Every finding on record at Rio Grande Home Health Agency Inc

Purpose of Visit: To conduct RE-Certification, Follow-up to Survey dated 04/29/22 and 2 Complaints On 10/20/22 at 2:24 p.m., the surveyor conducted an unannounced visit, and an entrance conference was conducted with the Adm and DON. Census: Licensed & Certified- 41 Licensed Home Health Services - 0 An exit conference was conducted on 10/26/22 at 3:12 p.m., with the Adm. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of deficiencies. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies

Purpose of Visit: To conduct RE-Certification, Follow-up to Survey dated 04/29/22 and 2 Complaints On 10/20/22 at 2:24 p.m., the surveyor conducted an unannounced visit, and an entrance conference was conducted with the Adm and DON. Census: Licensed & Certified- 41 Licensed Home Health Services - 0 An exit conference was conducted on 10/26/22 at 3:12 p.m., with the Adm. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies. Adm- Administrator Alt- Alternate ADON- Alternate Director of Nurses CMS- Center for Medicaid and Medicare Services Covid-19- Coronavirus Disease 2019 CTA- Cotton tipped applicator NS- Normal Saline DON- Director of Nurses LVN- Licensed Vocational Nurse M0090- date an assessment was conducted OASIS- Outcome and Assessment Information Set POC- Plan of Care PT-Physical Therapy PTA- Physical Therapy Assistant RN- Registered Nurse SN- Skilled Nurse SOC- Start of Care VAD- Ventricular Assist Device (a mechanical pump implanted in the body to help blood flow)

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 record review and interview, the agency failed to transmit completed OASIS assessments to the State agency within 30 days of completing the assessments for 25 of 25 patient validation reports reviewed. Failure of the agency to transmit OASIS data within the required time frame prevented the patient's data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. The Findings Included: Surveyor A requested final validation reports for a six-month period. The reports that were provided by the Adm were for 3 months only from 10/10/22 to 06/28/22 and contained the following submission dates 10/10/22, 10/05/22, 10/02/22, 09/12/22, 08/29/22, 08/09/22, 07/31/22, 06/30/22, and 06/28/22. These final validation reports were reviewed for the SOC, Recertification, Transfer, Resumption of Care and Discharge OASIS assessment submissions. After review of the Submission reports it was found that submission for OASIS should have been completed for the following: -Resumption of Care OASIS for Patient #4 - date assessment was done – 06/29/22, it was submitted 62 days after being conducted. -Transfer; Not Discharge OASIS for Patient #4 - date assessment was done – 06/24/22, it was submitted 66 days after being conducted. -Transfer; Not Discharge OASIS for Patient #4 - date assessment was done – 06/24/22, it was submitted 38 days after being conducted. -Resumption of Care OASIS for Patient #4 - date assessment was done – 06/20/22, it was submitted 70 days after being conducted. -Transfer; Not Discharge OASIS for Patient #4 - date assessment was done – 06/18/22, it was submitted 44 days after being conducted. -Recertification OASIS for Patient #4 - date assessment was done – 06/15/22, it was submitted 56 days after being conducted. -Recertification OASIS for Patient #5 - date assessment was done – 08/25/22, it was submitted 38 days after being conducted -Recertification OASIS for Patient #5 - date assessment was done – 06/26/22, it was submitted 45 days after being conducted. -Recertification OASIS for Patient #10 - date assessment was done – 07/19/22, it was submitted 42 days after being conducted. -Resumption of Care OASIS for Patient #10 - date assessment was done – 07/04/22, it was submitted 97 days after being conducted. -Transfer; Not Discharge OASIS for Patient #10 - date assessment was done – 06/24/22, it was submitted 38 days after being conducted. -Transfer; Not Discharge OASIS for Patient #10 - date assessment was done – 05/02/22, it was submitted 90 days after being conducted. -Resumption of Care OASIS for Patient #11 - date assessment was done – 09/08/22, it was submitted 32 days after being conducted. - Transfer; Not Discharge OASIS for Patient #11 - date assessment was done 08/19/22, it was submitted 52 days after being conducted -Resumption of Care OASIS for Patient 11 - date assessment was done – 08/03/22, it was submitted 68 days after being conducted. -Start of Care OASIS for Patient #11 - date assessment was done – 07/26/22, it was submitted 76 days after being conducted. -Discharge OASIS for Patient #12 - date assessment was done – 08/18/22, it was submitted 47 days after being conducted. -Transfer In Patient; Discharge OASIS for Patient #12 - date assessment was done – 07/02/22, it was submitted 59 days after being conducted. -Resumption of Care OASIS for Patient #12 - date assessment was done – 06/14/22, it was submitted 57 days after being conducted. -Recertification OASIS for Patient #13 - date assessment was done – 09/01/22, it was submitted 34 days after being conducted. -Recertification OASIS for Patient #13 - date assessment was done – 07/01/22, it was submitted 39 days after being conducted. -Transfer; Not Discharge OASIS for Patient #13 - date assessment was done – 05/25/22, it was submitted 68 days after being conducted. -Recertification OASIS for Patient #14 - date assessment was done – 09/03/22, it was submitted 32 days after being conducted. -Start of Care OASIS for Patient #14 - date assessment was done 07/06/22, it was submitted 69 days after being conducted. -Recertification OASIS for Patient #15 - date assessment was done -09/03/22, it was submitted 33 days after being conducted. -Resumption of Care OASIS for Patient #15 - date assessment was done -08/11/22, it was submitted 55 days after being conducted. -Recertification OASIS for Patient #16 - date assessment was done – 08/24/22, it was submitted 39 days after being conducted -Recertification OASIS for Patient #16 - date assessment was done – 06/22/22, it was submitted 78 days after being conducted -Recertification OASIS for Patient #17 - date assessment was done – 09/01/22, it was submitted 32 days after being conducted. -Discharge OASIS for Patient #18 - date assessment was done – 07/25/22, it was submitted 36 days after being conducted. -Transfer; Not Discharge OASIS for Patient #18 - date assessment was done – 07/03/22, it was submitted 58 days after being conducted -Resumption of Care OASIS for Patient #18 - date assessment was done – 06/03/22, it was submitted 102 days after being conducted. -Transfer; Not Discharge OASIS for Patient #18 - date assessment was done – 05/24/22, it was submitted 97 days after being conducted -Resumption of Care OASIS for Patient #18 - date assessment was done – 05/22/22, it was submitted 40 days after being conducted. -Transfer: Not Discharge OASIS for Patient #18 - date assessment was done – 05/11/22, it was submitted 111 days after being conducted -Start of Care OASIS for Patient #18 - date assessment was done 05/01/22, it was submitted 61 days after being conducted. -Transfer In Patient; Discharge OASIS for Patient #18 - date assessment was done – 04/26/22, it was submitted 166 days after being conducted -Start of Care OASIS for Patient #19 - date assessment was done – 07/22/22, it was submitted 53 days after being conducted. -Discharge OASIS for Patient #20 - date assessment was done – 04/22/22, it was submitted 130 days after being conducted. -Discharge OASIS for Patient #21 - date assessment was done – 04/18/22, it was submitted 133 days after being conducted. -Discharge OASIS for Patient #22 - date assessment was done -04/28/22, it was submitted 126 days after being conducted. -Discharge OASIS for Patient #23 - date assessment was done -04/01/22, it was submitted 151 days after being conducted. -Transfer In Patient; Discharge OASIS for Patient #24 - date assessment was done – 07/21/22, it was submitted 39 days after being conducted. -Resumption of Care OASIS for Patient #24 - date assessment was done – 06/13/22, it was submitted 58 days after being conducted. -Transfer; Not Discharge OASIS for Patient #24 - date assessment was done – 05/14/22, it was submitted 79 days after being conducted. -Transfer; Not Discharge OASIS for Patient #24 - date assessment was done – 6/10/22, it was submitted 52 days after being conducted. -Start of Care OASIS for Patient #25 - date assessment was done 07/27/22, it was submitted 33 days after being conducted. -Start of Care OASIS for Patient #26 - date assessment was done 07/16/22, it was submitted 45 days after being conducted. -Start of Care OASIS for Patient #27 - date assessment was done 06/22/22, it was submitted 49 days after being conducted. -Recertification OASIS for Patient #28 - date assessment was done – 06/14/22, it was submitted 57days after being conducted -Transfer In Patient; Discharge OASIS for Patient #28 - date assessment was done – 06/18/22, it was submitted 53 days after being conducted -Transfer In Patient; Discharge OASIS for Patient #29 - date assessment was done – 06/21/22, it was submitted 50 days after being conducted -Discharge OASIS for Patient #30 - date assessment was done -06/14/22, it was submitted 48 days after being conducted. -Discharge OASIS for Patient #31 - date assessment was done -06/13/22, it was submitted 49 days after being conducted. -Recertification OASIS for Patient #32 - date assessment was done – 05/09/22, it was submitted 51 days after being conducted The agency failed to reveal documented evidence that the OASIS were submitted within 30 days of completion. During an interview on 10/26/22 at 11:47 a.m. with the Alt Adm, surveyor presented the above findings. An opportunity was given to review the record. After review, Alt Adm acknowledged that the OASIS were not submitted within 30 days of completing the assessment. The Alt Adm stated, “there is a waiver due to Covid-19. I don’t submit them on time, most of the time.” Surveyor A then asked the Alt Adm if the admission rate was an issue. The Alt Adm stated, “admission rate is not an issue, it’s coordination with QA.” Surveyor asked if that would be the same response for all the late submission. Alt Adm stated, yes.” Review of the Agency's policy and procedure manual revealed a form titled "Timelines” IM.7 with a revision date of 08/01/20. It read in part: "…All completed and encoded OASIS data which accurately reflects the Patient’s/Client’s status at the time of the assessment will be transmitted via electronic communications software that is available from CMS… within 30 days of the M0090 date."

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 clinical record review and interview, the Agency failed to respect the patient's right to be informed about the frequency of visits for 1 of 4 Active Patient (#5) whose clinical record was reviewed. This failure violates patients right to have their physical needs treated and hinders a detailed approach to care customized to an individual patient's needs. Based on clinical record review and interview, the Agency failed to respect the patient's right to be informed about the frequency of visits for 1 of 4 Active Patient (#5) whose clinical record was reviewed. This failure violates patients right to have their physical needs treated and hinders a detailed approach to care customized to an individual patient's needs. The Findings included: During a home visit on 10/25/22 at 9:48 a.m. Surveyor reviewed Active Patient #5’s home folder. The home folder contained a blank form titled Medication Profile and a partially completed Calendar Worksheet. Continued review of a form titled “Calendar worksheet” revealed the patient’s name, soc 02/27/21 SN re-cert date 10/25/22 and SN frequency of 2w9 (twice a week for 9 weeks). Review of the POC dated 10/25/2022 – 12/23/22 that was presented by LVN E during the home visit on 10/25/22 currently read in part: “Frequency 3w1 (three visits a week for one week), 2w2 (two visits a week for two weeks), and 1w1 (one visit a week for one week) effective 10/05/22…” RN C failed to inform Patient #5 of the skilled nurse frequency. During an interview on 10/25/22 at 10:25 a.m. with Identifier 50, the Surveyor asked if RN C informed them of the SN frequency. Identifier 50 stated, “No, but I know when she (LVN E) comes.” During an interview on 10/25/22 at 5:02 p.m. with Adm and DON, Surveyor A asked when the RN conducts a recert what do you leave in the patient’s home folder. Don stated, “I fill in the calendar with the frequency. I also fill out the medication sheet.” Surveyor A then asked if the patient and caregiver are informed of the SN frequency. DON stated, “yes we do.” Review of the Agency's Policy and Procedure manual revealed a policy titled "Patient/Client Rights and Responsibilities: Rights of the Elderly" numbered RI.2 and revised on 01/13/18. It read in part: "…The patient has the right to: D. Participate in, be informed about… 5. the frequency of visits…”

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 record review and interview, the supervising nurse failed to ensure the services were provided as ordered in the POC for 1 of 4 Active Patients (#4) and 2 of 4 Discharged Patients (# 2 and #3) whose records were reviewed. This failure could place the agency's patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The Findings Include: 1. Review of Discharged Patient #2’s record revealed a POC for the period of 07/21/21 to 09/18/21 with a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and stage 1-4/unspecified chronic kidney disease (heart problems that occur because of the presence of high blood pressure over a long time. Chronic Kidney disease a gradual loss of kidney function. Heart failure means the heart isn’t pumping as well as it should) and a skilled nurse visit frequency of two visits a week for five weeks and one visit a week for 4 weeks. Further review of the POC revealed to instruct patient /caregiver on “strategies to mitigate pain including medication administration, cording and reporting pain, non-pharmacological treatments including positioning, massage, visualization, distraction and cold or warm compress, …disease process, including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management, activities permitted… self-management of oxygen therapy therapy…cardiovascular disease process to including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management, activities permitted…heart failure status and self-management program…all new and changed medications and reinforce teaching related to use of medications as part of disease process or demonstration of knowledge deficit… importance of proper diabetic foot care and precautions, including monitoring for the presence of skin lesions on the lower extremities…prevention of pressure ulcer development…pressure ulcer prevention and treatment …” Continued review of the POC revealed to notify physician of vital sign parameters out of range “…Pain level: Greater than (>) 7…” Review of Discharged Patient #2’s record included an SN visit note dated 08/06/21 revealed LVN E instructed on Covid-19 and how to prevent the spread of respiratory disease. Review of Discharged Patient #2 record included an SN visit note signed and by LVN E on dated 09/02/21 revealed no documented evidence the nurse assessed pain level. Discharged Patient #2’s record failed to include documented evidence the nurse followed the orders as per the POC to instruct on new or changed medications and did not assess discharged Patient #2’s pain. During an interview on 10/25/22 at 2:16 p.m. with DON, the surveyor presented the above findings. After review of the documents presented, the Don acknowledged LVN E had not followed the POC on instruction of new medications and had not assessed pain. The DON stated, she (LVN E) instructed on Covid-19, it’s part of the respiratory status.” The DON then stated, I don’t see her (LVN E) scoring on it (pain).” 2. Review of the Discharged Patient #3’s record revealed a POC for the period of 03/27/21 to 05/25/21 with a primary diagnosis of Displaced bicondylar fracture right tibia (a fracture in the right leg shin area where bones are broken in more than two pieces), subsequent for closed fracture with routine heal and a visit frequency of once a week for one week, three times a week for two weeks, two times a week for four weeks and once a week for two weeks. Continued review of the POC revealed in part: “… Sn to provide skilled assessment, teaching and training and reinforcement of teaching to properly assess, manage and mitigate pain... strategies to mitigate pain including medication administration, recording and reporting pain; non-pharmacological treatments including positioning, massage, visualization, distraction and cold or warm compress… management to include how to properly assess and mitigate pain…to instruct patient on disease process, including who to contact if signs and symptoms persist or worsens as well as dietary, hydration measures and medication management where indicate, …teach patient/caregiver care of incision to prevent infection, signs and symptoms to report immediately and who to contact. .. care of incision as follows: using aseptic technique and sterile supplies, SN to cleanse surgical incision with NS, pat dry with 4x4 gauze, wrap with kerlix, and secure with tape daily…instruct on anticoagulation monitoring and intervein to prevent complications…instruct on new and/or changed medications…fall prevention…infection control precautions such as hand hygiene, personal protection equipment, waste disposal, environmental sanitation and signs and symptoms of infection to report… Covid-19 infection and instruct patient/caregiver on emergency warning signs that indicate the need to seek medical attention immediately... on how Covid-19 spreads, steps to protect oneself and others…” Review of Discharged Patient #3’s record included a signed SN note by Ex-Employee BB on 03/30/21 titled “(Agency Name), SN Wound Care Visit” dated 03/29/21 that had no documentation evidence that Ex-Employee BB instructed on new or changed medications and was not performing wound care daily as per POC. During an interview on 10/25/22 at 2:42 p.m. with DON, the surveyor presented the above findings. After review of the documents presented DON Ex-Employee BB failed to document any teaching as per POC. Don stated, “no I don’t see that” (referring to teaching). 3. Review of Active Patient #4’s record revealed a POC for the period of 08/15/22 to 10/13/22 with a principal diagnosis of Encounter for surgical aftercare following surgery on the skin, subcutaneous (care after a surgical procedure) and a skilled nurse visit frequency of three visits a week for eight weeks and two visits a week for 2 weeks. Continued review of the POC revealed in part: “…SN to perform wound care to wound #1 surgical wound to left dorsal foot covered with non-removable Mepitel 3 times a week as follows: Remove outer dressing, cleans with NS and gauze, pat dry with gauze, apply Hydrogel with cta, cover with gauze, wrap with kerlix gauze, and secure with ace bandage…” Review of Active Patient #4’s record revealed that for the week of 8/28/22 to 9/01/22, only 2 of 3 ordered SN wound care visits were provided, which were signed and dated by LVN E on 08/29/22 and 8/31/22. During an interview on 10/25/22 at 4:00 p.m. with DON, the surveyor presented the above findings. After review of the documents presented DON acknowledged that the frequency was not followed as per POC. Surveyor asked the DON if the frequency of three visits a week were followed for the week of 08/28/22. DON stated, “no.” Review of the Agency's Policy and Procedure manual revealed a policy titled "Plan of Care" numbered PC.8 and reviewed on 01/01/22. It read in part: "…V. Each patient/client must receive the home health services that are written in an individualized plan of care…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals completed clinical notes were current and accurate for 2 of 4 Active Patients (#6 and # 7) and 1 of 4 Discharged Patient (#3) whose records were reviewed. This failure prevents the agency from ensuring patient services are provided and the needs are met and could place all agency patients as risk of harm. The findings include: 1. Review of the Discharged Patient #3’s record revealed a POC for the period of 03/27/21 to 05/25/21 with a diagnosis of Displaced bicondylar fracture, right tibia, (a fracture in the right leg shin area where bones are broken in more than two pieces) subsequent for close fracture with routine heal and a visit frequency of once a week for one week, three times a week for two weeks, two times a week for four weeks and once a week for two weeks. Review of Discharged Patient #3’s record included a signed SN note by Ex-Employee BB on 03/30/21 titled “(Agency Name), SN Wound Care Visit” dated 03/29/21 that included several uncompleted sections titled: “Discharge Planning, Care Coordination, Health Management, Interventions and Visit Narrative”. Review of the record revealed no documented evidence that SN note dated 03/29/21 was accurate and complete. During an interview on 10/25/22 at 2:42 p.m. with DON, the surveyor presented the above findings. After review of the documents presented DON acknowledge SN note dated 03/29/21 was inaccurate and incomplete. 2. Review of Active Patient #6's clinical record revealed a POC for the certification period of 09/12/22 to 11/10/22 with a principal diagnosis of Unspecified fracture shaft of right tibia (a fracture in the right leg shin area where bones are broken in more than two pieces), subsequent for closure with routine heal and a skilled nurse visit frequency of one visit a week for 9 weeks. PT frequency one visit a month for 1 month. Review of Active Patient #6’s record included an incomplete PT note titled “(Agency Name), PT Visit” signed and dated 09/20/22 by PT that included several blank sections titled: “Functional Limitations, Vital Signs, Subjective, Objective, Bed Mobility Training, Transferring Training, Gait Training, Teaching, Pain, Assessment, Plan, and Progress made towards goals.” Further review of the record revealed no documented evidence that PT note dated 09/20/22 was accurate and complete. During an interview on 10/25/22 at 5:24 p.m. with Adm and DON, the surveyor presented the above findings. After review of the documents presented, DON acknowledge PT note dated 09/20/22 was inaccurate and incomplete. Adm stated, “That note is not done, there is a lot of missing elements.” 3. Review of Active Patient #7’s record revealed a POC for the period of 07/06/22 to 09/03/22 with a principal diagnosis of Encounter for fitting and adjustment of urinary device (maintenance of a flexible tube that goes into the bladder to drain urine) and a skilled nurse visit frequency of one visit a week for nine weeks. Review of the skilled nursing visit notes for 07/14/22, 07/19/22 and 08/11/22 revealed documentation the skilled nurse obtained the client's blood pressure using the left arm. Review of the record revealed no documented evidence that SN notes dated 07/14/22, 07/19/22 and 08/11/22 were accurate. During an interview on 10/22/22 at 9:25 a.m. with Adm and DON present and LVN E via telephone conference, the surveyor presented the above findings. Surveyor asked LVN TT if Patient #7 had a shunt() and to which arm. LVN E stated, “he does, in the left arm. Surveyor then informed LVN E that Sn notes 07/14/22, 07/19/22 and 08/11/22 stated blood pressures using left arm. LVN E stated, “no, I have never taken a blood pressure where his shunt is at. That’s an error in my part.” Surveyor then asked LVN TT if the notes dated 07/14/22, 07/19/22 and 08/11/22 were accurate. LVN E stated, no they are wrong.” Review of the agency's policy manual included a policy titled "Medical Record Content” IM.5 with a revision dated of 02/01/19. The policy revealed, in part: “…II. information contained in the clinical record must be accurate…”