Every finding on record at Sher Den Home Health Inc

A relicensure/recertification survey entrance conference was conducted on 09/24/2024 at 11:20 AM. Census: LCHHS: 43 LHHS: 0 PAS: 8 The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted on 09/24/2024. Census: LCHHS: 43 LHHS: 0 PAS: 8 Abbreviations: Adm = Administrator Alt = Alternate CMS = Centers for Medicare & Medicaid Services DON = Director of Nurses HHA = home health agency IQIES = Internet Quality Improvement and Evaluation System LCHHS = Licensed and Certified Home Health Services LHHS = Licensed Home Health Services OASIS = Outcome and Assessment Information Set PAS = Personal Assistance Services Prn = as needed 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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patient) for 15.43% (54 of 350) of assessments transmitted during 09/24/2023-09/24/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 09/24/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 09/24/2023-09/24/2024. The HHA Error Summary by Agency report included 54 of 350 OASIS assessments (15.43%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Alt Adm/DON/PAS Supervisor on 09/24/2024 during the entrance conference. The Alt Adm/DON/PAS Supervisor stated she was responsible for submitting OASIS assessments to the CMS system. During an interview on 09/26/2024 at 3:30 PM, the surveyor reviewed the error summary report that included 54 OASIS assessments submitted late. The Alt Adm/DON/PAS Supervisor stated the agency only had prn nurses at the beginning of the period under review but now had a full-time nurse (RN A) who was hired at the end of June 2024. The Alt Adm/DON/PAS Supervisor stated it was hard getting the prn nurses to complete their paperwork on time. RN A did not have prior OASIS experience and was still learning. The prn nurses and RN A were not completing the OASIS assessments timely. During an interview on 09/27/2024 at 3:30 PM, the Alt Adm/DON/PAS Supervisor stated agency policy had not been followed because of the prn nurses and the newly hired nurse, RN A. Agency policy titled, “Encoding, Transmitting, and Validating OASIS Data” undated, read in part, “Purpose: Ensure timely encoding and transmission of OASIS data… Definitions… Transmission is the act of electronically sending the OASIS data from the home care agency to the State agency or… OASIS contractor… Policy/Procedure… The office manager or the billing clerk transmits… OASIS data for each patient at least monthly…”

A Recertification Survey entrance conference was conducted on 09/16/2021 at 2:45 PM with the Alt Adm/DON. Census: L&CHH: 64 LHH: 0 An exit conference was conducted on 09/22/2021 at 2:00 PM with the Alt Adm/DON and the ADON. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited. ABBREVIATIONS Adm - Administrator ADON - Alternate Director of Nurses Alt - Alternate CFR - Code of Federal Regulations DON - Director of Nurses/Supervising Nurse L&CHH- Licensed and Certified Home Health LHH - Licensed Home Health PM - Post meridiem

A Recertification Survey entrance conference was conducted on 09/16/2021 at 2:45 PM with the Alt Adm/DON. Census: L&CHH: 64 LHH: 0 An exit conference was conducted on 09/22/2021 at 2:00 PM with the Alt Adm/DON and the ADON. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS Adm - Administrator ADON - Alternate Director of Nurses Alt - Alternate CFR - Code of Federal Regulations CMS - Centers for Medicare and Medicaid Services DC - Discharge DON - Director of Nurses/Supervising Nurse L&CHH- Licensed and Certified Home Health LHH - Licensed Home Health No. - Number NOMNC - Notice of Medicare Non-Coverage OASIS- Outcome and Assessment Information Set PI - Performance Improvement PIP - Performance Improvement Project PM - Post meridiem POC - plan of care QAPI- Quality Assurance Performance Improvement QIO - Quality Improvement Organization SN - skilled nurse

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a completed written NOMNC no later than two days in advance of terminating on-going care that included the correct QIO phone number in three of three DC'd patient records (Patient 1, 2 and 3) reviewed with goals met as reason for DC. This failure prevented Patients from exercising the right to appeal the DC decision, if desired. FINDINGS INCLUDE: A patient DC list with DC reason was provided to the surveyor by the Alt Adm/DON on 09/16/2021 which included the DC date of 09/22/2020 for Patient 1, 11/05/2020 for Patient 2 and 05/14/2021 for Patient 3. DC'd Patient 1: Record review of Patient 1 included a POC dated 07/27/2020 to 09/24/2020. The record contained a SN DC OASIS visit on 09/22/2020 with the reason for DC as goals met. The record contained a two-page NOMNC form that was signed and dated by Patient 1 on 09/16/2020. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 9-22-20 ..." The form included the QIO phone number as 844-430-9504 to appeal the DC decision, if the patient chose to do so. DC'd Patient 2: Record review of Patient 2 included a POC dated 10/28/2020 to 12/26/2020. The record contained a SN DC OASIS visit on 11/05/2020 with the reason for DC as goals met. The record contained a three-page NOMNC form that was signed and dated by Patient 2 on 10/28/2020. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 11-5-20 ..." The form included the QIO phone number as 800-725-8339 to appeal the DC decision, if the patient chose to do so. DC'd Patient 3: Record review of Patient 3 included a POC dated 03/18/2021 to 05/16/2021. The record contained a SN DC OASIS visit on 05/14/2021 with the reason for DC as goals met. The record contained a two-page NOMNC form that was signed and dated by Patient 3 on 05/05/2021. The NOMNC read in part, " ...The effective date coverage of your current home health services will end: 5-14-21 ..." The form included the QIO phone number as 844-430-9504 to appeal the DC decision, if the patient chose to do so. During an interview with the Alt Adm/DON and the ADON on 09/22/2021 at approximately 12:35 PM, the surveyor reviewed the agency's NOMNC form that DC'd Patient 1, 2 and 3 signed. The surveyor presented the above findings of why DC'd Patient 1, 2 and 3 were given an NOMNC with the wrong phone number for the QIO. The Alt Adm/DON stated, " I didn't know that." Agency policy titled, "ADVANCED BENEFICIARY NOTICE - HOME HEALTH" read in part, "POLICY: Certified agencies must provide advance beneficiary notices ( ...NOMNC) to all Medicare patients in advance of ...discontinuation of services ... PURPOSE: To delineate the process for providing advance beneficiary notices as required by CMS ...NOTICE OF MEDICARE NON-COVERAGE (NOMNC) I. The agency must issue an NOMNC prior to termination of all Medicare covered home health services to a patient or an authorized representative ...The notice informs the patient of the expedited determination process in which the patient may appeal their service termination to a Quality Improvement Organization ...XII ...The agency shall inform ... E. Telephone number of the QIO to request the appeal ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDE: Record review of the agency's QAPI manual did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s), per federal regulatory requirements, for the years 2018, 2019 and 2020. The manual contained a one-page form titled, "PERFORMANCE IMPROVEMENT PROJECT" that was blank and contained no agency information. During an interview with the Alt Adm/DON and the ADON on 09/22/2021 at approximately 1:33 PM, the surveyor presented the above findings of what the agency's PIP had been for 2018, 2019 and 2020. The Alt Adm/DON stated, " ...that's probably what I'm lacking." Agency policy titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT - TEXAS" read in part, " ...The Texas Agency will develop, implement and maintain an effective, ongoing Agency wide, data-driven QAPI program which adheres to both Federal regulations ...and Texas regulations ...Performance Improvement Projects...The number and scope of distinct PI projects conducted annually must reflect the scope, complexity and past performance of the Agency's services and operations ..." Agency policy titled, "AGENCY QUALITY ASSESSMENT PERFORMANCE PLAN" read in part, " ...Performance Improvement Projects ...The number and scope of distinct PI projects conducted annually must reflect the scope, complexity and past performance of the Agency's services and operations ...The Agency should have one performance improvement project either in development, on-going or completed each calendar year ..."

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to send completed DC summaries. In three of three DC'd records reviewed (Patient 1, 2 and 3), a DC summary was not sent to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after DC within 5 business days. The failure placed patients at risk of negative outcomes, patient/caregiver receiving post-DC instructions, and the physician from ensuring patient services were provided and patient needs were met. FINDINGS INCLUDE: DC'd Patient 1: Record review of Patient 1 included a POC dated 07/27/2020 to 09/24/2020. The record contained a SN DC OASIS visit on 09/22/2020 that included a DC Summary that read in part, " ...Discharge from Home Health Services..." The DC Summary did not indicate the form was sent to the physician. DC'd Patient 2: Record review of Patient 2 included a POC dated 10/28/2020 to 12/26/2020. The record contained a SN DC OASIS visit on 11/05/2020 that included a DC Summary that read in part, " ...Discharge from Home Health Services..." The DC Summary did not indicate the form was sent to the physician. DC'd Patient 3: Record review of Patient 3 included a POC dated 03/18/2021 to 05/16/2021. The record contained a SN DC OASIS visit on 05/14/2021 that included a DC Summary that read in part, " ...Discharge from Home Health Services..." The DC Summary did not indicate the form was sent to the physician. During an interview with the Alt Adm/DON and the ADON on 09/22/2021 at approximately 12:37 PM, the surveyor presented the above findings of why the agency did not send the DC Summary for Patient 1, 2 and 3 to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after DC. The Alt Adm/DON stated the DC summary is only sent if the physician requests it and that had never happened before. Agency policy titled, "DISCHARGE PLANNING" read in part, "...PROCEDURE ...XIII ...the discharge summary is sent to the physician/practitioner within 5 business days of discharge ..." Agency policy titled, "TRANSFER OR DISCHARGE" read in part, "...PROCEDURE ...II ...a discharge summary must be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the Agency ...within 5 business days of the patient's discharge ..."