. Pt. #3. SOC 07/02/24. Pt. #4. SOC 05/07/24. Pt. #5. SOC 06/08/24. Pt. #6. SOC 10/18/23. Pt. #7. SOC 11/24/23. The clinical records lacked documentation that the Pt./representative was notified of the service(s) to be provided, and the frequency of each service. 2. Home visits were conducted on the following Pts. on 08/05/24 and 08/06/24: Pt. #1. SOC 04/30/24. Pt. #2. SOC 07/03/24. Pt. #3. SOC 07/02/24. During the home visits, the patient's admission folder was observed, and lacked documentation that the Pt./representative was notified of the service(s) to be provided, and the frequency of each service. 3. During an interview with the Administrator and Agency Supervisor on 08/07/24 at 10:45 AM, the Agency Supervisor confirmed the Agency failed to provide the Pt./representative in advance of treatment, the service(s) to be provided and frequency of visits in writing.