Every finding on record at Serenity Home Care LLC

Purpose of Survey – To conduct a recertification/relicensure and follow up to survey conducted on 06/10/22 and 1 complaint investigation. On 05/22/25 at 09:10 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Alt Adm Census L&CHHS – 1 LHHS – 0 Personal Assistance Services –217 Intake: · 380548 Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator CFR – Code of Federal Regulations DON – Director of Nurses The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of Survey – To conduct a recertification and follow up to survey conducted on 06/10/22 and 1 complaint investigation. On 05/22/25 at 09:10 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Alt Adm. Census: L&CHHS– 1 LHHS – 0 Personal Assistance Services –217 Intake: · 380548 Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator CMS – Centers for Medicare and Medicaid DON – Director of Nurses EMR – Electronic Medical Record HHSC – Health and Human Services Commission IQIES – Internet Quality and Improvement Evaluation System LHH – Licensed Home Health Services L&CHHS – Licensed and Certified Home Health Services OASIS – Outcome and Assessment Information Set) POC – Plan of Care PT – Physical Therapy OT – Occupational Therapy RN – Registered Nurse SN – Skilled Nurse SOC – Start of Care

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 (Outcome and Assessment Information Set) Assessments within 30 days of completions for 20 of 43 assessments submitted between 05/01/24 through 05/21/25. This failure prevented the patient’s data from being made available to the Centers for Medicare and Medicaid (CMS) for analysis to identify Agency performance levels in the provision of patient care. Findings included: Record review of the IQIES (Internet Quality and Improvement Evaluation System, an internet-based system that consolidates and replaces legacy systems for survey and certification functions) “Home Health Error by Summary Agency” report generated by the CMS national data system during presurvey preparation on 05/21/25 revealed the Agency had submitted and processed 49 assessments. The report indicated the Agency had a 40.82% of assessments with -3330 error that indicated the assessments were submitted after the 30th date of the M0090 date. Record review of the Agency OASIS final validation reports dated 05/01/24 through 05/21/25 revealed 43 were processed by the Agency. Further review of the Agency OASIS final validation reports revealed 20 of the 43 assessments had error -3330 indicating those records were submitted after the 30th date of the M0090 date. In an interview on 05/27//25 at 11:30 a.m., the Adm/DON stated the Agency’s policy for submitting OASIS assessments were within 30 days. The Adm/DON the Agency was aware they were submitting OASIS assessments after the 30 days because the Agency had gone through personnel change. The Adm/DON stated the person who was responsible for submitting assessments to CMS quit in September 2024 and a new person was hired. The Adm/DON stated the Agency had to train this person in IQIES software and how to submit OASIS assessments. The Adm/DON stated the Agency also had gone through computer and software issues around the same time that caused delays in submitting assessments. The Adm/DON stated she was the one responsible to ensure assessments were submitted within the 30 days and the Agency already had implemented a plan to ensure the assessments were submitted on a weekly basis. In a follow up interview on 05/28/25 at 01:30 p.m., the Adm/DON stated patients continued to be seen, and she did not think it would negatively affect patient care if the assessments were not submitted within the 30 days. The Adm/DON stated the standard of care for the Agency’s patients was there. The Adm/DON stated not submitting assessments withing the 30 days would instead affect the Agency because it was more of a “compliance issue”. Record review of the Agency policies titled, “Timelines, IM.35”, with a revised date 10/25/24, quoted in part, “The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations…II. All completed and encoded OASIS data will be transmitted via electronic communications software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that compiles with Federal Information Processing Standard (FIPS 140-2, issued May 20, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…”

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, observation, and interview, the Agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of 2 (Patient #1 and Patient #7) of 7 patients whose records were reviewed in that: · Patient #1’s initial comprehensive assessment visit was not held within 48 hours of referral. It was conducted approximately 72 hours (3 days) after the referral date and without coordination of the patient’s physician. · Patient #7’s initial comprehensive assessment visit was not held within 48 hours of referral. It was conducted 96 hours (4days) after the referral date and without coordination of the patient’s physician. This failure has the potential to delay the immediate care and support needs and prevent initiation of required services in a timely manner of patients. Findings included: Record review of the Agency’s “Unduplicated Census” roster provided by the Alt Adm upon entrance on 05/22/25 at 09:10 a.m., indicated Patient #1 was an “active” patient of the Agency with a start of care (SOC) date of 04/07/25 and a certification period of 04/07/25 through 06/05/25. Further review of the roster indicated Patient #7 was a discharged patient of the Agency with a SOC date of 11/11/24, a discharged date of 12/16/24 and a certification period of 11/11/24 through 12/16/24. Record review of Patient #1’s electronic medical record (EMR) included a “Patient Profile” that documented a SOC date of 04/07/25 and a referral date of 04/04/25. Further record review of Patient #1’s EMR included a “Home Health Certification and Plan of Care (POC)” signed and 05/23/25 that documented a SOC of 04/07/25 and a certification period of 04/07/25 through 06/05/25. Further review of the POC indicated Patient #1 was an 89-year-old male with a primary diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (chronic condition where the body has persistently high blood sugar levels with chronic complications of the kidney caused by elevated blood sugar levels). The POC documented the following orders: · Skilled nurse (SN) frequency: 1 time a week for 1-week (1w1), 2 times a month for 2 months (2m2), and 3 as needed (prn) visits. · Physical therapy (PT) frequency: evaluate and treat. · Occupational therapy (OT) frequency: evaluate and treat. Record review of Patient #1’s EMR included a referral with a date and time stamped 04/04/24 at 10:08 a.m. that documented “…Home health and physical therapy…” Record review of the OASIS comprehensive assessment for the start of care revealed it was conducted by RN A on 04/07/25 at 01:15 p.m., approximately 72 hours (3 day) after the referral order for home health was received by the Agency. Record review of Patient #1 failed to include documentation with the physician for a delayed or change in the ordered start of care date. The Agency failed to ensure the initial assessment of Patient #1 was completed within 48 hours of receipt of the referral. Record review of Patient #7’s EMR included a “Patient Profile” that documented a SOC date 11/11/24 and a referral date of 11/07/24. Further record review of Patient #7’s EMR included a POC signed and dated 12/24/24 that documented a SOC 11/11/24 and a certification period of 11/11/24 through 01/09/25. Further review of the POC indicated Patient #7 was a 73-year-old male with a primary diagnosis of other specified diabetes mellitus with foot ulcer (chronic condition where body has persistently high blood sugar levels with complications of an open sore or wound on the foot caused by elevated blood sugar levels”. The POC documented the following orders: · SN frequency: 2 times a week for 2 weeks (2w2), 1 time a week for 4 weeks (1w4) and 3 as needed (prn) visits. Record review of Patient #7’s EMR included a referral with a date and time stamped 11/07/24 at 11:25 a.m. that documented “…RN Eval/Nursing….” Record review of the OASIS comprehensive assessment for the start of care revealed it was conducted by RN A on 11/11/24 at 11:00 a.m., approximately 96 hours (4 days) after the referral order for home health was received by the Agency. Record review of Patient #7 failed to include documentation with the physician for a delayed or change in the ordered start of care date. The Agency failed to ensure the initial assessment of Patient #1 was completed within 48 hours of receipt of the referral. In a simultaneous observation and interview of Patient #1 during a home visit on 05/27/25 at 03:35 p.m., the surveyor was greeted and escorted by a provider who accompanied Patient #1 to Patient #1’s clean and well-kept living room. Patient #1 was sitting comfortably in a chair watching television. Patient #1 stated he was a patient of the Agency for approximately 1-2 months after his physician had referred him for physical therapy. Patient #1 stated he lived with his family member who provided care during the evenings and the provider who provided care during the day. Patient #1 stated he was unable to care for himself because he had weakness and was never left alone. The surveyor observed Patient #1 had limited mobility to his right upper extremity (arm). Patient #1 stated he only had one nurse who had come to visit with him and one therapist who provided therapy. In a simultaneous record review and interview on 05/28/25 at 01:50 p.m., RN A confirmed Patient #1 was an active patient with a SOC date of 04/07/25. RN A confirmed Patient #1’s current certification period was 04/07/25 through 06/05/25. RN A confirmed the Agency had received a referral on 04/04/25 for Patient #1. RN A confirmed the OASIS comprehensive assessment for the SOC was performed on 04/07/25 by her. RN A stated the patient was not seen within 48 hours of the receiving the referral. RN A stated there was a delay because “the physician’s office was supposed to update the referral but never sent the updated referral to reflect nursing services”. RN A stated the referral used was only for physical therapy and Patient #1 needed a nursing referral, but she did not follow up because “I left out of town”. RN A stated this was an oversight on her part because “I am the only one who sees the patient”. RN A stated she did not have any other documentation that provided information on why the client was not seen within the 48 hours. RN A confirmed Patient #7 was a discharged patient with a SOC date of 11/11/24. RN A confirmed Patient #7’s certification period was 11/11/24 through 01/09/25 and the receipt of a referral on 11/07/24. RN A confirmed the OASIS comprehensive assessment for the SOC was performed on 11/11/24 by her. RN A stated the patient was not seen within 48 hours of receiving the referral. RN A stated there was a delay because Patient #7 had been discharged from a skilled nursing facility and could not remember “exactly why there was a delay’. RN A stated Patient #7 was supposed to get wound care and a referral for that. RN A stated Patient #7 was supposed to go to his physician the following Monday for a follow up and a new referral for that wound care but did not go. RN A stated she could not provide any further documentation that reflected why there was a delay and why the client was not seen within 48 hours of the referral. In an interview on 05/28/25 at 03:20 p.m., the Adm/DON stated RN A did not follow Agency policy by not completing the initial comprehensive assessment within 48 hours. The Adm/DON stated the nurse was responsible for ensuring the initial assessment was completing the assessment within 48 hours of the receipt of the referral for Patient #1 and Patient #7. The Adm/DON stated this was not done because one client was needing to follow up with his physician for wound care orders and the other was waiting on a physical therapy referral. The Adm/DON stated she has oversight to ensure the nurse completes the initial assessment within 48 hours of receipt of the referral and this was not done. The Adm/DON stated this can negatively affect patient care if the patient’s having to wait for care “especially a whole weekend”. The Adm/DON stated it can also delay other services like therapy, “it is unacceptable”. Record review of the Agency’s policies titled, “Timelines, IM.35”, with a revised date 10/25/24, quoted in part, “The Agency will ensure timely provision of care and services to mee the patient’s /client’s needs in compliance with all federal and state laws and regulations…A. The evaluation for admission to Agency is conducted within 48 hours of referral, or within 48 hours of the patient’s/client’s return home or on the physician/and or non-physician practitioner start of care date. In instances where the patient/client requests a delay in the start of care date, the Agency will contact the physician and/or non-physician practitioner to request a change in the start of care date and such change will be documented in the medical record…”