Every finding on record at Shepherd's Services, Inc.

A recertification survey was conducted on 10/16/2024 at 11:30 a.m. with the Administrator. Marlin: Census: 89 Licensed and Certified Home Health: 89 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice: 0 NO DEFICIENCIES WERE CITED

A recertification survey was conducted on 10/16/2024 at 11:30 a.m. with the Administrator. Marlin: Census: 89 Licensed and Certified Home Health: 89 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice: 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency RN - Registered Nurse

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 encode and electronically transmit each completed OASIS assessment to the CMS system, within 30 days of completing the assessment of the patient for 14 of 485 assessments processed for the time period reviewed of 05/31/2023 - 12/31/2023. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 05/31/2023 - 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/31/2023 - 12/31/2023 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 14 assessments out of 485 assessments were submitted late. A joint interview was conducted with the Administrator and Alternate Administrator on 10/18/2024 at 1:30 p.m. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated the Agency was aware of the late submissions of OASIS assessments due to the Agency nurses submitting the OASIS assessments late during the period of 05/31/2023 - 12/31/2023. The Administrator further revealed that the Agency also frequently educated the Agency nurses on timely submission of documentation. Record review of an Agency policy titled, "Administrative Policy Manual- Timelines," dated 5/2/2024, read in part, “…II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS…it will be transmitted using electronic communications software…within 30 days of the M0090 date.”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to enforce written policies that detailed a review of all medications the patient was currently using with one of two discharged patients (Patient #7), whose records were reviewed which included oxygen therapy not written on the plan of care. This failure could place Agency clients who receive oxygen therapy at risk of inaccurate and inadequate care by Agency’s staff. Findings include: Record review of the Agency’s policy titled, “Medication List and Monitoring,” dated 5/2/2024, revealed in part, “I. The agency will maintain a current accurate list of all prescription and over the counter medications taken by the patient/client...Oxygen therapy, including liters per minute, rote, and frequency, will be documented on the medication profile. Professional clinical staff will update the medication list with any changes in the medication regimen.” Record review of Patient #7’s clinical records reveal a start of care date of 05/24/2024 with a diagnosis of Chronic obstructive pulmonary disease (a lung disease that causes breathing problems). Further review of the plan of care of Patient #7 revealed that Patient #7 received skilled nursing once weekly and a physical therapy evaluation. Further review revealed documentation signed by RN B, a medical history in the plan of care that included, “use of supplemental oxygen.” Record review of Patient #7’s plan of care revealed no detail on how the oxygen should be administered. In an interview with RN B on 10/18/2024 at 10:00 a.m., RN B stated that she didn’t think she needed to add any details about the oxygen therapy on her medication list at the time but that she understood the noncompliance. In an interview with the Alternate Administrator/ Nursing Supervisor on 10/18/2024 at 12:45 p.m., the Alternate Administrator/ Nursing Supervisor stated that nurses have been instructed on documenting oxygen therapy in the plan of care and will retrain the nurses on documentation. In an interview with the Administrator on 10/18/2024 at 1:00 p.m., the Administrator stated he has acknowledged the above findings and that the issue will be corrected.