Every finding on record at Shining Star Home Health Care Inc.

The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of visit: Recertification/Relicensure Survey Entrance: 03/28/2023 at 9:49 AM with the Administrator/Director of Nursing. Agency Census: Licensed Home Health Services (LHHS)-23 Licensed and Certified Home Health Services (L&CHHS)-0 Personal Assistance Services (PAS) -0 Exit Conference was conducted on 03/30/2023 with the Administrator/Director of Nursing, Alternate Administrator, Office Liaison and the Secretary at 2:35 PM. 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. Abbreviations: Licensed and Certified Home Health Services (L&CHHS) Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Outcome and Assessment Information Set (OASIS) Quality Improvement Organization (QIO) Skilled Nurse (SN) Discharge (D/C) Center for Medicare/ Medicaid Services (CMS)

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 home health agency failed to protect the patient's right to appeal discontinuation of home health services for five of (Patients #’s 6, 7, 8, 9 and 10) five discharged patient records reviewed, the agency failed to provide the correct contact phone number of the Quality Improvement Organization (QIO) for the patients to appeal the discharge decision prior to when home health services ended. This failure could have placed the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. Findings include: Review of the agency discharged list: Discharged Patient #6: revealed a start of care date 3/30/22, discharge date 5/9/22 with discharge reason "Goals Met". Discharged Patient #7: revealed a start of care date 4/27/21, discharge date 6/17/22 with discharge reason "Goals Met". Discharged Patient #8: revealed a start of care date 2/17/22, discharge date 9/19/22 with discharge reason "Goals Met". Discharged Patient #9: revealed a start of care date 2/16/22, discharge date 2/6/23 with discharge reason "Goals Met". Discharged Patient #10: revealed a start of care date 12/21/21, discharge date 2/28/23 with discharge reason "Goals Met". Review of discharge records: Discharged Patient #6 Review of the discharge record contained a discharge Outcome and Assessment Information Set (OASIS), digitally signed and dated by the Administrator/Director of Nursing on 5/9/22 that revealed a discharge date of 5/9/22. The record contained a for titled “SN DISCHARGE SUMMARY”, digitally signed and dated by the Administrator/Director of Nursing on 5/9/22 that revealed a discharge date of 5/9/22 read in part, “Reason for D/C: Goals Met”. The record contained a Center for Medicare/ Medicaid Services (CMS) 2-page form titled, "Notice of Medicare Non-Coverage". The first page included the incorrect Quality Improvement Organization (QIO), phone contact number 1800-430-9504. The second page had an area for the signature of patient or Representative which revealed the patient’s signature dated 5/04/2022. Patient #6 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), phone contact number 1-888-315-0636. Discharged Patient #7 Review of the discharge record contained a discharge Outcome and Assessment Information Set (OASIS), digitally signed and dated by the Administrator/Director of Nursing on 6/20/22 that revealed a discharge date of 6/17/22. The record contained a for titled “SN DISCHARGE SUMMARY”, digitally signed and dated by the Administrator/Director of Nursing on 6/21/22 read in part, “Reason for Discharge Goals met”. The record contained a Center for Medicare/ Medicaid Services (CMS) 2-page form titled, "Notice of Medicare Non-Coverage". The first page included the incorrect Quality Improvement Organization (QIO), phone contact number 1800-430-9504. The second page had an area for the signature of patient or Representative which revealed the patient’s signature dated 6/16/2022. Patient #7 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), phone contact number 1-888-315-0636. Discharged Patient #8 Review of the discharge record contained a discharge Outcome and Assessment Information Set (OASIS), digitally signed and dated by the Administrator/Director of Nursing on 9/29/22 that revealed a discharge date of 9/19/22. The record contained a for titled “SN DISCHARGE SUMMARY”, digitally signed and dated by the Administrator/Director of Nursing on 2/6/23, read in part, “Reason for D/C: Goals Met”. The record contained a Center for Medicare/ Medicaid Services (CMS) 2-page form titled, "Notice of Medicare Non-Coverage". The first page included the incorrect Quality Improvement Organization (QIO), phone contact number 1800-430-9504. The second page had an area for the signature of patient or Representative which revealed the patient’s signature dated 9/14/2022. Patient #8 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), phone contact number 1-888-315-0636. Discharged Patient #9 Review of the discharge record contained a discharge Outcome and Assessment Information Set (OASIS), digitally signed and dated by the Administrator/Director of Nursing on 2/6/23 that revealed a discharge date of 2/6/23. The record contained a for titled “SN DISCHARGE SUMMARY”, digitally signed and dated by the Administrator/Director of Nursing on 9/19/22 that revealed a discharge date of 9/19/22 read in part, “Reason for D/C: Goals Met”. The record contained a Center for Medicare/ Medicaid Services (CMS) 2-page form titled, "Notice of Medicare Non-Coverage". The first page included the incorrect Quality Improvement Organization (QIO), phone contact number 1800-430-9504. The second page had an area for the signature of patient or Representative which revealed the patient’s signature dated 02/1/2023. Patient #9 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), phone contact number 1-888-315-0636. Discharged Patient #10 Review of the discharge record contained a discharge Outcome and Assessment Information Set (OASIS), digitally signed and dated by the Administrator/Director of Nursing on 2/28/23 that revealed a discharge date of 2/28/23. The record contained a for titled “SN DISCHARGE SUMMARY”, digitally signed and dated by the Administrator/Director of Nursing on 2/28/23 that revealed a discharge date of 2/28/23 read in part, “Reason for D/C: Goals Met”. The record contained a Center for Medicare/ Medicaid Services (CMS) 2-page form titled, "Notice of Medicare Non-Coverage". The first page included the incorrect Quality Improvement Organization (QIO), phone contact number 1800-430-9504. The second page had an area for the signature of patient or Representative which revealed the patient’s signature dated 02/23/2023. Patient #10 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), phone contact number 1-888-315-0636. During an interview with the Alternate Administrator/Director of Nursing on 3/30/2023 at 2:20 PM, the surveyor reviewed and discussed the findings regarding the discharged Patients #’s 6, 7, 8, 9, and 10. The surveyor the Administrator/Director of Nursing and the Alternate Administrator reviewed the agency's Medicare QIO form provided to the discharged patients dated 08/2014. The surveyor the Alternate Administrator/Director of Nursing and the Alternate Administrator discussed the correct phone number for the QIO which changed 6/8/2019. The surveyor asked the Administrator/Director of Nursing and Alternate Administrator were they aware of the QIO phone number change on 6/8/2019? The Administrator/Director of Nursing stated, "I wasn’t aware the number changed, we will update our forms. " Review of agency policy dated 080120 read in part, "... Patient/Client Transfer and Discharge Notices PE.30…. The agency will deliver a Detailed Explanation of Non-Coverage …to the patient/client, or representative, at least two (2) calendar days before the Medicare covered services end…. IV. The Agency will deliver a Detailed Explanation of Non-Coverage…to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client request an expedited review by the QIO of the decision that coverage for items and/or services should end……”