Every finding on record at Red River Homecare LLC

A recertification survey, complaint investigation (Intake #533902) and follow up (SNUH11 exit 09/22/21) entrance conference was conducted on 09/27/24. The agency was in compliance with 42 CFR, Part 484.102, Emergency Preparedness Requirements for Home Health Agencies. Census: 234 Licensed and Certified- 57 Licensed Home Health- 177 Acronyms: CFR- Code of Federal Regulations

A recertification survey, complaint investigation (Intake #533902) and follow up (SNUH11 exit 09/22/21) entrance conference was conducted on 09/27/24. Census: 234 Licensed and Certified- 57 Licensed Home Health- 177 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 PCM- Patient Care Manager Mg- milligrams QI- quality improvement

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 275 of 3193 assessments submitted (8.61%). The agency did not code and electronically submit 275 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 09/26/23 to 09/26/24 generated by the surveyor during pre-survey on 09/26/24 indicated the agency failed to code and electronically transmit 275 of 3193 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 10/01/24 at 10:10 a.m., the RN Administrator said the quality review team reviewed OASIS and a validation report was sent out and checked every Monday. She said she did not know who transmitted OASIS to IQIES/CMS. During a concurrent interview via teams (online) meeting on 10/02/24 at 10:00 a.m., OASIS Coordinator M said he did OASIS transmissions. He said it was an automatic process done one time a week on Tuesdays. OASIS Coordinator M said the worker went into the electronic charting system and exported locked OASIS, then submitted them to IQIES. He said to avoid any late warnings, OASIS had to be transmitted within 30 days. OASIS Coordinator O said the locked process was at the agency level. She said once OASIS were locked, they were submitted to IQIES. She was not aware that 275 were late and said they were only submitted once locked. Regional Coordinator N said she was aware of the lag at the agency level and was very aware of late submissions which affected the whole organization. During an interview via teams (online) meeting on 10/02/24 at 10:05 a.m., Regional Coordinator N said in the prior process, the workload was handled by the patient care managers but was switched to the quality reviewer. She said assessments were getting held up. She said there were staffing issues in certain areas, and it took a while to figure out the quality reviewer teams. She said assessments weren’t being locked timely. During an interview on 10/02/24 at 10:48 a.m., the RN Administrator said the patient care managers were doing their own teams OASIS and then it migrated to the quality reviewers doing the whole agency. She said the RN or physical therapist documented the OASIS, then the quality reviewer audited them. She said if any changes needed to be made, the clinician had 48 hours to get a hold of the doctor and put the update in. She said once this was done the quality reviewer locked the OASIS. During an interview on 10/02/24 at 10:50 a.m., the RN Administrator said once the OASIS were locked, they were automatically sent to OASIS Coordinator M and his team then transmitted them to IQIES. She said the quality reviewers had been doing this (locking OASIS) for the last year. She said it took a while for the agency to get a quality reviewers system for locking OASIS. The RN Administrator said it took time for training and getting used to the new process and the agency had 2 to 3 quality reviewer changes with the processes and transitions. She said the agency was having a hard time picking spots for everyone and changed 2 to 3 times and this was the reason for late OASIS transmissions. Record review of an Oasis Data Capture, Transmission, Verification, Display and Reports policy dated 03/01/21 indicated “…2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date.…”

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: This is a continuing violation from event SNUH11 exit 09/22/21. Based on interview and record review, the agency failed to ensure the POC contained the required elements to cover all patient specific interventions and education and safety precautions to protect against injury for 1 of 12 patient records reviewed for plans of care. (Patient #12) Patient #12’s POC did not include orders to assess the patient's hemodialysis access site, nor did it address the location, safety measures, or care interventions for the protection of the dialysis access site. This failure could place patients at risk of injury and not receiving proper care/instruction leading to complications and hospitalization. Findings included: Record review of Patient #12's POC dated 09/10/24 to 11/08/24 indicated a SOC date of 03/14/24 and indicated she was 58 years old with diagnoses including congestive heart failure (heart can't pump enough blood to meet the body's needs), type 2 diabetes mellitus (body can't produce enough insulin), end stage renal disease, dependence on renal dialysis (a machine removes blood from the body, filters it, and returns the cleaned blood), acute osteomyelitis (bone infection), chronic obstructive pulmonary disease (a chronic lung disease that makes it difficult to breathe), and anxiety. The POC indicated Patient #12 was ordered skilled nursing visits two time a week for eight weeks, then one time a week for one week. The POC did not include the type/location of dialysis access site, orders to assess the site, safety measures or care interventions of the access site, patient teaching for the protection of the dialysis access site, or weight monitoring and teaching for a patient dependent on dialysis. Record review of a RN Recertification Visit Note Report for Patient #12 dated 09/06/24 indicated the patient’s dialysis access device was a catheter located in the right upper chest. Further review indicated the patient had hemodialysis on Mondays, Wednesdays, and Fridays. During an interview on 10/01/24 at 9:20 a.m., LVN K said the POC/485 were done by the RN upon admit and recertification. She said the 485/POC for a patient on dialysis should include the dialysis days of the week, keep the site clean, blood pressure parameters, and the access site should be on the POC. During an interview on 10/01/24 at 10:21 a.m., the RN Administrator said the POC was developed by the RN doing the OASIS (comprehensive) assessment and coordinated with the signing physician. She said the POC was updated every 60 days or if there was a change in condition. She said a patient on dialysis the 485 should include weights, shunt care, diet, blood pressures. She said no blood pressures or sticks on arm was listed under safety measures. She said if these items were not on the POC it could affect care greatly if a clinician did the blood pressure on a shunt. She said that was why it was under safety precautions. During an interview on 10/01/24 at 10:34 a.m., the RN Administrator said the dialysis access site should be on the 485/POC. She said the 485 should also include to assess site and when the patient went to dialysis. The RN Administrator said the goal was to keep the patient out of the hospital and it was part of their health and the “bigger picture.” During an interview on 10/02/24 at 8:25 a.m., Patient #12 said she had been with the agency about a year. She said she went to dialysis on Mondays, Wednesdays, and Fridays and had a chest port/catheter (flexible tube that's inserted into a vein in the chest to provide access to the blood for dialysis). Patient #12 said she had been on dialysis for 9 months. During an interview on 10/02/24 at 10:34 a.m., the RN Alternate Administrator said a 485/POC for a patient on dialysis should include weights or to measure the legs if the patient can’t stand. She said it should also include fluid restrictions, safety measures, shortness of breath education, access site location, the days the patient went to dialysis, SN assess the site, no blood pressures on arm with the access site. She said the RN would document the port site on the 485/POC. During an interview on 10/02/24 at 11:10 a.m., RN I said the 485/POC for a patient on dialysis should include to check the shunt or site to make sure the port was clean and dry and there were no signs or symptoms of infection. She said the location of the site was not on the 485. She said how often the patient went to dialysis should be on there. During an interview on 10/02/24 at 11:12 a.m., the RN Administrator said by the 485/POC not having the dialysis site/education and if the agency was not treating the whole patient, or not giving patient full care the patient could regress or be hospitalized. Review of Hemodialysis Catheters: How to Keep Yours Working Well accessed on 10/08/24 at https://www.kidney.org/kidney-topics/hemodialysis-catheters-how-to-keep-yours-working-well indicated “Hemodialysis is a treatment used when your kidneys fail and can no longer clean your blood and remove extra fluid from your body… By taking good care of your access, it will last longer and you will prevent problems such as infection and clotting. Here are some important steps to take: Keep the catheter dressing clean and dry… Never remove the cap on the end of your catheter. Air must not enter the catheter… You can shower or bathe if you have a clear dressing that sticks to your catheter site and the skin around it…. You should avoid letting the catheter or catheter site go under water during a bath. This would increase the chance of moisture getting near the catheter site, which can cause infection…. If the area around your catheter feels sore or looks red, call your dialysis care team at once… The signs and symptoms of a catheter infection include: Fever, chills, drainage from the catheter exit site, redness or tenderness around the catheter exit site, general feeling of weakness and illness…” Record review of a Plan of Care policy dated 09/01/24 indicated “… A POC is developed for all patients and updated no less than every 60 days… 2. The POC includes… g. Safety measures to protect against injury… i. Patient specific interventions and education…”

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 2 of 17 patients reviewed for infection control. (Patient #12 and #14) The agency did not include Patient #12 (wound infection) and Patient #14 (urinary tract infection) in the Online 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 #12's POC dated 09/10/24 to 11/08/24 indicated a SOC date of 03/14/24 and indicated she was 58 years old with diagnoses including congestive heart failure (heart can't pump enough blood to meet the body's needs), type 2 diabetes mellitus (body can't produce enough insulin), end stage renal disease, dependence on renal dialysis (a machine removes blood from the body, filters it, and returns the cleaned blood), acute osteomyelitis (bone infection), chronic obstructive pulmonary disease (a chronic lung disease that makes it difficult to breathe), and anxiety. The POC indicated Patient #12 was ordered skilled nursing visits two time a week for eight weeks, then one time a week for one week. The POC medication list indicated Patient #12 was ordered ceftriaxone (antibiotic) 1-gram intravenous (administered into a vein) solution, and daptomycin (antibiotic) 500mg intravenous solution with patient to receive antibiotics through dialysis days on Mondays, Wednesdays, and Fridays starting 08/30/24. Record review of a RN Recertification Visit Note Report for Patient #12 dated 09/06/24 indicated patient was recently hospitalized from 08/16/24 - 08/29/24 for infected left knee prosthesis with concern for abscess (pocket of pus). The note indicated wound noted to left knee incision with loosely adherent yellow slough (collection of dead cells, debris, and tissue that accumulate in a wound) noted to wound bed. The note indicated patient would be receiving ceftriaxone (antibiotic) 1 gram and daptomycin (antibiotic) 500mg on dialysis days. Record review of Patient #14's POC dated 03/15/24 to 05/13/24 indicated a SOC date of 03/15/24 and indicated he was 84 years old with diagnoses including acute cystitis (bladder infection), Escherichia coli (bacteria), retention of urine, hypertension (high blood pressure), and extended spectrum beta lactamase (esbl) (enzyme that makes some bacteria resistant to many antibiotics) resistance (the ability not to be affected by something) problems. The POC indicated Patient #12 was ordered skilled nursing visits one time a week for nine weeks. Record review of Patient #14’s Urinalysis Lab results dated 03/20/24 indicated organisms (a living thing that functions as an individual) detected was Escherichia coli (bacteria). Further review indicated antibiotic resistance genes detected were Sulfonamide Resistance (a bacterial trait that allows bacteria to survive the effects of sulfonamides) and Extended Spectrum Beta-Lactamase (enzyme that makes some bacteria resistant to many antibiotics). Record review of Patient #14’s medication report dated 04/22/24 indicated Patient #14 was ordered amoxicillin 875 mg-potassium clavulanate (antibiotic) 125 mg tablet by mouth two times daily with a start date of 03/20/24 and stop date of 04/03/24. Record review of the agency's Event Report for infections dated 09/27/2021 to 09/27/2024 did not include Patient #12 and Patient #14. During an interview on 10/01/24 at 10:15 a.m., the RN Administrator said when a patient had an infection, the PCMs and assistants put the infection in the log/QI event (online event reporting) and filled out the report. She said every infection from the day the clinicians went in (to see patient), should be on the log. She said if a patient was admitted with an infection, it should be on the log. During an interview on 10/01/24 at 12:23 p.m., LVN L said the SN logged infection reports on their tablet. She said if a patient had an infection or was on an antibiotic the SN would do infection log. She said any time a patient had a new antibiotic it would go on the log. During an interview on 10/01/24 at 3:26 p.m., RN D said if a patient had an infection the SN would enter it while in the home and call the doctor to let them know. She said if a patient was admitted with a urinary tract infection it would go on the infection control report. She said the admitting nurse would put the infection on the infection control log and all infections went on the log. During an interview on 10/02/24 at 10:34 a.m., the RN Alternate Administrator said LVN P added infections to the system. She said any diagnosis of infections or ordered antibiotic got put in the system on the infection control log. She said if a patient was admitted with a urinary tract infection it went on the log. During an interview on 10/02/24 at 10:42 a.m., LVN P said she entered infection reports in the infection control log. She said the report was audited by the Administrator. She said the PCMs entered the infection, printed off the report, then brought it to her. LVN P said the PCM printed the actual infection report then she (LVN P) entered the infections on the infection control log. LVN P said all infections went on the log and if a patient was started on an antibiotic it went on the log. She said she entered them as soon as the PCM brought them to her. She said she did not know if any had been missed. During an interview on 10/02/24 at 10:46 a.m., the RN Administrator said an infection not being entered on the log could cause a potential negative outcome and a patient could decrease in health status in the infection was not followed up on to make sure the bacteria was eliminated. She said infections should be entered on the log immediately once notified of the infections. The RN Administrator said audited the infection control log and risk management looked through them as well. During an interview on 10/02/24 at 11:10 a.m., RN I said she could not remember if Patient #12 had any infections. During an interview on 10/02/24 at 11:15 a.m., the RN Administrator said she did not know why Patient #12 or Patient #14 were not on the infection control log/report. Record review of an Infection Control Event Reporting – Patient and Employee policy dated 02/11/12 indicated "… 3. All other patient infections not included in the active surveillance areas, especially those that are highly transmissible/communicable or considered a reportable infection to the local health department, will be reported in the Online Event Reporting System for further follow-up/investigation and trending by the Risk Management Department AND the agency Clinical Director/Executive Director, Quality Coordinator, and /or Area/Regional Vice President…”

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the skilled professional provided services that were ordered by the physician or allowed practitioner as indicated in the plan of care for 1 of 7 (Patient # 8) patients reviewed for plans of care in which home visits were conducted, in that: LVN H did not apply barrier cream and dry dressing to Patient #8’s coccyx (tailbone) area during a home visit on 10/01/24. This failure could place patients at risk of improper skin care and could lead to wounds and further complications. Findings included: Record review of Patient #8’s POC dated 08/30/24 to 10/28/24 indicated a SOC date of 01/03/24, and indicated he was 77 years old with diagnoses including atrial fibrillation (irregular heartbeat), encounter for attention to cystostomy (surgical procedure that creates a connection between the bladder and the skin to drain urine), urinary tract infection, chronic kidney disease (stage 4-severe), heart failure, peripheral vascular disease (circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked), chronic obstructive pulmonary disease (a chronic lung disease that makes it difficult to breathe), and pressure ulcer of right buttock, stage 2 (skin injury caused by prolonged pressure). The POC indicated Patient #8 was ordered skilled nursing visits one time a week for eight weeks. The POC indicated skilled nurse to apply barrier cream to coccyx area every visit and apply dry dressing. Record review of Patient #8's medical record did not indicated there were changes to the POC regarding skin care. During a home visit observation on 10/01/24 at 1:15 p.m., Patient #8 said the spot on his bottom healed but was getting sore again. LVN H assessed Patient #8’s bottom and said there were no open wounds, only slight redness to patient’s coccyx. LVN H instructed Patient #8 to apply cream to his bottom (this was not done). Patient #8 said he could tell his bottom was getting sore/raw. He said he applied the cream himself when he went to the bathroom. LVN H did not apply barrier cream and dry dressing to Patient #8’s coccyx area. During an interview on 10/01/24 at 1:52 p.m., surveyor asked LVN H if the SNs usually applied the barrier cream. LVN H said Patient #8 did the cream himself. She said she had not seen him in a long time (1 year) and was going to call the doctor to see if they wanted to order cream and how often. During an interview on 10/02/24 at 10:34 a.m., the RN Alternate Administrator said the POC was updated every 60 days by the RN or physical therapist. She said the physician signed off on the POC and the POC was considered physician’s orders. She said if an order is on the 485/POC, it should be done. During an interview on 10/02/24 at 11:12 a.m., the RN Administrator said the 485/POC was considered doctor’s orders. She said if the POC said for the SN to apply cream each visit, the SN should be doing it unless the patient refused. The Administrator said by not following the 485/POC it could cause patient harm, delay in treatment, delay in progress, or regression. During an interview on 10/02/24 at 11:15 a.m., the RN Administrator said if something was on the 485/POC it had to be done and the SNs should be doing it. The Administrator said LVN H had been with the agency a long time and was nervous during the visit. Record review of a LVN job description signed by LVN H and dated 01/17/16 indicated "… Provides high quality clinical services within the scope of practice, as defined by the state laws governing the practice of nursing, in accordance with the plan of care…” Record review of a Plan of Care policy dated 09/01/24 indicated “… 7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. … Record review of a Physician’s Orders policy dated 10/01/23 indicated “…10. Services are provided according to the most recent orders updating the patient’s Plan of Care…” Record review of a Standards for Nursing Care and Practice (LVN) policy dated 04/01/24 indicated “…3. Use a systematic approach to provide individualized, goal-directed nursing care by…c. implementing nursing care…”